A 56-year-old woman presents to her primary care physician for a routine follow up. She has a history of hypertension and type 2 diabetes mellitus for which she is taking lisinopril 20mg and metformin 500mg twice daily. Her last HbA1C was 6.3% two months ago. She has no acute complaints. She does not smoke, but occasionally has a glass of wine on the weekends. She has been eating a healthier diet with more fiber and fruits in the past couple months, and she has been trying to exercise at least once a week by walking 2-3 miles. Vital signs include blood pressure is 122/60mmHg, heart rate 68 beats/min, and respirations 16/min with oxygen saturation of 99% on room air. Her lipid panel shows:
- Total cholesterol 167 mg/dl
- HDL cholesterol 43 mg/dl
- LDL cholesterol 101 mg/dl
- Triglycerides 175 mg/dl
- Her 10-year risk of cardiovascular event is calculated to be 5.3%
Which of the following is the most appropriate next step in management?
- A) Atorvastatin 40mg daily
- B) Co-Q10 supplement daily
- C) Omega-3 fish oil supplement daily
- D) Pravastatin 20mg daily
- E) Simvastatin 20mg daily
E) Simvastatin 20mg daily
The U.S. Preventive Services Task Force (USPSTF) recommends a statin for the primary prevention of cardiovascular disease for adults aged 40 to 75 years of age who have 1 or more cardiovascular risk factors such as hyperlipidemia, diabetes, hypertension, or current smoker, AND an estimated 10-year risk of a cardiovascular event of 10% or greater. Note that this patient does not meet criteria for initiation of a statin according to the USPSTF recommendation.
The 2019 American College of Cardiology (ACC) and the American Heart Association (AHA) Guideline has a Class I recommendation that in adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated.
Note the discrepancy in two different guidelines. According to the ACC and AHA guidelines, a moderate intensity statin therapy is indicated for this patient with a history of diabetes. The patient does not meet criteria for statin therapy according to the USPSTF recommendation; however, not offering statin is not an answer choice here.
Answer choice A: Atorvastatin 40mg daily, is incorrect. Atorvastatin 40mg is a high-intensity statin. It is recommended in patients with multiple risk factors such as having type 2 diabetes ≥10 years or more than 20 years of type 1 diabetes, or presence of retinopathy, neuropathy, or chronic kidney failure with eGFR <60 mL/min.
Answer choice B: DCo-Q10 supplement daily, is incorrect. Co-Q10 has not shown evidence as a lipid lowering agent.
Answer choice C: Omega-3 fish oil supplement daily, is incorrect. Fish oil decreases triglyceride levels, but it is not indicated as a guideline-directed therapy and is not indicated in this patient as her triglyceride level is borderline.
Answer choice D: Pravastatin 20mg daily, is incorrect. Pravastatin 20mg is a low-intensity statin. To make it moderate-intensity the dosage needs to be 40mg-80mg daily.
Key Learning Point
Understand the differences between American College of Cardiology/American Heart Association statin guidelines and the guidelines provided by the U.S. Preventative Services Task Force. Know which statin is low, moderate, and high intensity at a specific dosage.
Dr. Raj Dasgupta