What is the diagnosis for a 73-year-old male with hypercholesterolemia (elevated total cholesterol), low High-Density Lipoprotein (HDL) cholesterol, elevated Low-Density Lipoprotein (LDL) cholesterol, and hypertriglyceridemia (elevated triglycerides)?

From the Guidelines

This patient requires immediate initiation of statin therapy, given the elevated total cholesterol and LDL levels, to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) as per the 2019 ACC/AHA guideline on primary prevention of cardiovascular disease 1. The patient's lipid profile shows significant abnormalities, with a total cholesterol of 261 mg/dL, HDL of 29 mg/dL, LDL of 5 mg/dL (which appears to be a lab error and should be rechecked), and triglycerides of 261 mg/dL.

• Key considerations for this patient include:
  • Starting atorvastatin 20-40mg daily, as it is a first-line treatment for primary prevention of ASCVD in patients with elevated LDL levels, according to the 2019 ACC/AHA guideline 1.
  • Implementing lifestyle modifications, such as a Mediterranean or DASH diet, regular exercise (150 minutes weekly of moderate activity), weight management if needed, smoking cessation if applicable, and limiting alcohol consumption.
  • Rechecking the LDL level, as the reported value of 5 mg/dL is unusually low and may be a lab error.
  • Considering additional treatments, such as fenofibrate or omega-3 fatty acids, if triglycerides remain above 200 mg/dL despite statin therapy and lifestyle changes.
• Given the patient's age (73), it is essential to evaluate for other risk factors, such as hypertension, diabetes, and family history, to assess the overall cardiovascular risk profile.
• Regular monitoring of lipid levels and liver function tests should occur 4-12 weeks after starting medication therapy, with the goal of reducing LDL by at least 30-50% from baseline and improving the overall lipid profile to reduce cardiovascular risk.

From the FDA Drug Label

Atorvastatin calcium tablets are used: to reduce the risk of: heart attack, stroke, certain types of heart surgery and chest pain in adults who do not have heart disease but have other multiple risk factors for heart disease.

along with diet to reduce low density lipoprotein cholesterol (LDL-C) or bad cholesterol: in adults with primary hyperlipidemia

The patient has high total cholesterol (261) and low HDL (29), but the LDL is very low (5) and triglycerides are high (261). The primary concern is the high triglycerides and low HDL.

• The patient's LDL is already low, so the use of atorvastatin to lower LDL may not be the primary goal.
• Triglycerides are high, and atorvastatin can be used to treat hypertriglyceridemia.
• The patient's age and lipid profile suggest an increased risk of cardiovascular events, and atorvastatin may be beneficial in reducing this risk. However, the FDA label does not provide a clear answer to the question of how to manage this patient's specific lipid profile. 2

From the Research

Patient's Lipid Profile

The patient has a total cholesterol level of 261 mg/dL, HDL of 29 mg/dL, LDL of 5 mg/dL (which seems unusually low and may be an error), and triglycerides of 261 mg/dL.

Treatment Options

• Statin therapy is often the first line of treatment for elevated LDL cholesterol and can also help lower triglycerides and increase HDL cholesterol 3.
• However, statin monotherapy may not be sufficient to achieve recommended non-HDL cholesterol goals, especially in patients with combined dyslipidemia 4.
• Combination therapy with statins and omega-3 fatty acids has been shown to be effective in treating combined dyslipidemia and may be beneficial for patients with recent myocardial infarction 4, 5.
• Other treatment options include ezetimibe, bile acid sequestrants, fibrates, and fish oil, which can be used in addition to statins to address multiple lipid targets 6, 7.

Residual CVD Risk

• Significant residual CVD risk remains after treatment with statins, which may be due to low HDL cholesterol and/or elevated triglycerides 7.
• Combination therapy with a statin and another lipid-lowering agent, such as niacin or a fibrate, may be necessary to address multiple lipid targets and reduce residual CVD risk 7.

Safety and Efficacy

• Combination therapy with statins and omega-3 fatty acids has been shown to be generally safe and effective, but may increase the risk of gastrointestinal adverse events 5.
• Statin therapy has been associated with side effects such as myopathies and an increased risk of diabetes mellitus, but the benefits of statin therapy often outweigh the risks 6.