What preventive care should be provided for a 49‑year‑old man with obesity, hyperlipidaemia, obstructive sleep apnea, stable angina and a 10‑year atherosclerotic cardiovascular disease (ASCVD) risk of 12.2%?

Preventive Care for a 49-Year-Old with 12.2% ASCVD Risk, Obesity, HLD, OSA, and Stable Angina

This patient requires high-intensity statin therapy immediately, aggressive blood pressure control targeting <130/80 mmHg, beta-blocker therapy for stable angina, CPAP treatment for OSA, and comprehensive lifestyle modification—all initiated concurrently without delay given the high cardiovascular risk profile. 1, 2

Lipid Management

Initiate high-intensity statin therapy immediately given the 12.2% 10-year ASCVD risk (intermediate-risk category) combined with stable angina (clinical ASCVD). 1

• Start atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily to achieve at least 50% LDL-C reduction from baseline. 2
• The presence of stable angina places this patient in the secondary prevention category, making statin therapy a Class I indication regardless of baseline LDL-C level. 1
• Obtain fasting lipid panel 4-12 weeks after initiation to assess response and adherence. 2

If LDL-C reduction is <50% or LDL-C remains ≥70 mg/dL on maximally tolerated statin:

• Add ezetimibe 10 mg daily as first-line nonstatin therapy. 2
• Consider PCSK9 inhibitor if goals still not met after statin plus ezetimibe (provides additional 50-60% LDL-C reduction). 2

Blood Pressure Management

Target blood pressure <130/80 mmHg given the presence of coronary artery disease (stable angina). 1

Beta-blockers are the first-line antihypertensive choice for this patient with stable angina:

• Initiate a cardioselective beta-1 blocker without intrinsic sympathomimetic activity (e.g., metoprolol succinate, atenolol, or bisoprolol). 1
• Beta-blockers alleviate ischemia and angina through negative chronotropic and inotropic effects, increasing diastolic coronary perfusion time. 1
• They provide dual benefit: blood pressure control and angina management. 1

If blood pressure remains uncontrolled on beta-blocker monotherapy:

• Add an ACE inhibitor or ARB as second-line therapy. 1
• Consider adding a thiazide diuretic or calcium channel blocker if needed for additional BP control. 1

Follow-up blood pressure monthly until control achieved, then every 3-6 months. 1

Obstructive Sleep Apnea Management

Initiate continuous positive airway pressure (CPAP) therapy immediately. 3, 4

• OSA is a major independent risk factor for hypertension, cardiovascular disease, and contributes significantly to this patient's overall ASCVD risk. 3, 4
• CPAP therapy decreases sympathetic activity, blood pressure, heart rate, and cardiovascular disease mortality. 3
• OSA treatment is particularly critical given the coexistence of obesity, hypertension, and stable angina—OSA likely contributes to resistant hypertension and worsens cardiovascular outcomes. 3, 5
• The intermittent hypoxia from OSA independently increases hyperlipidemia prevalence and cardiovascular risk through inflammation, oxidative stress, and metabolic dysregulation. 6, 7

Weight Management and Lifestyle Modification

Prescribe structured weight loss program targeting 5-10% body weight reduction as obesity is the primary driver of OSA and contributes to all other risk factors. 3

Dietary interventions:

• Recommend Mediterranean or DASH diet to synergistically lower cholesterol and blood pressure. 2
• Restrict sodium intake to <2,300 mg daily (ideally <1,500 mg for optimal BP control). 1
• Reduce caloric intake by 500-750 kcal/day for gradual weight loss. 3

Physical activity prescription:

• Recommend 150-300 minutes of moderate-intensity aerobic activity per week (or 75-150 minutes vigorous-intensity). 2
• Start gradually given stable angina; ensure symptoms are controlled before advancing exercise intensity. 1

Smoking cessation (if applicable):

• Provide counseling and pharmacotherapy (varenicline, bupropion, or nicotine replacement). 2

Alcohol moderation:

• Limit to ≤2 drinks/day for men. 1

Antiplatelet Therapy

Initiate aspirin 81 mg daily for secondary prevention given the presence of stable angina (clinical ASCVD). 1

Monitoring Schedule

Initial intensive phase (first 3 months):

• Monthly blood pressure checks until target <130/80 mmHg achieved. 1
• Lipid panel at 4-12 weeks post-statin initiation. 2
• CPAP adherence assessment at 2-4 weeks, then monthly. 3
• Assess for statin-related muscle symptoms at each visit. 2

Maintenance phase:

• Blood pressure every 3-6 months once controlled. 1
• Lipid panel every 3-12 months after achieving target. 2
• Annual ASCVD risk reassessment as patient ages toward higher-risk categories. 2
• Monitor for angina symptom progression at each visit. 1

Critical Clinical Considerations

Do not delay pharmacotherapy for lifestyle modification trials at this risk level—the absolute cardiovascular benefit is too substantial to postpone statin and antihypertensive therapy. 2

Avoid excessive diastolic blood pressure lowering (<60 mmHg) in this patient with stable angina, as it may worsen coronary perfusion and ischemia. 1

The combination of obesity, OSA, and hyperlipidemia creates a particularly high-risk phenotype where OSA-mediated intermittent hypoxia independently worsens lipid metabolism and cardiovascular outcomes beyond traditional risk scores. 6, 7

CPAP adherence is critical—non-adherence negates cardiovascular benefits, so close follow-up and troubleshooting of CPAP issues is essential. 3