Week 3 DB: Chakrya, Ashley
The 42-year-old female, a 20-pack-a-year smoker with uncontrolled type 2 diabetes, has
the following test values: triglycerides 225, LDL 170, HDL 22, HgA1c 8.3%.
Based on her history and lab findings, she has a high cardiovascular risk factor. To
establish an accurate risk factor, her race, total cholesterol, and blood pressure must be obtained
as these numbers can affect her cardiovascular risk factor. The total cholesterol is 237, which
computed by adding HDL, LDL, and 20% of the triglyceride levels (American Heart
Association, 2020). Since the prompt did not provide the race, we will assume this patient is
White with no history of hypertension (BP 120/80). Based on these information, the patient’s 10year ASCVD risk is 26.9%, which is a high risk (American College of Cardiology, 2023). The
10-year ASCVD risk less than 5% is low, 5%-7.5% is borderline, 7.5-20% is intermediate, and
higher than 20% is high risk (Arps et al., 2018). The ASCVD risk assessment algorithm is an
important indicator of the need to initiate primary prevention for atherosclerotic cardiovascular
disease (Lloyd-Jones et al., 2019).
Statin therapy should be strongly suggested to people who are at high risk based on risk
alone (Arps et al., 2018). According to the practice guideline, patients with high risk CVD who
currently smoking and has diabetes should maximize statin therapy or add ezetimibe (Jialal &
Singh, 2019; O’Malley et al., 2020). For people with a higher risk, adding ezetimibe or PCSK9
inhibitors to moderate- or high-dose statin treatment has been shown to improve the important
outcome of cardiovascular morbidity (O’Malley et al., 2020). The NP can start this patient on
Atorvastatin 40 mg daily and add Ezetimibe 10 mg if numbers are not improving (Jialal & Singh,
2019; O’Malley et al., 2020; Sizar et al., 2023). Every three months, the patient's blood work
should be monitored until cholesterol, triglycerides, and HgbA1c are within normal limits
(Lloyd-Jones et al., 2019). Lifestyle modifications including weight loss and smoking cessation,
increased physical activity, and dietary modifications, are the first-line treatment for elevated
cholesterol levels (Sizar et al., 2023). American Diabetes Association recommends the
Mediterranean diet or DASH diet (Jialal & Singh, 2019).
References
American College of Cardiology. (2023). ASCVD risk estimator plus. Retrieved June 9, 2023,
from https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
American Heart Association. (2020). What your cholesterol levels mean. Retrieved June 9, 2023,
from https://www.heart.org/en/health-topics/cholesterol/about-cholesterol/what-yourcholesterol-levels-mean
(Arps et al., 2018)
Arps, K., Blumenthal, R., & Martin, S. (2018, November 15). New aspects of the risk assessment
guidelines: Practical highlights, scientific evidence and future goals. American College
of Cardiology. Retrieved June 9, 2023, from https://www.acc.org/Latest-inCardiology/Articles/2018/11/14/07/10/http%3a%2f%2fwww.acc.org%2fLatest-inCardiology%2fArticles%2f2018%2f11%2f14%2f07%2f10%2fNew-Aspects-of-the-RiskAssessment-Guidelines
(Jialal & Singh, 2019)
Jialal, I., & Singh, G. (2019). Management of diabetic dyslipidemia: An update. World Journal
of Diabetes, 10(5), 280–290. https://doi.org/10.4239/wjd.v10.i5.280
Lloyd-Jones, D. M., Braun, L. T., Ndumele, C. E., Smith, S. C., Sperling, L. S., Virani, S. S., &
Blumenthal, R. S. (2019). Use of risk assessment tools to guide decision-making in the
primary prevention of atherosclerotic cardiovascular disease: A special report from the
American Heart Association and American College of Cardiology. Circulation, 139(25).
https://doi.org/10.1161/cir.0000000000000638
(O’Malley et al., 2020)
O’Malley, P. G., Arnold, M. J., Kelley, C., Spacek, L., Buelt, A., Natarajan, S., Donahue, M. P.,
Vagichev, E., Ballard-Hernandez, J., Logan, A., Thomas, L., Ritter, J., Neubauer, B. E.,
& Downs, J. R. (2020). Management of dyslipidemia for cardiovascular disease risk
reduction: Synopsis of the 2020 updated U.S. Department of Veterans Affairs and U.S.
