A 36-year-old man comes to the physician for a routine visit. He has no complaints except for gradual weight gain over the past few years. He is an administrative assistant in a law firm and spends most of his time working at his desk. He eats mainly fast food for lunch and drinks a few beers while watching television on weekends. The patient does not use tobacco or recreational drugs. He has no family history of coronary heart disease, hypertension, or diabetes mellitus. His father died at age 47 in a ski accident. His mother is 66 years old and has no medical problems.
The patient's blood pressure is 124/70 mm Hg, pulse is 70/min, and body mass index is 30 kg/m². He has no other notable physical findings such as acanthosis, skin or tendon xanthomas, or thyromegaly. Examination of his fundi is normal.
Fasting laboratory results are as follows:
His serum creatinine, liver function tests, and thyroid-stimulating hormone are normal. His calculated 10-year risk of cardiovascular disease is approximately 1%.
In addition to lifestyle modification, which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old man comes to the physician for a routine visit. He has no complaints except for gradual weight gain over the past few years. He is an administrative assistant in a law firm and spends most of his time working at his desk. He eats mainly fast food for lunch and drinks a few beers while watching television on weekends. The patient does not use tobacco or recreational drugs. He has no family history of coronary heart disease, hypertension, or diabetes mellitus. His father died at age 47 in a ski accident. His mother is 66 years old and has no medical problems.
The patient's blood pressure is 124/70 mm Hg, pulse is 70/min, and body mass index is 30 kg/m². He has no other notable physical findings such as acanthosis, skin or tendon xanthomas, or thyromegaly. Examination of his fundi is normal.
Fasting laboratory results are as follows:

His serum creatinine, liver function tests, and thyroid-stimulating hormone are normal. His calculated 10-year risk of cardiovascular disease is approximately 1%.
In addition to lifestyle modification, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97bd_d27d_853d_a9ca5b92a030_MD0002_00 This patient has borderline high LDL cholesterol and mild hypertriglyceridemia. Hypertriglyceridemia is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD); however, it is unclear if this is due to a direct effect of triglycerides or to concurrent diabetes and hypercholesterolemia that are often present. It is also unclear whether pharmacologic therapy specifically targeted at lowering triglyceride levels reduces ASCVD risk. Therefore, mild hypertriglyceridemia (ie, 150-500 mg/dL) alone is not an indication for pharmacologic therapy. Many patients can be counseled regarding lifestyle interventions such as a reduced-calorie diet, reduced alcohol intake, and increased daily exercise. Those patients who should be placed on pharmacologic therapy are identified based on an indication for statin therapy for primary or secondary prevention of ASCVD. When indicated based on ASCVD risk factors, statins are the preferred first-line pharmacologic therapy for mild hypertriglyceridemia due to superior cardiovascular benefit compared to non-statin medications. indication for statin therapy (Choice A) This patient with mild hypertriglyceridemia does not have an indication for statin therapy for secondary (ie, established ASCVD) or primary (ie, age ≥40 with diabetes mellitus, LDL ≥190 mg/dL, or 10-year ASCVD risk >7.5-10%) prevention at this time. (Choices B and D) Fibrates (or fish oil or nicotinic acid if fibrates are not tolerated) are indicated for severe hypertriglyceridemia (eg, 1000 mg/dL) to lower triglyceride levels and reduce the risk of acute pancreatitis. However, these drugs do not play a role in patients with mild hypertriglyceridemia as statins are the preferred therapy for ASCVD risk reduction. (Choice C) Low-dose aspirin is generally recommended for primary prevention of ASCVD in patients age 50-70 with an estimated 10-year ASCVD risk ≥10%. In other patients it is unclear if the reduction in cardiovascular risk from low-dose aspirin outweighs the increased risk of bleeding. Educational objective: Many patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) can be managed with lifestyle interventions such as reduced-calorie diet, reduced alcohol intake, and increased daily exercise. When indicated based on atherosclerotic cardiovascular disease risk factors, statins are first-line pharmacologic therapy in patients with mild hypertriglyceridemia. __________ References: Determining triglyceride reductions needed for clinical impact in severe hypertriglyceridemia. (http://www.ncbi.nlm.nih.gov/pubmed/24384100) Omega-3 fatty acids and cardiovascular disease: new developments and applications. (http://www.ncbi.nlm.nih.gov/pubmed/24200766)

A 36-Year-Old Man Comes to the Physician for a Routine