Complex cases in dyslipidemia: HDL and triglycerides

Certified Clinical Lipid Specialist, DNP Student College of Nursing, LifeLink Healthcare Institute, Tampa, Florida

Certified Clinical Lipid Specialist, LifeLink Healthcare Institute, Tampa, Florida

This case represents a patient profile that is very commonly seen in all health care practices today in the United States. As the number of adult men and women with cardiovascular disease (CVD) continues to rise, so too are the numbers of people living with risk factors for CVD.

This first patient represents many adults seen in practices throughout the United States who meet the criteria for the diagnosis of metabolic syndrome. Approximately 37 million patients today meet the diagnosis criteria for metabolic syndrome: increased waist circumference, hypertension, elevated triglycerides, low high-density lipoprotein (HDL)-cholesterol, and elevated fasting blood glucose (FBG). A minimum of 3 of these 5 criteria will justify the diagnosis and, if left untreated, will dramatically increase a patient’s risk for developing adult-onset diabetes and CVD.

Presenting complaint

Sam F. is a 40-year-old Mexican-American man who presents to the cardiology clinic for a follow-up appointment after his recent discharge from the hospital. Two weeks previous, he was admitted to the hospital with chest pain and was found to have a non–ST-elevation myocardial infarction (MI). He was immediately taken to the cardiac catheterization lab, where he was found to have an 80% stenosis in the left anterior descending artery (LAD). He received a drug-eluting stent to the LAD without complications. He was also found to have a nonobstructive 30% stenosis in the mid-right coronary artery as well as minor irregularities throughout the circumflex artery. Sam states that since his discharge from the hospital, he has not experienced chest pain. He also states he has been taking his medications as prescribed.

Review of systems

• Cardiovascular: negative. He denies chest pain, dyspnea, or fatigue.

• Respiratory: positive for a history of loud snoring. He denies dyspnea or wheezing on exertion.

• Musculoskeletal: negative. He denies claudication, muscle aches, pain, or weakness.

Social history

Sam has been married for 15 years and has a 10-year-old son and a 12-year-old daughter. He has a high school education, works full-time as an auto mechanic, and enjoys fishing and watching sports on the weekend. Since age 15, Sam has smoked a pack of cigarettes a day. He drinks a “few” beers daily and denies over-the-counter or illegal drug use. He admits to a sedentary lifestyle, with minimal household and yard work.

Past medical/surgical history

Sam says that he enjoyed good health prior to his recent hospitalization. His only medical care was for a “bad” cold last year. He recalls having heartburn-like symptoms for a few months before his MI, which he treated with an occasional antacid. Looking back, he did not think that these symptoms were a warning sign of an impending MI. He denies a history of surgery.

Medications

• Aspirin, 81 mg once daily

• Carvedilol, 6.25 mg twice daily

• Clopidogrel, 75 mg once daily

• Lisinopril, 10 mg once daily

• Simvastatin, 20 mg once daily

Vital signs

• Blood pressure (BP): 140/85 mm Hg

• Pulse: 82 beats per minute

• Height: 5 feet 8 inches

• Weight: 208 pounds

• Body mass index (BMI): 31 kg/m²

• Waist circumference: 44 inches

• Electrocardiogram (ECG): Within normal limits

• Echocardiogram:

  – Normal left ventricular size and function

  – Ejection fraction >55%

  – Mild mitral regurgitation

Physical exam

• Cardiac:

  – Regular rhythm

  – Normal S₁, S₂

  – Grade 2/6 soft systolic murmur in the left sternal border, fifth intercostal space

• Carotid arteries: normal, negative for bruits

• Lungs: normal

• Musculoskeletal: normal

• Peripheral pulses: normal and equal in all extremities

• Skin: acanthus nigricans in the folds of the neck, skin tags present in axillae

Laboratory tests—baseline

• Comprehensive metabolic panel: normal except for FBG

  – FBG: 109 mg/dL (reference range, 65-99 mg/dL)

• Complete blood count: normal

• Thyroid-stimulating hormone: normal

• Creatinine kinase: 156 mg/dL (reference range, 50-250 mg/dL)

• Lipid panel:

Diagnosis/ICD-9 codes

Pathogenesis

• Atherosclerotic plaque formation

• Inflammation

• Endothelial dysfunction

• Microvascular damage

• Lipid abnormality

Pharmacology

• Anti-inflammatory

• Antiplatelet

• ACE inhibitor

• Beta-blocker

• Lipid agents

Treatment and follow-up

• Cardiac rehabilitation: home walking program

• Diet: low in cholesterol, fat, and triglycerides

• Medication regimen:

  – Add prescription formulation omega-3-acid ethyl esters, 1 g once daily

  – Discontinue simvastatin, 20 mg

  – Start rosuvastatin, 40 mg once daily

  – Start fenofibric acid, 135 mg once daily

Further testing

• Ankle-brachial index

• Carotid ultrasound

• Lipids

• Liver function tests

• Sleep apnea work-up

Discussion

Sam is representative of adult males at the “highest” risk for further development of CVD. Atherosclerosis is a disease of the arterial vessels marked by pathological changes, such as intimal thickening enhanced by the process whereby fatty streaks progress to more advanced lesions called fibrous plaques. Addressing the risk factors for atherosclerosis is key to slowing this progressive disease process. Evidence from numerous US clinical trials spanning more than 20 years has demonstrated and supported aggressive risk-reduction therapies that may not only prevent death but enhance quality of life.

