Optimization of lipids in CARDIOvascular patients
Overview
Focus on statin dose statin dose instead of LDL levels. It's not about aiming for LDL goals anymore. The new thinking is that it's more important to get patients on a statin dose proven to lower cardiovascular risk than to get LDL to a certain number. Use these common scenarios when helping your patients...
- How should patients new to a statin be managed?
- How should patients already on a statin be managed?
- How should patients over age 75 be managed?
- How should patients on non-statins (ezetimibe, etc) be managed?
Questions
How should patients new to a statin be managed?
Recommend a statin for those with CV disease, LDL ≥ 190 mg/dL or diabetes ages 40 to 75. For others, use the new CV risk estimator to help determine if a statin may be beneficial and take into account individual preferences.
- Suggest starting at the appropriate dose for most patients because there's no proof that titrating up prevents side effects.
- For a high-intensity statin that lowers LDL by ≥ 50%, suggest atorvastatin (Lipitor) 40 to 80 mg/day for most patients. It has the most evidence for preventing CV events in high-risk patients and available as a generic.
- For a moderate-intensity statin that lowers LDL by 30% to 49%, suggest atorvastatin 10 to 20 mg, simvastatin (Zocor) 20 to 40 mg, etc.
How should patients already on a statin be managed?
Check if patients are on a high-intensity statin if they have CV disease or LDL ≥ 190 mg/dL. If not, suggest a dose increase. For others, consider requesting pretreatment lipid values, so you can use the CV risk estimator to see if a dose change is needed. If baseline levels aren't available, suggest aiming for an LDL < 100 mg/dL especially in high-risk patients.
How should patients over age 75 be managed?
For patients with CV disease, suggest a moderate-intensity statin to limit side effects. But don't back off if patients are doing well on a high-intensity statin. For others over 75, suggest discussing benefits and risks before starting a statin. There is less evidence of benefit in these patients.
How should patients on non-statins (ezetimibe, etc) be managed?
Help re-evaluate whether non-statins are needed. So far, there's no proof they improve CV outcomes when added to a statin. In general, suggest saving non-statins for patients who can't take a statin or have triglycerides ≥ 500 mg/dL or high-risk patients who don't get the expected percent LDL-lowering from a statin. See additional note on, "Pharmacology of HMG-CoA inhibitors (Statins)".
References
- Bakhai S, Bhardwaj A, Sandhu P, Reynolds JL. Optimisation of lipids for prevention of cardiovascular disease in a primary care. BMJ Open Qual. 2018;7(3):e000071.
