If It Ain't Broke... There's Still Room to Optimize!

A 67-year-old woman attends your outpatient cardiology clinic this morning for routine follow up.

Background history includes the following:

  • Type 2 diabetes mellitus
  • Dyslipidemia
  • Hypertension
  • Coronary heart disease: NSTEMI 2012, percutaneous coronary intervention to left anterior descending artery, moderate right coronary artery disease.

Current medications are:

  • Metformin 1g twice daily
  • Glipizide ER 10mg once daily
  • Pioglitazone 15mg once daily
  • Lisinopril/HCT 20/12.5mg once daily
  • Atorvastatin 20mg once daily

Labs performed one month ago by her primary care physician include:

  • HbA1c 7.4%
  • eGFR 65mL/min/m2
  • LDL 105mg/dL; TG 175mg/dL

She has no new issues today and denies chest pain or exercise limitation. Examination reveals a blood pressure of 128/80 mmHg and a pulse rate of 68 beats per minute (regular). Calculated body mass index is 33kg/m2.

She has been coming to the clinic for almost 10 years and reports adherence to her medication profile. She is reluctant to make changes to her treatment regimen... 'if it ain't broke, don't fix it Doc?'

What change would be your first priority in reducing this patient's cardiovascular risk?

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