By Riddhi Patel, MD | Image – Ariwasabi/Shutterstock.com |
It is a well-known fact that total cholesterol concentration is directly related to coronary risk. As a result it is essential to treat patients with known cardiovascular disease risk aggressively.
All patients with high Low Density Lipoprotein levels should be recommended to make lifestyle modifications. These include exercise, healthy diet, and weight loss. It has been shown that dietary modifications alone can result in up to a 30% decrease in LDL levels. These lifestyle modifications can also reduce risk factors associated with cardiovascular disease.
Statins are the mainstay of treatment for hyperlipidemia. Studies have shown that statins will reduce risk of cardiovascular disease by twenty to thirty percent. There are two categories of statin intensity: moderate and high intensity.
Moderate intensity statins:
– Pravastatin 40 mg
– Lovastatin 40 mg
– Atorvastatin 10-20 mg
– Simvastatin 40 mg
– Rosuvastatin 5 to 10 mg
– Atorvastatin 40 to 80 mg
– Rosuvastatin 20 to 40 mg
Side Effects of Statin Therapy
Like all medications, statin can result in a variety of side effects. The most commonly reported is myopathy. It can also result in hepatic dysfunction, renal dysfunction, irritability, and aggression. For patients who are intolerant of statins due to side effects, it is recommended that they discontinue statins and use lifestyle modifications as their lipid lowering management. In the highest-risk patients who are statin intolerant, pro protein convertase subtilizing kexin 9 (PCSK9) inhibitors can be used. Examples of PCSK9 inhibitors are: evolocumab, alirocumab, and bococizumab. These are not commonly used because there is not yet good long-term evidence of using these medications as primary prevention.
Who to treat
When deciding whether to initiate statin therapy, patient’s cardiovascular disease risk should be calculated to determine if the benefits of treatment outweigh the risk. This is preferable to targeting a specific goal LDL. The Framingham 10-year risk calculator can be used to determine cardiovascular disease. It takes into account patient age, systolic blood pressure, total cholesterol, HDL cholesterol, and if the patient takes medication for hypertension, is a smoker, or has diabetes. It uses all these factors to determine the 10 year risk of cardiovascular events.
The American College of Cardiology/American Heart Association recommends:
For adults age 40 to 75 with LDL between 70 and 189:
Treat with at least a moderate statin
Treat with high-intensity statin if 10 year CVD risk > 7.5
Treat those with 10 year CVD risk > 7.5 with moderate-to-high intensity statin
Treat 10 year CVD risk between 5 and 7.5 with moderate intensity statin
For adults with LDL>190:
Treat with high intensity statin and consider use of non-statin medication
What should be done
Physicians should base their recommendations on statin therapy on risk calculators. There are numerous iphone apps and websites that providers can use to help calculate 10 year risk. In those with increased risk aggressive treatment must be initiated immediately.
- O’Riordan, M. Strong Results From Early Studies With PCSK9 Inhibitors Generating Big Buzz. http://www.medscape.com/viewarticle/822814. 2014
- Pignone, M. Treatment of lipids in primary prevention. Up to date. 2016.
- Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline.
- Taylor, FC; Huffman, M; Ebrahim, S (11 December 2013). “Statin therapy for primary prevention of cardiovascular disease.”. JAMA 310 (22): 2451–2