Cholesterol Management in a 46-Year-Old Man Following Myocardial Infarction

A 46-year-old man presents to clinic six months after sustaining an anterior ST-elevation myocardial infarction treated with primary PCI. A single drug-eluting stent was placed to treat the culprit lesion in the proximal left anterior descending artery. Coronary catheterization revealed moderate disease in the mid right coronary artery. Since his last visit, he denies dyspnea, his anginal equivalent, or side effects attributable to statin therapy. He maintains a low-fat, high-fiber diet and exercises on the treadmill 30 minutes every morning.

His past medical history is notable for hypertension and hyperlipidemia. His older brother suffered an MI at age 43 and his father died suddenly in his 50's. His medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin 80 mg daily. He reports daily compliance with this regimen. While taking prescription niacin many years ago, he reports developing nausea, anorexia, and "liver test abnormalities," resulting in the drug's discontinuation.

On physical examination, his blood pressure is 130/76 mmHg and his pulse is 63 bpm. His BMI is 26 kg/m2 and his cardiovascular examination is unremarkable. Laboratory values are notable for: LDL–C 102 mg/dL, HDL-C 52 mg/dL, triglycerides 126 mg/dL, creatinine 1.1 mg/dL, glucose 98 mg/dL, hemoglobin A1c 5.6%, uric acid 5.1 mg/dL. His untreated lipid profile is not available, and he reports initiating lipid-lowering therapy over 10 years ago.

What is the most appropriate cholesterol-lowering strategy for this patient?

Show Answer