WBR0557

Author	[[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 45-year-old man with a past medical history of diabetes mellitus presents to your office for follow up of his dyslipidemia that was diagnosed 5 months ago. He was advised on daily aerobic exercises with a reduced fat diet, and he has been fairly compliant. He presents for a follow up visit today. His social history is significant for smoking 1 pack per day for the past 25 years. He reports drinking about 1 pint vodka per day for the past 10 years because he read online that drinking alcohol would boost his “good” cholesterol. A repeat fasting lipid profile reveals: Total Cholesterol: 350 mg/dl HDL cholesterol: 35 mg/dl Triglycerides: 380 mg/dl What is the most important step at this time to address his lipid abnormalities?]]
Answer A	AnswerA::Niacin
Answer A Explanation	AnswerAExp::Incorrect. Niacin or nicotinic acid has been demonstrated to have the most effect on increasing the serum levels of HDL-C, but in this case, LDL is the next target in the management
Answer B	AnswerB::Gemfibrozil
Answer B Explanation	AnswerBExp::Incorrect. Fibrates are very effective in the treatment of high triglycerides.
Answer C	AnswerC::Pravastatin
Answer C Explanation	AnswerCExp::Correct. Statins are the most effective in lowering the serum LDL cholesterol. They have a tendency to cause myopathy.
Answer D	AnswerD::Alcohol consumption
Answer D Explanation	AnswerDExp::Incorrect. Moderate alcohol intake has been shown to increase serum HDL by 5-10%, but has no effect on lowering serum LDL.
Answer E	AnswerE::Smoking cessation
Answer E Explanation	AnswerEExp::Incorrect. Smoking cessation exerts about 5% increase in the serum level of HDL but has positive effect on lowering the serum levels of HDL.
Right Answer	RightAnswer::C
Explanation	[[Explanation::This patient has dyslipidemia coupled with a history of diabetes mellitus which increases her risk for coronary artery disease. Low HDL cholesterol has been linked to poor cardiovascular outcomes. According to ATP III guidelines, the primary target in a patient with low HDL cholesterol (less than 40 mg/dl) is achieving the LDL goal i.e. LDL-C<130 mg/dl for this patient. LDL-C can be calculated using the formula: LDL-C = Total cholesterol – HDL-C – Triglyceride/5 LDL-C = 239 mg/dl. The next step in the management of this patient is by addressing the high LDL cholesterol with a statin, which has been proven to be the most effective in lowering serum LDL cholesterol. Risk Category Non-HDL Goal (mg/dl) LDL Goal (mg/dl) 0 to 1 CHD risk factor <190 <160 2 or more CHD risk factors (10-year risk for CHD ≤20%) <160 <130 CHD and CHD risk equivalent (10-year risk for CHD >20%) <130 <100 Educational Objective: In a patient with dyslipidemia and a CHD risk equivalent (diabetes mellitus), the following represents the management plan according to the ATP III guidelines: 1) LDL cholesterol is the primary target. This is best achieved with statins. 2) If the serum triglyceride is between 200 and 499 mg/dl, then achieve non-HDL cholesterol goal first. Non-HDL cholesterol is calculated by subtracting HDL-C from the total cholesterol i.e. Non-HDL-C = TC – HDL-C. Non-HDL cholesterol is the summation of VLDL and LDL. Source: http://www.wikidoc.org/index.php/High_density_lipoprotein_medical_therapy Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Dyslipidemia, WBRKeyword::Low HDL, WBRKeyword::High LDL, WBRKeyword::non-HDL cholesterol
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::