HLD/Statin Flashcards
A 40-year-old female sees you for a health maintenance visit. She has no complaints and other
than being overweight she has an unremarkable examination. Laboratory results are also
unremarkable except for her lipid profile. She has a total cholesterol level of 251 mg/dL, an
HDL-cholesterol level of 31 mg/dL, and a triglyceride level of 1250 mg/dL. The
LDL-cholesterol level could not be calculated and measured 145 mg/dL.
In addition to lifestyle changes, this patient would most likely benefit from
(check one)
niacin
omega-3 fatty acid supplementation
atorvastatin (Lipitor)
ezetimibe (Zetia)
fenofibrate (Tricor)
fenofibrate (Tricor)
Treatment of hypertriglyceridemia depends on its severity. Contributing factors include a sedentary
lifestyle, being overweight, excessive alcohol intake, type 2 diabetes mellitus, and genetic disorders.
Triglyceride levels of 150–199 mg/dL are considered mild hypertriglyceridemia, levels of 200–999 mg/dL
are moderate, 1000–1999 mg/dL are severe, and levels >2000 mg/dL are considered very severe. Patients
with hypertriglyceridemia in the mild to moderate range may be at risk for cardiovascular disease, but
those who have severe or very severe hypertriglyceridemia have a significant risk of pancreatitis.
In addition to having the patient exercise, reduce intake of fat and carbohydrates, and lose weight, she
should also be counseled to avoid alcohol. For patients at risk for pancreatitis, fibrates are recommended
as the initial treatment for pancreatitis. It should be noted that statins may have a modest
triglyceride-lowering effect and may be helpful in decreasing cardiovascular risk in those who have
moderately elevated triglycerides. However, they should not be used alone in patients who have severe
hypertriglyceridemia. Studies have also shown that while omega-3 fatty acids decrease triglycerides and
very low density lipoprotein cholesterol levels, they may increase LDL-cholesterol levels. Treatment with
omega-3 fatty acids does not decrease total mortality or cardiovascular events, and therefore is not
recommended.
Niacin does seem to have the advantage of raising HDL cholesterol and lowering LDL cholesterol, but it
has never been proven in clinical trials to have benefit with regard to the primary outcome of
cardiovascular disease, and some trials have shown significant increases in adverse events.
A 66-year-old male recently underwent percutaneous angioplasty for persistent angina with exertion. He does not have any symptoms now. His LDL-cholesterol level is 90 mg/dL.
Which one of the following would be most appropriate for secondary prevention of this patient’s coronary artery disease? (check one)
No drug treatment
Evolocumab (Repatha), 140 mg subcutaneously every 2 weeks
Ezetimibe (Zetia), 10 mg daily
Rosuvastatin (Crestor), 20 mg daily
Simvastatin (Zocor), 40 mg daily
Rosuvastatin (Crestor), 20 mg daily
Patients <75 years of age with established coronary artery disease should be on high-intensity statin regimens if tolerated. These regimens include atorvastatin, 40–80 mg/day, and rosuvastatin, 20–40 mg/day. Moderate-intensity regimens include simvastatin, 40 mg/day. Monotherapy with non-statin medications (bile acid sequestrants, niacin, ezetimibe, and fibrates) does not reduce cardiovascular morbidity or mortality. The PCSK9 inhibitors evolocumab and alirocumab are second-line or add-on therapies at this time.
A healthy 55-year-old white male with a family history of coronary artery disease sees you for a routine health maintenance visit. He asks you what he could do to decrease his risk of cardiovascular disease. He is a nonsmoker, does not drink alcohol, and has no history of substance abuse. His BMI is normal and the physical examination is otherwise unremarkable. His vital signs include a heart rate of 80 beats/min, a blood pressure of 119/70 mm Hg, a respiratory rate of 15/min, and a temperature of 37.0°C (98.6°F).
