2.

  HB is a 44 year old man who had an angioplasty last year due to myocardial ischemia and blockage in his
coronary arteries.  He has an "apple" body shape with a BMI of 31 and well-controlled hypertension.  His
medications include Lisinopril 20 mg and Atorvastatin 40 mg. His recent fasting lipid profile revealed the
following results:  total cholesterol 184, triglycerides 200, LDL-C 110, HDL-C 34. Lp(a) is two times the upper
limit of normal.  Fasting glucose is 105 mg/dL.  ALT is within normal limits.  HB has heard about the DASH diet
for hypertension and knows what foods are high in cholesterol but it is difficult for him to follow these diets.  He
usually grabs fast food at lunchtime. 

a. What is his Framingham Risk Score?

According to the ATP III Guidelines At-A-Glance, HB would have 0 points for his age, 3 points for total
cholesterol, and 2 points for his HDL level. So based off of this information his 10-year risk would be 2%.
However, we don’t know if he is a smoker or what his systolic blood pressure is, so this score would be
assuming that HB is a non-smoker (0 points) and has a systolic blood pressure of less than 120 (0 points
whether treated or untreated).

b.  What is his LDL goal?

HB has multiple risk factors (abdominal obesity, triglycerides >150, HDL <40) and a 10-year risk of <20%, so
according to the ATP III Guidelines his LDL goal would be less than 130. So the LDL goal for HB has been
reached.

c.  What is Lp(a) and how does it factor into his risk assessment? Liporotien a or Lp(a) is LDL cholesterol
bound to the protein apolipoprotein(a).Several studies have shown that elevated Lp(a) levels are
associated with CAD. More studies are needed to provide evidence of effective treatment options as there
are currently no recommendations.
Boyles, S.(2009). Lipoprotein(a) linked to heart attacks. WebMD Health News.
http://www.webmd.com/heart-disease/news/20090609/lipoprotein-a-linked-to-heart-attacks
Lupattelli, G. Roscini, A., Siepi, D., & Mannarino , E. (2010). Hyperlipoprotienaemia(a): which is the
optimal therapy? A case report. Journal of Parmacy and Therapeutics 35, 613-615.

d.  What medications will you add to his drug regimen, if any?

Although HB has reached his LDL goal, his triglycerides are 200 so either the Atorvastatin dose could be
increased (up to 80 mg/day) or nicotinic acid or fibrate could be added. Since his triglycerides are 200 a non-
HDL goal (total-HDL) for total cholesterol should be set at 160 (

ATP III Guidelines At-A-Glance

e.  What is the DASH Diet?

The DASH diet is an eating plan that helps reduce blood pressure. The diet includes increasing intake of fruits,
vegetables, and lowfat dairy products and decreasing intake of saturated and total fat.

JNC-7 reference card

f.  What lifestyle measures will you suggest and how will you support HB in attempting these measures?

g.  Does he have diabetes or metabolic syndrome?  Will you do anything to treat this (if you answered yes)?
HB has metabolic syndrome. For treatment, he should lose weight and increase physical activity.
I would recommend for HB to start taking asprin 81 mg/day d/t metabolic syndrome and hx of CHD.