zaki
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A 68-year-old woman is referred for treatment of hypercholesterolemia. She has no family history of premature heart disease and no personal history of hypertension, diabetes, cigarette smoking, peripheral vascular disease, or coronary heart disease. She had an uneventful menopause 15 years ago and is now taking estrogen and medroxyprogesterone. She takes no other medications. She follows a strict low-fat, low-cholesterol diet and according to dietary history consumes less than 25% of her calories as fat (less than 7% saturated fat) and less than 200 mg/d of cholesterol. She is close to her ideal body weight. She has previously been treated with cholestyramine but was unable to tolerate the medication owing to bloating, gas, and constipation. She later tried lovastatin, but this had to be discontinued owing to myalgias, even though her creatine kinase (CK) level was normal. You order laboratory studies to be done after she fasts overnight.
Laboratory studies:
Plasma cholesterol (total)
275 mg/dL
Plasma high-density lipoprotein (HDL) cholesterol
75 mg/dL
Plasma low-density lipoprotein (LDL) cholesterol
180 mg/dL
Triglycerides
100 mg/dL
Fasting glucose, thyroid, renal, and liver function tests are normal. CK level is normal.
What is the most appropriate therapy for this woman
(A) Reassure her that because her HDL cholesterol level is elevated, she is not at increased risk for coronary heart disease and does not need to be treated for hypercholesterolemia.
(B) Refer her to the dietitian to further reduce dietary cholesterol levels and saturated fats.
(C) Tell her to continue her diet therapy, and reassure her that drug therapy is not necessary.
(D) Reinstitute therapy with a different hydroxymethylglutaryl coenzyme A (HMGCoA) reductase inhibitor, and monitor creatine kinase levels periodically.
(E) Begin therapy with niacin, beginning at a very low dose (50 mg twice daily) and increasing gradually to 1 g twice daily, as tolerated.
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Maverick
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| Ouli Maty
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Given her low risk factors, I think B is appropriate.
http://hin.nhlbi.nih.gov/atpiii/calculator.asp?us...
http://www.nhlbi.nih.gov/health/public/heart/chol...
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| zaki
Forum Guru
Topics: 92
Posts: 398
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No more reply so
Answer: C
Educational Objective: Know when to use cholesterol-lowering medication.
This woman has no major cardiovascular risk factors except for an elevated low-density lipoprotein (LDL) cholesterol level, and she has no known coronary or peripheral vascular disease. She already follows a step II American Heart Association cholesterol-lowering diet, and further dietary restriction is not necessary. Although her cholesterol level is elevated, her LDL cholesterol is less than 190 mg/dL; therefore, it is not recommended that she be treated with medication. Her high-density lipoprotein (HDL) cholesterol level is also elevated, and this is a negative cardiovascular risk factor. However, her LDL cholesterol level is still higher than the goal of less than 160 mg/dL for her cardiovascular risk category, and she should therefore be encouraged to continue to follow her cholesterol-lowering diet.
If her LDL cholesterol level rises to over 190 mg/dL, she would be a candidate for drug therapy. Trying another hydroxymethylglutaryl coenzyme A (HMGCoA) reductase inhibitor might be useful, but there is currently no evidence that there is any difference in the risk of side effects among the different agents. Treatment with niacin would be another option if drug therapy is needed.
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Maverick
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| Ouli Maty
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Thank you.
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