What is the significance of a 63-year-old male's lab results showing hypercholesterolemia with a total cholesterol level of 220, elevated low-density lipoprotein (LDL) of 145, and an elevated blood urea nitrogen (BUN) to creatinine ratio of 26?

From the Guidelines

This 63-year-old male on aspirin should discuss with his doctor about starting a statin medication to lower his elevated LDL cholesterol, with a goal of reducing LDL-C to less than 100 mg/dL, as recommended by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. The patient's total cholesterol of 220 mg/dL and LDL of 145 mg/dL are above recommended targets for someone his age, especially if he's already on aspirin which suggests cardiovascular risk factors.

• A moderate-intensity statin like atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily would likely be appropriate, as statins are the usual first-line treatment to reach the LDL-C goal and should be used up to the highest recommended dose or highest tolerable dose to reach the goal 1.
• The slightly elevated BUN of 26 mg/dL and BUN/creatinine ratio of 26 may indicate mild dehydration or early kidney function changes, which should be monitored but doesn't necessarily require immediate intervention, as recommended by the AHA guidelines for primary prevention of cardiovascular disease and stroke 1. He should ensure adequate hydration and have follow-up labs in 3 months to assess both cholesterol response to statin therapy and kidney function.
• Statins work by inhibiting HMG-CoA reductase, reducing cholesterol production in the liver and increasing LDL receptor activity, which helps clear LDL from the bloodstream, and this intervention is important because lowering LDL cholesterol has been consistently shown to reduce cardiovascular events, particularly in older adults with risk factors 1. Additionally, the patient should be advised to follow a healthy lifestyle, including a balanced diet, regular physical activity, and weight management, as recommended by the AHA guidelines 1.

From the FDA Drug Label

In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of atorvastatin calcium on cardiovascular disease (CVD) endpoints was assessed in 2,838 subjects (94% White, 2% Black or African American, 2% South Asian, 1% other; 68% male), ages 40 to 75 with type 2 diabetes based on WHO criteria, without prior history of cardiovascular disease and with LDL ≤160 mg/dL and triglycerides (TG) ≤600 mg/dL. The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. Atorvastatin calcium significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the atorvastatin calcium group vs. 127 events in the placebo group) with a relative risk reduction of 37%, HR 0. 63,95% CI (0.48,0.83) (p=0.001)

The patient has high LDL levels (145 mg/dL) and total cholesterol (220 mg/dL).

• Treatment with atorvastatin may help reduce the risk of major cardiovascular events, including myocardial infarction and stroke.
• The patient's LDL level (145 mg/dL) is close to the threshold used in the CARDS study (LDL ≤160 mg/dL).
• Based on the study, atorvastatin calcium 10 mg/day may be beneficial for this patient, but the decision should be made by a healthcare professional considering the patient's overall health and medical history 2.

From the Research

Patient's Blood Work Results

The patient's blood work results show:

• Total cholesterol: 220 mg/dL
• LDL (low-density lipoprotein) cholesterol: 145 mg/dL
• BUN (blood urea nitrogen): 26 mg/dL
• BUN/creatinine ratio: 26

LDL Cholesterol Targets

According to the study 3, lowering LDL cholesterol reduces vascular risk. The current guidelines recommend initiating statin therapy in patients with a yearly coronary heart disease risk of around 1.5-2%. The study suggests that intensive statin therapy is associated with larger reductions in vascular risk, and lower LDL-C targets should help reduce vascular mortality and major vascular morbidity substantially.

Statin Therapy

The study 4 shows that statin treatment typically reduces the relative risk of cardiovascular disease by 24-37%, regardless of age, sex, prior history of coronary heart disease, or other co-morbid conditions. Another study 5 found that statin therapy is effective in reducing cardiovascular disease risk, but there is room for better LDL-C management among high-risk CVD patients to reduce their overall CV risk.

Achieving Target LDL-C Levels

The study 6 compared the effect of ezetimibe/simvastatin and atorvastatin on achieving a target LDL-C goal in very high-risk patients. The results showed that both treatments had similar effects in achieving target LDL-C levels.

Effects of Statins on Endothelial Function

The study 7 compared the effects of atorvastatin and ezetimibe on endothelial function in dyslipidemic patients with chronic kidney disease. The results showed that atorvastatin was more potent than ezetimibe in improving the serum lipid profile, reducing oxidative stress, suppressing inflammation, and preserving endothelial function.

Key Points

• The patient's LDL cholesterol level is 145 mg/dL, which is higher than the recommended target level.
• Statin therapy is effective in reducing cardiovascular disease risk and lowering LDL cholesterol levels.
• Intensive statin therapy may be associated with larger reductions in vascular risk.
• Achieving target LDL-C levels is important for reducing cardiovascular risk, and both ezetimibe/simvastatin and atorvastatin can be effective in achieving this goal.
• Atorvastatin may be more potent than ezetimibe in improving endothelial function and reducing oxidative stress and inflammation.