A 55-year-old woman comes to the office for a preventive visit. She has no concerns at this time. The patient experienced a myocardial infarction 2 years ago. Current medications are metoprolol and aspirin. The patient does not smoke or use alcohol. Blood pressure is 125/80 mm Hg and pulse is 65/min. Physical examination is unremarkable. Fasting blood glucose level is 100 mg/dL. Laboratory results are as follows: The initiation of which of the following medications is most appropriate in this patient?

Question

A 55-year-old woman comes to the office for a preventive visit.  She has no concerns at this time.  The patient experienced a myocardial infarction 2 years ago.  Current medications are metoprolol and aspirin.  The patient does not smoke or use alcohol.  Blood pressure is 125/80 mm Hg and pulse is 65/min.  Physical examination is unremarkable.  Fasting blood glucose level is 100 mg/dL.  Laboratory results are as follows:  The initiation of which of the following medications is most appropriate in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be30_282f_8f63_c73fc98c1a73_MD0005_00 This patient has established atherosclerotic cardiovascular disease (ASCVD) based on her previous myocardial infarction. Patients with known ASCVD are at high risk for future cardiovascular events and death. Several randomized trials for secondary prevention of ASCVD have shown significant risk reduction in cardiovascular events and overall cardiovascular disease mortality in patients treated with statins. Current guidelines recommend high-intensity statin therapy (eg, atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) for secondary prevention in all patients age ≤75 with known ASCVD (moderate-intensity statin therapy is recommended for those age >75), regardless of baseline LDL level. Statin therapy is also recommended for primary prevention of ASCVD in patients with serum LDL ≥190 mg/dL, age ≥40 with diabetes mellitus, or with an estimated 10-year risk of ASCVD >7.5%-10% (guidelines vary on the exact cutoff) using the Pooled Cohort Equations risk calculator. risk calculator (Choice B) Bile acid sequestrants (eg, cholestyramine, colestipol, colesevelam) are effective in reducing LDL levels, but there is limited evidence of improvement in cardiovascular outcomes. (Choice C) Estrogen replacement therapy (eg, estradiol) has favorable effects on lipid levels (ie, reduced LDL, increased HDL) but does not lead to a lower risk of cardiovascular events. Estrogen replacement may actually increase cardiovascular risk in older, postmenopausal women (eg, age >60). (Choice D) Fibrates (eg, gemfibrozil) are the most effective pharmacologic therapy available for reducing triglyceride levels and are recommended in patients with severe hypertriglyceridemia (ie, >1000 mg/dL) to reduce the risk of pancreatitis. However, due to superior evidence of overall cardiovascular benefit, statins are the recommended first-line therapy for both secondary and primary prevention of ASCVD in patients with mild hypertriglyceridemia (ie, 150-500 mg/dL). hypertriglyceridemia (Choice E) Niacin (ie, nicotinic acid) is effective in increasing HDL levels and has modest effects in reducing LDL levels. However, despite the favorable effects on lipid profile, niacin has not shown improvement in cardiovascular outcomes in patients with known ASCVD. Educational objective: Statin therapy is recommended for all patients with established atherosclerotic cardiovascular disease, regardless of baseline LDL level. Therapy with nonstatin lipid-lowering medications has not been shown to improve cardiovascular outcomes and is not usually recommended. 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) Effects of extended-release niacin with laropriprant in high-risk patients. (http://www.ncbi.nlm.nih.gov/pubmed/25014686)

A 55-Year-Old Woman Comes to the Office for a Preventive