A 59-year-old man comes to the office for follow-up after a recent acute myocardial infarction. Three months ago, the patient was hospitalized with chest pain and was found to have subtotal occlusion of the mid-left anterior descending artery, which was treated with a drug-eluting stent. He currently has no chest pain, shortness of breath, or palpitations. Medical history is significant for hypertension. His father had a myocardial infarction at age 55. The patient currently takes aspirin, ticagrelor, metoprolol, and lisinopril; he was prescribed high intensity rosuvastatin therapy but stopped taking it a month ago due to muscle aches. Blood pressure is 122/73 mm Hg, and pulse is 65/min and regular. BMI is 28 kg/m². Physical examination is unremarkable. Lipid panel results are as follows: Which of the following is the best recommendation for lipid management in this patient?

Question

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This patient has established atherosclerotic cardiovascular disease (ASCVD) and was appropriately prescribed high-intensity statin therapy (ie, rosuvastatin). Statins have been shown to reduce the risk of myocardial infarction and ischemic stroke in patients with ASCVD. However, these drugs are associated with a small risk of adverse effects, including muscle injury (eg, myalgia, myonecrosis). The muscle injury associated with statins typically resolves with cessation of the drug. Those who develop rhabdomyolysis, a rare side effect of severe statin-induced myopathy, should discontinue statin use entirely. However, most muscle toxicity is mild (eg, myalgias), and the majority of patients can tolerate a different statin. Options include an alternate high-intensity statin (eg, atorvastatin 80 mg) or a moderate-intensity statin, which should be titrated to the maximal tolerated dose. Pravastatin, pitavastatin, and fluvastatin are moderate-intensity statins that have a lower risk of myopathy and are frequently used as alternate therapy. Subclinical hypothyroidism is associated with an increased risk of statin myopathy, and many experts advise measuring a serum TSH level before starting statins or when side effects occur in patients receiving treatment. (Choice A) Although high-fish diets are associated with a lower risk of ASCVD in some populations, studies on the risk of atherosclerotic events with fish oil supplements are inconsistent. (Choice B) Although lifestyle modifications (eg, exercise, smoking cessation) should be recommended to reduce the risk of myocardial infarction and stroke, this patient should also receive a lipid-lowering medication, preferably a statin, to reduce his risk. (Choice C) Ezetimibe can be considered as third-line therapy for patients who do not tolerate high- or moderate-intensity statins, but it is not as effective as statins in preventing cardiovascular events. PCSK9 inhibitors (eg, alirocumab) are another alternate therapy for these patients. (Choice D) Fibrates (eg, fenofibrate) do not lower the risk of atherosclerotic events in patients with normal triglyceride levels at baseline. They have been associated with improvements in cardiovascular risk in patients with very high triglycerides (ie >400 mg/dL) and low HDL (≤40 mg/dL) but are typically given with a statin. Educational objective: High-intensity statin therapy can reduce the risk of myocardial infarction and ischemic stroke in patients with atherosclerotic cardiovascular disease. For patients who are intolerant of one high-intensity statin, switching to a different high-intensity or a moderate-intensity statin should be considered. References: Statin non-adherence: clinical consequences and proposed solutions. (http://www.ncbi.nlm.nih.gov/pubmed/27134737)

A 59-Year-Old Man Comes to the Office for Follow-Up After