A 52-year-old man comes to the physician very concerned about his high triglyceride levels on a recent lipid profile. He has no complaints except gradual weight gain over the past few years. He eats mainly fast food at lunchtime and drinks a few beers while watching television on weekends. The patient does not smoke or use recreational drugs. His father died of a heart attack at age 50. His mother suffers from diabetes mellitus and experienced a minor stroke.
Blood pressure is 144/90 mm Hg, pulse is 73/min, and body mass index is 31 kg/m². Physical examination is unremarkable.
Fasting laboratory results are as follows:
The patient's serum creatinine and liver and thyroid function tests are normal. Repeat fasting triglyceride level is 460 mg/dL.
He is instructed about lifestyle changes. Which of the following will provide the greatest benefit in reducing this patient's cardiovascular risk?

Question

A 52-year-old man comes to the physician very concerned about his high triglyceride levels on a recent lipid profile. He has no complaints except gradual weight gain over the past few years. He eats mainly fast food at lunchtime and drinks a few beers while watching television on weekends. The patient does not smoke or use recreational drugs. His father died of a heart attack at age 50. His mother suffers from diabetes mellitus and experienced a minor stroke.
Blood pressure is 144/90 mm Hg, pulse is 73/min, and body mass index is 31 kg/m². Physical examination is unremarkable.
Fasting laboratory results are as follows:

The patient's serum creatinine and liver and thyroid function tests are normal. Repeat fasting triglyceride level is 460 mg/dL.
He is instructed about lifestyle changes. Which of the following will provide the greatest benefit in reducing this patient's cardiovascular risk?

Quizplus · Accepted Answer

11ec193a_97bd_0f2b_853d_8b977cf540b7_MD0002_00 This patient has elevated total cholesterol and triglyceride levels and a new diagnosis of diabetes mellitus. Hypertriglyceridemia is associated with an increased risk for atherosclerotic cardiovascular disease (ASCVD). However, it is unclear if this is due to a direct effect of triglycerides or to concomitant diabetes mellitus and hypercholesterolemia, which are frequently associated. It is also unclear whether treatment aimed at lowering triglyceride levels reduces the risk of cardiovascular events. In contrast, statin therapy has been shown to reduce the risk of cardiovascular events regardless of baseline cholesterol levels and is recommended: recommended for secondary prevention in patients with established ASCVDfor primary prevention of ASCVD in patients (such as this one) age ≥40 with diabetes mellitus, those with baseline LDL ≥190 mg/dL, and those with a calculated 10-year ASCVD risk >7.5-10% based on the Pooled Cohort Equations calculator. for secondary prevention in patients with established ASCVD for primary prevention of ASCVD in patients (such as this one) age ≥40 with diabetes mellitus, those with baseline LDL ≥190 mg/dL, and those with a calculated 10-year ASCVD risk >7.5-10% based on the Pooled Cohort Equations calculator. Pooled Cohort Equations calculator Therefore, in patients with mild hypertriglyceridemia (ie, 150-500 mg/dL), statins are first-line pharmacologic therapy when indicated based on ASCVD risk factors, as in this patient. In patients with mild hypertriglyceridemia in whom statins are not indicated based on ASCVD risk factors, lifestyle interventions including reduced-calorie diet, reduced alcohol intake, and increased daily exercise should be pursued. Pharmacologic therapy specifically aimed at reducing triglycerides (eg, fibrates, fish oil) does not play a role in patients with mild hypertriglyceridemia. (Choices A, B, and D) Patients with severe hypertriglyceridemia (eg, >1000 mg/dL) are at increased risk for pancreatitis, and should be given fibrate therapy (or fish oil/niacin if fibrates are not tolerated) to lower triglycerides and reduce this risk. Should triglyceride levels decrease to <500 mg/dL, the goal of pharmacologic therapy becomes ASCVD risk reduction, which is best accomplished with statins. (Choice C) A patient such as this with newly diagnosed diabetes mellitus and only mild elevations in hemoglobin A1c may be able to achieve targets (≤7%) with lifestyle modification alone. If a brief trial of conservative measures (eg, dietary changes, exercise, weight loss) fails to control this patient's diabetes, antidiabetic medications such as metformin would be indicated. Educational objective: Pharmacologic therapy in patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) is aimed at atherosclerotic cardiovascular disease (ASCVD) risk reduction. Statins provide superior cardiovascular benefit compared with non-statin medications (eg, fibrates, niacin, fish oil); therefore, when indicated based on ASCVD risk factors, statins are the preferred pharmacologic therapy in patients with mild hypertriglyceridemia. __________ References: The role of non-HDL cholesterol in risk stratification for coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/22203405) Evaluation and treatment of hypertriglyceridemia: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/22962670)

A 52-Year-Old Man Comes to the Physician Very Concerned About