A 40-year-old male with dyslipidemia and family history of premature coronary artery disease (CAD), he presents to clinic concerned about his personal risk for CAD. In the last five years, he reports gaining about 30 pounds and reports less exercise tolerance. On exam, his blood pressure is 118/84, pulse 82, weight 199.8 pounds, height 5 feet 9 inches, BMI 29.5 and waist circumference is 41.5 inches. His fasting glucose is 103, A1c is 5.8, total cholesterol is 235, LDL 125, HDL 26, and Triglycerides 439. Given the decreased exercise tolerance a treadmill stress test was ordered, which did not show any evidence of ischemia.
What is the first step in his management?
The correct answer is: A. Intensive Lifestyle Therapy
Since our patient does not have clinical atherosclerotic cardiovascular disease (ASCVD), nor an LDL that is >190 mg/dL, nor diabetes, we estimated his 10 year ASCVD risk using the global risk assessment tool (the new Pooled Cohort Equation) for primary prevention from the ACC/AHA 2013 guidelines. Using this equation, we calculated his ten year risk of having a hard atherosclerotic cardiovascular disease event to be low, 3.4%, but his lifetime risk was calculated to be 46%. Initiating lifestyle changes could lead to optimal risk factor control and decrease his lifetime risk to 5% if he can get is total cholesterol to 180 mg/dl, maintain his systolic BP at 120 mm Hg, not become diabetic (his A1c is elevated and shows insulin resistance), and not smoke.
His central obesity is resulting in insulin resistance as indicated by an A1c of 5.8, low HDL (26 mg/dL) and high triglycerides (439 mg/dL). Weight loss by initiating lifestyle changes is considered the most appropriate initial step in primary prevention and low ten-year risk. The patient was referred to an intensive, personalized lifestyle intervention because of his concerning family history of premature CAD. The patient was seen by our registered dietician (RD) and exercise physiologist. Our exercise physiologist created a personalized exercise program for him which included a walking program and flexibility activities that would enable him to attain a goal that eventually led to 10,000 steps a day to create a negative energy balance. He was given a pedometer to track his daily steps and keep a physical activity log. At the initial visit, the RD reviewed the patient's diet history and counseled him to follow a 1800 kcal cardio-protective DASH style personalized dietary pattern. A nutrition guide was provided to patient by the RD. The patient was instructed by the RD to keep food intake records, and daily weight logs. He received motivational interviewing techniques by the RD, exercise physiologist and cardiologist at each visit.
Over the course of 12 individual visits in a period of 4 months with our trained RD and exercise physiologist, the patient lost 30 pounds, decreased his waist size by 2 inches, his HDL increased to 31 mg/dL, LDL decreased to 103 mg/dL, and triglycerides decreased to 203 mg/dL.
Choice B: Initiating fibrates may not be the best first step in someone who has the motivation to change lifestyle. There isn't strong clinical trial evidence to support monotherapy with fibrates in primary prevention in individuals with triglyceride levels that are less than 500.
Choice C and D: Monotherapy with Statin or dual therapy with statin and fibrate are not indicated in this patient. Despite the inclination by some physicians to start statins in a person with family history of premature CAD, this criteria is not supported by current guidelines. His low calculated risk preclude him from the guideline recommended patient subgroups likely to have the most benefit from statin therapy.
Stone N, Robinson J, Lichtenstein A, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in Adults. J Am Coll Cardiol 2013. [Epub Ahead of Print].
Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013. [Epub Ahead of Print].
Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and The Obesity Society. J Am Coll Cardiol 2013. [Epub Ahead of Print].
Miller, M; Stone NJ, Ballantyne C, Bittner V et al. Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2011;123:2292-2333.