A 68-Year-Old Woman With SIHD and Obesity

A 68-year-old female patient with a medical history of obstructive sleep apnea, hypertension, prior transient ischemic attack, hyperlipidemia, Class III obesity, and prior percutaneous coronary intervention of the left circumflex artery in 2018 presents to her cardiologist for routine follow-up. Her medications include aspirin 81 mg daily, carvedilol 12.5 mg twice daily, lisinopril 5 mg daily, and atorvastatin 40 mg daily. She uses continuous positive airway pressure nightly.

In 2018, she had developed chest pain with walking. On the day of presentation, she had chest pain that occurred at rest that prompted her to present to the emergency department. A physical examination was normal, but electrocardiogram demonstrated T-wave inversions in the lateral precordial leads. A high-sensitivity troponin was elevated to 984 ng/L. She was referred for coronary angiogram, which showed single-vessel disease with significant stenosis of the proximal left circumflex artery. She underwent successful percutaneous intervention with placement of a drug-eluting stent at that time. She was started on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Clopidogrel was discontinued after 12 months. A review of symptoms at time of discontinuation was negative for chest pain, bruising, bleeding, melena, or hematochezia.

Today in clinic, she reports no chest pain with walking to work. On examination, her heart rate is 61 bpm, and her blood pressure is 129/74 mmHg. Her weight is 126.1 kg (278 lbs), and she is 180.3 cm (70.9 in) tall, resulting in a body mass index of 38.8 kg/m2. Laboratory results reveal total cholesterol of 129 mg/dL, high-density lipoprotein cholesterol of 44 gm/dL, low-density lipoprotein cholesterol of 69 mg/dL, and triglycerides of 268 mg/dL.

What adjustment in the patient's medication should the cardiologist make at this routine follow-up?

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