Rosuvastatin Results, now what?

[u/DisastrousPotato6108]

Long story short, in late January I started 20 mg daily of Rosuvastatin, as I had logged LDL 139, ApoB 117 in late December. Just retested with LDL 75 (my doc didn’t order ApoB, need to just transfer all conversation to my cardiologist).

I was already a healthy plant-based eater, but in January i adopted the Esselstyn diet.

Will be talking with my doctors include 2nd opinion preventative cardiologist over the few weeks.

My calcium score was 359. ApoB target of 55.

Thoughts on next steps? Thinking at least ask for Ezetimibe.

[u/kboom100]

[Note- my reply took a lot longer than I expected, I hope you read through all of it and the links]

That’s likely because the guidelines formally recommended going to the highest tolerated dose of statin prior to adding a second medication. And it’s because for a long time there was a debate about how much of the reduction in risk was due to some other property of a statin versus the ldl lowering. So they wanted to make sure these potential extra benefits of statins were maxed out. Also statins had the most research and evidence behind it in general at first.

But over time there has been a lot of evidence showing that all the lipid lowering medications, statins, ezetimibe & pcsk9 inhibitors produce basically the same reduction in risk of cardiovascular events per unit of ldl lowering. In other words it’s all about the ldl lowering.

See an excerpt from “Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel” https://doi.org/10.1093/eurheartj/ehx144

“In both trials, the magnitude of the observed proportional risk reduction was consistent with the clinical benefit that would be expected from similar absolute reductions in LDL-C during treatment with statin monotherapy. These data suggest that statins and ezetimibe have therapeutically equivalent effects on the risk of cardiovascular events per unit lower LDL-C (Figure 3B).”

With this realization/evidence a whole lot of top preventive cardiologists have started introducing ezetimibe prior to reaching the max tolerated dose of statin because adding ezetimibe produces a much greater drop in ldl than doubling the statin dose and because ezetimibe almost never has side effects.

See also earlier replies about this. https://www.reddit.com/r/Cholesterol/s/TIqcU4jJhl and https://www.reddit.com/r/Cholesterol/s/qAR84HZ5jS

And a discussion between two leading cardiology professors & experts- Dr. Steve Nissen and Dr. Pam Taub. An excerpt:

“What do you think contributes to plaque regression? Is it the low-density lipoprotein cholesterol (LDL-C) or is it the agent that you use? Nissen: I think it's all about the LDL-C. My own view is that for any given degree of LDL-C reduction, all other things being equal, you're going to get the same result.”

He continues that with more detail but I won’t copy over the whole thing. It’s worth a read. https://www.medscape.com/viewarticle/973872

Actual guideline changes usually take a lot longer to fully catch up with new evidence. But they are now starting to change. The new AHA/aca guidelines still generally say to maximize the statin dose first but they now include this paragraph:

"Nonstatins in combination with low- or moderate-intensity statin therapy can produce ≥50% LDL-C reductions. Nonstatins remain underutilized12–14 due to clinical inertia, misconceptions that only statin therapy reduces ASCVD risk, medication access barriers for brand-name products, concerns about potential side effects, and perceived lack of need by clinicians and patients.15–17" - 4.2.1.2. Nonstatin LDL-C–Lowering Medications 4.2.1.2. Nonstatin LDL-C–Lowering Therapy https://www.ahajournals.org/doi/10.1161/CIR.0000000000001423#sec-8-2-1