AJ is a 78-year-old African American female with hypertension, prediabetes, and chronic kidney disease who presents to the primary care physician's (PCP) clinic for her annual wellness visit. She is asymptomatic, follows a low sodium diet but does not follow a low-fat diet.
With a 10-year atherosclerotic cardiovascular disease (ASCVD) risk score of 17.4% and no history of clinical ASCVD, the PCP recommends initiation of lifestyle changes such as the DASH diet and exercising and use of a moderate intensity statin. During the clinician-patient discussion, the patient stated that she is willing to make lifestyle changes; however, she prefers not to initiate another medication.
According to the 2018 ACC/AHA multisociety cholesterol guideline, which ONE of the following choices is the best option at this time?
The correct answer is: C. Measure coronary artery calcium (CAC) score.
Option C is the best option for this patient at this time. According to the 2018 ACC/AHA multisociety cholesterol guideline, recommendations for primary prevention in older adults would apply to this patient. She is over 75 years old, her LDL-C is between 70-189 mg/dL, she has not had an ASCVD event but her 10-year ASCVD risk score is 17.4%, classifying her at an intermediate risk. In older adults greater than 75 with an intermediate risk score, initiating a moderate-intensity statin is reasonable for this patient. However, the patient stated that she prefers not to add another medication. According to the cholesterol guideline, it may be reasonable to measure coronary artery calcium (CAC) in adults 76 to 80 years of age to reclassify those with a CAC score of zero to avoid therapy. If the CAC score is zero, statin therapy may be avoided because the benefits of statin do not outweigh the risk for adverse events. A CAC score other than zero will serve as additional evidence to support the decision to start a statin therapy during clinician-patient discussion.1
Option A is not the best option for this patient at this time. While it is important to promote a healthy lifestyle in all populations in the management of blood cholesterol, starting a moderate intensity statin is supported by the cholesterol guideline as primary prevention to reduce risk of ASCVD event in older adults with a 10-year ASCVD risk score between 5% to 20% with risk enhancing characteristics such as family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dL, chronic kidney disease, metabolic syndrome, preeclampsia or premature menopause in women, inflammatory disease, or South Asian ancestry.1
Option B is not the best option for this patient. Even if the physician prescribes a statin, this patient has already made it clear that she does want to take any additional medication, which may lead to nonadherence. The cholesterol guideline emphasizes the importance of patients' involvement in the discussion and the shared decision making while selecting therapy to improve safety, adherence, and efficacy.1
Option D is not the best option for this patient. There is no recommendation for clinical use of red yeast rice, which has statin-like effects, in the ACC/AHA cholesterol guidelines.1
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol 2019;73:3168-3209.