Fast Five Quiz: Statins

Mary L. Windle, PharmD

Disclosures

May 17, 2021

According to ACC/AHA guidelines for statin treatment:

  • For patients aged 20-75 years with an LDL-C level ≥ 190 mg/dL, high-intensity statins can be used without risk assessment.

  • For patients with type 2 diabetes who are aged 40-75 years, use a moderate-intensity statin and risk estimate to consider high-intensity statins. Risk enhancers in patients with diabetes include ≥ 10 years with type 2 diabetes and ≥ 20 years for type 1 diabetes, ≥ 30 µg albumin/mg creatinine, estimated glomerular filtration rate < 60 mL/min/1.73 m2, retinopathy, neuropathy, and ankle-brachial index < 0.9. In those with multiple ASCVD risk factors, consider high-intensity statin with an aim of lowering LDL-C by ≥ 50%.

  • For patients without diabetes who are aged 40-75 years and have LDL-C levels ≥ 70 mg/dL and < 190 mg/dL, use the risk estimator that best fits the patient and risk enhancers to decide the intensity of statin therapy.

  • For patients with borderline ASCVD risk (5% to < 7.5%), if risk enhancers are present, discuss moderate-intensity statin and consider coronary artery calcium (CAC) in selected cases.

  • For patients with intermediate ASCVD risk (≥ 7.5% to 20%), use moderate-intensity statins and increase to high-intensity in those with risk enhancers. Use of CAC to risk-stratify is an option if the risk is uncertain. If the CAC score is 0, statins can be avoided and CAC assessment should be repeated in the future (5-10 years). However, exceptions to this include high-risk conditions such as diabetes, family history of premature coronary heart disease, and smoking. If the CAC score is 1-100, initiating moderate-intensity statins for persons aged ≥ 55 years is reasonable. If the CAC score is > 100 or 75th percentile or higher, use a statin at any age.

  • For patients at high ASCVD risk (≥ 20%), use risk discussion to initiate high-intensity statin to reduce LDL-C by ≥ 50%.

According to the ACC/AHA guidelines, both moderate- and high-intensity statin therapy reduce ASCVD risk; however, a greater reduction in LDL-C is associated with a greater reduction in ASCVD outcomes. The dose response and tolerance should be assessed in about 6-8 weeks. If LDL-C reduction is adequate (≥ 30% reduction with intermediate- and 50% with high-intensity statins), regular interval monitoring of risk factors and compliance with statin therapy are necessary to determine adherence and adequacy of effect (about 1 year).

For patients aged > 75 years, assessment of risk status and a clinician-patient risk discussion are needed to decide whether to continue or initiate statin treatment. The CAC score may help refine ASCVD risk estimates among lower-risk women (< 7.5%) and younger adults (< 45 years), particularly in the setting of risk enhancers.

Read more about risk assessment and primary prevention of coronary artery disease.

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