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With clinical atherosclerotic CV dz
Mod-intensity statin1 + lifestyle [E] - atorvastatin 10 mg daily
- rosuvastatin 10 mg daily
- simvastatin 20-40 mg daily
- pravastatin 40 mg daily
- lovastatin 40 mg daily
- fluvastatin 40 mg bid
Pre-statin eval - Fasting lipid panel, ALT, CK (if indicated)
- Eval/treat TG ≥500 mg/dL, unexplained ALT >3x ULN
- +/- Eval for secondary causes/conditions that may influence statin safety
Footnotes 1 Other FDA-approved options not included in RCTs: Atorvastatin 20 mg, rosuvastatin 5 mg, pravastatin 80 mg, fluvastatin XL 80 mg, pitavastatin 2-4 mg. Although simvastatin 80 mg was studied, this dose is not FDA-recommended d/t myopathy risk.
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Without clinical atherosclerotic CV dz
High-intensity statin1,2 + lifestyle [B] - atorvastatin 80 mg (or 40 mg)3 daily
- rosuvastatin 20 mg4 daily
Pre-statin eval - Fasting lipid panel, ALT, CK (if indicated)
- Eval/treat TG ≥500 mg/dL, unexplained ALT >3x ULN
- +/- Eval for secondary causes/conditions that may influence statin safety
Footnotes 1 If not high-intensity statin candidate, use mod-intensity tx like for >75 yo w/ AS-CVD.
2 It is reasonable to intensify statin tx to achieve at least a 50% LDL-C reduction [E]. After max statin intensity achieved, it is reasonable to add a nonstatin drug to further reduce LDL-C [E].
3 Atorvastatin 40 mg: Evidence from 1 RCT only after down-titration from 80 mg due to intolerance.
4 Rosuvastatin 40 mg not included in RCTs.
Mod-intensity statin1 + lifestyle [A] - atorvastatin 10 mg daily
- rosuvastatin 10 mg daily
- simvastatin 20-40 mg daily
- pravastatin 40 mg daily
- lovastatin 40 mg daily
- fluvastatin 40 mg bid
If 10-yr AS-CVD risk ≥7.5%, may use high-intensity statin + lifestyle [E] - atorvastatin 80 mg (or 40 mg)2 daily
- rosuvastatin 20 mg3 daily
Pre-statin eval - Fasting lipid panel, ALT, CK (if indicated)
- Eval/treat TG ≥500 mg/dL, unexplained ALT >3x ULN
- +/- Eval for secondary causes/conditions that may influence statin safety
Footnotes 1 Mod-intensity: Other FDA-approved options not included in RCTs: Atorvastatin 20 mg, rosuvastatin 5 mg, pravastatin 80 mg, fluvastatin XL 80 mg, pitavastatin 2-4 mg. Although simvastatin 80 mg was studied, this dose is not FDA-recommended d/t myopathy risk.
2 Atorvastatin 40 mg: Evidence from 1 RCT only after down-titration from 80 mg due to intolerance.
3 Rosuvastatin 40 mg not included in RCTs.
Discuss potential for risk-reduction benefits, adverse effects, drug interactions, pt preferences, etc, to inform tx decisions. If 10-yr AS-CVD risk ≥7.5% use mod or high-intensity [A]; mod-intensity reasonable if AS-CVD risk 5% to <7.5% [C] High-intensity statin + lifestyle - atorvastatin 80 mg (or 40 mg)1 daily
- rosuvastatin 20 mg2 daily
Mod-intensity statin3 + lifestyle - atorvastatin 10 mg daily
- rosuvastatin 10 mg daily
- simvastatin 20-40 mg daily
- pravastatin 40 mg daily
- lovastatin 40 mg daily
- fluvastatin 40 mg bid
Pre-statin eval - Fasting lipid panel, ALT, CK (if indicated)
- Eval/treat TG ≥500 mg/dL, unexplained ALT >3x ULN
- +/- Eval for secondary causes/conditions that may influence statin safety
Footnotes 1 Atorvastatin 40 mg: Evidence from 1 RCT only after down-titration from 80 mg due to intolerance.
2 Rosuvastatin 40 mg not included in RCTs.
3 Mod-intensity: Other FDA-approved options not included in RCTs: Atorvastatin 20 mg, rosuvastatin 5 mg, pravastatin 80 mg, fluvastatin XL 80 mg, pitavastatin 2-4 mg. Although simvastatin 80 mg was studied, this dose is not FDA-recommended d/t myopathy risk.
In these pts who are not in 1 of the 4 statin benefit groups, discuss potential for risk-reduction benefits, adverse effects, drug interactions, pt preferences, etc, to inform tx decisions. Consider these additional factors: [E] - Primary LDL-C ≥160 mg/dL, or other evidence of genetic hyperlipidemia
- Family hx premature AS-CVD w/ onset <55 yrs of age in 1st-degree male relative or <65 yrs of age in 1st-degree female relative
- High-sensitivity CRP ≥2 mg/L
- Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age/sex/ethnicity
- ABI <0.9
- Elevated lifetime risk of AS-CVD
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