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A 45-year-old man is being evaluated for hyperlipidemia. A recent lipid screen revealed an elevated LDL despite maximum doses of rosuvastatin and ezetimibe. His medical history includes a recent myocardial infarction that was treated with a bare-metal stent about 3 weeks ago and peripheral artery disease that is currently symptomatic. The patient continues to smoke 1 pack of cigarettes per day. His medications include aspirin, clopidogrel, rosuvastatin, ezetimibe, cilostazol, carvedilol, and valsartan. On physical exam, the patient's vital signs are within normal limits. His BMI is 27 kg/m2. Cardiac examination reveals a left femoral bruit and significantly diminished pedal pulses bilaterally. The patient's LDL is 132 mg/dL, HDL 55 mg/dL, triglycerides 245 mg/dL, and total cholesterol 239 mg/dL. What is the most appropriate management strategy for this patient?
A 45-year-old man is being evaluated for hyperlipidemia. A recent lipid screen revealed an elevated LDL despite maximum doses of rosuvastatin and ezetimibe. His medical history includes a recent myocardial infarction that was treated with a bare-metal stent about 3 weeks ago and peripheral artery disease that is currently symptomatic. The patient continues to smoke 1 pack of cigarettes per day. His medications include aspirin, clopidogrel, rosuvastatin, ezetimibe, cilostazol, carvedilol, and valsartan. On physical exam, the patient's vital signs are within normal limits. His BMI is 27 kg/m2. Cardiac examination reveals a left femoral bruit and significantly diminished pedal pulses bilaterally. The patient's LDL is 132 mg/dL, HDL 55 mg/dL, triglycerides 245 mg/dL, and total cholesterol 239 mg/dL. What is the most appropriate management strategy for this patient?
What category of drug should be administered to avoid fluid retention?
What category of drug should be administered to avoid fluid retention?
Which type of potassium current represents an evolutionarily old type of channel that is relatively insensitive to drugs, and is responsible for causing the resting potential to have a value near EK?
Which type of potassium current represents an evolutionarily old type of channel that is relatively insensitive to drugs, and is responsible for causing the resting potential to have a value near EK?
In which patient with HFrEF would ivabradine use be contraindicated?
In which patient with HFrEF would ivabradine use be contraindicated?
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A patient was prescribed doxycycline. Which statement by the patient indicates that more clarification is needed? (Select all that apply)
A patient was prescribed doxycycline. Which statement by the patient indicates that more clarification is needed? (Select all that apply)
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A patient diagnosed with active TB is given a multi-drug regimen that contains isoniazid. Which of the following mechanisms describes why it is particularly effective & selective in exerting harmful effects against mycobacteria?
A patient diagnosed with active TB is given a multi-drug regimen that contains isoniazid. Which of the following mechanisms describes why it is particularly effective & selective in exerting harmful effects against mycobacteria?
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Which of the following is NOT a risk factor for developing severe Respiratory Syncytial Virus (RSV) disease?
Which of the following is NOT a risk factor for developing severe Respiratory Syncytial Virus (RSV) disease?
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Which product may be considered in patients weighing >15 kg with resistance to all topical head lice treatments?
Which product may be considered in patients weighing >15 kg with resistance to all topical head lice treatments?
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The two most common side effects produced by the majority of anticancer drugs are:
The two most common side effects produced by the majority of anticancer drugs are:
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Dianne is a 58 year old overweight woman with a history of Type 2 diabetes that has been well controlled with metformin and glyburide (a sulfonylurea) until recently. Her record of glucose readings indicate normal morning (fasting) glucose levels (80-100 mg/dL), but a progressively increasing high glucose level before lunch (>110 mg/dL) and before dinner (190-200 mg/dL). Her lab values are all within normal limits, and she has no history of kidney or heart disease. Dianne states that she has a strong distaste for needles, and would prefer sticking to oral medications. Which medication would be appropriate for addressing Diane's problem with glucose control?
