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Fifty-Five-Year-Old Male Presents With a Complicated History

The patient is a non-smoker, eats a diet that is low in fats and carbohydrates and exercises often. He weighs 193 pounds, stands six feet tall, has a body mass index of 26.5 and a 38-inch waist circumference. His father died at the age of 50 from a myocardial infarction while his mother is 75 years old and has type 2 diabetes. 

Currently, he is on 81 mg of aspirin daily as well as 20 mg simvastatin daily. Some notable lipid panel results revealed that his total cholesterol was 170 mg/dL with his LDL particle number being 1407 nmol/L. 

Other labs showed that his liver enzymes were elevated. In addition, the patient's kidney function tests demonstrated creatinine clearance that is impaired, as well as elevated uric acid and blood urea nitrogen. 

A computed tomography angiography revealed that the patient has calcium in his arteries including soft plaque in the left anterior descending. In addition, he has remarkable coronary calcium. 

What would be your treatment plan for this patient?

  • from Doctor Unite 3 days 9 hours
    Full lipid evaluation including Lpa. Possible rapatha but eval liver test for fatty liver usg
    Cardiac eval heart score. Thall ett

    Eval for DM Hba1c thyroid etc.
  • from Doctor Unite 4 days 12 hours
    Needs to work on getting his LDL way down. Continue his healthy diet and lifestyle. Needs to work on getting his LDL lowered. Stay off Cigarettes and Alcohol. Get a male training partner with similar needs and desires.
  • from Doctor Unite 2 weeks 2 days
    This patient is clearly at an elevated cardiovascular risk. He is still above an ideal BMI. He needs to continue to work with diet and exercise to reduce his BMI. I would have a nutritionist make sure he is truly following a low saturated fat diet. I am not a fan of Simvastatin and would try a water soluble statin. Would try Rosuvastatin and maximize the dosage, if his LFT's allow it. If his LFT's remain elevated you could consider a PCSK9 although that would probably require help from a cardiologist to get authorized. Also, consider adding in Ezetimibe. What is his blood pressure as that needs to be optimized. He needs a liver ultrasound as his elevated LFT's are likely due to NAFLD. If he has a fatty liver, then weight loss is critical. What is his A1C as he has most likely has metabolic syndrome. With an elevated A1C, consider a GLP-1.
  • from Doctor Unite 3 weeks
    change diet and life style and repeat in 1 month
  • from Doctor Unite 3 weeks 2 days
    send to cardiology; adjust diiet repeat labs 30 days
  • from Generation NP 3 weeks 2 days
    Pt is high risk for coronary event based on his FH in father and mother's diabetic hx, his high cholesterol and his abdominal obesity. I would stop simvastatin and try atorvastatin at 40 mg and recheck LFT and CK in 2-4 weeks. I would also check BMP and HgA1C and initiate possibly jardiance if in prediabetes range. Pt needs counseling on nutrition to lose weight with goal BMI < 25. Needs further work-up for his elevated Cr and delve into possible causes, NSAID use, protein consumption, hydration. In addition start ASA 81 and set up for stress test. Initiate blood pressure control if indicated
  • from Doctor Unite 3 weeks 3 days
    We need to know what’s his Hba1c level as his mother suffers from Type 2 DM. He also needs base line EKG to look at the status of the heart. He might need Stress ECHO to R/O Coronary Atherosclerosis.
  • from Generation NP 3 weeks 3 days
    This man needs a lot of education about the importance of daily exercise, a plant-based diet and aggressive cholesterol management with ASA 162mg/day, zetia or crestor. If h has not had a stress test, he will need one w a cardiac onsult.
    If repeat lab are unchanged, consider pcsk9 inhibitor
  • from Doctor Unite 3 weeks 4 days
    Aggressive cholesterol treatment with Crestor and zetia. With full cardiac and carotid screening including cscore usg echo poss thall ett.
