April 15th, 2014
Case: Assessment of Cardiac Risk and Need for Preventive Medications
A 68-year-old white woman with a history of obesity and depression is seen for cardiac risk assessment. The quality of her diet varies greatly, and she admits to many dietary indiscretions. She has tried several different diets, including low-carbohydrate/high-fat diets. She does not use the treadmill or stationary bicycle in her house or routinely exercise elsewhere. There is no family history of premature atherosclerotic cardiovascular disease. She quit smoking 25 years ago, having previously smoked 1 pack per day for several years. Her current medications include aspirin 81 mg daily, a multivitamin, a calcium/vitamin D supplement, and escitalopram as needed.
The patient’s blood pressure is 118/72 mm Hg, and her body-mass index is 32 kg/m2. A recent fasting lipid panel shows total cholesterol of 250 mg/dL, an HDL level of 77 mg/dL, a triglyceride level of 163 mg/dL, a Friedewald-estimated LDL level of 140 mg/dL, and a non–HDL-cholesterol level of 173 mg/dL. The patient’s hemoglobin A1C level was 5.8%. Her primary care provider recommended starting simvastatin 20 mg daily. She is hesitant to take medications and asks whether she should use red palm oil instead.
1. How would you assess this patient’s risk of heart attack and stroke?
2. Would you recommend a statin for this patient?
3. What would be your advice about red palm oil?
4. Would you recommend that the patient stay on aspirin?
5. What dietary and exercise recommendations do you have?
April 24, 2014
1. Despite the recent debate about the latest cholesterol guidelines, I personally find the recommendations to be straightforward, practical, and intelligent. According to the risk-calculator app on my phone, this patient’s 10-year risk is 6.5% (or 5.6% if risk factors are optimized). The app recommends that the care provider consider a moderate-intensity statin (essentially half the maximal dose of currently available statins) with multiple disclaimers, including the addition of lifestyle modifications, a detailed risk-benefit discussion with the patient, and consideration of other factors (e.g., LDL >160 mg/dL, family history of premature atherosclerotic CVD, C-reactive protein (CRP) >2 mg/L, coronary artery calcium (CAC) >300, ankle-brachial index (ABI) <0.9, or elevated lifetime risk). Among the other factors to consider are the patient’s beliefs about taking medications to prevent heart disease.
2. At the first visit, I would not initiate a statin but, rather, discuss the issues with the patient and schedule a follow-up visit to assess progress (e.g., on weight loss, exercise, etc.). If progress was not significant at follow-up, I would consider statin therapy (in light of the risk calculator’s recommendation). Other risk-assessment instruments (e.g., CRP, CAC, ABI) may be useful adjuncts to provide this patient with more data about her risk.
3. I generally do not endorse alternative therapies, such as red palm oil, without an evidence base to support their use. The assumption that such therapies simply cause no harm is flawed, particularly when one considers potential drug interactions, the lack of regulatory control, unanticipated adverse effects, and so on.
4. Weighing this patient’s risk for bleeding (which appears low) against her modest CV risk (6.5%), I would consider continuing the aspirin but at a lower dosing level, such as every other day. The evidence base for aspirin in primary CV prevention in women is complex and driven largely by the Women’s Health Study. This large-scale randomized trial did not meet its primary endpoint of a first major CV event, but the risk for ischemic stroke was reduced by 25% in aspirin recipients. A subgroup analysis also suggested that aspirin lowered the risk for all CV endpoints in women older than age 65.
5. ACCF/AHA guidelines have outlined dietary and exercise recommendations. The U.S. Department of Health and Human Services currently recommends 150 minutes of moderate-intensity exercise or 75 minutes of vigorous exercise per week. The patient’s depression also needs to be addressed diligently. Although not common, bringing family into the discussion may be helpful as well.
May 2, 2014
We used the ACC/AHA smartphone app to estimate a 10-year risk of MI or stroke of 6.5%. However, the estimation did not account for her prior history of smoking, poor diet, and physical inactivity. As recommended by the guidelines, we considered other factors and performed a coronary artery calcium scan. Her LDL-C was <160 mm/dL, and she had no family history of premature ASCVD; however, her CAC score was 601 — in the 95th percentile for a 68 year-old white woman and consistent with much higher risk than was suggested by traditional risk factors alone.
We engaged the patient in a detailed discussion about the options for statin therapy as an adjunct to lifestyle changes, and she decided to start rosuvastatin 40 mg daily. I recommended against red palm oil, which she had become curious about because of the Dr. Oz show; I’m glad she asked my opinion, which gave us the opportunity to focus on evidence-based therapy. The patient remains on aspirin 81 mg daily, which seems reasonable, given her high absolute risk of ASCVD, and apparently low risk of bleeding.
The patient viewed the very high CAC score as a motivator to improve her diet and physical activity level, and we reviewed the lifestyle guideline recommendations. In addition, the patient elected to join mActive, a trial of digital activity-tracking and mobile phone-based text message coaching. Her depression has been mild and intermittent and is well managed by her PCP; it is our hope that her mood will improve with lifestyle change.