Laboratory Findings
Fasting glucose 92 mg/dL
Total cholesterol 190 mg/dL
LDL-cholesterol 98 mg/dL
HDL-cholesterol 50 mg/dL
Triglycerides 145 mg/dL
His calculated 10-year risk for cardiovascular disease is 5.4%. Which one of the following has the best evidence to prevent cardiovascular disease in a patient such as this? (check one)
Moderate-intensity exercise, 150 minutes weekly
A low-dose statin
Aspirin, 81 mg daily
Fish oil supplements
Niacin supplements
Moderate-intensity exercise, 150 minutes weekly
A systematic evidence review released by the U.S. Preventive Services Task Force (USPSTF) noted that the most active people had median cardiovascular risk reductions of about 30%–35% when compared with the least active. Statins are beneficial for both primary and secondary prevention of cardiovascular disease, but the benefit is greater when the baseline risk is greater. Current guidelines would not support statin therapy for a patient with a 10-year risk of atherosclerotic cardiovascular disease (ASCVD) <5%. Fish oil supplements have not proven to be useful for primary prevention of ASCVD. Aspirin is recommended for the prevention of cardiovascular disease in adults 50–59 years of age with a >10% 10-year ASCVD risk who are not at increased risk of bleeding, are expected to live at least 10 years, and are willing to take low-dose daily aspirin for 10 years (USPSTF B recommendation). Niacin is no longer recommended for cardiovascular risk reduction due to a lack of evidence for benefit.
You are utilizing shared decision-making with patients while determining whether to recommend starting a statin for the primary prevention of atherosclerotic cardiovascular disease. In which one of the following patients would a screening coronary artery calcium score be most appropriate for guiding this recommendation? (check one)
A 35-year-old at low (<5%) 10-year risk
A 55-year-old at high (20%) 10-year risk
A 55-year-old with diabetes mellitus at high (20%) 10-year risk
A 60-year-old at low (<5%) 10-year risk
A 60-year-old at intermediate (7.5% to <20%) 10-year risk
A 60-year-old at intermediate (7.5% to <20%) 10-year risk
For primary preventive interventions for the management of lipids, the 10-year atherosclerotic cardiovascular disease risk estimate is useful as a starting point for shared decision-making with patients. Specifically, it is a helpful tool when deciding on the use and intensity of statin therapy. The coronary artery calcium score can refine the risk assessment even further for those at intermediate predicted risk (7.5% to <20%) or borderline predicted risk (5% to <7.5%).
For those at intermediate or borderline risk with a coronary artery calcium score of 0, it would not be reasonable to start a statin. If the coronary artery calcium score is 100 or greater, starting a statin is acceptable in patients 55 years of age.
A 40-year-old African-American female brings you her lipid panel results from a work health fair and asks if she should start taking medication to lower her cholesterol. The results include a total cholesterol level of 295 mg/dL, an LDL-cholesterol level of 170 mg/dL, an HDL-cholesterol level of 42 mg/dL, and a triglyceride level of 200 mg/dL. The patient does not smoke and except for a BMI of 30.4 kg/m2 she is otherwise healthy. Her blood pressure is 132/76 mm Hg and she takes no medications.
Which one of the following would be consistent with current guidelines? (check one)
Initiating treatment with red yeast rice supplements
Initiating treatment with a statin medication only if she has a cardiovascular event or develops diabetes mellitus
Initiating treatment based on her calculated risk of a cardiovascular event in the next 10 years
Initiating treatment with a statin based on her current LDL-cholesterol level
Initiating treatment based on her calculated risk of a cardiovascular event in the next 10 years
The 2013 American College of Cardiology/American Heart Association cholesterol guideline suggests statin therapy for individuals with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or greater. The U.S. Preventive Services Task Force and the National Institute for Health and Care Excellence recommend statin therapy when the patient’s 10-year risk of cardiovascular disease is 10% or greater. While international guidelines differ somewhat, other major guidelines would support similar recommendations.
Which one of the following medical conditions is most likely the result of severely elevated triglycerides? (check one)
Asthma
Chronic kidney disease
Gallstones
Hypothyroidism
Pancreatitis
Pancreatitis
Hypertriglyceridemia, defined as triglyceride levels 500 mg/dL, increases the risk of pancreatitis. It does not increase the risk of asthma, chronic kidney disease, gallstones, or hypothyroidism. Patients with hypertriglyceridemia should initiate therapeutic lifestyle modifications and should be treated with fibrates or niacin to help reduce the risk of pancreatitis.