  • from Doctor Unite 3 weeks 4 days
    recommend mod- high intensity statin, check urine micoalbumin, place on AceI . Check GGT since increase lft might simply be steatosis can check abdominal u/s to confirm this .
  • from Generation NP 3 weeks 4 days
    Would get further labs- A1C, Urinalysis with urine micro, testosterone, stress test. Patient is high risk based on family history, would change to Atorvastatin to decrease LDL of less than 70 and monitor Lipid Panel and LFT in 3 months.
  • from Doctor Unite 3 weeks 4 days
    he has to many risks factors not to be considered CAD equivalent. theres no much information to make the appropriate agent choice but with the increase in lfts id hold statins check liver us for fatty liver ( in the meantime place in nexlizet samples I ) ordera heart calcium scan , see if insurance will consider paying for PCSK9, get his weight off and look into his other issues
  • from Doctor Unite 3 weeks 4 days
    I would switch the statin to atorvastatin 20 mg/d, and recheck a CMP / lipid profile in 1 month. I would also add a CRP, urine microalbumin, and an A1c to the lab testing in 1 month. I'd continue the low-dose ASA. I'd also check a renal artery doppler study to be sure he's not developing renal artery stenosis. If the A1c is elevated (above 6.0), then I'd consider a trial of low-dose metformin in the future. His diet needs to be explored further, with a goal towards getting his BMI under 25. He should consider a trial of a vegan diet.
  • from Doctor Unite 3 weeks 4 days
    Would recommend changing to atorvastatin 40mg check lipid in cmp is 3 mos to reevaluate lft's
  • from Doctor Unite 3 weeks 4 days
    Patient has a well known Cardiovascular Disease. Change Simvastatin to Atorvastatin 20 mg (LFTs elevated) to a target LDL of less than 70 and monitor Lipid Panel and LFT in 3 months. Diet and exercise to maintain BMI of <25.
  • from Generation NP 3 weeks 4 days
    He is at increased risk of a cardiac event, dietary education referral, refer to cardiology, screen for T2D
  • from Doctor Unite 3 weeks 4 days
    Pt has high cardiovascular risk, will optimize lipid treatment, change simvastatin for atorvastatin, or rosuvastatin, add zetia, if ldl not lower than 70 , consider Pcsk-9 inh, or nexletol, start aspirin.
  • from Generation NP 3 weeks 4 days
    Farxiga and maybe praulent
  • from PA Unite 3 weeks 5 days
    I would suggest dietary changes, and would increased his statin.
  • from PA Unite 3 weeks 5 days
    I would get further labs- A1C, Urinalysis with urine micro, testosterone, stress test to ensure exercise is safe given his plaque formations and family history and other conditions are ruled out. Ace inhibitor if BPs are elevated. Switching his statin to Lipitor 40 or Crestor given his plaque formation already in hopes of reversal. Nutritionist with dietary changes- Mediterranean diet and exercise after stress test is clear to reduce BMI and abdominal obesity. Recheck LFTs in 4 weeks with addition labs and RUQ Us if still elevated.
  • 3 weeks 5 days
    The patient has evidence of CAD so it is very important to control his risk factors. I would switch his simvastatin to atorvastatin 40 mg and recheck an NMR lipid panel in 2-3 months. If LDL-P > 1000 or LDL > 70, I would either increase atorvastatin to 80 mg depending on LFTs or add Zetia. If he is still not at goal, could add a PCSK9I.
  • from Doctor Unite 3 weeks 5 days
    Patient is high risk based on family history and his lab work/ studies to date. Need to clarify liver issues and renal issues. Is the LFT elevation and renal issues exacerbated by his strenuous exercising? Would consider switch to psk9 inhibitor. Also need additional cardiovascular work up .
  • from Doctor Unite 3 weeks 5 days
    While he has risk factors, it is not clear if he has an acute risk. He is on appropriate medications for his current history. His LFT's and kidney failure need to be addressed first.
