Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 70-year-old man is admitted to the hospital with a 1-hour episode of left arm and left leg weakness. He is diagnosed with a transient ischemic attack. The patient has a history of hypertension and type 2 diabetes mellitus and a 30-pack-year history of smoking. Family history is noncontributory. His medications are metformin and lisinopril.
On physical examination, the patient is afebrile, and blood pressure is 148/88 mm Hg. The remainder of the examination is unremarkable.
Laboratory studies show alanine aminotransferase 28 U/L, total cholesterol 239 mg/dL (6.19 mmol/L), LDL cholesterol 140 mg/dL (3.63 mmol/L), HDL cholesterol 38 mg/dL (0.98 mmol/L), serum creatinine 0.8 mg/dL (70.7 µmol/L), and triglycerides 302 mg/dL (3.41 mmol/L).
In addition to aspirin, which of the following is the most appropriate treatment?
A. Atorvastatin, high-intensity dosage
B. Atorvastatin, moderate-intensity dosage
D. Fenofibrate and atorvastatin, high-intensity dosage
MKSAP Answer and Critique
The correct answer is A. Atorvastatin, high-intensity dosage.
High-intensity statin therapy (atorvastatin, 40-80 mg/d; rosuvastatin, 20-40 mg/d) is appropriate in this patient who experienced a transient ischemic attack, a clinical manifestation of atherosclerotic cardiovascular disease (ASCVD). In addition to aspirin and treatment of other cardiovascular risk factors (hypertension, diabetes mellitus, smoking), statin therapy should be initiated for its well-established benefits in treating blood cholesterol levels to reduce future cardiovascular events. Even with concomitant hypertriglyceridemia, high-intensity statin therapy is still the primary treatment for patients with clinical ASCVD, unless patients have risk factors for statin-related adverse effects.
Moderate-intensity statin therapy (atorvastatin, 10-20 mg/d; simvastatin, 20-40 mg/d; fluvastatin, 40 mg twice daily; lovastatin, 40 mg/d; pitavastatin, 2-4 mg/d; pravastatin, 40-80 mg/d; rosuvastatin, 5-10 mg/d) is not the first choice for patients with clinical ASCVD due to the superior benefits of high-intensity statin therapy in this population. If the patient had risk factors for statin-related adverse effects, such as age older than 75 years or kidney or hepatic dysfunction, moderate-intensity statin therapy is an appropriate second-line treatment.
Fibrates are effective in treating hypertriglyceridemia; however, fibrate monotherapy, such as with fenofibrate, is not an acceptable initial choice for secondary prevention in patients with clinical ASCVD. Although treatment of hyperlipidemia no longer focuses on a specific LDL cholesterol target, the primary goal of treatment remains lowering LDL cholesterol, and statins have been shown to be effective at reducing LDL cholesterol levels and recurrent cardiovascular events. Only if triglyceride levels exceed 500 mg/dL (5.65 mmol/L) or the patient has a history of hypertriglyceridemia-induced pancreatitis should fibrate therapy be considered.
Studies have demonstrated that there is no additional ASCVD risk reduction with the use of combination therapy (statin plus nonstatin drugs). Nonstatin medications also have significant potential to cause adverse effects. Therefore, combination therapy is reserved for those with inadequate response or poor tolerance to statin therapy.
- High-intensity statin therapy is indicated for secondary prevention in patients with clinical atherosclerotic cardiovascular disease.
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