A 64-year-old man is assessed for discharge after being admitted 2 days ago for non-ST-segment elevation myocardial infarction. He underwent successful percutaneous coronary intervention to the right coronary artery on the day of admission and has since been symptom-free. The patient has a history of hypertension and was treated with lisinopril before admission. His father underwent coronary artery bypass grafting at age 65, and his sister has diabetes. The patient drinks a 6-pack of beer most nights and does not use tobacco or illicit drugs. Weight is 90 kg (198.4 lb) and height is 177.8 cm (5 ft 10 in). BMI is 28.5 kg/m². Blood pressure is 142/89 mm Hg. His dentition is poor. The lungs are clear on auscultation, and there are no heart murmurs. A faint bruit is heard over the right carotid artery, but there are no periumbilical bruits. Lower extremity pulses are full and there is no peripheral edema. Fasting laboratory results are as follows: Thyroid function tests are normal. In addition to high-intensity statin therapy, which of the following is the best recommendation for management of this patient's lipid disorder?

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11ec25c8_d34b_58f3_bc81_fdd413117edf_MD0003_00 This patient has hypertriglyceridemia, which can occur due to an inherited disorder (eg, familial hypertriglyceridemia), secondary to an acquired condition (eg, diabetes mellitus, obesity, hypothyroidism, nephrotic syndrome, alcohol abuse), or as an adverse effect of some medications (eg, tamoxifen, beta blockers, corticosteroids, antiretrovirals). Elevated triglyceride levels (ie, >150 mg/dL) are associated with increased cardiovascular risk, and severely elevated levels (ie, >1,000 mg/dL) can cause pancreatitis. In patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) who have known or are at high risk for atherosclerotic cardiovascular disease (ASCVD), initiation of a statin (eg, rosuvastatin, atorvastatin) is the recommended first-line pharmacologic therapy. In addition, lifestyle modifications targeting secondary causes of hypertriglyceridemia should be pursued. Although moderate alcohol intake may be associated with reduced cardiovascular mortality, heavy intake can significantly increase triglyceride levels; therefore, this patient should reduce alcohol intake to no more than 2 drinks a day (1 drink a day for women). Increased exercise and weight loss are also beneficial. (Choice A) Reduced intake of high-sugar foods (eg, high-fructose corn syrup) is beneficial in reducing triglyceride levels; however, a diet completely free of carbohydrates is not recommended. (Choice B) Niacin is effective in reducing triglyceride levels; however, its use in combination with statins is associated with an increase in adverse effects (eg, gastrointestinal upset) without improving cardiovascular outcomes. (Choice C) Fibrates (eg, gemfibrozil, fenofibrate) are the most effective pharmacologic therapy for reducing triglyceride levels and are recommended in patients with severe or sometimes moderate hypertriglyceridemia (eg, 500-1000 mg/dL). However, due to superior evidence of overall cardiovascular benefit, statins are the recommended first-line therapy in patients with ASCVD (or at high risk for ASCVD) and mild hypertriglyceridemia. Due to increased rates of adverse effects (eg, myopathy) and lack of proven cardiovascular benefit, the addition of a fibrate to a statin is rarely indicated. (Choice D) Metformin improves insulin sensitivity and reduces serum triglyceride levels; however, it is not indicated in this patient without diabetes. (Choice F) Vitamin E supplementation has no demonstrated benefit in the management of lipid disorders or cardiovascular disease. Educational objective: Patients with hypertriglyceridemia should be evaluated for secondary causes and initially managed with exercise, weight loss, low-fat/carbohydrate diet, and reduction or cessation of alcohol intake. In patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) who have known or are at high risk for atherosclerotic cardiovascular disease, statins are the first-line pharmacologic therapy. Fibrates and niacin reduce triglyceride levels but have not been shown to improve cardiovascular outcomes. 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) Niacin for primary and secondary prevention of cardiovascular events. (http://www.ncbi.nlm.nih.gov/pubmed/28616955)

A 64-Year-Old Man Is Assessed for Discharge After Being Admitted