A Young Man With a History of Myocardial Infarction and Low HDL-C
History of Presenting Illness:
A 41-year-old man presents with dyslipidemia, hypertension, and a history of myocardial infarction (MI) at age 37. He does not smoke, is physically inactive, and consumes a diet high in saturated fat. Medications include a high intensity statin (atorvastatin), a beta-blocker, an angiotensin converting enzyme inhibitor, and aspirin. Blood pressure is 110/80 mm Hg, body mass index is 32 kg/m2, and waist circumference is 43 inches.
- Total cholesterol: 148 mg/dL
- Triglycerides: 210 mg/dL
- High-density lipoprotein cholesterol (HDL-C): 29 mg/dL
- Friedewald estimated low-density lipoprotein cholesterol (LDL-C): 77 mg/dL
- Non-HDL-C: 119 mg/dL
- Fasting glucose: 115 mg/dL
- HbA1C 5.9%
- AST/ALT WNL
- TSH WNL
Normal sinus rhythm, normal ECG
This high-risk patient has been treated with high intensity statin therapy since his MI at age 37. His HDL-C remains low at 29 mg/dL. He has metabolic syndrome. What is the most reasonable first step to the management of his low HDL-C?