What is the appropriate management for a patient with hypertension and a low‑density lipoprotein (LDL) cholesterol of 135 mg/dL?

Management of Hypertension with LDL-C 135 mg/dL

For a patient with hypertension and LDL cholesterol of 135 mg/dL, initiate blood pressure control with antihypertensive medications (targeting <140/90 mm Hg) while simultaneously implementing intensive lifestyle modifications for 3–6 months before considering statin therapy, unless the calculated 10-year ASCVD risk is ≥7.5% or other high-risk features are present. 1, 2

Step 1: Calculate 10-Year ASCVD Risk

• Mandatory risk assessment: Use the ACC/AHA Pooled Cohort Equations incorporating age, sex, race/ethnicity, total cholesterol, HDL-C, systolic blood pressure, antihypertensive medication use, diabetes status, and smoking history. 2
• Risk thresholds for statin therapy:
  • <5% risk: Lifestyle modification only; statin not indicated. 2
  • 5–7.5% (borderline risk): Continue lifestyle modification; add statin only if risk-enhancing factors (e.g., family history of premature cardiac death) are present. 2
  • ≥7.5% risk: Initiate moderate-intensity statin (atorvastatin 10–20 mg or rosuvastatin 5–10 mg) in addition to lifestyle changes. 1, 2

Step 2: Blood Pressure Management

• Target blood pressure: <140/90 mm Hg for most patients with hypertension. 1
• Initial pharmacotherapy: Begin with β-blockers and/or ACE inhibitors, adding other agents as needed to achieve goal. 1
• Avoid adverse lipid effects: Select antihypertensive agents that do not worsen lipid profiles; ACE inhibitors and calcium channel blockers are preferred over thiazide diuretics in patients with concurrent hyperlipidemia. 3, 4
• Lifestyle modifications for blood pressure: Weight control, increased physical activity, alcohol moderation, sodium reduction (<6 g/day), and emphasis on fresh fruits, vegetables, and low-fat dairy products. 1

Step 3: Intensive Lifestyle Modification (3–6 Months)

Dietary Targets

• Saturated fat: <7% of total calories. 1, 2
• Dietary cholesterol: <200 mg/day. 1, 2
• Trans-fatty acids: <1% of total calories. 1
• Soluble fiber: 10–25 g/day to lower LDL-C. 1, 2
• Plant stanols/sterols: Up to 2 g/day for additional LDL-C reduction. 1, 2

Physical Activity

• Aerobic exercise: ≥150 minutes/week of moderate-intensity activity (e.g., brisk walking 15–20 minutes per mile). 1, 2
• Resistance training: 8–10 exercises, 1–2 sets of 10–15 repetitions at moderate intensity, 2 days/week. 1, 2

Weight Management

• Target: ≥10% body weight reduction within the first year if overweight or obese, which significantly improves blood pressure, lipid profile, and insulin sensitivity. 2

Step 4: Reassess After 3–6 Months

• Repeat lipid profile and ASCVD risk calculation: If 10-year risk reaches ≥7.5%, initiate moderate-intensity statin therapy. 2
• Monitor blood pressure control: Adjust antihypertensive regimen if BP remains ≥140/90 mm Hg. 1

Step 5: Statin Therapy Indications

Immediate Statin Initiation (Without Waiting for Lifestyle Trial)

• LDL-C ≥190 mg/dL: Start high-intensity statin immediately. 2, 5
• Diabetes mellitus: Initiate at least moderate-intensity statin regardless of calculated risk. 2, 5
• Clinical ASCVD: Prior MI, stroke, TIA, or peripheral arterial disease requires high-intensity statin. 2, 5

Statin After Lifestyle Modification

• 10-year ASCVD risk ≥7.5%: Add moderate-intensity statin (atorvastatin 10–20 mg or rosuvastatin 5–10 mg) aiming for 30–40% LDL-C reduction. 1, 2
• Borderline risk (5–7.5%) with risk-enhancing factors: Consider moderate-intensity statin after shared decision-making. 2

Step 6: LDL-C Treatment Goals

• Primary prevention without major risk factors: LDL-C <100 mg/dL. 1, 5
• Very high-risk patients (multiple risk factors or imaging evidence of ASCVD): LDL-C <70 mg/dL is reasonable. 1, 5
• Clinical ASCVD: LDL-C <55 mg/dL. 5

Step 7: Monitoring Strategy

• Lipid profile: Recheck 4–6 weeks after hospitalization or 2 months after medication initiation/change. 1, 5
• Liver function and creatine kinase: Monitor in patients on statin therapy as recommended by NCEP. 1
• Blood pressure: Reassess at every office visit and adjust therapy to maintain <140/90 mm Hg. 1
• ASCVD risk recalculation: Repeat every 4–6 years using Pooled Cohort Equations, as risk increases with age. 2

Critical Pitfalls to Avoid

• Do not prescribe statins as a substitute for lifestyle modification in patients with <7.5% 10-year risk; early lifestyle changes confer greater long-term benefit. 2
• Do not treat based solely on isolated LDL-C values unless LDL-C ≥190 mg/dL; the ACC/AHA guidelines emphasize risk-based decisions over target LDL-C levels. 2
• Do not use thiazide diuretics as first-line antihypertensives in patients with concurrent hyperlipidemia, as they adversely affect lipid profiles; prefer ACE inhibitors or calcium channel blockers. 3, 4
• Do not overlook weight management: Achieving 10% weight loss substantially improves both blood pressure and lipid profile, potentially obviating the need for statin therapy. 2

Additional Cardiovascular Risk Reduction

• Smoking cessation: Assess tobacco use at every visit and provide counseling, pharmacotherapy (nicotine replacement, bupropion, or varenicline), and referral to cessation programs. 1
• Aspirin prophylaxis: Consider 75–162 mg/day for patients with 10-year CHD risk ≥10%. 1
• Diabetes screening: Detect hyperglycemic risk (metabolic syndrome) and diabetes; target HbA1c <7% if diabetic. 1