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?
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.
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.