MKSAP: 59-year-old man is evaluated during a routine examination

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 59-year-old man is evaluated during a routine examination. He feels well and has no symptoms. Medical history is significant for hypertension. He does not smoke, and he does not have diabetes mellitus. He is active, performing aerobic exercise for 20 to 30 minutes four times per week. Medications are lisinopril and chlorthalidone.

On physical examination, the patient is afebrile, blood pressure is 122/74 mm Hg, and pulse rate is 76/min. Cardiac examination is unremarkable.

Laboratory studies:

Total cholesterol 169 mg/dL (4.38 mmol/L)
HDL cholesterol 36 mg/dL (0.93 mmol/L)
LDL cholesterol 106 mg/dL (2.75 mmol/L)
Triglycerides 135 mg/dL (1.53 mmol/L)

Which of the following is the most appropriate next step in management?

A. Begin low-intensity statin therapy
B. Begin moderate-intensity statin therapy
C. Begin high-intensity statin therapy
D. Calculate the 10-year atherosclerotic cardiovascular disease risk
E. Repeat lipid level measurement in 5 years

MKSAP Answer and Critique

The correct answer is D. Calculate the 10-year atherosclerotic cardiovascular disease risk.

The most appropriate next management step is to calculate this patient’s 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Results of lipid measurements and patient-specific data (age, race, blood pressure, hypertension treatment, diabetes mellitus, and smoking) allow for the calculation of 10-year ASCVD risk using the Pooled Cohort Equations. In adults aged 40 to 75 years who have at least one ASCVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year ASCVD risk of 10% or greater, the U.S. Preventive Services Task Force (USPSTF) recommends statin therapy for the primary prevention of ASCVD. The USPSTF also recommends that clinicians selectively prescribe statins to adults aged 40 to 75 years without a history of ASCVD who have one or more ASCVD risk factors and a calculated 10-year ASCVD event risk of 7.5% to 10% (grade C recommendation). Because this patient has one ASCVD risk factor (hypertension), it is appropriate that his risk be assessed, and through use of the Pooled Cohort Equations, his 10-year risk for ASCVD is 9.3%. According to the USPSTF recommendation, he should be considered as a potential candidate for statin therapy. The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends that patients without ASCVD or diabetes who have a 10-year ASCVD risk of 7.5% to less than 20% should be engaged in a discussion regarding cardiovascular risk reduction and offered moderate-intensity statin therapy if risk-enhancing factors are also present.

The initiation of statin therapy might be reasonable for this patient but not until his 10-year ASCVD risk is calculated. Such information can be used to determine the need for and intensity of stain therapy.

The optimal interval for assessment of ASCVD risk is undetermined; however, it is reasonable to measure lipid levels every 5 years in adults aged 40 to 75 years. This patient should not wait 5 years to have his ASCVD risk assessed and delay potentially beneficial therapy.

Key Point

  • Routine screening for lipid disorders and calculation of 10-year atherosclerotic cardiovascular disease risk by using the Pooled Cohort Equations should be performed in adults aged 40 to 75 years.

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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