A 58-year-old man is evaluated during a routine visit. He has rheumatoid arthritis and hypertension. His mother had a myocardial infarction at age 53 years. His current medications are methotrexate, folic acid, losartan, and amlodipine. On exam BP 138/80, HR 72, RR 12, O2 sat 98% on RA, afebrile and BMI 27. No other pertinent physical findings. Lipid panel and HgbA1c results are:
- HgbA1C 5.6
- LDL 162 mg/dL
- HDL 38 mg/dL
- TAG 275 mg/dL
- Total cholesterol 164 mg/dL
The patient's 10-year risk for atherosclerotic cardiovascular disease is 14.2%. In addition to therapeutic lifestyle changes, which of the following is the most appropriate treatment based on the ACC/AHA and USPTF?
- A) Ezetimibe
- B) Gemfibrozil
- C) Alirocumab (Praluent)
- D) High-intensity atorvastatin
- E) Moderate-intensity atorvastatin
E) Moderate-intensity atorvastatin
Adults aged 40 to 75 years without diabetes mellitus and with an LDL cholesterol level of 70 mg/dL to 189 mg/dL should undergo risk assessment for primary prevention of atherosclerotic cardiovascular disease (ASCVD). The 10-year risk for ASCVD can be categorized as low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%).
In adults at intermediate risk, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy. This patient has 2 risk-enhancing factors: rheumatoid arthritis and a family history of premature CAD. The American Heart Association/American College of Cardiology (ACC/AHA) recommendations for primary prevention of ASCVD support moderate-intensity statin therapy for this patient given his ASCVD risk is >7.5%. The U.S. Preventive Services Task Force (USPTF) recommends low- to moderate-intensity statin therapy for primary prevention in adults who have at least one ASCVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year ASCVD risk >10%.
Key Learning Point
Being aware of the 2 major guideline that influence the management of hyperlipidemia for primary prevention of CVD.
Dr. Raj Dasgupta
Dr. Raj Dasgupta