When will you Initiate Statin Therapy?

52 year old male with history of major depression disorder stable on fluoxetine 20 mg daily.

Medical History: diabetes mellitus

Labs: LDL-C: 130 mg/dL. 

Will You Initiate Statin Therapy in this patient? What more information you need?

 

Step 1: Is Clinical atherosclerotic cardiovascular disease (ASCVD) present (acute coronary syndrome, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic angina, peripheral arterial disease (of atherosclerotic origin) —> 

  • Initiate High Intensity Statin
  • For age>75 yr age or patient not tolerant to High intensity statin = Initiate Moderate Intensity Statin.

Step 2: If ASCVD is NOT present –> Check LDL-C.

Step 2a: If LDL-C > 190 mg/dL (4.92 mmol/L) —>

  • Initiate High Intensity Statin
  • For age>75 yr age or patient not tolerant to High intensity statin = Initiate Moderate Intensity Statin.

Step 3If LDL-C < 190 mg/dL (4.92 mmol/L) —> history of Diabetes Mellitus?

Step 3a: If Diabetes Mellitus is Present —> For Patient Age 40-75 yr with LDL 70-189 mg/dL —> Estimate 10 year ASCVD Risk (Use Pooled Cohort Equations or QRISK2)

Step 3a(1)10 year ASCVD Risk >10%

  • Initiate Moderate or High Intensity Statin
  • For age>75 yr age or patient not tolerant to High intensity statin = Initiate Moderate Intensity Statin.

 

Step 3a(2)10 year ASCVD Risk <10%

  • Initiate Low or Moderate Intensity Statin

 

NOTE: For patient Age <40 yr or >75 yr or LDL <70 mg/dL —> Consider Additional Risk Factors (for shared decision making)

Step 3bIf Diabetes Mellitus is Absent —> For Patient Age 40-75 yr with LDL 70-189 mg/dL —> Estimate 10 year ASCVD Risk (Use Pooled Cohort Equations or QRISK2)

Step 3b(1)10 year ASCVD Risk <5% —> Consider Additional Risk Factors (details below)

Step 3b(2)10 year ASCVD Risk >5%- <10% —> Initiate Low or Moderate Intensity Statin

Step 3b(3)10 year ASCVD Risk >10% —> Initiate Moderate or High Intensity Statin

Additional Risk Factors (for shared decision making):

  • Family history
  • LDL-C >160 mg/dL
  • High Sensitivity CRP 2mg/L
  • Coronary artery calcium score > 300
  • Ankle-Brachial Index < 0.9

 

Q: Now Important Question is: What medications are considered Low Intensity, Moderate Intensity and High Intensity Statin ?

 

High Intensity Statin

  1. Atorvastatin (Lipitor) 40-80 mg
  2. Rosuvastatin (Crestor) 20 mg

Moderate Intensity Statin

  1. Atorvastatin 10 mg
  2. Fluvastatin 40 mg BID
  3. Lovastatin 40 mg
  4. Pravastatin 40 mg
  5. Rosuvastatin 10 mg
  6. Simvastatin 20-40 mg

Low Intensity Statin

  1. Lovastatin 20 mg
  2. Pravastatin 10-20 mg 

Source: American Family Physician Vol 95, Number 2, Jan 2017.

 

 

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


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