A 45-Year-Old, Lifetime Nonsmoker With Premature CAD Needs Help Preventing Future CV Events

A 45-year-old male physician presented for an opinion on how to manage his premature CAD and wishes to know what he could do to prevent a further cardiovascular event. He is a lifetime nonsmoker with no hypertension or hyperlipidemia, but with a significant family history of CAD in his father, who died in his 40s secondary to a myocardial infarction. The patient had developed angina two years prior, while carrying his luggage in the airport. An initial nuclear stress test failed to demonstrate any ischemia; he was treated medically and remained asymptomatic for some time. The following year his anginal symptoms escalated significantly to where he would have angina with minimal exertion. He underwent a CT coronary angiogram which demonstrated significant proximal LAD disease. He had a cardiac catheterization subsequently confirming severe, 1-vessel CAD of the proximal LAD which was successfully treated with PCI and implantation of a zotarolimus drug-eluting stent. Since then, he has had no further chest discomfort, angina, or dyspnea and continues to exercise regularly. He currently takes ASA 81 mg daily, atorvastatin 20 mg daily, lisinopril 2.5 mg daily, and niaspan 500 mg daily. He currently exercises routinely 30 minutes daily and is following a Mediterranean diet. He measures his blood pressure at home and routinely runs in the 130 mmHg systolic range. On exam, his current blood pressure is 127/78 mmHg, and his exam is otherwise unremarkable. An ECG demonstrated sinus bradycardia at 52 bpm andwas otherwise normal. An echocardiogram demonstrated a left ventricular ejection fraction of 65% with no regional wall motion abnormalities. C-reactive protein was measured at 1 mg/L, and a prior assay of Lp(a) measured it at 47. His total cholesterol measured 88 with an LDL of 33, HDL of 43, and triglycerides of 60.

For this patient with established but stable CAD who is otherwise asymptomatic, which is the correct statement regarding his risk of a subsequent acute coronary syndrome (ACS)?

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