History of Present Illness: A 58-year-old black male patient is experiencing leg cramping pain located in bilateral calves. The leg pain occurs on the days that the patient is physically active at work and experiences symptom resolution within 10 minutes of rest. He is a manager at a local restaurant and does a lot of walking, cleaning, and lifting moderately heavy objects. He states he rarely has chest pain and cannot remember the last time he experienced chest pain symptoms.

Past Medical History: Stable ischemic heart disease with history of angina, hypertension, peripheral arterial disease, and heart failure with reduced ejection fracture

Social History: Former cigarette smoker, quit 1 year ago, was 1 pack per day since age of 16 years. Denies alcohol use. Denies recreational drug use. Frequently eats frozen, canned, and pre-packaged meals.

Current Medications: metoprolol succinate 50 mg by mouth daily, aspirin 81 mg by mouth daily, nitroglycerin 0.4 mg sublingual tablet dissolve under the tongue as needed for chest pain, rosuvastatin 40 mg by mouth daily, furosemide 40 mg by mouth every morning

Allergies: No known drug allergies

Vital Signs: Blood pressure 146/88 mmHg, Heart rate 52 bpm, Height 69 inches (175 cm), Weight 270 lb (122.7 kg), Body mass index 39.87 kg/m²

Lab Values: Sodium: 142 mEq/L (142 mmol/L); Potassium: 4.3 mEq/L (4.3 mmol/L); Chloride: 100 mEq/L (100 mmol/L); Bicarbonate: 24 mEq/L (24 mmol/L); BUN: 8 mg/dL (2.9 mmol/L); Serum Creatinine: 1.0 mg/dL (88.4 micromol/L); eGFR: 98.7 mL/min/1.73m2; Glucose: 92 mg/dL (5.1 mmol/L); Calcium: 9.8 mg/dL (2.5 mmol/L); Hemoglobin: 12.1 g/dL (7.51 mmol/L); Hematocrit: 40%; TSH 1.2 uIU/mL (1.2 mIU/L); Total Cholesterol 210 mg/dL (5.43 mmol/L); Triglycerides 204 mg/dL (2.30 mmol/L); HDL-C 34 mg/dL (0.88 mmol/L); LDL-C 123 mg/dL (3.18 mmol/L)

Procedure Data:

Physical Exam: Dorsalis pedis pulses are 3/4 left and 3/4 right, posterior tibial pulses are graded at 2/4 left and 2/4 right. Skin warm to the touch. Dry skin on lower bilateral legs and toes. No evidence of wounds.

Ankle Brachial Index: left 0.64, right 0.8

ECHO: Estimated ejection fraction 35%

EKG: inferior myocardial infarct, probably old. QT interval in acceptable range.

Other Data: not applicable

Question 1

Which of the medications can raise triglyceride levels?

1. Aspirin
2. Nitroglycerin
3. Metoprolol
4. Rosuvastatin

Answer: 3. Metoprolol

Rationale: Beta-blockers can increase triglyceride levels. Rosuvastatin can reduce triglyceride levels. Aspirin and nitroglycerin are not known to affect triglyceride levels.

Citation: Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73:e285-e350.

Question 2

Which therapy is recommended for this patient to increase walking distance and duration?

1. Cilostazol
2. Clopidogrel
3. Spironolactone
4. Walking exercise program

Answer: 4. Walking exercise program

Rationale:  Structured walking exercise programs have shown benefits that increase walking duration and distance, increase pain-free walking, delay onset of claudication, and improve functional status and quality of life. Option 1 is incorrect. Spironolactone is not utilized for the treatment of PAD. Option 2 is incorrect. Cilostazol is an effective treatment for intermittent claudication to reduce symptoms and increase walking distance. However, it is contraindicated in heart failure due to decreased survival. Option 3 is incorrect as clopidogrel does not have evidence to support its use for claudication symptoms and can be utilized in combination with aspirin to reduce the risk of ASCVD events in people with PAD and CAD.

Citation: Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726-e779.

