A 50-year-old man comes to the office to discuss heart disease prevention. The patient has a history of mild abnormality in liver function tests that he says he was told is "nothing to worry about"; he has no other significant medical history. Five years ago, the patient underwent repair of his anterior cruciate ligament. He drinks 1 or 2 beers on most nights and has smoked a half pack of cigarettes daily for the past 20 years. His father had a myocardial infarction at age 62. The patient eats a lot of fast food because of limited time during the workday. Prior to his knee injury, he played in a recreational soccer league and has not exercised regularly since. The patient sits for most of the day at his job. Temperature is 36.7 C (98.1 F) and blood pressure is 138/86 mm Hg. Weight is 91.6 kg (201.9 lb) and height is 175.3 cm (5 ft 9 in). BMI is 29.8 kg/m². Examination shows moist mucous membranes, normal jugular venous pressure, clear lung fields, and normal S1 and S2. The abdomen is soft and nontender. No hepatomegaly or splenomegaly is present. There is normal range of motion, and neurologic examination is within normal limits. Laboratory results are as follows: Which of the following would provide the most important information in determining whether to start lipid-lowering therapy in this patient?

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11ec25c8_d242_e944_bc81_ff984c92e134_MD0003_00 Current guidelines recommend the use of statins (eg, atorvastatin, rosuvastatin) for secondary prevention in patients with known atherosclerotic cardiovascular disease (ASCVD), including history of myocardial infarction, angina, arterial revascularization, stroke/transient ischemic attack, and peripheral artery disease. In addition, patients with serum LDL ≥190 mg/dL (suggestive of familial hypercholesterolemia) and those age ≥40 with diabetes mellitus are considered at high risk for ASCVD, and primary prevention with statin therapy is indicated. In patients who do not meet any of the above criteria, the decision to initiate statin therapy for primary prevention of ASCVD is less straightforward; it is generally based on an estimated future risk of cardiovascular events. Guidelines recommend using the Pooled Cohort Equations cardiovascular risk calculator, which takes into account ethnicity, age, sex, total cholesterol, HDL, diabetes status, smoking status, and blood pressure, to estimate the 10-year risk of ASCVD. Initiation of statin therapy is recommended in patients with an estimated 10-year risk of ASCVD >7.5%-10% (guidelines vary on the specific cutoff). A healthy lifestyle (eg, exercise, diet) should be encouraged in all patients regardless of whether statin therapy is indicated. cardiovascular risk calculator (Choice A) Family history of premature ASCVD in a first-degree relative (eg, onset at age <50 in father) is associated with increased risk of cardiovascular events. However, in part due to inaccurate reporting, it is a less useful parameter than pooled analysis of other traditional risk factors. (Choice B) Exercise stress testing is used to evaluate for ASCVD in patients with symptoms suggestive of the condition (eg, reproducible chest pain with exertion), but it is not typically indicated in asymptomatic patients. (Choice C) Elevated high-sensitivity C-reactive protein levels have been correlated with increased risk of cardiovascular events. However, the test is nonspecific and is not preferred over pooled analysis using traditional risk factors. (Choice D) Some apolipoproteins (eg, apolipoprotein B-100) function as lipid structural proteins. However, serum apolipoprotein concentrations are not routinely used to evaluate ASCVD risk. (Choice F) Unless the level is ≥190 mg/dL, LDL alone is not typically used to guide the initiation of statin therapy. LDL<70 mg/dL is sometimes used as a cutoff to withhold statin therapy when it is otherwise indicated. Educational objective: Estimated atherosclerotic cardiovascular disease (ASCVD) risk can be calculated using the Pooled Cohort Equations cardiovascular risk calculator. Initiation of statin therapy is recommended for primary prevention in patients with a 10-year ASCVD risk >7.5%-10%. References: 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/30879355)

A 50-Year-Old Man Comes to the Office to Discuss Heart