Should this patient with a 10‑year ASCVD risk of 20‑30% be started on rosuvastatin 10 mg daily (high‑intensity) or rosuvastatin 5 mg daily (moderate‑intensity)?

Start with Rosuvastatin 20 mg (High-Intensity), Not 5 mg or 10 mg

For a patient with 20-30% 10-year ASCVD risk, you should initiate high-intensity statin therapy with rosuvastatin 20 mg daily to achieve ≥50% LDL-C reduction and maximize cardiovascular risk reduction. 1

Why High-Intensity Therapy is Indicated

Your patient's 20-30% 10-year ASCVD risk places them in the high-risk category where maximal ASCVD risk reduction is the priority. The 2019 ACC/AHA guidelines explicitly state that high-intensity statin therapy provides increased benefit, especially when 10-year ASCVD risk is ≥20%. 1

Evidence Supporting This Approach

• The JUPITER trial demonstrated that rosuvastatin 20 mg daily achieved 50% LDL-C reduction and highly significant ASCVD risk reduction at just 1.9 years in patients at elevated risk. 1

• Greater LDL-C lowering translates directly to greater ASCVD risk reduction. Meta-analyses confirm that net benefit of LDL-C-lowering therapy is greater with greater reductions in LDL-C, and the magnitude of percent LDL-C reduction achieved determines benefit. 1

• Patients at greater baseline risk (like yours with 20-30% 10-year risk) derive greater absolute benefits from statin therapy. 1

Why Not Start with Lower Doses?

Rosuvastatin 10 mg is Moderate-Intensity

• Rosuvastatin 10 mg is classified as moderate-intensity therapy (30-49% LDL-C reduction), not high-intensity. 1, 2

• While rosuvastatin 10 mg showed benefit in intermediate-risk patients (7.5-20% risk) over 5.6 years, your patient's 20-30% risk demands more aggressive initial therapy. 1

Rosuvastatin 5 mg is Insufficient

• Rosuvastatin 5 mg produces approximately 35% LDL-C reduction, falling short of the ≥50% reduction target for high-risk patients. 3

• This dose is typically reserved for moderate-intensity therapy in lower-risk patients or those with statin intolerance. 4

Practical Implementation Algorithm

Step 1: Initiate rosuvastatin 20 mg daily (high-intensity dose) 1, 2

Step 2: Assess LDL-C at 4 weeks to determine adherence and adequacy of response 2

Step 3: If LDL-C reduction is <50% or LDL-C remains ≥70 mg/dL:

• Increase to rosuvastatin 40 mg daily, OR
• Add ezetimibe 10 mg to rosuvastatin 20 mg 1, 2

Step 4: If statin-associated muscle symptoms develop:

• Consider switching to rosuvastatin 10 mg + ezetimibe 10 mg (provides similar LDL-C reduction with better tolerability) 5, 6

Important Caveats

Asian Ancestry Exception

• If your patient is of Asian ancestry (excluding South Asian), start with rosuvastatin 5 mg due to increased plasma concentrations, then titrate up as tolerated. 2

• South Asian patients should receive standard doses comparable to non-Hispanic whites. 2

Age Considerations

• If the patient is >75 years old, the combination of rosuvastatin 5 mg + ezetimibe 10 mg may be preferable to rosuvastatin 20 mg monotherapy due to lower risk of statin-associated muscle symptoms (0.7% vs 5.7%) while achieving similar LDL-C targets. 6

Common Pitfall to Avoid

Do not start with moderate-intensity therapy (rosuvastatin 5-10 mg) in high-risk patients simply to "start low and go slow." This approach delays achieving optimal LDL-C reduction and misses the opportunity for maximal cardiovascular risk reduction during the critical early treatment period. 1, 2