Pharmacotherapy Case 15: Dyslipidemia Management By Dr. Nehad Ahmed

 

Chief Complaint:

A 55-year-old female presents to the clinic for a routine follow-up to manage her dyslipidemia and to review her current medication regimen. She is concerned about the long-term effects of her cholesterol levels and asks if any changes need to be made to her therapy.

Subjective Data:

History of Present Illness (HPI):

The patient is a 55-year-old female with a history of dyslipidemia. She was first diagnosed 5 years ago during a routine check-up. Since then, she has been on statin therapy for lipid management. Her current medications include atorvastatin 40 mg daily. She reports feeling well overall, with no chest pain, palpitations, or shortness of breath. She denies any muscle aches or weakness, which can sometimes occur with statins. She is concerned about her cholesterol levels and whether she needs to make any lifestyle changes or medication adjustments.

Past Medical History (PMH):

Dyslipidemia (diagnosed 5 years ago)

Hypertension (diagnosed 10 years ago)

Obesity (BMI: 32 kg/m²)

No known history of diabetes, coronary artery disease, or stroke.

Medications:

Atorvastatin 40 mg daily

Amlodipine 5 mg daily (for hypertension)

Hydrochlorothiazide 12.5 mg daily (for hypertension)

Vitamin D 1000 IU daily (for deficiency)

No known over-the-counter medications or herbal supplements.

 

Allergies:

No known drug allergies (NKDA).

Family History:

Father had a history of heart disease and dyslipidemia (passed away at age 60 due to myocardial infarction).

Mother has hypertension and type 2 diabetes.

Social History:

Smoking: Non-smoker.

Alcohol: Drinks 1-2 glasses of wine per week.

Physical activity: Sedentary lifestyle, does not engage in regular physical exercise.

Diet: Diet high in saturated fats, limited intake of fruits and vegetables, and often consumes fast food.

Married, lives with her spouse.

Review of Systems:

Cardiovascular: No chest pain, palpitations, or shortness of breath.

Neurological: No headaches, dizziness, or visual changes.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Musculoskeletal: No muscle aches or weakness.

Endocrine: No symptoms of thyroid dysfunction or changes in appetite.

Psychiatric: No symptoms of depression or anxiety.

 

 

 

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 138/85 mmHg

Heart Rate: 72 bpm (regular rhythm)

Respiratory Rate: 16 breaths/min

Temperature: 36.8°C (98.2°F)

Oxygen Saturation: 98% on room air

Weight: 95 kg (BMI: 32 kg/m²)

Height: 165 cm

Physical Exam:

General: Alert, oriented, and in no acute distress.

Cardiovascular: Regular rate and rhythm, no murmurs, no jugular venous distension, and peripheral pulses are intact.

Respiratory: Clear lung fields bilaterally, no wheezes or crackles.

Gastrointestinal: Abdomen is soft, non-tender, with no hepatomegaly or ascites.

Musculoskeletal: No muscle tenderness or weakness.

Neurological: Cranial nerves intact, no focal deficits.

Dermatological: No xanthomas or other skin findings suggestive of hyperlipidemia.

Laboratory Results:

Lipid Profile (current):

Total Cholesterol: 220 mg/dL

LDL: 130 mg/dL (target <100 mg/dL for high-risk patients)

HDL: 50 mg/dL (goal >40 mg/dL)

Triglycerides: 170 mg/dL (goal <150 mg/dL)

Complete Blood Count (CBC): Normal

Electrolytes: Sodium 138 mEq/L, Potassium 4.2 mEq/L

Creatinine: 0.9 mg/dL (normal renal function)

Liver Function Tests (LFTs): Normal

Blood Glucose: 92 mg/dL (normal, no signs of diabetes)

EKG:

Normal sinus rhythm, no arrhythmias, no evidence of ischemia.

Abdominal Ultrasound (for liver evaluation):

Normal, no signs of fatty liver or other abnormalities.

Assessment:

The patient is a 55-year-old female with dyslipidemia, hypertension, and obesity, being managed with atorvastatin for cholesterol control. She has a family history of cardiovascular disease and is at moderate risk for cardiovascular events due to her hypertension, dyslipidemia, and obesity. Despite being on atorvastatin 40 mg daily, her LDL cholesterol remains elevated at 130 mg/dL, which is above the recommended target of <100 mg/dL for high-risk patients. Her HDL cholesterol is acceptable at 50 mg/dL, but her triglycerides are borderline elevated at 170 mg/dL, which is slightly above the normal range.

The patient’s blood pressure (138/85 mmHg) is above the recommended target of <130/80 mmHg for patients with hypertension and dyslipidemia, indicating room for improvement in her blood pressure management. Her lifestyle factors, including sedentary behavior and a diet high in saturated fats, contribute to her overall cardiovascular risk.

 

 

 

Plan:

Pharmacotherapy:

Continue atorvastatin 40 mg daily but increase the dose to 80 mg daily to further reduce LDL cholesterol and improve lipid profile. The goal is to reduce her LDL to <100 mg/dL.

Lifestyle modifications will remain a focus, but pharmacologic therapy may be considered in the future if further LDL reduction is required.

Omega-3 fatty acids (e.g., icosapent ethyl) may be considered if triglycerides persistently remain elevated above 150 mg/dL.

Reevaluate lipid profile in 6 weeks to assess the effect of the increased statin dose.

Blood Pressure Management:

Maintain current antihypertensive regimen with amlodipine 5 mg daily and hydrochlorothiazide 12.5 mg daily.

Aim to achieve a target blood pressure of <130/80 mmHg. If blood pressure remains elevated, consider adding an ACE inhibitor or angiotensin receptor blocker (ARB), given the patient’s risk factors.

Reassess blood pressure in 1-2 weeks.

Lifestyle Modifications:

Dietary counseling: Encourage a heart-healthy diet, such as the DASH diet or Mediterranean diet, to reduce saturated fat intake and increase fiber. Focus on weight loss, aiming for a 5-10% reduction in body weight.

Exercise: Recommend starting moderate-intensity aerobic exercise (e.g., walking, cycling) for at least 30 minutes on most days of the week to improve cardiovascular health and help with weight management.

Smoking cessation: Although the patient does not smoke, reinforcing the importance of avoiding smoking is essential in reducing cardiovascular risk.

 

Monitoring:

Follow up in 6 weeks for a recheck of lipid profile and blood pressure.

Reassess weight and dietary habits at each visit.

Assess for any potential side effects of increased statin dose, particularly muscle aches or fatigue.

Patient Education:

Educate the patient on the importance of medication adherence to achieve optimal lipid and blood pressure control.

Discuss the role of lifestyle changes in reducing cardiovascular risk and improving overall health.

Advise the patient to recognize signs of muscle pain or weakness, which can sometimes occur with statin therapy.

Provide resources for dietary modifications and encourage participation in a local exercise program or community walking group.

Discussion:

The management of dyslipidemia is essential for reducing cardiovascular risk, particularly in patients with other comorbidities like hypertension and obesity. Statin therapy remains the cornerstone of treatment for elevated LDL cholesterol, and increasing the dose in this patient may help achieve the target goal of <100 mg/dL. Lifestyle modifications, including dietary changes and exercise, play a vital role in managing dyslipidemia and preventing cardiovascular events. Additionally, monitoring and adjusting pharmacotherapy in response to the patient’s clinical progress is critical for effective long-term management.