What is the best tool to stratify a patient's risk for Coronary Artery Disease (CAD) and Hyperlipidemia (HLD) to determine the need for statin therapy?

From the Guidelines

To stratify a patient's risk for cardiovascular disease and determine the need for statin therapy, the most effective tool is the Pooled Cohort Equations (PCE) risk calculator, as recommended by the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline 1. I recommend using this calculator as your primary risk assessment tool, as it estimates the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) based on age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure treatment status, diabetes, and smoking status. For primary prevention, statin therapy is generally recommended for patients with a 10-year ASCVD risk ≥7.5% 1. High-intensity statins (atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily) are recommended for patients with established ASCVD, LDL-C ≥190 mg/dL, or diabetes with high risk. Moderate-intensity statins (atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, or pravastatin 40-80mg daily) are appropriate for lower-risk patients. When implementing statin therapy, baseline liver function tests should be checked, and lipid panels should be repeated 4-12 weeks after initiation to assess response and adherence. The PCE calculator is preferred because it incorporates multiple risk factors and provides a comprehensive assessment that guides evidence-based treatment decisions to reduce cardiovascular events. Additionally, coronary artery calcium scoring (CACS) can be used to further stratify risk in intermediate-risk patients, with a CACS score of 0 indicating a lower risk and a score ≥100 indicating a higher risk 1. This approach allows for personalized treatment decisions and can help reduce cardiovascular events. Some key points to consider when using the PCE calculator and CACS include:

• The PCE calculator estimates 10-year ASCVD risk based on multiple risk factors.
• Statin therapy is recommended for patients with a 10-year ASCVD risk ≥7.5%.
• High-intensity statins are recommended for patients with established ASCVD, LDL-C ≥190 mg/dL, or diabetes with high risk.
• CACS can be used to further stratify risk in intermediate-risk patients.
• A CACS score of 0 indicates a lower risk, while a score ≥100 indicates a higher risk. It's also important to consider the patient's individual risk factors and preferences when making treatment decisions, as recommended by the guidelines 1. Overall, using the PCE calculator and CACS can help healthcare providers make informed decisions about statin therapy and reduce the risk of cardiovascular events.

From the Research

Stratifying Patient Risk for Statin Therapy

To determine the best tool for stratifying patient risk and the need for statin therapy, several guidelines and studies can be considered. The 2018 AHA/ACC cholesterol guideline recommends a maximally-tolerated statin with add-on lipid-lowering therapy for adults with very-high atherosclerotic cardiovascular disease (ASCVD) risk to achieve a low-density lipoprotein cholesterol (LDL-C) <70 mg/dL 2.

Risk Assessment Tools

• The 2022 USPSTF recommendations suggest statin therapy for primary prevention in those with a 10-year ASCVD risk of ≥10% and ≥ 1 CVD risk factor (diabetes mellitus, dyslipidemia, hypertension, or smoking) 3.
• The 2018 AHA/ACC/MS Cholesterol guideline recommends considering statin therapy for primary prevention for those with diabetes mellitus, or 10-year ASCVD risk ≥20% or 10-year ASCVD risk 7.5 to <20% after accounting for risk-enhancers and shared decision making 3.
• A study published in the Journal of the American College of Cardiology suggests that adding nonstatin therapy, such as ezetimibe or PCSK9 inhibitors, to background statin therapy may be beneficial for patients with high-risk or very high-risk ASCVD 4.

Patient Factors to Consider

• Smokers, adults with diabetes, hypertension, and chronic kidney disease are more likely to be recommended add-on lipid-lowering therapy 2.
• Patients with clinical ASCVD and comorbidities, or those with heterozygous familial hypercholesterolemia, may benefit from the addition of nonstatin therapy to background statin therapy 4.
• The use of PCSK9 inhibitors may be effective in reducing LDL-C levels, especially in high-risk patients with established ASCVD or familial hypercholesterolemia (FH) 5.

Treatment Considerations

• Statins remain the first-line therapy for primary and secondary prevention of ASCVD, but nonstatins and PCSK9 inhibitors may be recommended for secondary prevention in patients with clinical ASCVD 6.
• Clinical guidelines recommend add-on therapy with ezetimibe and PCSK9 inhibitors when maximally tolerated statin therapy results in suboptimal LDL-C reduction 5.
• Barriers to treatment, such as clinical inertia, high out-of-pocket costs, and pharmacy benefit access issues, may limit the use of PCSK9 inhibitors 5.