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Sixty-One-Year-Old Male with Family History of Myocardial Disease

A 61-year-old male desired a thorough exam and preventative treatment given his familial history. When he was 50, the patient's father died of myocardial infarction. The patient himself denies being a smoker, drinker or user of illicit substances. He exercises frequently and follows a diet that is low in both fats and carbohydrates.

Standing at six feet, the patient weighs in at 195 pounds. His total cholesterol is 170 mg/dL with his LDL particle number being elevated at 1,407 nmol/L (less than 1,000 nmol/L is desired).

His left anterior descending artery revealed significant calcium and soft plaque with his other arteries showing calcium. Currently, he is taking 81 mg aspirin daily and 20 mg simvastatin.

How would you treat this patient? Why would you choose that particular treatment?

  • from Doctor Unite 1 day 21 hours
    Would switch his simvastatin to rosuvastatin 40 mg daily with a goal LDL less than 70 and LDL-P less than 1000. Add zetia or PCSK9I if not at goal. I would also obtain an exercise nuclear stress test to evaluate for large areas of ischemia and if there is a large area of ischemia, then proceed with Cardiac Cath. Encourage continued diet and exercise. Would recommend an aspirin daily.
  • from Doctor Unite 1 day 21 hours
    Would switch his simvastatin to rosuvastatin 40 mg daily with a goal LDL less than 70 and LDL-P less than 1000. Add zetia or PCSK9I if not at goal. I would also obtain an exercise nuclear stress test to evaluate for large areas of ischemia and if there is a large area of ischemia, then proceed with Cardiac Cath. Encourage continued diet and exercise. Would recommend an aspirin daily.
  • from Doctor Unite 1 day 21 hours
    I would make sure that he is taking a Baby ASA 81, unless otherwise contraindicated, Increase his Lipitor to 90 or Crestor 20mg daily; needs daily exercise, healthy diet, lose weight, get a Nuclear Medicine Stress Test or Stress Echo, obtain standard labs, Possible send him for a CT Calcium score
  • from Doctor Unite 2 days 16 hours
    Pertinent details missing/ambiguous: how old was father when he died? history of diabetes/blood glucose, HDL? triglycerides? BP? What is his muscle mass (BMI overwieght)? Is he symptomatic? LDL size? Lpa status apoB status? inflammatory markers? Actual history presented and labs insufficient to change current regiment, but would recommend stress test
  • 2 days 22 hours
    stress test (imaging if abn ECG). much attention paid to lifestyle - exercise, diet etc. Education about possible symptoms. Aspirin and moderate intensity statin.
  • from Doctor Unite 3 days 14 hours
    High intensity statin and add Vascepa if Trig greater than or equal to 150
  • from Endocrinologist Nation 4 days 16 hours
    change simvastatin to Atorvastatin 80 or Rosuvastatin 40 mg. If LDL still above 70 add a PCSK9 inhibitor
  • from Doctor Unite 4 days 21 hours
    To lower the risk and ldl particle I would switch simvastatin to atorvastatin or rosuvastain, add zetia, vascepa, , if ldl is > 70 consider nexletol or pcsk-9 inh
  • from Doctor Unite 4 days 22 hours
    I would start high intensity statin : atorvastatin 80 or rosuvastatin 40
    Asa 81
    Exercise nuclear medicine stress test
    Encourage dietary modifications
    Make sure that he has no DM
    Regular follow up
    Ldl goal < 70
  • from PA Unite 4 days 22 hours
    I see many comments to switch to crestor which I agree. I would also check triglycerides and even add a Vascepa for the added improvement to his LDL.
  • 5 days
    I would switch his simvastatin to rosuvastatin 40 mg daily with a goal LDL less than 70 and LDL-P less than 1000. Add zetia or PCSK9I if not at goal. I would also obtain an exercise nuclear stress test to evaluate for large areas of ischemia and if there is a large area of ischemia, then proceed with angiogram. Encourage continued diet and exercise.