Department of Defense clinical practice guideline. Annals of Internal Medicine, 173(10),
822–829. https://doi.org/10.7326/M20-4648
(Sizar et al., 2023)
Sizar, O., Nassereddin, A., & Talati, R. (2023). Ezetimibe. StatPearls.
http://www.ncbi.nlm.nih.gov/books/NBK532879/
Hello Chakrya,
Thank you for your thorough and informative discussion of how to manage patients with
hyperlipidemia and high ASCVD risk. The first-line treatment for elevated cholesterol levels is
lifestyle modifications, including weight loss and smoking cessation, increased physical activity,
and dietary modifications (Sizar et al., 2023). I agree with you that people at elevated risk should
be strongly recommended statin therapy (Arps et al., 2018). According to the practice guideline,
patients at high risk for CVD who are currently smoking and have diabetes should receive
maximal statin therapy or add ezetimibe (Jialal & Singh, 2019; O'Malley et al., 2020). It has
been demonstrated that the addition of ezetimibe or PCSK9 inhibitors to moderate- or high-dose
statin therapy improves the vital outcome of cardiovascular morbidity in individuals at a higher
risk (O'Malley et al., 2020). The NP can initiate this patient on Atorvastatin 40 mg daily and add
Ezetimibe 10 mg if the patient's numbers do not improve (Jialal & Singh, 2019; O'Malley et al.,
2020; Sizar et al., 2023).
References
Arps, K., Blumenthal, R., & Martin, S. (2018, November 15). New aspects of the risk assessment
guidelines: Practical highlights, scientific evidence and future goals. American College
of Cardiology. Retrieved June 9, 2023, from https://www.acc.org/Latest-inCardiology/Articles/2018/11/14/07/10/http%3a%2f%2fwww.acc.org%2fLatest-inCardiology%2fArticles%2f2018%2f11%2f14%2f07%2f10%2fNew-Aspects-of-the-RiskAssessment-Guidelines
Jialal, I., & Singh, G. (2019). Management of diabetic dyslipidemia: An update. World Journal
of Diabetes, 10(5), 280–290. https://doi.org/10.4239/wjd.v10.i5.280
O’Malley, P. G., Arnold, M. J., Kelley, C., Spacek, L., Buelt, A., Natarajan, S., Donahue, M. P.,
Vagichev, E., Ballard-Hernandez, J., Logan, A., Thomas, L., Ritter, J., Neubauer, B. E.,
& Downs, J. R. (2020). Management of dyslipidemia for cardiovascular disease risk
reduction: Synopsis of the 2020 updated U.S. Department of Veterans Affairs and U.S.
Department of Defense clinical practice guideline. Annals of Internal Medicine, 173(10),
822–829. https://doi.org/10.7326/M20-4648
Sizar, O., Nassereddin, A., & Talati, R. (2023). Ezetimibe. StatPearls.
http://www.ncbi.nlm.nih.gov/books/NBK532879/
Hello Ashley,
Thank you for a very informative discussion of congestive heart failure and other
differential diagnoses. You have defined congestive heart failure very well. Heart failure is a
complex clinical syndrome that occurs when the heart cannot pump enough blood to satisfy the
body's needs (Malik et al., 2023). It is caused by any condition that impairs the absorption or
ejection of blood from the ventricles into the systemic circulation (Malik et al., 2023). Typically,
patients present with fatigue and dyspnea, as well as decreased exercise tolerance and fluid
retention (Malik et al., 2023). The primary goal of therapy for chronic CHF is to enhance
symptom management and quality of life, reduce hospitalizations, and reduce the disease's
overall mortality rate (Malik et al., 2023). The objective of pharmacologic therapy is to
administer all indicated agents as opposed to singular agents. The combination therapy includes
diuretics, ACE inhibitor, ARB, and a beta-blocker (Malik et al., 2023).
References
Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2023). Congestive Heart Failure. StatPearls
Publishing. http://www.ncbi.nlm.nih.gov/books/NBK430873/