  • from Doctor Unite 3 weeks 5 days
    Aside from what others have said, possibly stop baby aspirin due to kidney issues
  • from Doctor Unite 3 weeks 5 days
    When I hear "exercises often" I am very skeptical. The narrative does not mention any current complaints so I will assume he is in for routine medical care/advice. Exercise regimen needs to be nailed down and he should be told the need to exercise daily. He could wear a simple heart rate monitor to ensure he gets his rate to a predetermined, by his physician, rate, hopefully at 85% of his maximum predicted rate.
  • from Doctor Unite 3 weeks 5 days
    First I would get the ldl particles under control with repatha - monoclonal - seeks ldl - reduces plaque - and avoids liver issues.
    Second - liver issue - genetic ( his dad died and he is not metabolizing the statin - would check gene - mthfr-C677 gene and hemachromatosis - can be ferritin issue
    Third - what’s his testosterone. ? No matter how lean , fit, dietary control - he is an aging male with lowering hormones - testosterone and thyroid - both which when low elevated cholesterol.
    I dive into the cellular chemistry and genetics - different approach with great results.
  • 3 weeks 5 days
    He needs a functional study ie a nuclear stress to determine the significance of his CTA findings. If + for ischemia, he needs to go on medical rx such as a beta blker. Also needs more agrressive rx of his increased LDL particle with either a stronger statin and /or addition of zetia or nexletol. w/u of renal insufficiency obviously to r/o bilateral renal artery atherosclerosis, diabetic nephropathy, etc
  • 3 weeks 5 days
    Given that family history, I would get a lipoprotein (a) level. If elevated that would encourage me to add a PCSK-9 to his statin. Note that while the history reports low fat and low carbs, detailed nutritional intake is needed. If he truly is exercising often I would definitely screen for symptoms and consider stress testing. I would still focus on aggressive lifestyle and medical management, including a metabolic approach. His LDL goal should be <100 and his LDL particle number <1000 at minimum - more aggressive if the Lp(a) is elevated or stress test is abnormal
  • 3 weeks 5 days
    We are not aware of his specific lab values. The history and lab values suggest further metabolic workup is indicated. This suggests metabolic syndrome and fatty liver but more data is necessary. Given that his cholesterol is not under control, needs a higher statin dose or a more potent statin, as he likely has fatty liver rather than statin toxicity. He needs to be screened for insulin resistance and type 2 diabetes, He would benefit from nutrition counseling, physical activity and weight loss. A cardiac stress test is indicated given his coronary calcium though we don’t have a score.
  • from Doctor Unite 3 weeks 5 days
    I would try a PCSK9
  • from Generation NP 3 weeks 5 days
    The liver enzymes is an issue so this needs investigation prior to increasing the statin. Is he taking any alternative medications that could be elevating Enzymes? NSAIDS? that could be affecting the kidney, alcohol? hepatitis? Is there more to this story? I need more information personally. Also, if he doesn't see a cardiologist, he should see one on a regular basis due to the family history. We need to see all of his labs, diabetic workup?
  • from PA Unite 3 weeks 5 days
    This patient is at high risk for a cardiovascular event , to reduce the risk and plaque will change simvastatin to rosuvastatin...high risk for cardiac event...heart cath
  • from PA Unite 3 weeks 5 days
    he needs cardiac referral, high dose crest, possibly pcsk9inhibitror a good diet and exercis
  • from Doctor Unite 3 weeks 5 days
    This patient has high cardiac risk factors; depending on how high lft’s are, would go to more potent statin and consider adding zetia to lower ldl to less than 70; consider stress test, additional weight loss diet and needs renal evaluation , and alc screen.
  • from Generation NP 3 weeks 5 days
    Higher potency statin for sure, may need zetia. Needs full cardiac evaluation. Would check A1c, renal u/s., comprehensive, TFT, hepatitis panel,
  • from Doctor Unite 3 weeks 5 days
    All the comments seem to ignore the elwvated liver enzymes when they recommend high dose statin wuthiut knowing how high the enzymes are. He doesnt meet criteria for a PCSK9I so Nexleto is appropriate. For those who said coronary angio...are you kidding me?