The American Heart Association (AHA) and the American College of Cardiology (ACC),¹ along with other national organizations such as the American Diabetes Association (ADA), have developed guidelines and goals for therapy for managing patients at risk. Guidelines for managing patients with dyslipidemia are part of the AHA/ACC 2004 Update to the Adult Treatment Panel III.² These guidelines advise that an LDL level <70 mg/dL is reasonable, and when this goal cannot be achieved with single-drug therapy, combination therapy is warranted and advised. The ADA recommendations support an LDL goal of <100 mg/dL in patients with type 2 diabetes and an LDL of <70 mg/dL for those with CVD. In addition, the guidelines recommend that when triglyceride levels are >200 mg/dL, the non-HDL level should be <130 mg/dL.

In Sam’s case, we considered adding either a fibrate or niacin along with a statin, which could be beneficial in lowering triglycerides and achieving the non-HDL goal. We recommended a diet of 2 to 3 servings of fish (preferably oily) per week. People who are unable to consume this amount may supplement their diet with 1 g of omega-3-acid ethyl esters per day.

Sam also represents a patient with familial combined hyperlipidemia, the most common familial lipid disorder in survivors of MI. The clinical diagnosis is characterized by elevations of cholesterol (250-350 mg/dL) and hypertriglyceridemia, as well as a first-degree relative with a similar lipid pattern.³

We switched Sam to a more powerful statin—rosuvastatin, 40 mg once daily—in an effort to lower his cholesterol by half, lower his triglycerides, and achieve his HDL goal. As an adjunct to his diet, we added a daily prescription-strength supplement of 1 g of omega-3 fish oil.

We started Sam on fenofibric acid, 135 mg once daily, to address his elevated triglycerides and low HDL-cholesterol. In a recent paper, Jones et al demonstrated the safety and efficacy of this statin-fibrate combination in achieving all of the lipid goals set forth in the national guidelines.⁴

We referred Sam to a dietitian, who will monitor Sam’s weight, waist circumference, and BMI as a measure of his progress in weight reduction. Our activity goal for Sam included 30 minutes of aerobic activity 5 to 7 days a week to help him lose weight.

Sam also has insulin resistance and possible excessive alcohol use. We counsel Sam to reduce his intake of alcohol to low-to-moderate levels in order to lower his triglycerides, glucose, and caloric intake. Sam stated that he has stopped smoking since his hospitalization, but he is only marginally hopeful that he can remain tobacco-free. We will continue to monitor his progress by asking him at each visit if he still avoids cigarettes and by reviewing possible smoking cessation treatments.

Sam’s new medication regimen is as follows (Table 1):

• Aspirin, 81 mg once daily

• Carvedilol, 6.25 twice daily

• Clopidogrel, 75 mg once daily

• Lisinopril, 10 mg once daily

• Omega-3-acid ethyl esters, 1 g at bedtime

• Rosuvastatin, 40 mg once daily

• Fenofibric acid, 135 mg once daily

Follow-up visit 4 weeks later (Table 2):

• Continues smoking cessation

• Weight loss: 10 pounds

• BP: 122/82 mmHg

• Lipid panel:

• FBG: 98 mg/dL (goal, <100 mg/dL)

To further lower Sam’s cholesterol and triglyceride levels and raise his HDL levels, we added ezetimibe, 10 mg once daily. He will continue to take the fibrate at the present dose level. We gave Sam positive reinforcement about the health benefits of his progress and continued avoidance of cigarettes. He admits to drinking 1 beer per evening, has added 1 to 2 servings of fish per week to his diet, and no longer eats fried foods. We reviewed with Sam how to read food labels and select foods low in saturated fat and sugar and instructed him to avoid processed foods, which can be high in salt, cholesterol, and carbohydrates. He reports that he has been walking 2 miles every day, and we encouraged him to increase his daily walk to 60 minutes. He was asked to follow up again in 4 to 6 weeks.

6-Week follow-up (Table 2):

• Continues smoking cessation

• Weight loss: 13 pounds (from visit 1)

• BP: 118/78 mmHg

• Lipid panel:

• FBG: 98 mg/dL (goal, <100 mg/dL)

Summary

Sam represents someone at very high risk for future cardiovascular events, who requires frequent monitoring, continued support, and aggressive risk management. It will also be important to assist him in maintaining his current high level of motivation to be successful in reaching his goals. We believe that nurse practitioners (NPs) are the best suited to manage patients like Sam, who live with a chronic disease that requires vigilance in managing multiple risk factors and encouragement in making lifestyle changes that are often difficult to achieve. NPs are trained to access, diagnose, and manage very complicated patients with multiple problems, such as Sam, who live at high risk for future CVD events.

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