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Clinical Case Study: Assessing Cardiovascular Risk in a Person with Diabetes
You are a family physician, practicing in the Northeast. Harold, one of your regular patients, a 48-year-old financial analyst, is attending his regularly scheduled appointment with you today. He has type 2 diabetes mellitus and takes 1000 mg metformin BID, and has done so for the last 2 years.
He is now very concerned about his risk of cardiac disease as his father recently died from a heart attack at age 74. There is a strong family history of diabetes and hypertension. Harold has been a smoker for 30 years at 1 pack/day. He consumes alcohol 5-6 times per week (1 glass of wine per day).
On examination, his resting pulse rate is 80/min, BP 130/80 mmHg, temperature 98.6°F and RR 18/min. His waist circumference is 100 cm and BMI is 29.6 kg/m2
No clinical abnormality is detected on his examination.
You review the laboratory results of his recent fasting lipid profile.
- TC (Total cholesterol) 289 mg/dl
- HDL-cholesterol 61 mg/dl
- LDL-cholesterol 202 mg/dl
- Triglycerides 123 mg/dl
As evident from the lipid profile reports, Harold's TC and LDL-cholesterol levels are higher than desired, and the plan is to start Harold on lipid-lowering agents. Prior to starting treatment you also want to assess his renal and hepatic panels, and long-term glycemic levels. You order a comprehensive metabolic panel, along with a HbA1c, and arrange follow-up appointment in 2 days.
Prior to Harold's appointment, you decide to go through the Skyscape resources installed on your iPhone to brush up your knowledge on the management of dyslipidemia, especially in regard to goals for Harold.
The following resources are installed on your iPhone
You browse the section, 'Dyslipidemia in Diabetes Mellitus' in the Merck Manual of Diagnosis and Therapy
and note that Harold comes under the 'high-risk' category, according to the 'National Cholesterol Education Program Adult Treatment Panel III Approach to Dyslipidemias' and 'National Cholesterol Education Program Adult Treatment Panel III Guidelines for Treatment of Hyperlipidemia.'
The LDL levels of Harold are definitely above desired levels. While browsing the section on 'Dyslipidemia' in Merck Manual of Diagnosis and Therapy
you note recommendations suggesting drug therapy, along with lifestyle changes in patients with high cardiovascular risk. You also note that statins are the drugs of choice for lowering elevated LDL levels, as they have shown demonstrable reduction in cardiovascular mortality.
You also read through the latest guidelines for optimal management of diabetes mellitus while browsing through the above mentioned Skyscape resources.
Harold comes to your office for the scheduled appointment. His blood investigation results are as follows:
- Fasting blood glucose: 170 mg/dL
- Post prandial glucose: 230 mg/dL
- HbA1c: 8.6%
His liver and renal function tests are within normal range. You discuss the elevated LDL and glucose levels with Harold and educate him about the necessary changes he has to make in his lifestyle (diet and exercise) and also the necessity of starting drug therapy for management of his dyslipidemia and supplementing his anti-diabetic therapy with other agents for better glycemic control.
Additionally, you enroll Harold in the quit smoking program via phone from your office as continued smoking is a major concern.
Earlier, while browsing through the treatment of Diabetes mellitus section in the Merck Manual of Diagnosis and Therapy
you had noted that it is advisable to start the patient on additional oral hypoglycemic agents or insulin for better glycemic control. You explain to Harold about the treatment options available to optimize his glycemic level. Harold is not keen on starting insulin therapy and wants to go for an additional oral hypoglycemic agent before considering insulin therapy.
You start Harold on atorvastatin 10 mg po QD for management of hypercholesterolemia as mentioned under the Management of Hypercholesterolemia in 5-minute Clinical Consult
, along with glipizide 5 mg po QD, for better glycemic control as mentioned under the section- Treatment of Type 2 Diabetes Mellitus in 5-minute Clinical Consult
and advise him to come back after 4 weeks to reassess his lipid and glucose levels and make adjustments in dosage, if necessary.
Your Skyscape resources have helped you to ascertain the cardiovascular risk in a person with diabetes and initiate/modify treatment as the situation warranted.
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