Should a patient on atorvastatin 20 mg with LDL at target but low HDL (35 mg/dL) continue the medication?

Continue Atorvastatin 20 mg and Address the Low HDL-C

Yes, this patient should absolutely continue atorvastatin 20 mg, and the low HDL-C of 35 mg/dL does not change this recommendation. The primary benefit of statin therapy is LDL-C reduction for cardiovascular risk reduction, not HDL-C modification, and discontinuing a statin because HDL-C remains low would be a critical error. 1

Why Continuation is Mandatory

• Statins reduce major adverse cardiovascular events (MACE) and mortality through LDL-C lowering, regardless of baseline or achieved HDL-C levels. The 2024 ACC/AHA perioperative guideline gives a Class I, Level B-NR recommendation for continuing statins in patients already on therapy, because discontinuation increases total and cardiovascular mortality. 1

• The cardiovascular benefit of statins is linearly related to LDL-C reduction without a lower threshold, meaning every 39 mg/dL (1 mmol/L) reduction in LDL-C produces a 9% reduction in all-cause mortality and 13% reduction in vascular mortality in patients with diabetes. 1

• Low HDL-C (35 mg/dL) is a cardiovascular risk factor but is not a contraindication to statin therapy—in fact, it strengthens the indication for aggressive LDL-C lowering. The 2023 ADA guidelines classify patients with diabetes and additional risk factors (such as low HDL-C) as high-risk, warranting at least moderate-intensity statin therapy. 1

Assess Whether Current Therapy is Adequate

Calculate 10-Year ASCVD Risk

• Use the ACC/AHA Pooled Cohort Equations to determine whether this patient requires moderate-intensity (atorvastatin 10–20 mg) or high-intensity (atorvastatin 40–80 mg) therapy. The decision depends on age, sex, race, blood pressure, smoking status, diabetes status, and whether the patient has established ASCVD. 2

• If the patient has diabetes (type 1 or 2), established ASCVD, or a 10-year ASCVD risk ≥20%, high-intensity statin therapy (atorvastatin 40–80 mg) is recommended with a target LDL-C <70 mg/dL and ≥50% reduction from baseline. 1, 2, 3

• If the patient is age 40–75 with diabetes but without additional high-risk features, moderate-intensity therapy (atorvastatin 10–20 mg) targeting LDL-C <100 mg/dL is acceptable. 1, 3

Verify LDL-C is at Goal

• Confirm the patient's current LDL-C level. If LDL-C is <100 mg/dL on atorvastatin 20 mg and the patient is moderate-risk, the current dose is appropriate. 1, 2

• If LDL-C is ≥100 mg/dL or the patient is high-risk (diabetes with additional risk factors, established ASCVD, or 10-year risk ≥20%), increase to atorvastatin 40 mg to achieve high-intensity therapy (≥50% LDL-C reduction). 1, 2, 3

Address the Low HDL-C

Statins Have Modest and Variable Effects on HDL-C

• Atorvastatin 20 mg increases HDL-C by only 2–5% on average, and the effect is greater in patients with low baseline HDL-C (<40 mg/dL) and high triglycerides. 4, 5

• The HDL-C increase with atorvastatin is dose-dependent but modest: atorvastatin 10 mg raises HDL-C by ~4%, and 20 mg by ~5–7%, primarily by increasing large HDL particles and reducing small HDL particles. 4, 5, 6

• Do not expect atorvastatin to normalize HDL-C in this patient—the primary goal is LDL-C reduction, and the cardiovascular benefit of statins is independent of HDL-C changes. 1, 7

Optimize Lifestyle and Screen for Secondary Causes

• Counsel on a heart-healthy diet emphasizing vegetables, fruits, whole grains, legumes, fish, and nuts while limiting sweets, sugar-sweetened beverages, and red meat. Weight loss (if overweight) and aerobic exercise (3–4 sessions per week, 40 minutes of moderate-to-vigorous intensity) can raise HDL-C by 5–10%. 2

• Screen for secondary causes of low HDL-C: smoking (most common), obesity, physical inactivity, high carbohydrate intake, uncontrolled diabetes, hypothyroidism, nephrotic syndrome, and medications (beta-blockers, thiazide diuretics, anabolic steroids). 2

Consider Adding Fibrate or Niacin Only in Select Cases

• If triglycerides are >200 mg/dL despite statin therapy, consider adding fenofibrate (not gemfibrozil, which increases rhabdomyolysis risk with statins). Fibrates raise HDL-C by 10–15% and lower triglycerides by 25–50%, but do not reduce cardiovascular events when added to statins in most patients. 2

• Niacin is no longer recommended for raising HDL-C in statin-treated patients because large trials (AIM-HIGH, HPS2-THRIVE) showed no cardiovascular benefit and increased adverse effects (flushing, hyperglycemia, myopathy). 2

Monitoring and Follow-Up

• Recheck fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) 4–12 weeks after any dose adjustment. 2, 3

• Monitor for statin-associated muscle symptoms (myalgia, weakness, cramps) and obtain baseline and follow-up ALT, AST, and creatine kinase (CK) as clinically indicated. If CK is >10× upper limit of normal or ALT/AST >3× upper limit of normal, temporarily withhold atorvastatin and repeat labs in 2 weeks. 1, 2

• Assess medication adherence at every visit—non-adherence is the most common cause of suboptimal LDL-C lowering and accounts for 46–47% of patients discontinuing statins long-term. 2

Common Pitfalls to Avoid

• Do not discontinue atorvastatin because HDL-C is low—this would eliminate the proven cardiovascular benefit of LDL-C lowering. 1

• Do not assume atorvastatin 20 mg is adequate without calculating 10-year ASCVD risk and confirming LDL-C is at goal—many patients require high-intensity therapy (atorvastatin 40–80 mg). 1, 2, 3

• Do not add niacin or gemfibrozil to raise HDL-C—niacin provides no cardiovascular benefit in statin-treated patients, and gemfibrozil increases rhabdomyolysis risk. 2

• Do not base treatment decisions solely on isolated cholesterol values without comprehensive risk assessment—the 2013 ACC/AHA guideline emphasizes risk-based statin intensity, not treat-to-target HDL-C. 2