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Lipid Management in Post-Menopausal Patient

History of Present Illness 

Patient is a 58-year-old female, 61 inches tall, 228 lbs., with history of obesity, high cholesterol, and hypothyroidism. Patient presents with complaints of fatigue, mild chest pain, and general complaint of “I just don't feel good.” She has not received medical care for two years. 

Medical History 

Patient is non-compliant with instructions to lose weight. She is post-menopausal, having entered menopause at age 41. She reports that her PCP stated that she "don’t need cholesterol medicine,” because although her LDL was 161, HDL was 59. She complies with taking thyroid medication. 

Social History 

Patient lives alone, and engages in little activity. 

Questions 

1. Why do you need to pay attention to cardiovascular risk with this patient? 
2. Do you agree with the PCP’s decision not to prescribe a statin? 

  • from Generation NP 2 weeks
    She presents with multiple risk factors for heart disease including obesity, being a postmenopausal female, high cholesterol, and a sedentary lifestyle. She definitely needs a statin drug as her LDL is over twice as high as it should be for a person with multiple risk factors for heart disease. Her goal is <70 not only to decrease her risk for an MI, but decrease her risk of a stroke as well. I would have her maintain a 2 week bp log for review, and I would draw a HGBA1C to assess her for diabetes. I would obtain an echocardiogram before considering a stress test, but any significant abnormalities on the echo would convince me to order one. I would also order a sleep study as she likely suffers from sleep apnea which is an additional risk factor for heart disease. I would obtain a thorough family history as well. An MI can be devastating to one's overall health, so prevention is of the utmost importance.
  • 2 weeks 1 day
    I took some liberties with numbers not listed (BP, total cholesterol) and missing information (smoking and diabetes) but it does not really appear that her 10 year risk of a cardiac event is going to be high unless she smokes or is diabetic. If she is having exertional symptoms worrisome for ischemia, a stress test would certainly be reasonable.

    Her risk is going to go up substantially in coming years. Although I think her LDL is high and that treatment with a statin is not wrong, and that it will certainly reduce her risk of an MI or cardiac event, in reality her obesity and sedentary lifestyle are in my opinion a greater danger to her. Certainly doing one thing does not preclude doing another but if she takes a statin and thereby lowers her risk "some" but does nothing else to improve her health, her prognosis for a healthy body during the final 1/3 of her life is poor.
  • from Doctor Unite 2 weeks 2 days
    This patient as presented appears to be at a high cardiovascular risk. Statins are the cornerstone of the pharmacologic preventive strategy for CAD and are probably indicated in this patient.

    Begin with a complete h and p, basic blood work plus UA, TSH, fasting lipid panel, hgba1c, CRP, framingham risk score, ekg, and a stress test looking for ischemia and assesment of fitness in this patient with chest pain. She is likely a metabolic syndrome patient and i bet her trigs are high. She is probably at least prediabetic. No need for advanced lipid profiling yet.
    For treatment she needs to see a dietician and weight loss counseling. She needs discussion re statin which i would strongly advise., unless there is a strong contraindication. I love calcium scanning to notify us of actual CAD and convince a skeptical patient of need for statin. She may be a metformin candidate as well. Depending on trig determination she may be a candidate for pharma grade EPA.

    No need for zetia, citric lyase inhibition, pcsk9 inhibs, unless patient can't tolerate statin or difficulty getting to lipid goals. Difficult question is use of ASA for primary prevention of CAD events. If calcium scan positive in this patient with chest pain would recommend low dose ASA.

    She lives alone which could be an invitation to depression. This also makes diet success less likely. She will likely require more counseling and more frequent office visits to alter lifestyle issues.
  • from PA Unite 2 weeks 2 days
    High cardiovascular risk for sure...heading steadily to an event. Agree with Swati on the cardiac work up and "clearance" with stress testing and possible nuclear imaging to insure baseline understanding and care of cardiac anatomy and physiology. Nexletol suggested by Amy is certainly a possible too. I'm always skeptical about thyroid compliance and additional testing is warranted to be sure dosing is correct looking at mean TSH comparison etc. This might inspire switching to other thyroid supplementation after talking with the patient about s/s. This patient could benefit with statin-free, but aggressive medical / non-surgical weight loss management with at least weekly visits (live or telehealth) for support and nutritional guidance. Lifestyle modifications that Karis suggests for sure with a exercise (working up to 60 min mild/moderate 6 days per week), hydration (at least a gallon a day if the kids are working ok) additional testing (perhaps clarifying her thyroid function, CBC w/diff, CMP, A1C, insulin, hormones and full lipid panel etc), perhaps an introductory keto/calorie reduced diet start with specific identified protein/veggie/fruit recommendation, a grocery store visit with a health/nutrition specialist/coach with attention to food substitutes high in protein, fiber, low in unhealthy fats and carbohydrates. I think she would benefits from high dose EPA, calcium pyruvate, a good MV, antioxidant and perhaps some red yeast rice, alpha lipoic acid and/or chromium to start. This all in the scenario of some attentive motivational interviewing to insure patient compliance and participation. She'd feel much better with a 25-30 pound weight loss to start, monitoring and treating the rest of her physiology while she gets there.
  • from Doctor Unite 2 weeks 2 days
    Patient definitely needs a exercise stress test or MPS .Also needs a cholesterol lowering medication-statin to start with,weight loss with medication as she is non compliant with diet and exercise.Would keep her TSH between 1and2 after ruling out ischemic heart disease.
  • from Doctor Unite 2 weeks 2 days
    Pt is in need of lifestyle modifications with a daily exercise plan and diet. Because of her multiple risk factors for cardiac disease put her on a statin and do EKG along with possible MPI testing.
  • from Doctor Unite 2 weeks 2 days
    The patient’s calculated BMI is 43.1 which puts her in the obese category for her height and puts her at risk for chronic conditions such as high blood pressure, diabetes, and cholesterol. Her LDL levels of 161 puts her at high cardiovascular risk. She has not received medical care for two years, so her statement about her PCP “don’t need cholesterol medicine” is outdated now. She needs to be on a LDL lowering medication such as Nexletol along with exercise and dieting.