  • from Doctor Unite 3 weeks 5 days
    Would check a Comprehensive Panel, and HbA1c. Need to be more aggressive with LDL shooting for a level < 70. Would also consider adding Zetia.
  • from Doctor Unite 3 weeks 5 days
    And for his atherosclerosis
  • from Endocrinologist Nation 3 weeks 5 days
    His cholesterol is not under control, needs a higher statin dose or a more potent statin, probably has fatty liver too, needs to be screened for insulin resistance and type 2 diabetes, may benefit from weight loss and cardiac stress test
  • from Doctor Unite 3 weeks 5 days
    I would recommend obtaining. Fasting lipid panel with an A1C
  • from Doctor Unite 3 weeks 5 days
    Prescribe Nexletol for cholesterol and to help with his diabetes.
  • from Endocrinologist Nation 3 weeks 5 days
    Weight loss, change to more potent statin. likely has fatty liver.
  • from Doctor Unite 3 weeks 5 days
    he needs cardiac referral, high dose crest, possibly pcsk9inhibitror a good diet and exercise
  • from Doctor Unite 3 weeks 5 days
    Needs a cards work up and place on statins
  • from Doctor Unite 3 weeks 5 days
    He has high cardiovascular risk. I recommend a cardiac stress test. Recommend weight reducing diet to decrease truncal obesity. Switch to Rosuvstatin and closely monitor renal and liver function.
  • from Doctor Unite 1 month 3 weeks
    Cards consult. Stress test/coronary angiogram. High dose statin.
  • from Doctor Unite 1 month 4 weeks
    Start him on a high dose statin and order a cardiac work up.
  • 1 month 4 weeks
    I definitely would change his simvastatin to high intensity statin such as Lipitor 40 mg or Crestor 20 mg. Also I would check for his Lpa level and get hscrp
  • 2 months
    I would switch his simvastatin to high intensity statin (Lipitor or Crestor) and recheck lipids and CMP 6 weeks later. If lipids or LFTs remain elevated, consider a PCSK9 inhibitor along with maximally tolerated statin.
  • from Doctor Unite 2 months
    He has high cardiovascular risk.Referral to a cardiologist for stress test and catheterisation.Continue ASA81mg for cardiac protection.Change to Crestor to improve LDL< 70mg/dl and monitor liver enzymes at<3times upper normal limit.Check liver ultrasound,if he has NAFLD ,add Vascepa.Referral to a nephrologist for renal US and start allopurinol to normalize Utica acid level.
  • from Doctor Unite 2 months
    Based on the Soft Plaque in the LAD and the increased LDL particle size he needs to be on the PCSK9 inhhbitor aloing with the potent statin like Rosuvstatin to halt /reverse the atheroscelrotic process ! Wether he needs cardiac cath or not depends on the symptoms and the reason why the CTA was ordered in the first place if CTA was ordered to evaluate the symptoms then cardiac cath is must as there is enough evidence for CAD ! Liver Enzymes elevation could be due to Fatty liver but need the complete eval of the abnormal LFTS , So does the Impaired Renal fucntion Urine for proteinuria , HTN eval , Renal Ultrasound , Eelvated Uric Acid ? Urate Nephropathy , All Pointing out towards Inflamatory Metabolic State !
  • 2 months
    At this point, the patient is at increased cardiovascular risk. I would start aspirin 81 mg today along with rosuvastatin 20 mg a day. Monitor liver function enzymes and continue dietary modification and regular exercise regimen. Yearly treadmill surveillance. He does have atherosclerosis by abnormal coronary calcium score.
  • from Doctor Unite 2 months
    He is not obese, exercises and is a non-smoker, however has evident high-risk for vascular disease in view of his CTA findings, uric acid and family history. His liver issues may result from fatty liver related to a pre-diabetic condition, in view of his family history and renal issues are concerning, also. Alcohol intake should be curtailed of course and diabetic workup should be done.
