doc_clotaire
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A 29-year old man comes to your office for a routine visit. His only
complaint is leg pain after walking a three-block distance. He states
that six months ago he was able to walk a longer distance without
having to stop. His father died of a heart attack at the age of 44.
His mother had diabetes mellitus, and she too died of a heart attack
at the age of 47. His older brother, who is now 35 years old, had a
stroke and underwent a carotid endarterectomy last year.
The patient presents as a thin individual with a blood pressure of
135/70 mm Hg and a heart rate of 78/min. Physical examination findings
are remarkable for the presence of multiple xanthelasmas on the face,
chest, and upper back. There is bilateral, irregular, firm, and
nodular thickening in the Achilles tendons and extensor tendons of the
hands. This patient's medications include atorvastatin, gemfibrozil at
maximum doses, and niacin, which was added to the regimen six months
ago. He is maintaining a fat-free diet and exercises regularly.
Laboratory test results show: total cholesterol 815 mg/dL,
triglycerides 515 mg/dL, and HDL 55 mg/dL. The level of total
cholesterol has increased by 15% since the last visit.
What would you recommend to this patient?
(A) Nutritionist consult
(B) Stress test for detection of silent ischemia
(C) Plasmapheresis
(D) Liver transplantation
(E) Increase the dose of statins as long as transaminases are within
the normal range
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| sprint123
Forum Guru
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Stress test for silent ischemia...?!
Since the patient have symptoms of occlusion,I think we should rule out CAD and then increasing the dose of statins....Since he was normal 6 months back.
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| mdwannabe
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Posts: 1,133
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Yeah, probably best thing to do is Stress Test...he is showing signs of PVD which is one of the equivalents of CAD. So he needs a stress test to determine a baseline. Thereupon crank up the dose of Statins. He is suffering from HeFC.
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| doc_clotaire
Forum Guru
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Sorry guys , I am afraid to let you know that B is the most common WRONG answer !
Please try again !
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| mdwannabe
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Posts: 1,133
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then crank up the statins right off the bat.
___________________
"Life not lived for others, is not worth living" Uncle Einstein
"A life is not important, except in the impact it has on other lives" -Jackie Robinson
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| NE
Forum Guru
Topics: 53
Posts: 504
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It's familial hypercholesterolemia - LDL receptor deficiency. I read a study few month ago and plasmapheresis can improve the life for this patients but the sample was to small.
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| doc_clotaire
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(C) Plasmapheresis
Explanation:
This patient presents with familial hypercholesterolemia (FH), which
is a common autosomal dominant disorder due to absent or defective LDL
receptors and resulting in a decreased capacity to remove plasma LDL.
LDL cholesterol levels are markedly increased. It is associated with
characteristic xanthomas in the Achilles, patellar, and extensor
tendons of the hands and by the presence of xanthelasma. Corneal arcus
is frequently seen. It is frequently associated with early coronary
artery disease (CAD), peripheral vascular disease, and cerebral
vascular disease. The plasma cholesterol level is generally in the
range of 300 to 500 mg/dL, and in some patients homozygous for FH, it
can exceed 800 to 1,000 mg/dL. Triglyceride levels are usually normal,
but in 10% of patients, they may be mildly elevated.
Because of the risk of CAD, these patients need especially vigorous
therapy. A low-fat and low-cholesterol diet should be initiated,
although it gives only a moderate result and will not be enough to
control the problem by itself. Effective therapy can be achieved with
HMG-CoA reductase inhibitors (statins) as first-line therapy. They
lower LDL by 20 to 45%. When they are combined with a bile
acid-binding resin, levels of LDL may be decreased by 50 to 60%. In
some patients, triple therapy with a statin, a bile acid-binding
resin, and niacin may be necessary. Patients homozygous for FH may not
be responsive to these measures. For them, measures such as
plasmapheresis or LDL apheresis are indicated. Liver transplant is the
last resort when all else fails as treatment.
This patient is already on maximum doses of statins and bile
acid-binding agent. The addition of niacin did not help. There is very
little chance that any additional medical therapy will solve this
patient's problem; that is why plasmapheresis is indicated.
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| docnikki
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Posts: 680
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im surprised..I also would have chosen B..
How would plasmapharesis be helpful? thats not clear in the explaination..is FH due to presence of antibodies to LDL receptor??
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