MKSAP Quiz: Treatment of elevated cholesterol levels
A 58-year-old man is evaluated during a routine visit. He has psoriatic arthritis and hypertension. Following a physical exam and lab studies, what is the most appropriate treatment?
A 58-year-old man is evaluated during a routine visit. He has psoriatic arthritis and hypertension. His father had a myocardial infarction at age 53 years. His current medications are methotrexate, allopurinol, lisinopril, and amlodipine. The patient is White.
On physical examination, blood pressure is 140/82 mm Hg, and pulse rate is 70/min. BMI is 28. Other physical examination findings are normal.
Laboratory studies:
| LDL cholesterol | 160 mg/dL (4.14 mmol/L) |
| HDL cholesterol | 40 mg/dL (1.04 mmol/L) |
| Total cholesterol | 270 mg/dL (6.99 mmol/L) |
| Triglycerides | 350 mg/dL (3.95 mmol/L) |
The patient's 10-year risk for atherosclerotic cardiovascular disease is 15.7%.
In addition to therapeutic lifestyle changes, which of the following is the most appropriate treatment?
A. Ezetimibe
B. Gemfibrozil
C. High-intensity atorvastatin
D. Moderate-intensity atorvastatin
MKSAP Answer and Critique
The correct answer is D. Moderate-intensity atorvastatin. This content is available to MKSAP 19 subscribers as Question 46 in the General Internal Medicine 1 section. More information about MKSAP is available online.
The most appropriate treatment is initiation of moderate-intensity statin (e.g., atorvastatin) therapy (Option D). Adults aged 40 to 75 years without diabetes mellitus and with an LDL cholesterol level of 70 mg/dL to 189 mg/dL (1.81-4.90 mmol/L) should undergo risk assessment for primary prevention of atherosclerotic cardiovascular disease (ASCVD) by using the Pooled Cohort Equations. The 10-year risk for ASCVD can be categorized as low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%). In adults at intermediate risk, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy. This patient has two risk-enhancing factors: psoriatic arthritis (an inflammatory condition) and a family history of premature ASCVD. The American Heart Association/American College of Cardiology recommendations for primary prevention of ASCVD support moderate-intensity statin therapy for this patient. The U.S. Preventive Services Task Force recommends low- to moderate-intensity statin therapy for primary prevention in adults who have at least one ASCVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year ASCVD event risk of 10% or higher. The 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense cholesterol guideline recommends moderate-intensity statin therapy for primary prevention in patients with a 10-year cardiovascular risk of 12% or higher, an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or greater, or diabetes.
Ezetimibe (Option A) in addition to maximally tolerated statin therapy is indicated in very high-risk patients with ASCVD when the LDL cholesterol level remains 70 mg/dL (1.81 mmol/L) or greater. Ezetimibe can be considered for primary prevention of ASCVD in patients with an initial LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or greater in whom maximally tolerated statin therapy does not achieve a 50% reduction in LDL cholesterol. Ezetimibe monotherapy is not indicated for this patient.
Although this patient has hypertriglyceridemia, a fibrate, such as gemfibrozil (Option B), is not indicated before intensifying statin therapy, lifestyle interventions, and addressing reversible factors.
This patient does not have an indication for high-intensity statin therapy (Option C) because he is in the intermediate 10-year ASCVD risk category. In adults aged 40 to 75 years at high risk for ASCVD, high-intensity statin therapy should be initiated for primary prevention to reduce LDL cholesterol level by 50% or more.
Key Points
- The American Heart Association/American College of Cardiology recommend consideration of moderate-intensity statin therapy in adults at intermediate risk for atherosclerotic cardiovascular disease with risk-enhancing factors.
- The U.S. Preventive Services Task Force recommends low- to moderate-intensity statin therapy for primary prevention in adults who have at least one atherosclerotic cardiovascular disease (ASCVD) risk factor and a calculated 10-year ASCVD event risk of 10% or higher.