Episode 113: Statins in Primary Care - a podcast by Rio Bravo Family Medicine Residency Program

Episode 112: Statins in Primary Care

Dr. Tiwana explains the use of statins for the primary prevention of cardiovascular disease.

Written by Ripandeep Tiwana, MD (Post-Doctoral Research Fellow at Cedar Sinai Medical Center – Heart Institute). Edition of text and comments by Hector Arreaza, MD.

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You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Definition.

Statins commonly referred to as lipid-lowering medications, are important in primary care as they serve multiple long-term benefits than just lipid lowering alone. They are HMG-CoA reductase inhibitors. As a refresher, this is the rate-controlling enzyme of the metabolic pathway that produces cholesterol. This enzyme is more active at night, so statins are recommended to be taken at bedtime instead of during the day. Statins are most effective at lowering LDL cholesterol. However, they also help lower triglycerides and raise HDL cholesterol.

Statins are not limited to just patients with hyperlipidemia. They reduce illness and mortality in those who have diabetes, have a history of cardiovascular disease (including heart attack, stroke, peripheral arterial disease), or are simply at high risk for cardiovascular disease. Statins are used for primary and secondary prevention.

Types of statins.

How do we determine which statin our patients need?

First, we need to know that not all statins are created equal. They vary by intensity and potency thus, and they are categorized as either low, moderate, or high intensity.

Several statins are available for use in the United States. They include Atorvastatin (Lipitor), Fluvastatin (Lescol XL), Lovastatin (Altoprev), Pitavastatin (Livalo, Zypitamag), Pravastatin (Pravachol), Rosuvastatin (Crestor, Ezallor), Simvastatin (Zocor)

Commonly used in clinics: Simvastatin, Atorvastatin, and Rosuvastatin.

Statin Dosing and ACC/AHA Classification of Intensity

                                  Low-intensity                                   Moderate-intensity                                     High-intensity

Atorvastatin              NA 1                                                          10 to 20 mg                                                   40 to 80 mg

Fluvastatin                20 to 40 mg                                          40 mg 2×/day; XL 80 mg                                NA

Lovastatin                 20 mg                                                       40 mg                                                                         NA

Pitavastatin               1 mg                                                          2 to 4 mg                                                                   NA

Rosuvastatin             NA                                                            5 to 10 mg                                                          20 to 40 mg

Simvastatin                10 mg                                                      20 to 40 mg                                                             NA

Of note, atorvastatin and rosuvastatin are only for moderate or high-intensity use, and do not use simvastatin 80 mg.

Identifying patients at risk.

How do we determine who needs statin therapy?

Once we become familiar with the different statins, we must figure out which intensity is advised for our patient. Recommendations for statin therapy are based on guidelines from The U.S. Preventive Services Task Force (USPSTF), American Diabetes Association (ADA), and the American College of Cardiology/American Heart Association (ACC/AHA) which recommend utilizing the ASCVD risk calculator in those patients who do not already have established cardiovascular disease.

ASCVD stands for atherosclerotic cardiovascular disease, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin. ASCVD remains a leading cause of morbidity and mortality in the United States, especially in individuals with diabetes.

The ASCVD risk score determines a patient’s 10-year risk of cardiovascular complications, such as a myocardial infarction or stroke. This risk estimate considers age, sex, race, cholesterol levels, use of blood pressure medication, diabetic status, and smoking status. Regarding age, this calculator only applies to the age range of 40-79 as there is insufficient data to predict risk outside this age group.

There are several online and mobile applications available to calculate this score. Once calculated it gives a recommendation for which intensity statin to use. However, as this is a recommendation, it is essential to use your own clinical judgment to decide what is best for your individual patient. Please refer to the above table as a reference for which statin and dose you may consider using.

Keeping the above calculator in mind, additional statin guidelines are recommended by the ACC:

• Patients ages 20-75 years and LDL-C ≥190 mg/dl use high-intensity statin without risk assessment. (You do not need the calculator.)
• People with type 2 diabetes and aged 40-75 years use moderate-intensity statins, and risk estimate to consider high-intensity statins. (It means moderate for all diabetics older than 40, high for some.)
• Age >75 years, clinical assessment, and risk discussion.
•  Age 40-75 years and LDL-C ≥70 mg/dl and <190 mg/dl without diabetes, use the risk estimator that best fits the patient to decide the intensity of statin.
  •  Risk 5% to <7.5% (borderline risk). Risk discussion: if risk-enhancing factors are present, discuss moderate-intensity statin and consider coronary calcium score in select cases.
  • Risk ≥7.5-20% (intermediate risk). Risk discussion: use moderate-intensity statins and increase to high-intensity with risk enhancers.
  • Risk ≥20% (high risk). Risk discussion to initiate high-intensity statin to reduce LDL-C by ≥50%.

