When thinking about lipid management, what considerations do you need to have? What resources should you be using when determining which therapies a patient should be treated with? What is a coronary CT scan and when should you consider getting this scan to help establish cardiovascular risk?

What is the patient’s current physical activity level? Does he exercise regularly? Would lifestyle modifications be suitable and realistic for this patient? As part of the management plan, exercise is a critical recommendation for improving cardiovascular health, weight management, and lipid profile. Given his overweight status and the stress of his sedentary job, starting with small, achievable goals may be more appropriate, such as short walks or light physical activities that don’t require significant time commitments.

While it is essential to encourage some form of physical activity, gradual implementation of exercise is important, recognizing that the patient might need support and motivation over time. Adjust expectations and offer practical strategies, such as breaking up exercise into manageable sessions (e.g., 10 to 15-minute walks throughout the day) or incorporating activity into daily tasks (e.g., taking the stairs, walking during lunch breaks). In addition, discussing any potential barriers, like fatigue or lack of motivation, will be key in finding solutions and increasing his chances of success.

This patient would also benefit from smoking cessation counseling and pharmacologic options. Patients can start on two forms of nicotine replacement therapy such as a nicotine patch and gum. It is important this patient has shared decision-making in his plan, receives supplemental behavioral counseling, and understands the importance of quitting.

While not applicable for this patient, coronary CT angiography or calcium scoring can be useful and can be considered in individuals with borderline intermediate risk of ASCVD to help guide treatment decisions.

Which medications or drug classes would you first consider initiating in this patient? How frequently should you be checking lipids? If you need to escalate or change the medication due to ineffectiveness or adverse drug reactions, which medications should you consider adding?

Given this patient falls into high-risk group within secondary prevention, it is recommended to initiate a high-intensity statin, such as atorvastatin 80 mg or rosuvastatin 40 mg. Labs should be measured 4 to 12 weeks after initiating statin therapy. Lipids can be checked every 3 to 12 months thereafter as needed per multi-society guidelines. It is important to offer additional counseling and education on lifestyle modifications and suggest gradual, incremental changes to diet and exercise.

The main adverse events related to statin therapy include muscle symptoms (rhabdomyolysis/myopathy) and new onset diabetes. While initiating a statin, it is important to monitor a patient’s lipid panel, hepatic transaminase levels, and CPK if signs of muscle pain. Counseling can include important lifestyle modifications in addition to pharmacotherapy, to avoid consumption of grapefruit juice, to avoid red yeast rice, and to notify us if pregnancy is planned or suspected in female patients.

When considering additional nonstatin therapies, guidelines recommend initiating ezetimibe or PCSK9 inhibitors—(like alirocumab (Praluent) and evolocumab (Repatha).

Does it matter if a patient was fasting prior to getting the lipid panel? If so, why does it matter? Can you use any information from that lab test? What if you also got a Lipoprotein (a) test?

Fasting can impact certain components of a lipid panel, particularly the triglycerides. Food intake can moderately increase labs associated with cholesterol and triglycerides. Per AHA/ACC guidelines, pharmacotherapy recommendations and dose adjustments are most often based on LDL-C; however lipoprotein(a) is clinically correlated to ASCVD risk and subsequent events.

If a patient has high triglycerides, should you treat them?

By definition, hypertriglyceridemia occurs when the TG level reaches ≥150; however, elevated triglyceride levels are not a target for therapy unless ≥500 with recommendations being to reduce levels to <500. AHA/ACC guidelines recommend first identifying and treating secondary factors of hypertriglyceridemia, such as diabetes, hypothyroidism, or drug-induced causes. For patients with elevated triglycerides >500, AHA/ACC recommend initiation or intensification of statin therapy. Icosapent ethyl can be considered if triglycerides are >150 mg/dL, the patient has diabetes, and a high risk of ASCVD or known ASCVD.

What is the role of aspirin in primary prevention of cardiovascular disease? When should we consider or discontinue this medication in our patients?

Low-dose aspirin might be considered in select adults 40 to 79 years old who are at a higher ASCVD risk but not an increased bleeding risk. ACC recommendations the consideration of aspirin 81 mg/day if 10-year ASCVD risk is ≥10% if benefit outweighs bleed risk after clinician-patient discussion.

For secondary prevention, aspirin 81-162mg/day indefinitely is recommended. DAPT, or dualantiplatelet therapy, is recommended in addition to aspirin after PCI. DAPT is discussed further separately.

For our 55-year-old patient, he would be a candidate for indefinite low-dose aspirin therapy following his MI. While not currently an issue in this patient, in the event he were to be started on anticoagulation therapy such as a DOAC, aspirin is recommended to be discontinued.