Ace the Case: A 65-Year-Old Man with a History of Diabetes Mellitus, Hypertension, and Dyslipidemia

Case Presentation

Chief Complaint: Outpatient follow-up of a patient with longstanding, well-controlled type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia.

History of Present Illness: The patient is a 65-year-old, obese, Caucasian man who presents to your office for routine follow-up after switching providers 2 months ago. He recently had a stress test that was negative. He is taking his medications regularly with no adverse events. He reports no issues with statin medications in the past. He has been checking his blood pressure at “that local grocery store” and has noticed it to be “high as of late.” He denies chest pain, pressure, shortness of breath, orthopnea, or paroxsismal nocturnal dyspnea. He notes no vision changes or headaches.

Past Medical History: Dyslipidemia, hypertension, obesity, obstructive sleep apnea, T2DM

Medications: Pravastatin 10 mg daily, Atenolol 50 mg daily, ASA 81 mg daily, metformin 1000 mg twice a day (BID), Empagliflozin 10 mg daily

Physical Examination:
BP: 160/90 mm Hg; HR: 70 beats/minute; RR: 12; BMI: 35 kg/m2
General Appearance: Patient is in no acute distress
HEENT: Nondilated, funduscopic examination showed no obvious abnormalities
Mouth: Dentition is in good repair
Neck: No carotid bruit or jugular venous distention
Respiratory: Lungs are clear to auscultation bilaterally
Cardiovascular: Heart is regular without murmur, rub, or gallop
Gastrointestinal: Abdomen is obese, but nontender
Extremities: No clubbing, cyanosis, or edema
Foot Examination: Mild onychomycosis bilaterally; no cracks, fissures, or ulcerations. Normal sensation to monofilament and vibratory testing
Psych: Alert and Oriented X 3

A1C: 7.5%; creatinine: 1.7 mg/dL, with an eGFR of 43 mL/min/1.73 m2; micro albumin/creatinine ratio of >30 on 3 occasions; total cholesterol: 202 mg/dL; HDL: 32 mg/dL; LDL: 120 mg/dL; triglycerides: 250 mg/dL

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Based on the patient’s clinical history and current lipid panel, which of the following changes should be made to his current medical therapy?
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Correct Answer: C

Rationale: The American Diabetes Association recommends 2 statin dosing intensities for use in clinical practice: high-intensity statin therapy can achieve ≥50% reduction in low-density lipoprotein (LDL), whereas moderate-intensity statin therapy can achieve a 30% to 50% reduction in LDL. For patients with T2DM aged 40 to 75 years and without cardiovascular disease (CVD), moderate-intensity statin therapy should be prescribed. Our patient is age 65 years and does not have known CVD. Therefore, he should be given moderate-intensity statin therapy.