Today, we’re examining a clinical case of a 42-year-old woman who’s a smoker with hypertension. What’s the next step in her care?
A 42-year-old woman comes to her primary care physician for a routine visit. She is asymptomatic. Her past medical history is significant for hypertension, which is controlled by losartan. She has been smoking 2-3 cigarettes daily for the past 10 years. Family history is noncontributory. Temperature is 37 ºC (98.6 °F), heart rate is 66/min, blood pressure is 115/75 mmHg, and respiratory rate is 14/min. Cardiopulmonary examination is unremarkable. Laboratory studies are shown below.
Which of the following is the most appropriate next step in management?
| Lipid panel | |
| Total cholesterol | 236 mg/dL (6.24 mmol/L) |
| HDL cholesterol | 92 mg/dL (2.56 mmol/L) |
| LDL cholesterol | 122 mg/dL (3.00 mmol/L) |
| Triglycerides | 124 mg/dL (1.45 mmol/L) |
A. Initiate high-intensity statin
B. Repeat lipid panel while fasting
C. Initiate low-dose aspirin
D. Calculate the 10-year atherosclerotic cardiovascular disease (ASCVD) risk
E. Obtain an electrocardiogram (ECG)
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 Question is…
D. Calculate the 10-year atherosclerotic cardiovascular disease (ASCVD) risk
Correct: See Main Explanation.
Incorrect Answer Explanations
A. Initiate high-intensity statin
Incorrect: According to the ACC/AHA guidelines, high-intensity statin therapy is indicated for primary prevention of ASCVD in patients with an LDL cholesterol level ≥ 190 mg/dL and for patients with diabetes and multiple atherosclerotic cardiovascular disease (ASCVD) risk factors. This patient’s ASCVD score should be calculated before determining the necessary intervention, but this patient would likely not require high-intensity statin therapy.
B. Repeat lipid panel while fasting
Incorrect: Fasting and nonfasting total cholesterol and HDL cholesterol levels have fairly similar prognostic value and association with cardiovascular outcomes. LDL levels vary slightly with and without fasting. Fasting is not generally required. It may be required with elevated triglyceride levels.
C. Initiate low-dose aspirin
Incorrect: The U.S. Preventive Services Task Force advises individualized decision-making regarding low-dose aspirin therapy for adults aged 40 to 59 years with a 10-year ASCVD risk of ≥ 10% and no elevated risk of bleeding, provided they have a life expectancy of ≥ 10 years and are willing to commit to daily aspirin for a decade. Conversely, the American College of Cardiology/American Heart Association guidelines suggest limited use of aspirin in routine primary ASCVD prevention, citing a lack of overall benefit. This patient’s ASCVD score should be calculated first before deciding on treatment.
E. Obtain an electrocardiogram (ECG)
Incorrect: The USPSTF does not recommend screening for coronary artery disease with a resting ECG in asymptomatic patients at low risk, defined by the USPSTF as a 10-year cardiovascular event risk of <10%. This patient’s ASCVD score should be calculated first.
Main Explanation
While a general estimate of the relative risk for ASCVD in patients can be approximated by counting the number of traditional risk factors present, a more precise estimation of the absolute risk for a first ASCVD event is necessary when making treatment recommendations in patients aged 40-75 years who have no prior ASCVD and are asymptomatic. For this patient with a history of hypertension and smoking, the 10-year risk for atherosclerotic cardiovascular disease (ASCVD) should be calculated, and based on the level of risk, prevention strategies and decisions regarding the lipid panel results can be made.
For all asymptomatic patients without a history of ASVD who are being screened for cardiovascular disease, the initial step in management involves determining the presence of one or more of the traditional risk factors (hypertension, cigarette smoking, diabetes mellitus [DM], premature family history of ASCVD, chronic kidney disease, obesity) for ASCVD. If a risk factor is present, then the 10-year risk for atherosclerotic cardiovascular disease (ASCVD) should be calculated to classify patients into various risk categories: low risk (< 5%), borderline risk (5%‒ 7.4%), and intermediate risk (7.5%‒19.9%) and high risk (>20%). Based on this classification, optimal risk factor modification and primary prevention strategies, including statin therapy can be determined. All patients ≥ 20 years of age should have a baseline lipid profile, and treatment decisions for prevention of ASCVD should be based on the results of the lipid panel, patient age, and the patient’s calculated 10-year risk for ASCVD.
Major Takeaway
When screening patients for cardiovascular disease and making decisions regarding prevention of atherosclerotic cardiovascular disease (ASCVD) in patients without prior ASCVD who are asymptomatic, the presence of traditional risk factors for cardiovascular events should be determined. If risk factors are present, then the 10-year risk for atherosclerotic cardiovascular disease (ASCVD) should be calculated to guide all prevention and treatment decisions, including statin therapy.
Want to learn more about this topic?
Watch the Osmosis video: Cardiovascular disease screening: Clinical sciences
References
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi:https://doi.org/10.1161/cir.0000000000000678
- Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2356-2361. doi:10.1016/j.jacc.2015.09.034
- US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for Cardiovascular Disease Risk With Electrocardiography: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(22):2308-2314. doi:10.1001/jama.2018.6848
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