A 60-year-old African-American woman has asked whether she should be taking a statin to reduce her risk of stroke, but is worried about the statin causing diabetes. Her mother had diabetes and had a stroke at age 62. She is a nonsmoker. Blood pressure is 142/88 mm Hg on 2 antihypertensive medications and BMI is 31. Her fasting lipid panel reveals a total cholesterol 200 mg/dL, HDL–C 55 mg/dL, triglyceride 100 mg/dL, and LDL–C 125 mg/dL. Her fasting blood sugar is 109 mm/dL and hemoglobin A1c is 5.9%. According to the Pooled Cohort Equation for African-American Women, her estimated 10-year ASCVD risk is 8.7%.
Which of the following statements is the best answer?
Show Answer
The correct answer is: c. She should start a moderate or high intensity statin.
She has no clinical ASCVD and no diabetes with an LDL–C between 70 and 189 mg/dL. Due to her elevated 10-year ASCVD risk ≥7.5%, she is in a statin benefit group. She should initiate moderate or high intensity statin therapy based on evidence from 3 RCTs performed in exclusively primary prevention populations (AFCAPS/TexCAPS, MEGA, and JUPITER). These trials showed that moderate- and high-intensity statin therapy reduce ASCVD events compared to placebo/control. JUPITER enrolled individuals with LDL–C <130 mg/dL, with additional evidence from the 2010 CTT meta-analysis that statins reduce ASCVD events across the range of LDL–C levels >70 mg/dL.
African-American women have higher risk of ASCVD at a given age than similarly aged non-Hispanic White women. In addition, women are more likely to have stroke as the first manifestation of ASCVD and a significant reduction in the risk of stroke has been demonstrated in RCTs of women receiving statin therapy. The Pooled Cohort Equations more accurately estimate the heart attack and stroke risk in African-Americans. The use of the Framingham "hard CHD" risk score underestimates her total ASCVD risk because it does not consider stroke and is derived from a non-Hispanic white population.
This patient is already at high risk of developing diabetes even without taking a statin due to the presence of multiple diabetes risk factors: blood glucose 100-125 mg/dL, BMI ≥30, and a family history of diabetes. Moderate-intensity statin therapy in primary and secondary prevention studies results in about 1 excess case of new diabetes while preventing 5.4 ASCVD events per 1000 individuals treated for 1 year. A high-intensity statin used in a primary prevention population results in about 3 excess cases of new diabetes while preventing 5.9 ASCVD events per 1000 individuals treated for 1 year. A post hoc analysis of JUPITER found that the diagnosis of new onset diabetes occurred 6 weeks earlier in the rosuvastatin 20 mg group than in the placebo group. This may suggest the modest risk of excess diabetes even with high intensity statins may be of little long-term consequence, and certainly not comparable to the excess risk of a nonfatal or fatal MI or stroke arising from no treatment. This patient needs intensive lifestyle change, including weight loss and regular physical activity, to prevent progression to diabetes, along with statin therapy to reduce her risk of stroke and MI.
In JUPITER women ≥60 years with hs-CRP ≥2.0 had a reduction in ASCVD events with rosuvastatin 20 mg/dL compared to placebo. This patient already qualifies for statin treatment on the basis of her 10-year ASCVD risk so there is no reason to measure an hs-CRP level. In a patient with estimated 10-year ASCVD risk <7.5%, an hs-CRP >2.0 mg/L may be one factor to consider in the decision to use statin therapy.
References
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