A 43-year-old man comes to the physician for a follow-up visit. He was diagnosed with coronary artery disease and received a stent to the left circumflex artery a year ago. At that time, he was started on aspirin, clopidogrel, metoprolol, and atorvastatin. About a week ago, the patient was seen in the emergency department for pain in both thighs following a 15-mile walk sponsored by a local organization. His serum creatine kinase level was 500 units/L (normal 25-90 units/L). Atorvastatin was discontinued, and he was discharged with a prescription for ibuprofen. The patient also was advised to consult his primary care physician. His symptoms have improved markedly since discharge from the emergency department. His physical examination is normal. The patient's most current lipid profile, performed about 15 days ago while on medication, shows low-density lipoprotein cholesterol of 132 mg/dL, triglycerides of 100 mg/dL, and high-density lipoprotein cholesterol of 40 mg/dL. He asks about restarting atorvastatin. Which of the following is the best recommendation for this patient?

Question

A 43-year-old man comes to the physician for a follow-up visit.  He was diagnosed with coronary artery disease and received a stent to the left circumflex artery a year ago.  At that time, he was started on aspirin, clopidogrel, metoprolol, and atorvastatin.  About a week ago, the patient was seen in the emergency department for pain in both thighs following a 15-mile walk sponsored by a local organization.  His serum creatine kinase level was 500 units/L (normal 25-90 units/L).  Atorvastatin was discontinued, and he was discharged with a prescription for ibuprofen.  The patient also was advised to consult his primary care physician.  His symptoms have improved markedly since discharge from the emergency department.  His physical examination is normal.  The patient's most current lipid profile, performed about 15 days ago while on medication, shows low-density lipoprotein cholesterol of 132 mg/dL, triglycerides of 100 mg/dL, and high-density lipoprotein cholesterol of 40 mg/dL.  He asks about restarting atorvastatin.  Which of the following is the best recommendation for this patient?

Quizplus · Accepted Answer

Explanation: Statin therapy is an effective treatment for hypercholesterolemia and is recommended for secondary prevention of cardiovascular events in all patients with known coronary heart disease. Statin-induced myopathy is the most common complication of statin use and can range from asymptomatic elevation of serum creatine kinase (CK) levels to rhabdomyolysis. Statins can also potentiate muscle injury with elevation of CK levels in patients with an episode of prolonged vigorous exercise. Patients with symptomatic myopathy from statin use should discontinue therapy. In asymptomatic patients, a CK level >10 times the upper limit of normal range is considered an indication for discontinuation of statin therapy. This patient developed clinically significant myopathy. However, it seems to be temporally related to prolonged exercise as he had tolerated atorvastatin previously without any significant side effects. The most appropriate next step is to recheck CK levels and restart atorvastatin if the levels have normalized. (Choices A, B, and C) The elevated CK levels are most likely related to prolonged vigorous exercise, and atorvastatin should not be completely discontinued. Statin therapy is preferred over non-statin drugs (eg, gemfibrozil, nicotinic acid, ezetimibe) for the secondary prevention of cardiovascular events in patients with known coronary heart disease in light of superior evidence showing reduction in cardiac risk. (Choice E) This patient should have serum CK levels rechecked to ensure that they are normalized prior to restarting therapy with atorvastatin. This will confirm resolution of the initial injury and avoid confounding future assessment in case he was to develop recurrent symptoms. Educational objective: Statin therapy can potentiate muscle injury and elevation of creatine kinase (CK) levels following prolonged and vigorous exercise. Most such patients should be restarted on statin therapy after CK levels have normalized. References: Statin-associated myopathy and its exacerbation with exercise. (http://www.ncbi.nlm.nih.gov/pubmed/20878737)

A 43-Year-Old Man Comes to the Physician for a Follow-Up