From the Guidelines
Atorvastatin 40 mg orally daily is the best medication to initiate for primary prevention of ASCVD events in this patient. The patient has multiple risk factors, including type 2 diabetes, chronic kidney disease (CKD), hypertension, and dyslipidemia, which increase his risk of cardiovascular events 1. His LDL level is elevated at 110 mg/dL, and he has albuminuria (UACR 50 mg/g), indicating kidney damage. Although his 10-year ASCVD risk is only 3.5%, the presence of diabetes and CKD places him in a higher risk category that warrants statin therapy regardless of his calculated risk score 1. High-intensity statin therapy with atorvastatin 40 mg is appropriate given his risk profile and would help reduce his LDL cholesterol, thereby decreasing his risk of cardiovascular events. The 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease recommends statin therapy as first-line treatment for primary prevention of ASCVD in patients with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion 1.
Some key points to consider in this patient's management include:
- The patient's elevated LDL level and presence of albuminuria indicate a higher risk of cardiovascular events, making statin therapy a priority 1.
- The patient's diabetes and CKD increase his risk of cardiovascular events, and statin therapy is recommended for primary prevention of ASCVD in patients with diabetes mellitus 1.
- High-intensity statin therapy with atorvastatin 40 mg is appropriate given the patient's risk profile and would help reduce his LDL cholesterol, thereby decreasing his risk of cardiovascular events 1.
- The other options (dulaglutide, hydrochlorothiazide, and finerenone) may have benefits for various aspects of his condition, but they are not the first-line agents specifically for ASCVD prevention in this clinical scenario where the patient has untreated dyslipidemia and established risk factors.
Overall, initiating atorvastatin 40 mg orally daily is the best course of action for primary prevention of ASCVD events in this patient, given his risk profile and the current guidelines for statin therapy in patients with diabetes and CKD 1.
From the Research
Patient Profile
- The patient is a 36-year-old man with a past medical history of chronic kidney disease (CKD), dyslipidemia, hypertension, insomnia, and type 2 diabetes (T2D).
- He is currently taking amlodipine 10 mg daily, canagliflozin 100 mg daily, metformin 1000 mg twice daily, and olmesartan 40 mg daily.
- The patient’s vital signs include blood pressure 128/78 mm Hg, heart rate 78 beats/min, and body mass index (BMI) 23 kg/m2.
- Pertinent laboratory values include HbA1c 6.9%, estimated glomerular filtration rate (eGFR) 50 mL/min/1.73 m2, serum potassium 5.1 mEq/L, low-density lipoprotein 110 mg/dL, and urine albumin-to-creatinine ratio (UACR) 50 mg/g.
- He has a 10-year risk of an atherosclerotic cardiovascular disease (ASCVD) event of 3.5%.
Recommended Medication for Primary Prevention of ASCVD Events
- Based on the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report, the best medication to initiate for primary prevention of ASCVD events in this patient is Atorvastatin 40 mg orally daily 2, 3, 4.
- This recommendation is supported by studies that demonstrate the efficacy of statins in reducing the risk of ASCVD events in patients with elevated cardiovascular risk 5, 3, 4.
- The patient's high LDL-C level (110 mg/dL) and 10-year ASCVD risk of 3.5% make him a good candidate for statin therapy 2, 3, 4.
Rationale for Choosing Atorvastatin
- Atorvastatin is a statin that has been shown to be effective in reducing LDL-C levels and preventing ASCVD events in patients with elevated cardiovascular risk 5, 3, 4.
- The patient's current medication regimen does not include a statin, making atorvastatin a good addition to his treatment plan 2, 3, 4.
- The recommended dose of atorvastatin is 40 mg orally daily, which is consistent with guidelines for primary prevention of ASCVD events in patients with elevated cardiovascular risk 2, 3, 4.