Dianne is a 58 year old overweight woman with a history of Type 2 diabetes that has been well controlled with metformin and glyburide (a sulfonylurea) until recently. Her record of glucose readings indicate normal morning (fasting) glucose levels (80-100 mg/dL), but a progressively increasing high glucose level before lunch (>110 mg/dL) and before dinner (190-200 mg/dL). Her lab values are all within normal limits, and she has no history of kidney or heart disease. Dianne states that she has a strong distaste for needles, and would prefer sticking to oral medications. Which medication would be appropriate for addressing Diane's problem with glucose control?
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Which of the following best describes risk factors for endometriosis development?
Which of the following best describes risk factors for endometriosis development?
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A patient complains of pain and stiffness in the wrists and knees. Stiffness is worst in the morning. Blood test confirms rheumatoid arthritis. You recommend a short course of corticosteroids. Which of the following is the most potent corticosteroid?
A patient complains of pain and stiffness in the wrists and knees. Stiffness is worst in the morning. Blood test confirms rheumatoid arthritis. You recommend a short course of corticosteroids. Which of the following is the most potent corticosteroid?
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A patient treated with verapamil for hypertension and ischemic heart disease developed constipation. Which of the following is an osmotic laxative that can be used to treat constipation?
A patient treated with verapamil for hypertension and ischemic heart disease developed constipation. Which of the following is an osmotic laxative that can be used to treat constipation?
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Which of the following is NOT a prophylactic strategy for asthma?
Which of the following is NOT a prophylactic strategy for asthma?
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A 56-year-old woman presents with almost daily heartburn and regurgitation after eating meals. She has a past medical history of bipolar disorder, hypertension, dyslipidemia, and iron deficiency anemia. Her medications include lithium, amlodipine, atorvastatin, and ferrous sulfate. The clinician would like to prescribe a medication that works on the hydrogen potassium ATPase proton pump to treat her heartburn symptoms. Serum levels of which of the following may be decreased with the addition of this medication?
A 56-year-old woman presents with almost daily heartburn and regurgitation after eating meals. She has a past medical history of bipolar disorder, hypertension, dyslipidemia, and iron deficiency anemia. Her medications include lithium, amlodipine, atorvastatin, and ferrous sulfate. The clinician would like to prescribe a medication that works on the hydrogen potassium ATPase proton pump to treat her heartburn symptoms. Serum levels of which of the following may be decreased with the addition of this medication?
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A 35-year-old male presents for an evaluation. He has a history of homozygous familial hypercholesterolemia at 15 years old, following his father's sudden death by a serious myocardial infarction at 43 years old. Two uncles have died suddenly, at the ages 37 and 43 years old. His LDL-C was 530 mg/ dL, and he was advised with LDL-C apheresis and administered a statin. He reported discounting the statin following five months because he felt discomfort about taking it. He stopped apheresis as well because he needed a 3-hour drive to reach the medical unit, and his health insurance just covers about 35% of these expenses. He also reported discontinuing seeing his provider. At 33 years old, he survived an inferior wall myocardial infarction. On the cardiac catheterization procedure, he was discovered having a diffuse multi-vessel disease with approximately 80% occluded left major coronary artery, a 75% occluded proximal circumflex artery, and an obstructed mid-part of the right coronary artery. He had a successful three-vessel coronary artery bypass. The provider has prescribed lomitapide 5 mg once per day. After two weeks, the patient called the provider to report his new lab results for the LDL-C, which was 207 mg/dL. What should be the next step in managing this patient's condition?
A 35-year-old male presents for an evaluation. He has a history of homozygous familial hypercholesterolemia at 15 years old, following his father's sudden death by a serious myocardial infarction at 43 years old. Two uncles have died suddenly, at the ages 37 and 43 years old. His LDL-C was 530 mg/ dL, and he was advised with LDL-C apheresis and administered a statin. He reported discounting the statin following five months because he felt discomfort about taking it. He stopped apheresis as well because he needed a 3-hour drive to reach the medical unit, and his health insurance just covers about 35% of these expenses. He also reported discontinuing seeing his provider. At 33 years old, he survived an inferior wall myocardial infarction. On the cardiac catheterization procedure, he was discovered having a diffuse multi-vessel disease with approximately 80% occluded left major coronary artery, a 75% occluded proximal circumflex artery, and an obstructed mid-part of the right coronary artery. He had a successful three-vessel coronary artery bypass. The provider has prescribed lomitapide 5 mg once per day. After two weeks, the patient called the provider to report his new lab results for the LDL-C, which was 207 mg/dL. What should be the next step in managing this patient's condition?