  • 5 days 1 hour
    -Weight loss and regular exercise (30-60 min a day of moderate aerobic activity, 6 days per week).
    -continue aspirin 81mg daily
    -Change simvastatin to rosuvastatin 20mg daily
    -add fish oil 3g/day or Vascepa if covered
    -reassess lipid panel and other labs (including a1c) after 3 months of intervention.. If the ldl remains elevated, increase crestor to 40mg daily and add ezetamibe. If subsequent labs remain abnormal, can consider a pcsk9 inhibitor
    -screen for symptoms of coronary disease at visits q3-6 months... If symptoms present that are consistent with angina (or what he experienced with prior myocardial disease), then stress test or coronary ct
  • from Doctor Unite 5 days 2 hours
    He needs to lose more weight and needs to be on a stronger statin such as crestor, with an LDL goal of less than 70. There’s no mention of his BP - may need to have him on a B-blocker as well if BP not at goal. And if his plaque is that significant, he should be on plavix along with the baby aspirin. Definitely needs close f/u by cardiology.
  • from Doctor Unite 5 days 2 hours
    Switch to crestor 20mg and advance to 40mg depending on response and consider zetia addition at some point. Asa 81mg, start altace 10mg qd, yearly check of FBS,HgbA1c, baseline ETT.
  • from Doctor Unite 5 days 2 hours
    In light of his family history a PCSK9 should be on board
  • from Doctor Unite 5 days 3 hours
    I would switch his Simvastatin to Rosuvastatin 20mg with goal of getting his LDL below 70. Would get more information regarding the type of exercise he is doing, how often and for how long. Consider nuclear stress test especially if having any anginal symptoms. His BMI calculates to 26.4 which is considered overweight so would recommend at least 15 pound weight lose to bring BMI below 25. Would check A1c and 2 hour postprandial blood glucose ( R/O early glucose impairment ). Would start him on baby ASA 81 mg and would get serial BP measurements
  • from Doctor Unite 5 days 4 hours
    Goal LDL would be 70. Change to atorvastatin 40 mg. Consider adding zetia. Cont asa.
    NonHDL is important to consider as is particle size. Consider advanced lipid testing. Obviously simvastatin at 20 mg is not getting plaque regression as shown on calcium scoring. Repatha would be great choice if not getting to goal LDL.
  • from Generation NP 5 days 4 hours
    I would continue the Aspirin, increase Atorvastatin to 40mg start on Repatha if insurance covers it, if not start Zetia. Increase exercise 5x per week for at least 30mins. Repeat lipid panel in 6 months.
  • from Doctor Unite 5 days 4 hours
    His strong family history and cath results suggest lifestyle modifications alone leaves him too high risk. Would switch his simvastatin to crestor. Continue aspirin. Follow closely with a cardiologist
  • from Doctor Unite 5 days 4 hours
    Nonstatin such as Nexletol for cholesterol and prevent CVD.
  • from Doctor Unite 5 days 4 hours
    I would ask the patient to intensify his diet and exercise program and give the results of the LAD findings would suggest changing his statin to crestor 40 mg daily to drive his LDL to less than 70. He should have a follow up appointment in 4 weeks to repeat blood work. Continue with ASA.
  • 5 days 5 hours
    He's not diabetic, so risk factors include fhx and cacs. Suspect his cac is >300 AU (although a number has not been provided), prophylactic ischemia detection by stress testing is class 2b indication. If truly asympt w exercise in day to day life, can omit this. Intensify diet and lifestyle changes, continue ASA 81 (since CAC>100) and change simva to rosuva 20, goal LDL-C <100 (70 optional but preferable). Follow lipids and clinically q 6-12 mo. Check Lp(a).
  • from Doctor Unite 7 months
    Screen for CAD with stress thallium or stress each.
    Switch statin to Crestor.