    Generally, statin drugs should be fine in this situation and rosuvastatin (20mg/d to start) would be safe and more effective than simvastatin. Probably, the 81mg of aspirin is sufficient dose for CV prophylaxis and should be continued. Continuing regular exercise and normal body weight is encouraged. My primary concerns is that he may be diabetic or prediabetic; if workup confirms this, early use of metformin and/or SGLT2 inhibitor such as empagliflozin would be indicated.
  • from Doctor Unite 2 months
    The soft plaque is concerning. The fact that his LDL particle size seems small is also concerning. Would get a ETT on him to ensure stability from a cardiac standpoint. Would like a hepatic ultrasound to look for fatty liver. If that is present would take steps to lower Triglycerides. Would be carful increasing Statins with the impaired renal function. Would consider non statin agent to be added but would first want to know metabolization principals of agents being considered. Would like a set of vital signs on him to check for other risk factors.
  • from Doctor Unite 2 months
    Need full cardiac work up thalll ett carotid and 2decho. Evaluation of liver test for fatty liver
  • from Doctor Unite 2 months
    This patient is at high risk for a cardiovascular event , to reduce the risk and plaque will change simvastatin to rosuvastatin, and get led to < 70 mg /dl, start jardiance in A1c is elvated, , vascepa to reduce cardiovascular risk, reduce uric acid level to < 6 mg /dl, consider cardiac cath , may need stent.
  • from Doctor Unite 2 months
    nice to know other risk factors, is he being treated for hypertension, diabetes, thyroid disease, does he have liver disease such as NAFLD, or we are assuming his eleavated enzyme all attributed to statin, is LFT > 3 unl ? Does he have a baseline EKG? Assess his Lp a? Does he have stable angina. Does he has PAD, what is ABI ratio. Like to have hs CRP. Would not increase simvastatin, could add ezetimibe. He is not a good candidate for bempedoic due to elevated risk of uric acid level. Consider cardiac work up, intensify his diet and aerobic activities. He is certainly at risk for CVD.
  • from Doctor Unite 2 months
    Would like to know how high are the liver enzymes,also look for another cause for elevated liver enzymes like fatty liver. If mild elevation- would change statin to Crestor and monitor liver enzymes.
    Do CT calcium scan,stress test,continue baby aspirin. Deft need to bring LDL under 70.
  • from Doctor Unite 2 months
    Would like to know extent of impaired GFR and would likely need nephrology opinion for angiogram with potential PTCA. Change Zocor to Crestor 20 mg and recheck LFT or consider Repatha. Begin low dose allopurinol for Uric acid.
  • from Doctor Unite 2 months
    I think he is a good candidate for PCSK9 inhibitor due to his genetic disposition, risk for heart attack or stroke, and elevated liver enzymes.
  • from Doctor Unite 2 months
    Full work up. It would be nice to have a blood pressure reading. Screen for diabetes. HDL levels? Concerned about his creatinine clearance. Would not give another medication that would cause uric acid levels to increase. Cardiac referral.
  • from Doctor Unite 2 months
    With the information provided, the patient is at risk of suffering from myocardial infarction. We need to work on his LDL. Increase his aspirin dosage.
  • from Doctor Unite 2 months
    Would not increase statin due to elevated liver enzymes, which requires workup if not due to the statin. He is high risk, so could add zetia before trying the more expensive pcsk9 inhibitor.
  • from Doctor Unite 2 months
    Switch to psk9 and work on cholesterol levels. Type and amount of exercise? Dietician advisable.
  • from Doctor Unite 2 months
    That fact that his father died at age 50 is very concerning. A dietary consult would be beneficial with a focus on increasing his HDL levels and maintaining the optimum weight/muscle mass. Close home monitoring of his BP should be suggested. I would consider increasing ASA to 325mg
  • 2 months
    he certainly is at increased risk
    I would measure inflammatory markers such as crp
    given abn lfts I would be reluctant to increase simvastin and feel he would be a good candidate for a psk9 inhibitor I would also continue asa