Best Statins for cholesterol of 5 mmol/l

Most appropriate statin treatment for a patient with a cholesterol level of 5 mmol/L:

• For primary prevention of cardiovascular disease, the recommended starting statin is atorvastatin 20 mg daily, as it is clinically effective and cost effective and has substantial evidence in reducing morbidity and mortality. This dose is considered the lowest effective dose to start treatment, with up-titration considered based on the clinical response and patient preferences.
• Cholesterol level of 5 mmol/L alone does not determine the choice of statin or initiation; the decision depends on the overall cardiovascular risk, notably the 10-year QRISK3 score, comorbidities, and other factors. Atorvastatin 20 mg should be offered to those with a QRISK3 score ≥10%, and can be considered in others with lower risk if desired.
• Simvastatin may be an option at low or medium intensities but atorvastatin and rosuvastatin are preferred for high-intensity treatment. Simvastatin 80 mg is generally reserved for severe hypercholesterolaemia and high risk where lower doses are insufficient, due to increased risk of myopathy.
• If statins are contraindicated or not tolerated, ezetimibe monotherapy is recommended as an alternative regardless of cholesterol levels.

Measure a full non-fasting lipid profile 2–3 months after starting treatment to assess response, aiming for a >40% reduction in non-HDL cholesterol in primary prevention. If lipid targets are not met, consider treatment optimization including dose increase or adding ezetimibe after discussing risks and benefits with the patient.

In summary, for a patient with a cholesterol level of 5 mmol/L without other details, atorvastatin 20 mg once daily is the most appropriate initial statin treatment for primary prevention, guided by overall cardiovascular risk.