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Question 3#

A 60-year-old white man has just moved to town and needs to establish care. He had a “heart attack” last year. Preferring a “natural” approach, he has been very conscientious about low-fat, low-cholesterol eating habits and a significant exercise program. He has gradually eliminated a number of prescription medications (he does not recall their names) that he was on at the time of hospital discharge. Past history is negative for hypertension, diabetes, or smoking. The lipid profile you obtain shows the following:

• Total cholesterol: 194 mg/dL
• Triglycerides: 140 mg/dL
• HDL: 42 mg/dL
• LDL (calculated): 124 mg/dL
• ECG shows Q waves in leads II, II, and aVF consistent with an old inferior MI

Which of the following recommendations would most optimally treat his lipid status?

A. Continue current dietary efforts and exercise
B. Add an HMG-CoA reductase inhibitor (statin drug) to reduce LDL cholesterol to less than 100 mg/dL with an ideal goal of 70 mg/dL if achievable
C. Add a fibric acid derivative such as gemfibrozil or fenofibrate
D. Review previous medications and resume an angiotensin-converting enzyme inhibitor
E. Have the patient buy over-the-counter fish oil tablets and take 2 g in the morning and 2 g in the evening

Correct Answer is B

Comment:

The National Cholesterol Education Program Adult Treatment Panel III recommendations include lowering the LDL cholesterol to less than 100 mg/dL in those with known coronary heart disease (secondary prevention). The 2004 update to these guidelines adds an optional goal of LDL less than 70 mg/dL in very high-risk patients. In this case, with dietary efforts and exercise already well established, it is unlikely that the LDL will be further reduced hence a statin drug is indicated. Statins typically lower LDL by 20% to 50%. Gemfibrozil is used primarily for hypertriglyceridemia; this patient’s triglyceride level is normal (< 150 mg/dL). ACE inhibitors have no significant effect on lipids. While high-dose fish oil does lower triglyceride levels, it is not effective at lowering LDL cholesterol levels. Lowering LDL cholesterol is of prime importance in the prevention of coronary heart disease of coronary heart disease prevention.