Combining the ASCVD score with the coronary artery calcium score can help you better stratify at-risk patients.

USPSTF Update, August 22, 2022:

Grade B - Adults 40-75 years with >=1 cardiovascular risk factor (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year ASCVD risk > 10%. Grade B recommendation: prescribe a statin for the primary prevention of CVD.

Grade C – 40-75 years with >= 1 cardiovascular risk factor AND estimated 10-year ASCVD risk 7.5-10%. Grade C recommendation: selectively offer a statin for the primary prevention of CVD. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater.

Grade I - The USPSTF found insufficient evidence to recommend for or against initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older.

The USPSTF is also very clear regarding the intensity of statin therapy. They explained that there is limited data directly comparing the effects of different statin intensities on health outcomes. Most of the trials they reviewed used moderate-intensity statin therapy. They conclude that moderate-intensity statin therapy seems reasonable for most persons' primary prevention of CVD.

The USPSTF has a broader recommendation, whereas the ACC guidelines are more detailed and individualized and provide guidance on the recommended intensity of statin therapy.

Labs needed.

Establish baseline labs for serum creatinine, LFTs, and CK only if there is a myopathy risk. Routine monitoring of LFTs, serum creatinine, and CK is unnecessary; only check if clinically indicated.

A lipid panel should be checked in 6-8 weeks, and the patient should monitor themselves for any side effects, including myalgias. If LDL-C reduction is adequate (≥30% reduction with intermediate statins and 50% with high-intensity statins), regular interval monitoring of risk factors and compliance with statin therapy is necessary to sustain long-term benefit.

Side effects and contraindications.

Some common side effects include URI-like symptoms, headache, UTI, and diarrhea. Some patients are very hesitant to take any medications. Warning about side effects may decrease compliance. Major  contraindications for statin therapy include active liver disease, muscle disorders, pregnancy, and breastfeeding.

Special considerations.

Chronic kidney disease: The preferred statins for CKD with severe renal impairment are atorvastatin and fluvastatin because they do not require dose adjustment. Pravastatin would be a second choice.

Chronic liver disease: Statins are contraindicated in patients with decompensated cirrhosis or acute liver failure. Abstinence from alcohol is critical in patients with chronic liver disease who are taking statins. Pravastatin and rosuvastatin are the preferred agents. Check lipid levels to determine if LDL-C reduction is accomplished with no changes in aminotransferases. You may consider stopping, increasing dose, or changing statin as you discuss the risks vs. benefits with your patient.

Conclusion: Simply put, if a patient has an LDL of greater than 190, is a diabetic, has an established history of cardiovascular disease, or is at risk for it, then the patient should ideally be taking a statin unless there is a contraindication, allergy, or other special circumstance that limits him/her from doing so. If you have patients that apply to any of the above scenarios and are not already on a statin, determine their risk, and consider starting them on a statin “stat” to reduce morbidity and mortality. On the other hand, be mindful of overprescribing. Do not prescribe statins to patients who do not meet the above criteria.

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Now we conclude our episode number 113, “Statins in Primary Care.” Statins are powerful medications for the prevention of cardiovascular disease. Do not forget to recommend non-pharmacologic measures such as healthy eating and physical activity, but let’s also consider adding a statin to patients who are at moderate to high risk for cardiovascular disease.

This week we thank Hector Arreaza and Ripandeep Tiwana. Audio by Adrianne Silva.

Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you; send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!

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References:

1. Statins, U.S. Food & Drug Administration, 2014, December 16, fda.gov, https://www.fda.gov/drugs/information-drug-class/statins, accessed September 14, 2022.

2. Chou R, Cantor A, Dana T, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Aug. (Evidence Synthesis, No. 219.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK583661/

3. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; March 17. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention.

 

4. ASCVD Risk Estimator Plus, published by the American College of Cardiology, https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/, accessed September 14, 2022.

5. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication, U.S. Preventive Services Task Force, Final Recommendation Statement, 2022, August 23. https://uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication

6.  Videvo. “Distinction.” Https://Www.videvo.net/Royalty-Free-Music-Track/Distinction/227882/, Https://Www.videvo.net/, https://www.videvo.net/royalty-free-music-track/distinction/227882/. Accessed 26 Sept. 2022.

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