What management approach is recommended for a 78-year-old male patient with atherosclerosis of the aorta, hyperlipidemia, and anemia?

From the Guidelines

The recommended management approach for a 78-year-old male with atherosclerosis of the aorta, hyperlipidemia, and anemia should prioritize statin therapy, such as atorvastatin 20-40 mg daily or rosuvastatin 10-20 mg daily, to reduce low-density lipoprotein cholesterol (LDL-C) levels, along with aspirin 81 mg daily for antiplatelet therapy and lifestyle modifications to address all three conditions.

Management of Hyperlipidemia

For hyperlipidemia, the goal is to reduce LDL-C levels, and according to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, high-intensity statin therapy is recommended for patients with clinical atherosclerotic cardiovascular disease (ASCVD), aiming to lower LDL-C levels by ≥50%.

• Key considerations include:
  • Using a maximally tolerated statin to achieve the desired LDL-C reduction
  • Considering the addition of non-statins (like ezetimibe) to statin therapy in very high-risk ASCVD patients with an LDL-C threshold of 70 mg/dL
  • Potential addition of a PCSK9 inhibitor in very high-risk patients whose LDL-C remains ≥70 mg/dL on maximally tolerated statin and ezetimibe therapy

Management of Atherosclerosis

For atherosclerosis of the aorta, managing risk factors such as hyperlipidemia, hypertension, and smoking is crucial.

• Blood pressure control to below 130/80 mmHg using medications like ACE inhibitors or ARBs is recommended.
• Lifestyle modifications, including a Mediterranean or DASH diet, regular moderate exercise, smoking cessation, and limiting alcohol consumption, are essential.

Management of Anemia

The anemia requires investigation to determine its cause, with initial laboratory tests including complete blood count, iron studies, vitamin B12, and folate levels.

• If iron deficiency is identified, oral iron supplementation such as ferrous sulfate 325 mg twice daily should be initiated.

Regular Monitoring

Regular monitoring is crucial, with lipid panels every 3-6 months, complete blood counts to track anemia, and periodic cardiovascular assessments. This multifaceted approach addresses the atherosclerotic disease process by reducing cholesterol levels and inflammation, while simultaneously investigating and treating the anemia to improve oxygen delivery to tissues and overall quality of life, as supported by guidelines such as the European guidelines on cardiovascular disease prevention in clinical practice 1.

From the Research

Management Approach

The patient's condition, which includes atherosclerosis of the aorta, hyperlipidemia, and anemia, requires a comprehensive management approach.

• The primary goal is to reduce the risk of cardiovascular events, and according to 2, aggressive cholesterol-lowering therapy is recommended for patients with atherosclerotic disease.
• Statins are considered first-line therapy for reducing low-density lipoprotein cholesterol (LDL-C) and preventing cardiovascular events, as stated in 3.
• However, patients taking statins may experience adverse effects, and strategies for managing statin intolerance include changing statins, intermittent dosing, and using other LDL-C-lowering agents, as mentioned in 3.

Lipid-Lowering Therapy

• Guidelines recommend intensive low-density lipoprotein (LDL) cholesterol lowering for patients with coronary artery disease, as stated in 4.
• Achieving optimal lipid goals is crucial, and combination lipid-lowering therapy may be necessary to achieve the recommended levels, as discussed in 4.
• In addition to lowering LDL-C, raising high-density lipoprotein-cholesterol (HDL-C) and lowering triglyceride (TG) levels may be secondary therapeutic targets for patients who achieve LDL-C levels below the recommended targets but are still at risk of coronary heart disease, as mentioned in 5.

Antiplatelet Therapy

• Antiplatelet drugs, such as aspirin, are commonly used in combination with lipid-lowering agents, as discussed in 6.
• The combination of antiplatelet therapy and lipid-lowering agents, including statins and PCSK9 inhibitors, may reduce the incidence of atherothrombotic vascular events, as stated in 6.

Patient Advice

• Based on the patient's condition and the recommended management approach, the patient should be advised to:

• Adhere to the prescribed lipid-lowering therapy and antiplatelet therapy, as recommended by 3, 6, and 2.
• Make lifestyle modifications, such as dietary changes and increased physical activity, to help achieve optimal lipid goals, as mentioned in 3 and 4.
• Regularly monitor their lipid profiles and adjust their treatment plan as needed, as discussed in 4 and 5.