What is the recommended management plan for a 68-year-old female with a history of hyperlipidemia (high cholesterol), hypertension (high blood pressure), and recent atypical chest pain and shortness of breath, now admitted to rehab for continued recovery?

Recommended Management Plan for 68-Year-Old Female Post-Hospitalization for Atypical Chest Pain

Continue current statin therapy for hyperlipidemia and maintain close monitoring without intensifying antihypertensive therapy, as her blood pressure is already well-controlled at 104/67 mmHg and further reduction risks symptomatic hypotension in this patient with polypharmacy and fall risk. 1

Blood Pressure Management

Current Status: Well-Controlled, No Intervention Needed

• Her BP of 104/67 mmHg is already below the 2024 ESC target of 120-129 mmHg systolic for most adults 1
• Critical caveat: Further BP reduction is contraindicated given her recent fall, polypharmacy with sedating medications, and diastolic BP already at 67 mmHg 1
• The 2024 ESC guidelines specifically recommend applying the "as low as reasonably achievable" (ALARA) principle when target BP of 120-129 mmHg causes poor tolerance, which applies here given her fall risk and current medications 1
• Do not add or intensify antihypertensive agents - her current regimen is appropriate 1
• Monitor for orthostatic hypotension at each visit, particularly given her sedating medications and fall history 1

Lipid Management

Continue Current Statin Therapy with Monitoring

• Continue her current statin regimen as prescribed 1, 2
• Target LDL-C <100 mg/dL given her multiple cardiovascular risk factors (age 68, hypertension, hyperlipidemia, obesity) 3, 2
• Obtain fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) at next outpatient cardiology follow-up to assess adequacy of current therapy 1, 2
• If LDL-C remains ≥100 mg/dL on current statin dose, consider intensifying to high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) to achieve at least 50% LDL-C reduction 2, 4
• Monitor liver enzymes and creatine kinase if statin dose is adjusted 2

Cardiac Risk Stratification Post-Atypical Chest Pain

Low Probability of Acute Coronary Syndrome - Conservative Management Appropriate

• Her presentation was not consistent with acute coronary syndrome: normal EF 65-70%, troponins that declined to <6, unremarkable CT chest, and musculoskeletal etiology from fall 1
• EKG findings of "possible inferior and anterior MI of indeterminate age" require clarification but do not mandate acute intervention given negative ischemic workup 1
• No indication for dual antiplatelet therapy - she does not have confirmed coronary artery disease requiring PCI or recent acute coronary syndrome 1
• Continue aspirin if already prescribed for primary prevention given her cardiovascular risk factors, but this is not mandatory 1

Lifestyle Modifications - Essential Component

Implement Comprehensive Risk Factor Modification

• Dietary modifications: Reduce saturated fat to <7% of total calories, limit cholesterol to <200 mg/day, eliminate trans fats 2, 4
• Weight management: Target BMI 18.5-24.9 kg/m² (current BMI 30.54 indicates obesity requiring intervention) and waist circumference <35 inches 1, 2
• Physical activity: Minimum 30 minutes of moderate-intensity activity most days of the week, progressing as tolerated in rehabilitation setting 1, 3
• Sodium restriction: Moderate sodium restriction given hypertension history, though BP currently well-controlled 1
• Increase consumption of fruits, vegetables, whole grains, low-fat dairy, fish, and legumes 3, 4

Rehabilitation and Fall Prevention

Address Polypharmacy and Fall Risk

• Critical priority: Review all sedating medications with rehabilitation team to minimize fall risk 1
• The mild leukocytosis (WBC 12.74) is likely reactive to recent hospitalization and requires no intervention unless fever or infectious symptoms develop 5
• Encourage incentive spirometry to prevent atelectasis given recent hypoventilatory changes on CT 1
• Maintain adequate hydration given mild BUN elevation (24 mg/dL) 1
• Monitor oxygen saturation daily during rehabilitation stay 1

Monitoring and Follow-Up Schedule

Structured Surveillance Plan

• No immediate repeat labs needed unless new symptoms arise (chest pain, dyspnea, fever, altered mental status) 5
• Consider rechecking CBC/BMP in 3-5 days only if clinical concerns develop 5
• Outpatient cardiology follow-up after rehabilitation discharge for ongoing cardiovascular risk management 1
• Obtain fasting lipid panel at cardiology follow-up to guide statin therapy optimization 1, 2
• Annual BP monitoring once stable, with more frequent checks if medications adjusted 1
• If chest pain or dyspnea recurs, pursue ischemic evaluation at that time - not indicated currently given negative workup 1

Key Clinical Pitfalls to Avoid

• Do not intensify antihypertensive therapy - her BP is already well-controlled and further reduction risks symptomatic hypotension, particularly dangerous given her fall history and polypharmacy 1
• Do not initiate dual antiplatelet therapy - she has no indication (no PCI, no confirmed ACS) and this would increase bleeding risk unnecessarily 1
• Do not overlook medication-related fall risk - sedating medications combined with potential orthostatic hypotension from antihypertensives require careful monitoring 1
• Do not assume EKG findings represent acute pathology - "possible MI of indeterminate age" with normal troponins and normal EF suggests old or artifact, not acute intervention needed 1