Clinical Case & Quiz

Instructions: Please read the following clinical case on for a secondary prevention patient with an acute coronary syndrome (ACS).

Once you review the case, please take two minutes to complete the case questions regarding lipid management and treatment for this patient.

The correct response and supporting reference will be revealed for each question.

Should there be any errors or questions missed, the portal will alert you prior to being able to move on to the next section.

61-year-old male

Patient History: Chronic stable angina. Post-anterior MI and LAD stent 3 years ago

Current Lipid Medication: Treated with atorvastatin 80 mg, acetylsalicylic acid 81mg

Current Presentation:

  • Admitted for inferior MI - primary PCI and three stents in the right coronary artery
  • No restenosis in the LAD or atherosclerosis progression.
  • LV dysfunction with EF 41%
  • Lipid profile on admission: LDL= 2.1 mmol/L; fasting TG = 1.3 mmol/L

MI, myocardial infarction; LAD, left anterior descending artery; PCI, percutaneous coronary intervention; LV, left ventricular; EF, ejection fraction; LDL, low-density lipoprotein; TG, triglycerides; ACS, acute coronary syndrome; OD, once daily





The correct answer is E) B or C

  • The 2016 CCS Guidelines recommend an LDL-C goal of < 1.8mmol/L for patients with a recent acute coronary syndrome and established coronary disease1
  • The 2019 ESC Guidelines recommend an LDL-C target of < 1.4 for all very high-risk patients, including those with ASCVD.2

References:

  1. Anderson TJ et al. Can J Cardiol. 2016 Nov; 32(11):1263-1282.
  2. 2019 ESC/EAS Guidelines for the management of dyslipidemias European Heart Journal (2020) 41,111-188





The correct answer is B or F

Both the 2016 CCS Guidelines and the 2019 ESC Guidelines provide the following recommendations for pharmacological low-density of LDL-C1,2

  • A high-intensity statin is prescribed up to the highest tolerated dose to reach the goals set for the specific level of risk.
  • If the goals are not achieved with the maximum tolerated dose of a statin, combination with ezetimibe is recommended
  • For patients whose LDL-C is <15-20% away from target, the addition of ezetimibe is likely to achieve target. However, for patients whose LDL-C is >20% away from target, no add-on drug other than a PCSK9 inhibitor is likely to get the LDL-C to target.1
  • For secondary prevention, patients at very-high risk not achieving their goal on a maximum tolerated dose of a statin and ezetimibe, a combination with a PCSK9 inhibitor is recommended.

References:

  1. Anderson TJ et al. Can J Cardiol. 2016 Nov; 32 (11):1263-1282.
  2. 2019 ESC/EAS Guidelines for the management of dyslipidemias European Heart Journal (2020) 41,111-188



The correct answer is B

  • The ESC Guidelines recommend that in in all ACS patients lipid levels should be re-evaluated 4–6 weeks after ACS to determine whether the LDL-C goal has been achieved.
  • If the LDL-C goal is not achieved after 4–6 weeks with the maximally tolerated statin dose, combination with ezetimibe is recommended.
  • If the LDL-C goal is not achieved after 4–6 weeks despite maximal tolerated statin therapy and ezetimibe, adding a PCSK9 inhibitor is recommended.

Reference:

  1. 2019 ESC/EAS Guidelines for the management of dyslipidemias European Heart Journal (2020) 41,111-188


The correct answer is C

  • The ESC Guidelines recommend that once the optimal LDL-C is achieved, lipids should be tested annually (unless there are adherence problems or other specific reasons for more frequent reviews).1

 Reference:

  1. 2019 ESC/EAS Guidelines for the management of dyslipidemias European Heart Journal (2020) 41,111-188.

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