A 45-year-old man comes to the clinic for follow-up of hypertension. He was diagnosed 6 months ago and prescribed antihypertensive therapy. The patient is an ex-smoker with a 25-pack-year history; he quit smoking 2 years ago. Medical history includes a laparoscopic cholecystectomy 5 years ago after an episode of acute cholecystitis. He eats a well-balanced diet, walks 2-3 miles daily, and does not consume alcohol. His father had a heart attack at age 62, and his mother died of a stroke at age 67. Blood pressure is 140/88 mm Hg and pulse is 67/min. BMI is 30 kg/m². Physical examination is unremarkable. Fasting laboratory results are as follows: Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_beae_3157_8f63_6399ad7b4ca6_MD0005_00 This patient has multiple risk factors for atherosclerotic cardiovascular disease (ASCVD), including hypertension, family history, and hypercholesterolemia. Statins reduce the risk of developing clinically significant ASCVD and are indicated for the primary prevention of ASCVD in substantially at-risk patients. Patients with LDL ≥190 mg/dL are at high risk and should be prescribed high-intensity statin therapy. In addition, all patients age ≥40 with diabetes mellitus are considered at substantial risk and should be given moderate- or high-intensity statin therapy. For all other patients, the decision to start statin therapy should be based on a calculation of the estimated 10-year ASCVD risk using the Pooled Cohort Equations calculator. Those with an estimated 10-year ASCVD risk >7.5-10% (the exact cutoff varies among guidelines) should be prescribed moderate- or high-intensity statin therapy. Pooled Cohort Equations calculator This patient's estimated 10-year ASCVD risk is approximately 6.5%; therefore, statin therapy is not currently indicated. Continued lifestyle modification (eg, healthy diet, weight loss, exercise) and optimization of other risk factors (eg, blood pressure control) is most appropriate. (Choice B) Fibrates (eg, fenofibrate) are rarely indicated for cardiovascular risk reduction in patients with mild hypertriglyceridemia (eg, 150-500 mg/dL). Management instead focuses on lifestyle modification and removal of exacerbating factors (eg, heavy alcohol use); statins are given as first-line therapy if pharmacologic risk reduction is indicated. Fibrates are indicated for severe hypertriglyceridemia (eg, >1000 mg/dL) to prevent acute pancreatitis. Management (Choice C) Coronary artery calcium score testing uses CT scanning to visualize calcifications in the coronary arteries and estimate atherosclerotic disease burden. The test may be considered to further quantify ASCVD risk in patients who are borderline for initiating statin therapy based on the Pooled Cohort Equations calculator. (Choice D) This patient's estimated 10-year ASCVD risk should first be calculated to determine if the initiation of statin therapy is indicated. (Choice E) Metformin can assist with weight loss in patients with type 2 diabetes mellitus, but it is not indicated for weight reduction in nondiabetic patients. Educational objective: Statins are recommended for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with LDL ≥190 mg/dL and those age ≥40 with diabetes mellitus. For all other patients. the initiation of statin therapy for primary prevention of ASCVD is based on an estimated 10-year ASCVD risk >7.5-10% using the Pooled Cohort Equations calculator. 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)

A 45-Year-Old Man Comes to the Clinic for Follow-Up of Hypertension