Question 3

Which lifestyle intervention would be most likely to produce the greatest impact on blood pressure reduction in this patient?

1. Alcohol cessation
2. DASH dietary plan
3. Dynamic resistance exercise 90-150 minutes per week
4. Smoking cessation

Answer: 2. DASH dietary plan

Rationale: Implementing health eating using the DASH dietary plan can reduce blood pressure by 11 mmHg and has the greatest impact compared to other lifestyle strategies. Option 1, alcohol cessation, is incorrect and not expected to impact the patient’s blood pressure because they are already abstaining from alcohol intake. Option 3 is incorrect. Dynamic resistance exercise 90-150 minutes per week can reduce blood pressure by 4 mmHg, a less significant change in blood pressure compared to the DASH plan. Option 4, smoking cessation, is incorrect and not expected to impact the patient’s blood pressure because they quit tobacco use 1 year ago.

Citation: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, J Am Coll Cardiol. 2017;71:e127-e248. DOI: 10.1016/j.jacc.2017.11.006.

Burns DM. Nicotine Addiction. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.lib

Question 4

Which additional antihypertensive agent is recommended in this scenario?

1. Amlodipine
2. Carvedilol
3. Diltiazem
4. Lisinopril

Answer: 4. Lisinopril

Rationale: Angiotensin converting enzyme inhibitors in addition to beta blockers are recommended first-line antihypertensives in adults with stable ischemic heart disease or heart failure and hypertension.

Option 3 is incorrect as dihydropyridine calcium channel blockers (CCB) are second-line options for persistent elevated blood pressure. in patients with stable ischemic heart disease. Amlodipine, a dihydropyridine CCB, is recommended for angina when heart rate is < 60 bpm and blood pressure is > 130/80 mmHg. Option 1 is incorrect because non-dihydropyridine calcium channel blockers are to be avoided in heart failure and should not be used in combination with beta blockers due to the risk of severe bradycardia and heart block. Option 2 is incorrect. Carvedilol should not be added due to duplication of therapy with metoprolol.

Citation: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol. 2017;71:e127-e248. DOI: 10.1016/j.jacc.2017.11.006.

Question 5

Which cholesterol treatment is appropriate to add on to rosuvastatin at this time according to the AHA/ACC Blood Cholesterol Guidelines?

1. Initiate evolocumab 420 mg under the skin once monthly
2. Initiate ezetimibe 10 mg by mouth daily
3. Initiate gemfibrozil 600 mg by mouth twice daily
4. Initiate niacin 500 mg by mouth daily

 Answer: 2.Initiate ezetimibe 10 mg by mouth daily

Rationale: t is reasonable to add ezetimibe in very high-risk ASCVD patients with LDL-C ≥70 mg/dL (≥1.8 mmol/L) while taking maximal statin therapy. This patient is considered very high-risk in the setting of a probable history of myocardial infarction per the EKD and multiple ASCVD risk factors/high risk conditions (peripheral artery disease, stable ischemic heart disease, hypertension). PCSK9 inhibitors, such as evolocumab, should be considered for patients with clinical ASCVD at very high risk on maximally tolerated statin and ezetimibe. Statin therapy initiation and/or optimization if 10-year ASCVD risk is >/= 7.5% and attention to lifestyle factors are recommended for moderate hypertriglyceridemia (triglycerides 175-499 mg/dL or 1.9-5.6 mmol/L). This patient is currently taking rosuvastatin at an optimized high-intensity dose. Gemfibrozil and niacin would not be indicated based on triglyceride levels < 500 mg/dL (< 5.6 mmol/L). Additional pharmacotherapy, such as fibrates or niacin, would be considered to reduce pancreatitis risk in the setting of severe hypertriglyceridemia (>/= 500 mg/dL or >/= 5.6 mmol/L). Fenofibrate is the preferred fibrate to use in combination with statin therapy because the risk of severe myopathy is lower than with gemfibrozil.

Citation: Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, J Am Coll Cardiol. 2019;73:e285-e350.