Scenario
R.M. is an active 61-year-old man who works full time for the postal service. He walks 3 miles every other day and admits he doesn’t eat a “perfect diet.” He enjoys 2 or 3 beers q HS (every night), he uses stick margarine, eats red meat 2 or 3 times per week, and is a self-professed “sweet eater.” His cardiac history includes a recent inferior myocardial infarction (MI) and a heart catheterization revealing 3-vessel disease: in the left anterior descending (LAD) coronary artery, a proximal 60% lesion; in the right coronary artery (RCA), proximal 100% occlusion with thrombus; and a circumflex with 40% to 60% diffuse ectatic lesions. A stent was deployed to the RCA and reduced the lesion to 0% residual stenosis. He has had no need for nitroglycerin (NTG). Six weeks after his MI and stent deployment, he had a fasting advanced lipid profile. The results were total cholesterol 188 mg/dl, HDL 34 mg/dl, triglycerides 176 mg/dl, LDL 98 mg/dl, pattern B LDL typing at 19 nm, homocysteine 18 mg/dl, high-sensitivity C-reactive protein (HS CRP) 12 mg/dl, fasting blood glucose (FBG) 101 mg/dl, thyroid-stimulating hormone (TSH) 1.04 mg/dl.
Given the information above, what questions are important to ask R.M.?
The patient’s family history is important. What age did his parents die (or are they still alive)? How did they die? Does/did the patient smoke? How many pack years? Is the patient having any dyspnea on exertion or paroxysmal nocturnal dyspnea? Is there any pedal edema? How has he been feeling overall since his MI and stent?
What medications you prescribe according to evidence-based guidelines? Write the prescriptions using the prescription pad in #12. (Make as many copies as you need.)
The patient needs treatment for his hyperlipidemia. His lipid levels put him at risk for additional MIs and atherosclerotic disease, including stroke. I would prescribe Vytorin (ezetimibe-simvastatin) for this patient. This medication decreases LDL and triglycerides and increases HDL. The patient also needs to be placed on niacin, folic acid, B12, B6 and omega-3 fatty acids.
PART ONE Medical-Surgical Cases
3. When you start to discuss R.M.’s laboratory values with him, he is pleased that his total
cholesterol is less than 200 mg/dl and that his low-density lipoprotein (LDL) is less than
100 mg/dl. He thinks he needs no further alteration in his lipid values. What do you tell
him about his triglycerides and pattern B type?
The patient needs to understand that his lipid panel needs to be viewed in its completion to form a complete picture of his cardiac risk. His triglycerides are over 150mg/dl, which significantly increases his risk. Individuals with high pattern B type LDL also often have low HDL, high triglycerides and are at risk for developing diabetes mellitus. Individuals with an elevation in pattern B type have a 3 to 5 fold increase in MI (Scott, 2011).
4. You add niacin, folic acid, B12, B6, and omega-3 fatty acids to the list of R.M.’s
medications. How do the new medications affect lipids? What is new evidenced-based literature about the combination of the medications.
Niacin acts to decrease LDL and triglycerides and increase LDL.
Omega-3-fatty acids decreases triglycerides.
B12 and folic acid in combination have been shown to lower homocysteine levels.
B6 also lowers homocysteine levels. The B vitamins work to lower homocysteine levels by converting it into methionine. Without these vitamins, the level of homocysteine increases (HSPH, 2013).
According to information just released, combining niacin with statins may actually increase risk to patients with no benefit. The study indicated that there was no reduction of MI risk. The risk of bleeding did increase. More information is needed (Preidt, 2013).
I would allow him to use OTC Omega-3-fatty acids, TID, but Rx for the other meds. I would encourage him to eat more fatty fish to further increase his intake of Omega-3s, and also to hopefully decrease his poorer food choices. I would also encourage him to use ground flax seed in his cereal, oatmeal, ect.
5. What treatment options are known to decrease CRP?
Obviously, the patient should be encouraged to make lifestyle changes. These would decrease his CRP, and also his LDL, triglycerides and increase his HDL. There are also multiple categories of medications that have been shown to effectively lower CRP. These include cyclooxygenase inhibitors, ACE inhibitors, angiotensin receptor blockers and statins (Prasad, 2006, p. 33).
6. HS CRP is an indicator of: tissue injury or inflammation. The high sensitivity test detects CRP in individuals who do not have evidence of inflammation or injury. This may indicate a risk of cardiovascular disease. It likely detects the accumulation of lymphocytes, macrophages and lipids (Crowley, 2004, p. 325).
7. Identify the most common side effect of niacin and statins.
Niacin is well known for causing a flush effect due to vasodilation. It is self-limiting.
The most common side effect of statins is muscle pain.
8. Elevated homocysteine can be a factor in what type of vascular complication?
Elevated homocysteine levels are associated with arteriosclerosis (Crowley, 2004, p. 325).
9. Name one food or other substance that will increase the homocysteine level.
Coffee and caffeine increases homocysteine levels.
CASE STUDY PROGRESS
You enter R.M.’s room and hear the physician say, “There are many options to change the metabolic makeup of your small dense LDL and increased homocysteine. You need to continue modifying your diet and exercise to enhance your medication regimen.” The physician asks R.M. if he has any questions, and the patient responds, “No.”
10. R.M. tells you he really didn’t understand what you said. Explain the necessary lifestyle changes to R.M.
The patient needs to reduce his sweet consumption. He also needs to reduce his alcohol intake. His use of margarine needs to be changed to butter, which should be used only in moderation. Red meat consumption should be decreased to once a week. He should aim to increase the fruits and vegetables in his diet, as well as whole grains and fiber. He also needs to walk every day; he may require a cardiovascular therapist to increase his exercise and make the necessary health changes. If he does need this support, it should be offered to him. If he is smoking, he must stop! Second-hand smoke exposure also needs to be eliminated.
11. A normal homocysteine level is:
< 6.3 mg/dl. Different labs utilize different ranges and reporting.
