Episode Details

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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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 Tas