Would you start a statin in a 32-year-old African-American diabetic who has a hemoglobin A1c of 7.5% and an LDL of 65 mg/dL?
—Ivanka Vassileva, MD, Lawton, Okla.

You can certainly make a good argument for this approach, based on several recent studies that all diabetics can benefit from statin therapy, even those with relatively low LDL levels. The Collaborative Atorvastatin Diabetes Study (CARDS) compared the use of atorvastatin vs. placebo in type 2 diabetics with relatively low LDL levels.

The study was halted when the primary end point of cardiac death, nonfatal MI, unstable angina, resuscitated cardiac arrest, revascularization, or cerebrovascular accident showed significant reduction (37%) in the atorvastatin arm compared with placebo.

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That being said, in a patient this young, I would consider other factors, such as overall risk and the risk/benefit ratio. For example, in a woman who wants to become pregnant and is otherwise at low-to-moderate risk, I would utilize exercise, weight loss, other risk factor modification, and tight glycemic control as the first line of defense. In a man with a strong family history of premature atherothrombosis and hypertension, however, I would strongly consider starting a statin.
—Norma M. Keller, MD (106-12)