A 67-Year-Old Man With Diabetes and Recurrent ACS

A 67 year-old man with coronary artery disease, hypertension, obesity, and diabetes mellitus presents to your office for follow-up after a recent hospitalization during which he underwent percutaneous coronary intervention for unstable angina two weeks ago. He underwent coronary artery bypass surgery for unstable angina in 2007 with LIMA-LAD, RIMA-RCA, and SVG-obtuse marginal grafts. During his recent hospitalization, he received a drug eluting stent to his native Ramus Intermedius branch with resolution of his chest discomfort. He is without complaints on this visit.

He has a six pack-year smoking history, which he quit in 1970. He drinks a glass of wine nightly. He continues to exercise on a treadmill at a brisk pace for 30 minutes, five times a week, as he was doing before his recent hospitalization. He is trying to follow a Mediterranean diet plan with the hopes of losing weight.

His blood pressure is 128/80, pulse is 64, BMI is 28, and waist circumference is 41 inches. His exam is otherwise unremarkable except for a well-healed right femoral access site from his recent catheterization and central adiposity.

His lab work from just prior to this visit shows creatinine 1.2 mg/dL, hemoglobin A1c 6.8%, TC 149 mg/dL, Trig 170 mg/dL, HDL-C 45 mg/dL, LDL-C 70 mg/dl, and apolipoprotein B (apoB) 87 mg/dL.

His medications have included aspirin, metoprolol, lisinopril, metformin and atorvastatin 80 mg daily for several years with the addition of clopidogrel after his recent PCI. He reports full adherence to his medical regimen.

In addition to weight loss and referral to cardiac rehabilitation, he asks what he can do to try to improve his risk.

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