  • from Doctor Unite 7 months 2 weeks
    change to better statin- seek cardio advice re further w/u and/or therapy
  • from Doctor Unite 7 months 2 weeks
    due to the added stresses in life now, and his age, and his cardiovascular history and the Covid-19 risks from blood clot and pulmonary effects.. general review of family/recreational/community and religious interactions/attitudes about mandated distancing and masks/ use of OTCs/ etc. are things to consider j johns md
  • from Doctor Unite 7 months 3 weeks
    Switch to high intensity statin from simvastatin : atorvastatin 40 or rosuvastatin 20. If data is based on CT calcium score would obtain nuclear medicine exercise stress test. Encourage strict dietary and lifestyle modifications: low saturated fat diet, weight loss , regular exercise.
    Need to f/u every year if stress test is negative
  • from Doctor Unite 8 months
    as he already is agreeable to statin, would strongly recommend changing to a high intensity statin at maximum tolerated dose. Not sure that a cath is indicated in a nonsymptomatic patient, but consideration for stress testing - although if clearly no symptoms with his current exercise regimen, not sure about coverage for testing. I like the CC score to risk stratify, but it appears he already is at least somewhat high risk.
  • from Doctor Unite 8 months
    This type of family history requires al the environmental risk factors be considered, e,g, ldl-c,=or < than 70, BMI < 30, mediterranean or dash diet, encourage exercise and patience with wt loss. This patient warrants a cardiac cta and calcium scoring evry other year f no symptoms
  • from Doctor Unite 8 months 1 week
    Although he may be at higher risk for CVD, I will also need to know what his blood pressure is, and also his blood sugar or HbA1c level for further clarification of risk assessment. He may need high intensity statin therapy, but this preliminary assessment should be done first before addressing treatment options.
  • from Doctor Unite 8 months 1 week
    needs high dose statin- rosuvastatin- likely with zetia if does not bring down enough need to consider use of a drug like repatha as well.What is his Lp(a) level and his apo-B? there is clearly history for premature CVD and likely he needs to be treated as such. Would like to know family history of other relatives of his father re CVD and any other first degree relatives he has.
  • from Doctor Unite 8 months 1 week
    He needs aggressive lipid lowering. I would switch him from Simvastatin 20 mg to a high potency statin at the maximum dose With ezetimibe added. I would also check an lp(a) and also be sure his triglycerides are optimized. You can get marginal mortality benefit wit Vascepa. Continue the low dose ASA, exercise, proper diet, and not smoking. Be sure the HgBA1C is in range.
  • from Doctor Unite 8 months 1 week
    I will obtain a detail history. What’s his race. Who has been managing him. Can we get his medical records.
    When was the last visit and labs done.
    If not will obtain baseline : CRPs, Liver , basic chemistry , A1c and Renal FT. Fasting Lipid
    In office: ABI, vital to include BP sitting and standing
    With family:will switch to high intensity statin Atovarstatin 40mg with education. Collaborate with :cardiology, dietician , PharmD (switch
    apixaban. ASA), encourage lifestyle modification.
    Follow up in 4-6 weeks or sooner if any adverse effect from med
  • from Doctor Unite 8 months 1 week
    Needs more potent statin therapy and review of diet and stress test; he is high risk ; may review calcium level with cardiologist (no information as to how this was found); follow closely and add additional lipid lowering therapy if needed.
  • 8 months 1 week
    I would assume that the calcification described was detected either by a coronary calcium scan or a coronary CT angiogram. Either way, he is at increased cardiovascular risk which is addressed (at least initially) with a healthy lifestyle (diet and exercise) and achievement of a targeted LDL cholesterol (likely 70-100mg%). This latter issue is unlikely to occur with simvistatin 20mg. I agree with higher doses of a more potent statin to reach the target. His regular exercise is, in effect, a "poor man's stress test," so additional cardiac testing is not indicated at present. I would caution the gentleman to let me know should he experience chest discomfort, unusual dyspnea, or a change in stamina while exercising. He would benefit from regular medical follow up as well. This could be accomplished either via his PCP, a cardiologist, or both.
