What is the management plan for a patient with negative Helicobacter pylori (H. pylori) test, elevated Low-Density Lipoprotein (LDL) cholesterol, normal High-Density Lipoprotein (HDL) cholesterol, normal triglycerides, and leukopenia (low White Blood Cell (WBC) count)?

From the Guidelines

The patient should start a statin medication due to an elevated ASCVD risk of 12.3% and elevated LDL cholesterol, while also addressing the low white blood cell count (neutropenia) and monitoring for potential infection symptoms. The patient's lab results showed negative H. pylori, so no antibiotics are needed, though a GI referral may be considered if symptoms persist. The patient's triglycerides and HDL cholesterol are within normal limits. Dietary recommendations include reducing trans fats and increasing healthy saturated fats, as suggested by the American Heart Association guidelines 1.

The patient's elevated ASCVD risk and LDL cholesterol levels are concerning, and the most recent guidelines recommend starting statin therapy in patients with an ASCVD risk of 12.3% or higher, as seen in the 2007 update on core components of cardiac rehabilitation/secondary prevention programs 1. The goal is to reduce LDL-C levels to less than 100 mg/dL, and further reduction to less than 70 mg/dL is considered reasonable for high-risk patients, as stated in the 2006 update on secondary prevention for patients with coronary and other atherosclerotic vascular disease 1.

However, the patient's low white blood cell count (neutropenia) increases the risk of infection, which could be due to various causes including familial neutropenia, viral infections, medications, nutritional factors, hematologic malignancies, rheumatologic disorders, autoimmune conditions, or aplastic anemia. The patient should seek urgent medical attention if infection symptoms develop. The patient already has a hematologist, and the provider is sending these lab results to the hematologist and ensuring follow-up appointments are scheduled.

Key points to consider:

• Start statin medication to reduce LDL-C levels and ASCVD risk
• Monitor and address low white blood cell count (neutropenia) and potential infection symptoms
• Dietary recommendations include reducing trans fats and increasing healthy saturated fats
• Follow-up appointments with the hematologist are crucial to monitor the patient's condition and adjust treatment as needed, as recommended by the American Heart Association guidelines 1.

From the FDA Drug Label

EZETIMIBE tablets, for oral use ... INDICATIONS AND USAGE EZETIMIBE Tablets is indicated (1): • In combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH) ... DOSAGE AND ADMINISTRATION 10-mg orally once daily, with or without food (2)

The patient's LDL (bad cholesterol) is elevated and the patient is already being started on a statin. Ezetimibe can be used in combination with a statin to reduce elevated LDL-C levels. The recommended dosage of ezetimibe is 10-mg orally once daily. Given the patient's elevated LDL levels and the decision to start a statin, ezetimibe could be considered as an adjunct to diet and statin therapy to further reduce LDL-C levels 2.

From the Research

Patient's Condition and Treatment

• The patient's H. pylori test is negative, and no antibiotics are required.
• The patient's triglycerides and HDL (good cholesterol) are within normal limits (WNL).
• The patient's LDL (bad cholesterol) is elevated, and the patient can benefit from decreasing bad trans fat in their diet and increasing good saturated fat.
• The patient's ASCVD risk is 12.3%, and the patient will be started on statin therapy 3, 4, 5.
• The patient's kidney and liver function are WNL, and TSH is also WNL.

Low White Blood Cell Count

• The patient has a low white blood cell (WBC) count, which can increase the risk of infection.
• Possible causes of low WBC count include familial neutropenia, infection, medications, nutritional deficiencies, hematologic malignancies, rheumatologic disorders, autoimmune neutropenia, and aplastic anemia.
• If the patient experiences infection-type symptoms, an urgent evaluation in the clinic or hospital is necessary.

Statin Therapy and ASCVD Risk

• Statins are effective in reducing the risk of ASCVD and are recommended as a first-line therapy for primary and secondary prevention of ASCVD 3, 4, 5.
• The choice and dose of statin can impact the percentage of LDL cholesterol reduction and achievement of ≥50% reduction in LDL cholesterol 4.
• High-intensity statins are recommended for patients with ASCVD or high-risk patients without clinical ASCVD 5.
• Combination therapy with a statin and non-statin agents, such as ezetimibe or PCSK9 inhibitors, may be considered for patients at very high risk of ASCVD events 3, 6, 7.