For a 60‑year‑old Black woman with total cholesterol 99 mg/dL, high‑density lipoprotein cholesterol 27 mg/dL, triglycerides 194 mg/dL, and non‑high‑density lipoprotein cholesterol 72 mg/dL who has been on atorvastatin 40 mg daily for two years, should the statin dose be reduced to moderate intensity or switched to another statin?

Maintain Current Atorvastatin 40 mg Without Dose Reduction or Switching

Continue atorvastatin 40 mg daily without any dose adjustment or medication change, as this patient has achieved excellent LDL-C control but requires ongoing high-intensity statin therapy to address her severely elevated cardiovascular risk from markedly low HDL-C (27 mg/dL) and elevated triglycerides (194 mg/dL). 1

Rationale for Maintaining High-Intensity Statin Therapy

Current Lipid Profile Analysis

• Total cholesterol of 99 mg/dL and LDL-C well below 100 mg/dL (calculated LDL-C approximately 33 mg/dL using Friedewald equation) confirms excellent response to high-intensity statin therapy, consistent with the expected >50% LDL-C reduction from atorvastatin 40 mg. 1

• However, the HDL-C of 27 mg/dL is severely low (well below the 40 mg/dL threshold) and represents an independent cardiovascular risk factor that mandates continued aggressive lipid management. 2

• Triglycerides of 194 mg/dL remain in the moderate hypertriglyceridemia range (175-499 mg/dL), which is a factor favoring continuation or intensification—not reduction—of statin therapy. 1

• Non-HDL-C of 72 mg/dL is well-controlled but does not eliminate the residual cardiovascular risk from the atherogenic dyslipidemia pattern (low HDL-C plus elevated triglycerides). 1

Why Dose Reduction Is Inappropriate

• ACC/AHA guidelines explicitly state that achieving LDL-C <100 mg/dL on moderate-intensity statin does not justify stopping intensification—in fact, evidence suggests that high-intensity statin provides greater ASCVD event reduction even when LDL-C is already below target. 1

• The guideline monitoring framework indicates that LDL-C levels are used only to assess response and adherence, not as performance standards for dose reduction. 1

• In patients with atherogenic dyslipidemia (low HDL-C plus elevated triglycerides), high-intensity statin therapy provides additional cardiovascular benefit beyond LDL-C lowering through triglyceride reduction (atorvastatin 40 mg reduces triglycerides by approximately 23-35%) and modest HDL-C elevation. 3, 4, 5, 6

Race-Specific Considerations for Black Women

• No sensitivity to statin dosing has been documented in Black individuals compared to non-Hispanic white individuals, so standard dosing applies. 1

• Baseline creatine kinase values are higher in Black patients, but this does not warrant dose reduction in the absence of symptoms—it simply requires awareness when interpreting CK elevations. 1

Addressing the Residual Cardiovascular Risk

Hypertriglyceridemia Management

• With triglycerides at 194 mg/dL and ASCVD risk likely ≥7.5% (given the severe atherogenic dyslipidemia), it is reasonable to consider persistently elevated triglycerides as a factor favoring continuation of current high-intensity statin therapy. 1

• If triglycerides remain >200 mg/dL after optimizing lifestyle factors and addressing secondary causes (diabetes, hypothyroidism, obesity, alcohol), consider adding icosapent ethyl 2-4 g daily as adjunctive therapy to reduce cardiovascular events. 7

Low HDL-C Management

• Implement therapeutic lifestyle changes as first-line strategy: at least 150 minutes per week of moderate-intensity aerobic activity, weight reduction of 5-10%, restriction of added sugars to <6% of total calories, and a heart-healthy diet emphasizing whole grains, fish, vegetables, and nuts. 7, 2

• Atorvastatin 40 mg may provide modest HDL-C increases of 8-11% (potentially raising HDL-C from 27 mg/dL to approximately 29-30 mg/dL), though this effect is more pronounced in males than females. 3, 4

• If HDL-C remains <40 mg/dL despite optimized lifestyle and statin therapy, consider adding fenofibrate or niacin for additional HDL-C raising, though this requires careful monitoring for myopathy risk when combined with statin. 2

Secondary Causes to Evaluate

• Order hemoglobin A1c and fasting glucose to assess for uncontrolled diabetes, which commonly drives both hypertriglyceridemia and low HDL-C. 2

• Order TSH level to assess for hypothyroidism, a common secondary cause that must be treated before expecting full lipid response. 2

Monitoring Strategy

• Recheck fasting lipid panel in 3-6 months after implementing lifestyle modifications and addressing any secondary causes. 1

• Monitor for statin-related adverse effects (myalgias, hepatotoxicity) at each visit, but do not reduce dose in the absence of symptoms or significant laboratory abnormalities. 1

• Adherence assessment is critical—confirm the patient is taking atorvastatin 40 mg daily as prescribed, as non-adherence is a common reason for suboptimal outcomes. 1

Common Pitfalls to Avoid

• Do not reduce statin intensity simply because LDL-C is "too low"—there is no evidence that LDL-C levels in the 30-50 mg/dL range on statin therapy cause harm, and lower LDL-C consistently correlates with better cardiovascular outcomes. 1

• Do not switch to a different statin without a specific indication (intolerance, drug interaction, or inadequate response)—atorvastatin 40 mg is achieving its intended high-intensity effect. 1

• Do not overlook the severely low HDL-C—this patient's residual cardiovascular risk is driven primarily by the atherogenic dyslipidemia pattern, not by LDL-C. 2