BCGP / Cardiovascular

Answer D. Risk factors for myopathy are hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Answer B. This patient belongs in one of the four statin benefit groups because his estimated 10-year ASCVD risk is over 7.5%. Adults 40 to 75 years of age with LDL–C 70 to 189 mg/dL, with an estimated 10-year ASCVD risk ≥7.5% and without clinical ASCVD or diabetes should receive either a moderate-intensity or high-intensity statin. Since the extent of reducing the risk of ASCVD is proportionally related to the degree of LDL-C reduction, risk could be reduced more so with a high intensity statin. Considering the given options, Atorvastatin 80 mg PO QHS is the best choice.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Answer C. A stroke falls under the category of clinical ASCVD, which includes includes acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin. Patients with clinical ASCVD are at an increased risk for recurrent ASCVD and ASCVD death. This patient is under 75 years old, and such patients with clinical ASCVD should receive moderate-intensity statin therapy. However, ATP4 acknowledges that the older patients in the corresponding RCTs were likely to be healthier than those in the general population, so treatment can be individualized. Given the options above, a high intensity statin is the most appropriate option. The decision to start at the 80 mg dose of atorvastatin instead of the 40 mg dose is based on the recommendation to down titrate if the patient is unable to tolerate the 80 mg dose as opposed to up-titrating in accordance with the IDEAL trial.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Answer C. Agents that can cause elevated triglycerides: oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), and thiazides.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Answer C. Diltiazem has a major drug interaction with Simvastatin. Diltiazem is a CYP3A4 inhibitor, and since Simvastatin is metabolized by CYP3A4, its level can build up and the risk of myopathy increases. It is recommended to switch to a non-CYP3A inhibitor such as Pitavastatin, Pravastatin, or Rosuvastatin, and if Simvastatin is to be kept on it should not exceed 10 mg/day. The same interaction also exists with lovastatin, and the recommendation is to not exceed a total dose of 20 mg/day po of Lovastatin. Given the current options, the best choice is to change to Atorvstatin 40 mg po daily.
Reference:
1. Gold Standard, Inc. Lovastatin (Interactions). Clinical Pharmacology [database online]. Available at: https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=359&sec=moninte&t=0. Accessed: June 1, 2016
2. Zocor (simvastatin) package insert. Whitehouse Station, NJ: Merck & Co., Inc.; 2015 Feb

Answer B. LDL can be elevated by diuretics, cyclosporine, glucocorticoids, and amiodarone.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013; 129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.