What is the management approach for a 67-year-old male with hypercholesterolemia (elevated total cholesterol of 237 mg/dL), elevated low-density lipoprotein (LDL) cholesterol at 146 mg/dL, high-density lipoprotein (HDL) cholesterol of 59 mg/dL, and hypertriglyceridemia (elevated triglycerides, TG, of 162 mg/dL), who is not currently medicated?

From the Guidelines

This 67-year-old male should start on a moderate-intensity statin such as atorvastatin 20mg daily or rosuvastatin 10mg daily, along with lifestyle modifications including a Mediterranean or DASH diet, regular exercise (150 minutes weekly of moderate activity), weight management if needed, and limiting alcohol consumption. His LDL of 146 mg/dL and total cholesterol of 237 mg/dL exceed recommended targets for his age group, and both values have increased from previous measurements 1. While his HDL level of 59 mg/dL is favorable, his triglycerides are borderline elevated at 162 mg/dL. Statins work by inhibiting HMG-CoA reductase, reducing cholesterol synthesis in the liver and increasing LDL receptor activity, which helps clear LDL from the bloodstream 1. For optimal results, take the statin at night when cholesterol synthesis is highest. After starting medication, lipid levels should be rechecked in 4-12 weeks to assess response and adjust therapy if needed. Some key lifestyle modifications to focus on include:

• Dietary intake: Advocate consumption of a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, poultry, and lean meats 1
• Physical activity: Goal of at least 30 min of moderate-intensity physical activity on most days of the week 1
• Weight management: Initiate weight-management program through caloric restriction and increased caloric expenditure as appropriate 1 Side effects may include muscle pain, which should be reported to a healthcare provider if persistent. It is also important to consider the patient's overall cardiovascular risk factors, including blood pressure control, smoking status, and family history of premature CHD 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD As an adjunct to diet to reduce low-density lipoprotein cholesterol (LDL-C) in: Adults with primary hyperlipidemia.

The patient has elevated LDL levels and primary hyperlipidemia.

• The patient's LDL level is 146, which is elevated.
• The patient's cholesterol level is 237, which is also elevated.
• Atorvastatin can be used to reduce the risk of myocardial infarction, stroke, and angina in adults with multiple risk factors for coronary heart disease.
• Atorvastatin can also be used as an adjunct to diet to reduce LDL-C in adults with primary hyperlipidemia. The patient may be a candidate for atorvastatin therapy to reduce their LDL and cholesterol levels 2.

From the Research

Patient's Cholesterol Levels

• The patient's cholesterol level is 237, which is elevated, with an LDL level of 146, also elevated, an HDL level of 59, and a triglyceride level of 162 3.
• The patient is not currently medicated for their high cholesterol.

Treatment Options

• Statins are often the first line of treatment for high cholesterol, but they may not be sufficient to decrease LDL cholesterol levels, and they can pose a significant on-treatment residual risk of major cardiovascular events 3.
• Ezetimibe, a cholesterol absorption inhibitor, can be added to statin therapy to further reduce LDL cholesterol levels and decrease the risk of atherosclerotic cardiovascular disease (ASCVD) 3, 4.
• PCSK9 inhibitors, such as alirocumab and evolocumab, can also be used to lower LDL cholesterol levels and reduce the risk of ASCVD, especially in patients with a high risk of cardiovascular events 3, 5.

Lifestyle Changes

• Increasing physical activity can help improve blood pressure and blood cholesterol levels, and is a recommended lifestyle change for patients with mildly or moderately elevated blood pressure and cholesterol 6.
• Lifestyle-only approaches, including physical activity, can be an effective first-line treatment for patients with mildly or moderately elevated blood pressure and cholesterol 6.

Emerging Therapies

• Newer medications, such as bempedoic acid and inclisiran, are being developed to further lower LDL cholesterol levels and reduce the risk of ASCVD 4, 5.
• These emerging therapies may provide additional treatment options for patients who are unable to achieve adequate LDL cholesterol reduction with current therapies 4, 5.