Blurred Lines: The High-Risk Patient with Subclinical Atherosclerosis

A 57-year-old Caucasian male with history of hypertension, hyperlipidemia, gastroesophageal reflux disease, and anxiety presents to clinic with several months of fatigue and reduced exercise capacity. He is an active adult who played lacrosse competitively in college, a former Marine Corps officer, and exercises two hours daily at the gym. He follows a Mediterranean diet though he reports increased cheese intake. He is a non-smoker and consumes two alcoholic beverages daily. Family history is significant for premature atherosclerotic cardiovascular disease (ASCVD). His father died of a "heart attack" at age 53 years. His brother suffered a myocardial infarction (MI) and underwent multiple coronary interventions at age 44 years, and then had repeat MI with subsequent coronary bypass surgery at age 49.

Physical examination noted blood pressure 162/94 mmHg with BMI 27.2 kg/m2 and cardiac exam was normal with regular rate and rhythm, normal heart sounds with no murmur, and lungs clear to auscultation bilaterally. Lipid panel revealed total cholesterol 253 mg/dL, LDL-C 186 mg/dL, HDL-C 37 mg/dL, and triglycerides 146 mg/dL. His 10-year ASCVD risk by the Pooled Cohort Equations is 16%. EKG showed normal sinus rhythm with right bundle branch block, and echocardiogram showed normal biventricular function with no valvular abnormalities.

Due to his symptoms of fatigue and reduced exercise capacity, he was referred for exercise nuclear myocardial perfusion imaging. He exercised on the Bruce protocol for 9 minutes and 4 seconds, achieving 10.1 METs, with normal heart rate and blood pressure response. He did not experience chest pain and no ischemic EKG changes were noted. There was normal myocardial perfusion, normal myocardial thickening and wall motion, and normal left ventricular ejection fraction of 65%. However, he was noted to have extensive subclinical atherosclerosis with multivessel coronary artery calcification (Agatston score 1315, 98th percentile for age and race matched group).

Therapy was initiated with ramipril 10 mg daily, atorvastatin 40mg daily, and he continued previous medications which included aspirin 81mg daily, fish oil supplements, and multivitamin. At 3 month follow-up visit, blood pressure improved to 124/66 mmHg. However, the patient complained of myalgias in his arms and legs limiting his ability to exercise and climb stairs. Repeat lipid panel showed total cholesterol 186 mg/dL, LDL-C 121 mg/dL, HDL-C 40 mg/dL, and triglycerides 125 mg/dL.

Which of the following is the next best step in the management of this patient?

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