Sounds like a typical metabolic syndrome patient with insulin resistance. Lifestyle change implementation along with as assessment of her cardio metabolism. Besides having a lipid profile at hand, I would want to know her coronary calcium burden. Statin therapy is indicated, to an LDL goal below 70.

1. How often is she exercising and how does she feel when she is dancing? I would encourage daily walking if she feels fine with dancing.
2. What does "feeling feeble" mean? I would try to flesh that out a little more in case there is some effort intolerance there that might be a red flag
3. Dietary history to try to help her find ways to eat better (dietitians do this better than we do)
4. BP? If at all elevated first choice would be an ACEI or ARB
5. Risk factor profile probably supports statin therapy. If she is reluctant, coronary calcium score can bring home individual risk very clearly.

If she is prediabetic and overweight, obviously, I would monitor her HbA1C and recommend weight loss through a combination of diet with a dietician and more intense exercise than dancing.
Her total cholesterol and LDL level are above the reference ranges of 200 mg/dL and 100 mg/dL, respectively. Her calculated LDL/HDL ratio is puts her at below average risk. I would still work on lowering her LDL level using statin therapy.
Given her current age of 67 and family history of diabetes and cardiovascular disease, she may need more help if unable to comply with above recommendations. She may eventually need medication if she does become diabetic and a more effective cholesterol medication such as bempedoic acid (Nexletol).

The most important pieces of information missing in this picture is her Blood Pressure and the BMI that is going to modify the approach for the interevetion , Based on those numbers her data can be plugged in the two risk calculators one is amnd the other one is https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/ Focusing on the LDL alone based on these models there is no indication for Statin at this stage however if the Hba1c hits 6.5 then she is a diabetic then a Statin is must , She would need to have the Hba1c monitored closely , advised diet low in saturated fat for now , for Pre diabetes and a rising level of Hba1c metformin can be considered ofcourse once she goes to the diabetic range then she would need the diabetic combo therapy but before that based on holistic approach non pharamacetical approach can be adopted for now and monitored !

This patient certainly has risks for ASCVD but she currently does not have major risk factors. Therefore as per guideline, her goal LDL should be less than 100 mg/dl. If she is not able to achieve this goal with lifestyle modifications in 3 months she should be started on a moderate statin therapy and remeasured in another 3 months to consider intense statin treatment or addition of other agents until her goal is reached.

I would obtain a HgbA1c and a coronary calcium score CT scan to help risk stratify her. I would encourage diet, exercise, and weight loss. If her HgbA1c or her coronary calcium score are elevated, then I would start her on statin medication. If her HgbA1c is elevated, I would recommend starting her on metformin.

Given the limited amount of information provided, I still feel that this patient is at high risk. The fact that she is pre-diabetic and obese it would be safe to assume that she has 2 out of the 5 possible risks factors for the diagnosis of Metabolic syndrome those being hyperglycemia and waist circumference of >35 in for a female. Her obesity would possibly also leads us to belief of abnormal lipid parameters, if we add high trigs and low HDL, it would be safe to assume that her LDL, whatever the value, would be small and dense particles making them very atherogenic. Positive family for acute coronary syndrome complicates her prognosis. I believe that it would be a dis-service to the patient not to initiate medical therapy immediately. Not saying that lifestyle modifications should not also be encouraged but waiting any more time before starting medical management is exposing her to a possible negative outcome. I feel therapy with a statin, GLP-1, ACE inhibitor would be a start along with some diagnostic bloodwork.

I would try 2 months of diet and exercise
Could supplement this with non Rex treatment such as Metamucil or oatmeal
If ldl still elevated could do calcium score as a tiebreaker and if elevated would then start statin

I would like to order lab data including a lipid panel and A1C.

I would encourage diet and exercise for the next 3 months. A1C % would be of benefit.. If patient is a diabetic and that fail diet and exercise recommendations of a GLP be considered for its sugar lower potential and weight lost. If cholesterol remains high with a diagnosis of diabetes, statin would be the next recommendation

Although no A1c is presented, as she is called "pre-diabetic" and is over-weight, my assumption is that her A1c is >5.7% and below 6.5%. With this A1c, and a stong FHx of diabetes, and being over-weight, her risk of developing type 2 diabetes is pretty high. I am not sure that she cyrrently meets the definition of Metabolic Syndrome, as based on the presented data all she has is an increased WC and a modestly elevated total & LDL-cholestetol, but neither hypertriglyceridemia nor a low HDL-cholestetol, with no mention of eithef HTN or hyperglycemia.

Having said this, based on the UKPDS study it is highly likely that a fasting insulin/glucose ratio would be elevated, indicating insulin resistance. In addition to these tests, and an A1c if not checked within 3 months, I would get a hsCRP. Based on paternal history of MI, and her pre-diabetes, if hsCRP is high I might start her on a statin.