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A patient with heart failure, arrhythmia, arthritis, and depression begins treatment with furosemide for the heart failure. Which drug, if taken with furosemide, will cause a drug interaction?
A patient with heart failure, arrhythmia, arthritis, and depression begins treatment with furosemide for the heart failure. Which drug, if taken with furosemide, will cause a drug interaction?
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A 69 yo woman presents to the Tulane ED with signs of ankle edema, shortness of breath & other symptoms consistent with CHF. Her echocardiogram indicates that she has a relatively normal EF of 54%. A drug that would be contraindicated in treating this patient is:
A 69 yo woman presents to the Tulane ED with signs of ankle edema, shortness of breath & other symptoms consistent with CHF. Her echocardiogram indicates that she has a relatively normal EF of 54%. A drug that would be contraindicated in treating this patient is:
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While beta-lactam antibiotics remain one of the most commonly prescribed types of antibiotics, they have side effects that can range from mild to life-threatening in nature. What type of side effect is most commonly observed?
While beta-lactam antibiotics remain one of the most commonly prescribed types of antibiotics, they have side effects that can range from mild to life-threatening in nature. What type of side effect is most commonly observed?
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On discharge from hospital, the patient was advised not to rely solely on oral contraceptives to prevent pregnancy because they would not be effective while taking antimycobacterial drugs. Agent most likely to interact with oral contraceptives is
On discharge from hospital, the patient was advised not to rely solely on oral contraceptives to prevent pregnancy because they would not be effective while taking antimycobacterial drugs. Agent most likely to interact with oral contraceptives is
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Study Notes
Patient Evaluation for Hyperlipidemia
- A 45-year-old male presents with elevated LDL despite maximum doses of rosuvastatin and ezetimibe.
- Medical history includes recent myocardial infarction (treated with bare-metal stent 3 weeks prior) and peripheral artery disease.
- Currently smokes 1 pack of cigarettes per day.
- Medications include aspirin, clopidogrel, rosuvastatin, ezetimibe, cilostazol, carvedilol, and valsartan.
- Physical exam reveals normal vital signs, BMI of 27 kg/m^2, left femoral bruit, and diminished pedal pulses bilaterally.
- Lipid panel: LDL 132 mg/dL, HDL 55 mg/dL, triglycerides 245 mg/dL, and total cholesterol 239 mg/dL.
Management Strategy
- The most appropriate management strategy involves smoking cessation and addition of alirocumab.
- Continuing atorvastatin and ezetimibe alone is insufficient to reduce ASCVD risk further.
- PCSK9 inhibitors (like alirocumab) are recommended for patients with high ASCVD risk, already on maximum statin and ezetimibe doses, and LDL above 70 mg/dL or non-HDL above 100 mg/dL.
- Smoking cessation is recommended regardless of age or comorbidities due to the high risk of ASCVD.
Teaching Points
- For patients at very high risk for ASCVD, adding a PCSK9 inhibitor like alirocumab is recommended when on maximum statin and ezetimibe doses and LDL over 70 mg/dL or non-HDL over 100 mg/dL
- Smoking cessation is important regardless of age or other health conditions.
- PCSK9 inhibitors are expensive and require injections every 2-4 weeks.
Other Topics
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Hyperlipidemia: Elevated levels of lipids in blood.
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ASCVD: Atherosclerotic cardiovascular disease.
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LDL: Low-density lipoprotein, often called "bad" cholesterol.
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HDL: High-density lipoprotein, often called "good" cholesterol.
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PCSK9 inhibitor: A class of drugs that lowers LDL cholesterol.
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Alirocumab: Example of a PCSK9 inhibitor.
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Rosuvastatin: A statin drug used to lower cholesterol.
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Ezetimibe: A drug that lowers cholesterol absorption.
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Description
This quiz explores the case of a 45-year-old male with elevated LDL and a background of cardiovascular issues. It focuses on effective management strategies, including smoking cessation and the role of PCSK9 inhibitors. Test your knowledge on hyperlipidemia management and cardiovascular risk reduction.
