Multiple tools available to minimize likelihood Greater risk reduction with high-intensity statins Inclination to start with moderate-intensity statins Employ systematic approach if muscle symptoms ariseīenefit of statin substantially outweighs risk RCTs report similar incidence with high- vs moderate-intensity statins. Table 2 Overcoming Common Barriers to Use of High-Intensity Statins in the Clinician-Patient Risk Discussion Barrier If only moderate-intensity statins are tolerated, add ezetimibe at 10 mg/d (± bile acid resin or bempedoic acid If symptoms persist-especially weakness-prompt evaluation is needed with physical examination, laboratory studies such as measurement of CK and sedimentation rate/CRP to rule out inflammation, and a lipid specialist consultationĨ. After a brief abstinence and resolution of symptoms, rechallenge with a lower dose or alternative statin in a starting dose is appropriate. If statin-related symptoms occur, they usually abate with stopping the statin, so a lower dose or different statin can be given after a brief abstinence and resolution of symptomsīilateral proximal extremity (often lower) muscle pains, aches, or muscle fatigue that occurs within 1-2 wk and disappears promptly within 4-7 d of cessation of the statin suggests that the symptom is statin-related. In placebo-controlled studies, significant numbers of patients have been found to not have statin-related symptomsĬareful questioning of patients as to location, timing, and other causes of pain may reveal the cause of current symptomsħ. Do not assume that statin-associated symptoms are due to the statin many are not If atorvastatin at 80 mg or rosuvastatin at 40 mg are not tolerated or acceptable, try atorvastatin at 40 mg or rosuvastatin at 20 mg to get approximately 50% lowering of LDL-CĦ. Rule out and address secondary causes of hypercholesterolemiaĮxamples include hypothyroidism, nephrotic syndrome, poor diet, uncontrolled diabetes, and medications Weight reduction if metabolic syndrome is presentĤ. High-intensity statins that achieve 50% or more LDL-C lowering can reduce risk for ASCVD by one-third more than moderate-intensity statinsĪpproximately 90% of patients can tolerate high-intensity statins without substantial statin-associated adverse effects.
Abbreviations and Acronyms: AHA/ACC/MS ( American Heart Association/American College of Cardiology/multisociety), ASCVD ( atherosclerotic cardiovascular disease), CAC ( coronary artery calcium), LDL-C ( low-density lipoprotein cholesterol), PCE ( pooled cohort equations), PCSK9 ( proprotein convertase subtilisin/kexin type 9), RCT ( randomized controlled trial)ĪSCVD, atherosclerotic cardiovascular disease CK, creatine kinase CRP, C-reactive protein LDL-C, low-density lipoprotein cholesterol PCSK9, proprotein convertase subtilisin/kexin type 9. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit.
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