To me, job one is decreasing her risk of becoming diabetic, so I would immediately start her on metformin whike strongly encouraging weight loss by a combination of caloric restriction and increased activity. I would refer her to a RD to aid in improving her diet. I would start the metformin dose low, increasing to 1.5 gm/day over about 6 weeks to help assure tolerability, and see her bsck in 3 months to monitor weight, A1c, FPG, BP, etc. If she had lost close to 3 lbs, and A1c is stable or lower, I might keeo her on metformin for another 3 months. But is her weight is stable or increased despite her efforts (assisted by RD) to "diet" and increase her activity, I would discuss the benefits and risks of GLP-1 analogs, and consider starting her on either semagutide SC once per week (Ozempic) or PO daily (Rybelsus)., in order to "jump-start" her weight loss, which should improve her FPG, A1c, BP, and lipids.

David B. Karpf, MD
Adj. Clinical Professor of Endocrinology, Gerontology & Metabolism
Stanford University School of Medicine

I would encourage life style modification with the goal of weight loss of 5-10%. I would encourage use of metformin. Will see her cholesterol change in the next 3-6 months to decide if statin would be necessary.

I would encourage life style modification with the goal of weight loss of 5-10%. I would encourage use of metformin. Will see her cholesterol change in the next 3-6 months to decide if statin would be necessary.

I would encourage life style modification with the goal of weight loss of 5-10%. I would encourage use of metformin. Will see her cholesterol change in the next 3-6 months to decide if statin would be necessary.

I would encourage life style modification with the goal of weight loss of 5-10%. I would encourage use of metformin. Will see her cholesterol change in the next 3-6 months to decide if statin would be necessary.

I would first question her alcohol intake. Most tend to underestimate. Would order a carbohydrate transferrin deficiency test to investigate chronic use. Would discuss that drinking alcohol is counter-productive to heart and losing weight. I would commend her on exercising and encourage it. Would get a baseline EKG as well as stress test. I would check an A1c and consider Metformin if close over 6.0. Would make sure BP is below 130/80. Her 10 year ASCVD risk is below 7.5 so would not institute a statin or baby aspirin.

I believe more laboratory data is needed. Occasional dancing is likely insufficient to be considered “exercise” so more lifestyle modifications are in order. I would keep a low threshold to starting metformin and or a statin

I would risk stratify with a stress but also I would add a statin and an GLP1 agonist to lower her CV risk

Based on the information provided we have an overweight 67-year-old Hispanic prediabetic patient with hyperlipidemia. I would encourage lifestyle changes including diet and exercise modification, have the patient follow up in 3 months to recheck lipids, A1c. Her 10 year ASCVD risk is 5.9, so if her cholesterol still elevated she could start on a moderate intensity statin. I would also consider initiating metformin if her BMI went above 30.

Of course lifestyle changes are in order. Need more data: thyroid, CMP, lipoprotein profile, A1c.
Treatment could begin after labs drawn. Metformin and a statin. Prefer to wait for lab results.
Due to family history, More intense work up would include EKG, Echo, cardiac calcium scoring. These are people who benefit from preventive measures. Depending on labs, Farxiga may be helpful for cardio protection and glucose control

The patient has hyperlipidemia and metabolic syndrome. She has cardiovascular risk. She has not had an event. I would treat her with Farxiga which should engender a modicum of weight loss, control her glucose, and primary CV prevention. I would treat her hyperlipidemia with Rosuvastatin 10 mg daily. Reassess in 3 months. Dietary and exercise counseling would be a given.

More labs, referral to dietician for weight loss before introducing metformin(may avoid), statin to lower LDL under 70, ace inhibitor specifically altace 10mg.

ONE ASSUME SHE DOES NOT HAVE HYPERTENSION OR UNDER TREATMENT, ANY OTHER LAB SUCH AS CRP, CALCSIUM SCORE, EKG, THYROID PANEL. ASCVD CALCULATION (ASSUME NORMTENSIVE ) DOES NOT INDICATE STATIN MANAGEMENT. I WILL FOLLOW HER LAB, INTENSIFY LIFE STYLE MANAGEMENT, WEIGHT REDUCTION, ASPIRIN LOW DOSE, OTC OMEGA 3.

Diet and. regular exercise would be all that is needed at this point, given that her ldl is only mildly elevated and her tc/hdl ratio is quite good; this can also help prevent diabetes; repeat lipid profile, diabetic screen in 6-12 months if she is doing well.

Diet exercise statin metformin

Definitely I would try to introduce metformin ( I see no CI in the H&P) , refer to Nutrition/CDE to introduce NCS diet and start a statin like simvastatin or atorvastatin aiming for LDL<100 mg/dl in the beginning. She is allergic to sulfa, therefore sulfonamides are CI for her. Saxenda for weight loss if BMI high( not given in H&P), or Qsymia.

I would further labs to get a clearer picture, discuss diet changes and regular exercise. Once labs are back consider Lipitor and Metformin with close follow up.

I would further labs to get a clearer picture, discuss diet changes and regular exercise. Once labs are back consider Lipitor and Metformin with close follow up.