What additional management is recommended for a 67-year-old male with a history of anterior myocardial infarction (MI) 20 days ago, treated with percutaneous coronary intervention (PCI), aspirin (ASA), ticagrelor (Ticag), bisoprolol (2.5mg), ramipril (2.5mg), and empagliflozin (Jardiance, 10mg), with current normotension, normal pulse, and elevated low-density lipoprotein (LDL) levels, currently asymptomatic and on rosuvastatin (Crestor, 40mg)?

From the Guidelines

The patient's current management appears appropriate for a recent anterior myocardial infarction, but consideration should be given to further optimizing lipid-lowering therapy to achieve a target LDL-C level of < 1.4 mmol/L, as recommended by the 2024 international lipid expert panel guidelines 1. The patient is already on Crestor (rosuvastatin) 40mg daily, which is a high-intensity statin. However, the current LDL level is 1.16 mmol/L, which is above the target level.

• Consider adding ezetimibe 10mg daily to the patient's regimen, as recommended by the guidelines 1, if the LDL goal is not achieved with statin therapy alone.
• The patient should continue dual antiplatelet therapy (ASA and ticagrelor) for 12 months post-PCI, then transition to single antiplatelet therapy indefinitely, as per standard practice.
• Gradual uptitration of beta-blocker (bisoprolol) and ACE inhibitor (ramipril) doses would be beneficial if tolerated hemodynamically, to optimize blood pressure control and reduce cardiovascular risk.
• Cardiac rehabilitation should be initiated, and the patient should be counseled on lifestyle modifications including smoking cessation if applicable, heart-healthy diet, regular physical activity, and stress management, as outlined in the 2002 AHA guidelines for primary prevention of cardiovascular disease and stroke 1.
• Regular follow-up appointments should be scheduled to monitor medication tolerance, blood pressure control, and lipid levels, and to assess the need for further adjustments to the patient's management plan.
• An echocardiogram would be valuable to assess left ventricular function and guide further management decisions, particularly regarding the potential addition of an aldosterone antagonist if ejection fraction is reduced.

From the FDA Drug Label

In the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study, the effect of Atorvastatin on the occurrence of major CV disease events was assessed in 17,802 males (≥50 years) and females (≥60 years) who had no clinically evident CV disease, LDL-C levels <130 mg/dL and hsCRP levels ≥2 mg/L. Rosuvastatin significantly reduced the risk of major CV events (252 events in the placebo group vs. 142 events in the rosuvastatin group) with a statistically significant (p<0. 001) relative risk reduction of 44% and absolute risk reduction of 1. 2%

The patient is already on Crestor 40, which is the same as rosuvastatin 40, and has an LDL of 1.16, which is relatively low.

• The patient's current medication regimen appears to be adequate for managing their cardiovascular risk factors.
• No additional medications are recommended based on the provided information.
• It is essential to continue monitoring the patient's lipid profile, blood pressure, and cardiovascular health to ensure the current treatment plan remains effective. 2

From the Research

Current Treatment and Status

The patient is currently asymptomatic, with a blood pressure of 115/70 mmHg and a pulse of 70 beats per minute. The patient's LDL level is 1.16 mmol/L, and they are being treated with Crestor 40mg, in addition to other medications such as ASA, ticagrelor, bisoprolol, ramipril, and Jardiance.

Considerations for Additional Treatment

• The patient's current statin treatment is Crestor 40mg, which is a high-intensity statin. According to the study 3, high-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD) for secondary prevention, with a goal of reducing LDL cholesterol by 50% or more.
• The study 4 compared the effectiveness of high-intensity rosuvastatin and atorvastatin therapy in patients with acute coronary syndrome (ACS) and found that both treatments had comparable cardiovascular effectiveness and safety outcomes.
• The patient is already taking ticagrelor, which is an antiplatelet medication. The study 5 found that the combination of ticagrelor and aspirin reduced the risk of stroke or death within 30 days in patients with acute ischemic stroke or transient ischemic attack (TIA).
• The study 6 found that statins as a class reduced the risk of non-fatal myocardial infarction (MI), cardiovascular disease (CVD) mortality, and all-cause mortality in primary prevention populations, but increased the risk of myopathy, renal dysfunction, and hepatic dysfunction.

Potential Additions to Treatment

• Considering the patient's current treatment and status, there may not be a need to add any new medications. However, the patient's LDL level is 1.16 mmol/L, which may not be at the target level for secondary prevention. According to the study 3, the goal for LDL reduction is 50% or greater.
• The patient's current treatment with ticagrelor and aspirin may be sufficient for antiplatelet therapy, as shown in the study 5.
• The study 6 suggests that atorvastatin and rosuvastatin are the most effective statins in reducing CVD events, while atorvastatin appears to have the best safety profile. However, the patient is already taking Crestor 40mg, which is a high-intensity statin.

Key Points to Consider

• The patient's current treatment and status should be closely monitored to ensure that their LDL level is at the target level for secondary prevention.
• The patient's antiplatelet therapy with ticagrelor and aspirin may be sufficient, but should be continued as prescribed.
• The patient's statin treatment with Crestor 40mg may be sufficient, but should be continued as prescribed and monitored for any potential side effects.