What is the plan of care and diagnosis for a patient with hyperlipidemia (elevated total cholesterol), elevated low-density lipoprotein (LDL) cholesterol, and a reactive hepatitis B surface antibody?

Diagnosis and Plan of Care

This 28-year-old female has borderline elevated LDL cholesterol (129 mg/dL) with low HDL cholesterol (42 mg/dL) and should be started immediately on high-intensity statin therapy (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) combined with intensive therapeutic lifestyle changes, targeting at least a 30-50% reduction in LDL-C with a goal of <100 mg/dL. 1, 2, 3

Primary Diagnosis

Hyperlipidemia with mixed dyslipidemia pattern:

• Elevated total cholesterol (202 mg/dL, goal <200 mg/dL) 4
• Borderline-high LDL cholesterol (129 mg/dL, borderline range 110-129 mg/dL) 5
• Low HDL cholesterol (42 mg/dL, abnormal for females <50 mg/dL) 1
• Elevated triglycerides (173 mg/dL, abnormal ≥150 mg/dL) 5
• Elevated cholesterol/HDL ratio (4.9, goal <3.5 for females) 1

Secondary finding:

• Reactive hepatitis B surface antibody (37.60) indicates immunity from prior vaccination or resolved infection, not active disease 6, 7

Risk Stratification

Calculate 10-year ASCVD risk to determine treatment intensity:

• If 10-year ASCVD risk ≥7.5%, initiate high-intensity statin therapy 1, 3
• If 10-year ASCVD risk <7.5%, initiate moderate-intensity statin therapy 1
• Evaluate for risk-enhancing factors: metabolic syndrome, chronic inflammatory conditions, family history of premature ASCVD, elevated lipoprotein(a) 3

Given the combination of borderline-high LDL-C, low HDL-C, and elevated triglycerides, this patient likely warrants high-intensity statin therapy regardless of calculated risk. 1, 2

Immediate Treatment Plan

Pharmacological Intervention

First-line therapy - High-intensity statin:

• Atorvastatin 40-80 mg daily OR rosuvastatin 20-40 mg daily 1, 2, 3, 8
• Target: ≥50% reduction in LDL-C from baseline (129 mg/dL → <65 mg/dL) 1, 2
• Absolute LDL-C goal: <100 mg/dL 1, 3, 4

Baseline laboratory monitoring before initiating statin:

• ALT, AST, creatine kinase, glucose, creatinine 2, 3
• Fasting lipid profile on two separate occasions to confirm values 3

Intensive Lifestyle Modifications

Dietary interventions (implement immediately, not after medication failure):

• Reduce saturated fat to <7% of total calories 1, 2
• Limit dietary cholesterol to <200 mg/day 5, 1
• Add plant sterols/stanols 2-3 g daily (provides additional 9-20% LDL-C reduction) 2
• Increase viscous fiber to 10-25 g/day 2
• Heart-healthy diet pattern (Mediterranean or DASH-style) 1, 3

Physical activity and weight management:

• Regular aerobic exercise (minimum 150 minutes/week moderate intensity) 2, 4
• Weight reduction if BMI ≥25 kg/m² 1, 4

Additional risk factor control:

• Blood pressure optimization (target <130/80 mmHg) 2
• Smoking cessation if applicable 2, 3

Follow-up and Monitoring Schedule

4-6 weeks after initiating statin:

• Repeat fasting lipid profile to assess LDL-C response 1, 2, 8
• Monitor for statin-associated side effects (muscle pain, weakness) 8, 9
• Check liver enzymes if risk factors for hepatotoxicity present 2, 3

Treatment intensification if goals not achieved:

If LDL-C remains >100 mg/dL or <50% reduction on maximally tolerated statin:

• Add ezetimibe 10 mg daily (provides additional 15-20% LDL-C reduction) 5, 1, 2, 3, 9
• Reassess lipid profile 4-12 weeks after adding ezetimibe 2, 9

If LDL-C goals still not met on statin + ezetimibe:

• Consider PCSK9 inhibitor (evolocumab or alirocumab) for additional 50-60% LDL-C reduction 5, 1, 3
• Refer to lipid specialist if unable to achieve goals 3

For persistent hypertriglyceridemia (≥150 mg/dL) after 4-12 weeks of statin therapy:

• Evaluate and manage secondary causes (obesity, diabetes, alcohol use, medications) 5
• Consider adding fibrate therapy with caution (increased risk of myositis when combined with statins) 5

Addressing the Hepatitis B Finding

The reactive hepatitis B surface antibody indicates immunity and does not affect lipid management:

• No contraindication to statin therapy 8
• No need for additional hepatitis B-specific interventions 6, 7
• Note that chronic HBV infection (not present here) is associated with lower HDL-C and increased cardiovascular risk, but this patient has immunity, not active infection 6, 7

Long-term Monitoring

Once LDL-C goals achieved:

• Monitor lipid profile every 3-12 months 2
• Annual assessment of adherence to lifestyle modifications and medications 5, 2
• Monitor for statin-associated side effects: measure creatine kinase if musculoskeletal symptoms develop 2, 8
• Monitor glucose/HbA1c if diabetes risk factors present (statins may modestly increase diabetes risk) 2

Critical Pitfalls to Avoid

Do not delay statin initiation while attempting lifestyle changes alone - guidelines recommend simultaneous implementation of medication and lifestyle modifications in patients requiring significant LDL-C lowering 1, 2, 3

Do not use total cholesterol alone for treatment decisions - always use LDL-C as the primary target 2

Do not overlook the low HDL-C - this significantly increases cardiovascular risk and may warrant more aggressive LDL-C lowering 1, 6, 7

Do not assume reactive hepatitis B surface antibody indicates active infection - this represents immunity and does not contraindicate statin therapy 6, 7

Monitor for statin-associated muscle symptoms - discontinue if myopathy suspected and check creatine kinase 8, 9

If adding ezetimibe, administer at least 2 hours before or 4 hours after bile acid sequestrants if using combination therapy 9