A 72-year-old woman is evaluated for sharp chest pain that occurs randomly. She walks 3 to 4 miles daily, and her symptoms have never occurred with exertion. She has never smoked. Medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Medications are low-dose aspirin, metformin, lisinopril, and simvastatin (10 mg/d). She has no known drug allergies.
On physical examination, blood pressure is 122/76 mm Hg, pulse rate is 76/min, and respiration rate is 12/min. Cardiac examination shows a normal S1 and S2; there is no S3, S4, murmur, or rub. The remainder of the examination is normal.
Laboratory findings include a serum total cholesterol level of 200 mg/dL (5.18 mmol/L), LDL cholesterol level of 126 mg/dL (3.26 mmol/L), and HDL cholesterol level of 50 mg/dL (1.30 mmol/L).
An exercise treadmill test is administered for 8 minutes, 40 seconds. There are no electrocardiogram changes at rest or with exercise. She does not have chest pain during exercise or recovery.
Which of the following is the most appropriate management?
A. Increase simvastatin to 80 mg/d
B. Continue current therapy
C. Start atorvastatin, discontinue simvastatin
D. Start clopidogrel
MKSAP Answer and Critique
The correct answer is C. Start atorvastatin, discontinue simvastatin. This item is available to MKSAP 17 subscribers as item 40 in the Cardiovascular Medicine section. More information about MKSAP 17 is available online.
This patient should start atorvastatin, discontinue simvastatin, and continue her other medications. The most recent cholesterol guidelines recommend a moderate- or high-intensity statin, such as atorvastatin, in patients aged 40 to 75 years with diabetes mellitus who have a 10-year cardiovascular risk greater than or equal to 7.5%. This patient's 10-year cardiovascular risk is above 10%. A cardiovascular risk calculator based on the Pooled Cohort Equations for the purpose of managing cholesterol levels is available from the American Heart Association/American College of Cardiology. In patients with diabetes in this age group with a 10-year risk below 7.5%, a moderate-intensity statin (such as simvastatin 20-40 mg/d) would be recommended. While there are multiple options for a high-intensity statin, the fact that atorvastatin has a generic alternative makes it a more attractive choice.
Increasing simvastatin from 10 mg/d to 80 mg/d is incorrect, as the FDA issued a black box warning against the use of simvastatin 80 mg/d because of a heightened risk of muscle adverse effects.
Continuing the patient's current medications is incorrect because this patient's cardiovascular risk warrants change to a moderate- or high-intensity statin.
The addition of clopidogrel to this patient's drug regimen is incorrect because dual antiplatelet therapy (such as aspirin plus clopidogrel) increases the risk of bleeding and is not routinely recommended for patients for primary prevention of cardiovascular events.
Despite a negative exercise stress test, aspirin therapy would be recommended in this woman who has several risk factors for cardiovascular events and stroke, including hypertension, type 2 diabetes mellitus, hyperlipidemia, and her age. In the Women's Health Study of 40,000 healthy women, 100 mg/d of aspirin decreased the risk of stroke, myocardial infarction, and cardiovascular death in patients older than 65 years.
- A moderate- or high-intensity statin is recommended for patients aged 40 to 75 years with diabetes mellitus who have a 10-year cardiovascular risk greater than or equal to 7.5%.