In clinical work, some patients are sometimes encountered because of high cholesterol, and doctors give oral simvastatin, pravastatin, pitvastatin and other treatments.
For people at high risk of cardiovascular disease, high-intensity cholesterol-lowering therapy (LDL-C is more than 50% lower than baseline levels), these statins are not suitable, we look at the following cases.
Table: Comparison table of cholesterol-lowering effects of various types of statins in China
Case 1
Male, 40 years, height 156 cm, weight 47.2 kg, BMI 19.4 kg/m, blood pressure 100/60 mmHg, non-smoking alcohol, father's hypertension, type 2 diabetes mellitus, history of cerebral infarction (58 years).
Patients with LDL-C of 4.82 mmol/L, close to 4.9 mmol/L, with a family history of early-onset cardiovascular disease (father 58 years of cerebral infarction), are at high risk of cardiovascular disease, and should initiate statin cholesterol lowering, target LDL-C
However, the patient's compliance is poor, and then he changed to pravastatin 40 mg/day orally, the maximum dose of pravastatin domestic instructions on the 1 day is 40 mg, and the LDL-C reduction is 38%, theoretically, it is impossible to reduce LDL-C to less than 2.41 mmol/L (4.82 - 4.82 × 38% = 2.99 mmol/L), and the instructions are changed to rosuvastatin 10 mg/day in the later stage, and the blood lipids are reviewed after 1 month.
Case 2
Male, 56 years, height 177 cm, weight 75.5 kg, BMI 24 kg/m, blood pressure 118/80 mmHg, non-smoking, intermittent alcohol consumption. Father has a history of hypertension, cerebral infarction (60+ years).
For hypertension 5 to 6 years, amlodipine 5 mg/day orally and losartan 50 mg/day.
Carotid ultrasound 1 year ago: plaque at the beginning of the right internal carotid artery, left common carotid plaque, left vertebral artery plaque; chest CT shows: aorta, coronary artery left branch wall scattered in calcified plaque. Oral pitvastatin 2 mg/day.
The 10-year risk of cardiovascular disease was 6.4% based on pre-statin lipid levels, classified as low-intermediate-risk, but with significant coronary calcification, calcification scores > 100 points, close to 300 points, should be reclassified as a medium-high-risk group, LDL-C is best reduced by more than 50% (
The actual decrease in pitvastatin 2 mg/day was 38%, the actual decrease was (3.69 - 2.38)/3.69 = 1.31/3.69 = 35.5%, and the pitavastatin 4 mg/day LDL-C range was 41%, which did not meet the expected target value.
It is recommended that resuvastatin 10 mg/day orally, with coronary calcification scores of > 100 points, can be combined with aspirin 100 mg/day orally in people at low risk of bleeding to further reduce the risk of cardiovascular disease.
Case 3
Male, 51 years, height 175 cm, weight 74 kg, BMI 24.2 kg/m, blood pressure 118/80 mmHg. Less exercise, previous smoking, 15 packs/year, smoking cessation for 20 years.
In this case, LDL-C > 4.9 mmol/L, without calculating the risk of cardiovascular disease for 10 years, directly classified as a high-risk group, and coronary calcification score > 0, Lp(a) was also significantly elevated, > 500 mg/L, belonging to the very high-risk group, when oral pitvastatin 2 mg/day treatment, 6 months after re-examination of lipids:
Patients with an actual 18.7% decrease in LDL-C, far below the guidelines of more than 50%, should initially be direct-high-intensity statin (rosuvastatin 20 mg/day) + ezezermebu 10 mg/day lowering cholesterol, target LDL-C LDL-C
If the target is not met after 4 to 6 weeks, a PCSK-9 inhibitor may be added. Monitoring of coronary calcification scores, if progressed to ≥ 100 points, can be added with aspirin antiplatelets.
brief summary
Some statins, such as pitvastatin, pravastatin, lovastatin, simvastatin, and fluvastatin, cannot reduce LDL-C by more than 50% even at the highest dose of the instructions, and these statins are not suitable for people at high risk of cardiovascular disease.
Direct use of atorvastatin 20 to 80 mg/day or rosuvastatin 10 to 20 mg/day (atorvastatin half-life of 15 to 30 hours, rosuvastatin half-life of 19 hours, both of which have a significantly stronger inhibitory effect on cholesterol synthesis rate-limiting enzyme HMG-CoA reductase than other statins, and have a stronger cholesterol-lowering effect). If necessary, combine ez-wheat cloth with 10 mg/day to achieve more than 50% of the reduction required by the guidelines as soon as possible.
bibliography:
1. 2016 Guidelines for the Prevention and Treatment of Dyslipidemia in Adults in China.
2. 2018 AHA/ACC Guidelines for the Administration of Lipids.
3. 2019 EAS/ESC Lipid Management Guide.
4. Carl E Orringer, etc. The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction. J Clin Lipidol. Jan-Feb 2021;15(1):33-
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This article was first published on Lilac Garden's professional platform: Cardiovascular Time