  • from Endocrinologist Nation 8 months 1 week
    Agree with above and diet. Would go to more potent statin then likely vascepa.
  • from Doctor Unite 8 months 1 week
    Given his familial history. He exercises frequently and already follows a diet low in fats and carbs. He seems to be doing his best in trying to lead a healthy lifestyle. His LDL particle number is elevated. He probably would benefit from a nonstatin such as Nexletol, due to the side effect of rhabdomyolysis from using statins. I am concerned about deposits in his left anterior descending artery (widow-maker infarction), and I would refer him to a cardiologist.
  • from Endocrinologist Nation 8 months 1 week
    Lifestyle changes then medications if not better
  • from Doctor Unite 8 months 1 week
    Start with a more strict diet to correct the weight and lipid levels.Continue ASA 81mg.Check CPK and liver enzymes,if normal,can increase dosage of Zocor.Get a nuclear stress test .
  • from Doctor Unite 8 months 1 week
    Agree with my other colleagues, more aggressive statin therapy with mid-high dosages is indicated. I would use 20-40mg of crestor or 40-80mg of lipitor. Continue aspirin. Referral to cardiology for consideration of cardiac catherization (not sure how calcium was observed in arteries). Blood pressure and blood sugar control needs to be optimal. Consider using a betablocker and/or ACE inhibitor - no mention of his blood pressure above. Once cleared by cardiology aggressive lifestyle modification with moderate physical activity and a plant based diet would be recommended.
  • from Doctor Unite 8 months 1 week
    Note that autocorrect made many errors on NYC first post and it was difficult to navigate back to correct them on my phone. Should have been... without knowing the rest of his profile ... LDL particle number ... no Bc
  • from Doctor Unite 8 months 1 week
    Patients should not be treated on limited information. Should assessed for b lifestyle, blood pressure, metabolic syndrome, inflammatory markers, lipoprotein (a) and a stress ECHO.
  • from Doctor Unite 8 months 1 week
    He is at extremely high risk due to plaque and family history, wiyy thy hour even knowing the rest of his lipid profile, A1c, Lp(a), etc. He would be far safer with maximum treatment and his goal LDL Psrt le number should be below 500 nmol/l, preferably below 300. He should be on Crestor 40 mg, Zetia 20 mg. If not at goal, should add Repatha in Bc addition to the other two meds. Add Vascepa if triglycerides above 100 mg/dL after a meal.
  • from Doctor Unite 8 months 1 week
    Agree with switching to more aggressive statin therapy and monitoring closely for improvement. Not sure where or how the observations were made about the coronary arteries but would get more accurate quantification of the lad plague and calcium and intervene if necessary now rather than wait
  • from Doctor Unite 8 months 1 week
    his LDL goal would be under 70 so would start him on Crestor 20 daily,also do stress test,then CT Angio,continue baby asa.Advise regular exercise,healthy diet,maintain weight and regular follow up.
  • from Doctor Unite 8 months 1 week
    Would swich to Crestor 20mg, recheck lipids and if not reaching goal increase statin. Check triglycerides; do a baseline stress test. Consider adding Altace 10mg qd (per HOPE study).
  • from Doctor Unite 8 months 1 week
    encourage him to exercise regularly,work on loosing wight, high dose statin, detailed CVD risk evaluation including stress or nuclear scan and necessary labs.
  • from Doctor Unite 8 months 1 week
    This patient meets criteria for high intensity statin. I would switch from 20 mg simvastatin to atorvastatin 40-80 mg or rosuvastatin 20-40mg.
  • from Doctor Unite 8 months 1 week
    Would switch to Crestor 20 mg QD. What are his triglycerides. Would consider adding Vascepa and stress diet. Would get cardiac Cath if not done