A 70-year-old man is admitted to the hospital with a 1-hour episode of left arm and left leg weak point. He’s recognized with a transient ischemic assault. The affected person has a historical past of hypertension and kind 2 diabetes mellitus and a 30-pack-year historical past of smoking. Household historical past is noncontributory. His medicines are metformin and lisinopril.
On bodily examination, the affected person is afebrile, and blood strain is 148/88 mm Hg. The rest of the examination is unremarkable.
Laboratory research present alanine aminotransferase 28 U/L, whole ldl cholesterol 239 mg/dL (6.19 mmol/L), LDL ldl cholesterol 140 mg/dL (three.63 mmol/L), HDL ldl cholesterol 38 mg/dL (zero.98 mmol/L), serum creatinine zero.eight mg/dL (70.7 µmol/L), and triglycerides 302 mg/dL (three.41 mmol/L).
Along with aspirin, which of the next is probably the most acceptable remedy?
A. Atorvastatin, high-intensity dosage
B. Atorvastatin, moderate-intensity dosage
D. Fenofibrate and atorvastatin, high-intensity dosage
MKSAP Reply and Critique
The proper reply is A. Atorvastatin, high-intensity dosage.
Excessive-intensity statin remedy (atorvastatin, 40-80 mg/d; rosuvastatin, 20-40 mg/d) is suitable on this affected person who skilled a transient ischemic assault, a scientific manifestation of atherosclerotic heart problems (ASCVD). Along with aspirin and remedy of different cardiovascular threat components (hypertension, diabetes mellitus, smoking), statin remedy ought to be initiated for its well-established advantages in treating blood levels of cholesterol to cut back future cardiovascular occasions. Even with concomitant hypertriglyceridemia, high-intensity statin remedy remains to be the first remedy for sufferers with scientific ASCVD, until sufferers have threat components for statin-related hostile results.
Reasonable-intensity statin remedy (atorvastatin, 10-20 mg/d; simvastatin, 20-40 mg/d; fluvastatin, 40 mg twice day by day; lovastatin, 40 mg/d; pitavastatin, 2-Four mg/d; pravastatin, 40-80 mg/d; rosuvastatin, 5-10 mg/d) isn’t the primary selection for sufferers with scientific ASCVD as a result of superior advantages of high-intensity statin remedy on this inhabitants. If the affected person had threat components for statin-related hostile results, corresponding to age older than 75 years or kidney or hepatic dysfunction, moderate-intensity statin remedy is an acceptable second-line remedy.
Fibrates are efficient in treating hypertriglyceridemia; nevertheless, fibrate monotherapy, corresponding to with fenofibrate, isn’t an appropriate preliminary selection for secondary prevention in sufferers with scientific ASCVD. Though remedy of hyperlipidemia now not focuses on a particular LDL ldl cholesterol goal, the first purpose of remedy stays reducing LDL ldl cholesterol, and statins have been proven to be efficient at lowering LDL levels of cholesterol and recurrent cardiovascular occasions. Provided that triglyceride ranges exceed 500 mg/dL (5.65 mmol/L) or the affected person has a historical past of hypertriglyceridemia-induced pancreatitis ought to fibrate remedy be thought-about.
Research have demonstrated that there is no such thing as a extra ASCVD threat discount with using mixture remedy (statin plus nonstatin medicine). Nonstatin medicines even have important potential to trigger hostile results. Subsequently, mixture remedy is reserved for these with insufficient response or poor tolerance to statin remedy.
- Excessive-intensity statin remedy is indicated for secondary prevention in sufferers with scientific atherosclerotic heart problems.
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