Reducing Cardiovascular Risk Following Stroke

A 71-year-old woman attends your outpatient clinic after a recent admission for a stroke.

Background history includes the following:

  • Type 2 diabetes mellitus
  • Hypertension
  • Coronary artery disease: CT coronary angiogram – 20-30% (mild) diffuse disease in left anterior descending artery.

Current medications are:

  • Metformin 1g twice daily
  • Perindopril 5mg once daily
  • Atorvastatin 40mg once daily
  • Aspirin 100mg once daily
  • Clopidogrel 75mg once daily (three-month course per neurologist)

Labs performed prior to her visit today reveal the following:

  • HbA1c 7.6%
  • eGFR 75mL/min/m2
  • LDL-C 61mg/dL; TG 115mg/dL

Approximately two months ago the patient was admitted to the local hospital with speech difficulties and weakness of her right upper and lower limb. CT imaging showed a small ischemic stroke with diffuse intracranial atherosclerotic disease. CT imaging of her neck vessels revealed 20-30% disease in her extracranial vessels. A 24-hour Holter monitoring showed no evidence of atrial fibrillation. She was discharged on a three-month course of dual antiplatelet therapy with plans for aspirin monotherapy thereafter.

On review today almost all of her deficits have improved with only very mild residual dysarthria. Blood pressure is 128/70 mm Hg seated, heart rate is 72 beats per minute and regular. Her body mass index (BMI) is 32kg/m2.

Which of the following changes would be your first priority in reducing this patient's cardiovascular risk?

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