A 51-year-old man comes to the office for a follow-up visit. He has no concerns. His medical conditions include type 2 diabetes mellitus, hypertension, and obesity. The patient does not use tobacco, alcohol, or illicit drugs. His mother and maternal grandfather also had diabetes. His current medications include aspirin, glyburide, metformin, and lisinopril. Blood pressure is 144/79 mm Hg and pulse is 88/min. Weight is 120 kg (265 lb). Examination shows no abnormalities. Laboratory results are as follows: Which of the following is the most appropriate therapy to prevent atherosclerotic cardiovascular disease in this patient?

Question

A 51-year-old man comes to the office for a follow-up visit.  He has no concerns.  His medical conditions include type 2 diabetes mellitus, hypertension, and obesity.  The patient does not use tobacco, alcohol, or illicit drugs.  His mother and maternal grandfather also had diabetes.  His current medications include aspirin, glyburide, metformin, and lisinopril.  Blood pressure is 144/79 mm Hg and pulse is 88/min.  Weight is 120 kg (265 lb).  Examination shows no abnormalities.  Laboratory results are as follows:  Which of the following is the most appropriate therapy to prevent atherosclerotic cardiovascular disease in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be2a_82db_8f63_cf400bec2e41_MD0005_00 The indications for statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) are mostly based on estimated cardiovascular risk. This patient's cardiovascular risk factors include diabetes mellitus, hypertension, obesity, and hypercholesterolemia. Current recommendations are that all patients age ≥40 with diabetes mellitus should be treated with moderate- or high-intensity statin therapy regardless of other risk factors. For patients without diabetes, the 10-year ASCVD risk should be estimated using the Pooled Cohort Equations calculator. Moderate- or high-intensity statin therapy is indicated for those patients with an estimated 10-year ASCVD risk >7.5-10% (guidelines vary on the exact cutoff). Statins are also indicated for patients with a baseline LDL level ≥190 mg/dL as this suggests familial hypercholesterolemia. calculator For patients with established ASCVD (eg, history of myocardial infarction), statin therapy is indicated for secondary prevention. High-intensity statin therapy is recommended up to age 75, and moderate-intensity statin therapy is recommended thereafter. (Choice A) Regular exercise (and dietary changes with weight loss) will likely improve this patient's blood pressure, glycemic control, and lipid levels. However, statin therapy would still be recommended in addition. (Choice B) Fibrates (eg, gemfibrozil) are indicated to reduce the risk of acute pancreatitis in patients with severe hypertriglyceridemia (eg, >1000 mg/dL). However, because of superior overall cardiovascular benefit, statins are the recommended first-line pharmacologic therapy for patients with mild hypertriglyceridemia (eg, 150-500 mg/dL). indicated (Choice C) Niacin is the most potent medication available for raising HDL cholesterol, and it also lowers LDL and triglycerides. However, statins are more effective in reducing cardiovascular risk. (Choice D) Orlistat is an intestinal lipase inhibitor that can be used for the treatment of obesity. It likely has some effect in lowering cholesterol levels, but it is not as effective in reducing cardiovascular risk as statins. Educational objective: Indications for statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) are mostly based on cardiovascular risk factors. Statins are indicated for all patients age ≥40 with diabetes mellitus. For patients without diabetes mellitus, statins are indicated for those with an estimated 10-year ASCVD risk >7.5-10%, and for those with a baseline LDL level ≥190 mg/dL. References: Primary prevention of major cardiovascular and cerebrovascular events with statins in diabetic patients: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23186103) 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 51-Year-Old Man Comes to the Office for a Follow-Up