What is the next step for a 52-year-old female with a strong cardiac history, experiencing chest discomfort, a positive electrocardiogram (EKG) stress test indicating ischemia, but a negative Cardiolite (Technetium-99m sestamibi) study, and elevated low-density lipoprotein (LDL) cholesterol of 124?

From the Guidelines

The next step for this 52-year-old female with strong cardiac history, chest discomfort, positive stress EKG but negative cardiolite study, and LDL of 124 mg/dL should be to initiate medical therapy, including a moderate-intensity statin such as atorvastatin 20 mg daily or rosuvastatin 10 mg daily to lower her LDL to below 100 mg/dL, as recommended by the AHA/ACC guidelines for secondary prevention in patients with coronary and other vascular disease 1.

Medical Therapy

The patient's LDL level of 124 mg/dL is above the primary goal of LDL 100 mg/dL, and according to the lipid management guidelines, intensifying LDL-lowering therapy with a statin or resin is recommended for patients with LDL levels between 100-129 mg/dL 1.

• The use of statins has been shown to reduce the risk of major vascular events in patients with coronary artery disease, and the choice of statin and dose should be individualized based on the patient's risk factors and medical history.
• Aspirin 81 mg daily should also be initiated for cardiovascular protection, as recommended by the AHA/ACC guidelines for patients with coronary artery disease 1.

Lifestyle Modifications

In addition to medical therapy, the patient should be counseled on lifestyle modifications, including:

• A heart-healthy diet with emphasis on fruits, vegetables, and low-fat dairy products, as well as moderation of alcohol and sodium intake 1.
• Regular exercise, with a minimum goal of 30 minutes of moderate-intensity aerobic activity 3-4 days per week, and optimal daily activity of 30-60 minutes of aerobic activity supplemented by increased daily lifestyle activities 1.
• Smoking cessation, if applicable, and avoidance of secondhand smoke, as smoking is a significant risk factor for cardiovascular disease 1.
• Stress management, as stress can exacerbate cardiovascular disease.

Further Evaluation

The discordance between the stress EKG and nuclear imaging results warrants further investigation, and a coronary CT angiography (CCTA) or invasive coronary angiography may be considered to further evaluate for coronary artery disease.

• The patient should be instructed to seek immediate medical attention if her chest discomfort worsens or is accompanied by other concerning symptoms such as shortness of breath, diaphoresis, or radiation to the jaw or arm.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD The recommended starting dosage is 10 or 20 mg once daily; dosage range is 10 mg to 80 mg once daily.

The patient has a strong cardiac history and has been having chest discomfort with a positive stress test for ischemia. Given her LDL level of 124, which is slightly elevated, and her high risk of cardiovascular events, the next step would be to consider initiating statin therapy to reduce her risk of myocardial infarction, stroke, and other cardiovascular events.

• The starting dose of atorvastatin could be 10-20 mg once daily, with the goal of reducing her LDL level and decreasing her risk of cardiovascular events 2, 2.
• It is essential to monitor her liver enzymes and muscle symptoms while on atorvastatin therapy, as it can increase the risk of myopathy and hepatic dysfunction.
• The patient should be instructed to report any unexplained muscle pain, tenderness, or weakness to her healthcare provider promptly.

From the Research

Next Steps for Patient Care

The patient's LDL level is 124, and she has a strong cardiac history with recent chest discomfort and a positive stress test for ischemia, but a negative cardiolite study. Considering her condition, the following steps could be taken:

• Evaluate the need for lipid-lowering therapy to reduce the risk of major adverse cardiovascular and cerebrovascular events (MACCEs) 3
• Consider statin therapy, as it has been shown to reduce periprocedural myocardial infarction and contrast-induced nephropathy after percutaneous coronary intervention (PCI) 4, 5
• Assess the patient's clinical presentation, severity of ischemia, and coronary anatomy to determine the best therapeutic approach, which may include medical therapy or PCI 6
• Monitor lipid levels after initiating lipid-lowering therapy to assess adherence and medication efficacy, and consider adding nonstatin therapy if necessary 7

Considerations for Lipid-Lowering Therapy

• The patient's LDL level is above the recommended goal, and intensive lipid-lowering therapy may be beneficial in reducing the risk of MACCEs 3
• Statin therapy has been shown to have beneficial effects on endothelial function and atherosclerotic plaque, and may reduce the risk of periprocedural myocardial infarction and contrast-induced nephropathy 4, 5

Diagnostic and Therapeutic Approaches

• The decision to perform PCI or recommend medical therapy should be based on individual patient factors, including clinical presentation, severity of ischemia, and coronary anatomy 6
• Lipid monitoring after initiating lipid-lowering therapy is important to assess adherence and medication efficacy, and to determine if additional therapy is needed 7