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.

Laboratory Data:

  • 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%

Electrocardiogram (ECG):

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?

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