A 35-year-old man has a strong family history of premature coronary disease, with both father and brother having an MI before age 55. He is a nonsmoker, nondiabetic and exercises for 150 minutes/week. He has gained 10 lbs since age 18. His BP is 140/90 mm Hg, weight is 170 pounds, height is 70 inches, and BMI is 24.4. On a fasting lipid panel, his LDL–C is 160 mg/dL, HDL–C 45 mg/dL and triglyceride 100 mg/dL. His fasting blood glucose is 92 mg/dL. He is on a heart-healthy diet and exercises 150 minutes a week. He and his wife would like to discuss statin therapy given his strong family history.
Which of the following is likely to be helpful in making a decision regarding statin therapy in this patient?
Show Answer
The correct answer is: f. All of these factors can be considered
This patient is not in 1 of the 4 statin benefit groups. Yet there may be some individuals who still merit therapy. No individuals <40 years were included in the primary prevention statin RCTs. Nor were individuals <40 years included in the Pooled Cohort Equations for estimating 10-year ASCVD risk. Therefore, in selected cases, clinical judgment is needed for patients <40 years or for those individuals where quantitative ASCVD risk assessment alone is felt inadequate to guide the treatment decision.
After an extensive review of data from epidemiologic studies and meta-analyses of epidemiologic studies, the Risk Assessment Panel Work Group found that additional factors may be used to inform treatment decisions. These factors include family history of premature ASCVD, coronary calcium score of ≥300 units or more, hs-CRP ≥2.0 and lifetime risk of ASCVD. The Cholesterol Expert Panel also considers an LDL–C ≥160 mg/dL to identify individuals likely to benefit from statin therapy. This individual is likely to have a 10-year ASCVD risk <5%, and the risk of adverse events from high intensity statin therapy may outweigh the potential for an ASCVD risk reduction benefit. However, moderate intensity of statin therapy, such as simvastatin 20 to 40 mg/day, atorvastatin 10 mg/day, or rosuvastatin 10 mg/day may be reasonable but the benefits and risks should be carefully discussed with the patient and his wife.
A heart healthy dietary pattern and regular physical activity should be reinforced.
References
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB Sr, Gibbons R, Greenland P, Lackland DT, Levy D, O'Donnell CJ, Robinson J, Schwartz JS, Smith SC Jr, Sorlie P, Shero ST, Stone NJ, Wilson PW. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013. (In press)
Eckel RH, Jakicic JM, Ard, JD, Hubbard VS, de Jesus JM, Lee IM, Lichtenstein AH, Loria CM, Millen BE, Houston Miller N, Nonas CA, Sacks FM, Smith SC Jr, Svetkey LP, Wadden TW, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013. (In press)
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