1. Train-the-Trainer Cases
*Developed by Brazilian faculty
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2. Case #1: Statin Intolerance
Teaching Point
In patients with statin-associated muscle symptoms, try 2-3 different statins, including one at the lowest approved dose, before consideration of non-statin therapy
Learning Objective
Select best management for patients with possible statin-associated muscle symptoms

3. Case #1: Statin Intolerance
A 74-year-old man who underwent coronary stent placement 6 months ago presents to clinic for follow up. He was initially started on atorvastatin 40mg daily, but he developed muscle pain and proximal muscle weakness within 2 weeks. Symptoms resolved with discontinuation.

4. Case #1: History Patient’s past medical history: HTN and Diabetes
Current medications: Aspirin 100 mg daily, metoprolol 50 mg twice a day, metformin 500 mg twice a day
Physical Exam: 46 kg (101 lbs.), BP 130/80 mmHG, HR 65 bpm
Labs: Total cholesterol today is 6.1 mmol/L (236 mg/dL) and LDL-C is 3.7 mmol/L (143 mg/dL), Thyroid stimulating hormone 1.0 U/L
No muscle tenderness to palpation. Good strength in all limb muscles. No other significant findings.

5. What is the Next Best Management Strategy for the Patient’s Muscle Pain and Elevated Lipid Levels?
Change to rosuvastatin 40 mg daily
Recommend use of red yeast rice preparation and coenzyme Q10
Patient is statin intolerant. Begin therapy with ezetimibe 10 mg daily
Patient is statin intolerant. Begin therapy with PCSK9 inhibitor

6. Case #2: High Risk Patients with Primary ASCVD Prevention
Teaching Point
Consider the use of non-statin therapy in patients with heterozygous FH after initial treatment with maximally tolerated statin dose.
Learning Objective
Differentiate between various secondary treatment choices for patients with heterozygous FH

7. Case #2: High Risk Patients with Primary ASCVD Prevention
30-year-old man with a long history of elevated cholesterol numbers. He was found to have LDL-C 270 mg/dL (7.0 mmol/L) when he was 25 years old. He started simvastatin 20 mg daily at that time. One year ago, on simvastatin therapy his LDL-C was 275 mg/dL (7.1mmol/L). He was then changed to atorvastatin 40 mg daily. Today, his LDL is 200 mg/dL (5.2mmol/L).

8. Case #2: History
Patient’s family history: both father (age 53) and paternal uncle (age 49) had heart attacks and severe hypercholesterolemia
Patient Evaluation: Patient’s BMI is 30 kg/m2, BP is 150/90 mmHg and HR 90 bpm.
Normal cardiac physical exam, abdomen is obese, subtle xanthomas Achilles tendons joints

9. What would be the next best initial strategy to manage this patient’s elevated LDL-C and reduce risk of cardiovascular events?
Continue atorvastatin 40 mg daily
Change to rosuvastatin 40 mg daily
Continue atorvastatin 80 mg daily and add ezetimibe 10 mg daily
Stop atorvastatin and begin therapy with PCSK9 inhibitor

10. Case #3: Recurrent ASCVD Patient
Teaching Point
Initiate non-statin therapy in a patient with recurrent ASCVD patients already on statins
Learning Objective
Select the appropriate non-statin therapy for patients with recurrent ASCVD

11. Case #3: Recurrent ASCVD Patient
55-year-old man with known peripheral artery disease presents to the hospital complaining of chest pain and is found to have non-ST segment elevation myocardial infarction (NSTEMI). He is treated with coronary stenting.
He initially stated on atorvastatin 40 mg 2 years ago when he was first diagnosed with PAD. At the time of his NSTEMI, his total cholesterol was 200 mg/dL (5.2 mmol/L) and LDL was 120 mg/dL (3.1 mmol/L). Ezetimibe 10 mg daily was added. Follow-up lipid panel in 3 months showed LDL-C 90 mg/dL (2.3 mmol/L).

12. Case #3: History
Patient’s past medical history: PAD with a left iliac artery stent
Family History: father died at age 60 years from a myocardial infarction
Current medications: aspirin 100 mg daily, atorvastatin 40 mg daily, ezetimibe 10 mg daily, clopidogrel 75 mg daily, metoprolol 50 mg twice a day.

13. What is the best next step in the management of this patient’s hyperlipidemia in the setting of his recent NSTEMI?
Continue atorvastatin 80 mg daily and ezetimibe 10 mg daily
Change atorvastatin to rosuvastatin 20 mg daily and continue ezetimibe 10 mg daily
Stop atorvastatin, continue ezetimibe 10 mg daily, and begin therapy with PCSK9 inhibitor
Continue atorvastatin 80 mg and ezetimibe 10 mg daily and add PCSK9 inhibitor

14. Select appropriate lipid therapy for patients with known ASCVD
Case #4: VERY High-risk ASCVD Patient: Multiple Myocardial Infarctions and Recent Acute Coronary Syndrome
Teaching Point
Use high-intensity statin for initial treatment of patients with known ASCVD
Learning Objective
Select appropriate lipid therapy for patients with known ASCVD

15. Case #4: History
60-year-old man presents to the hospital with 30 minutes of increasing chest pain and sweating. He has a known history of prior LAD stent for new onset angina.

16. Case #4: History
Current medicine: Atorvastatin 40 mg daily, Lisinopril 5 mg daily, metformin 500 mg twice a day
Past Medical History: HTN, diabetes, tobacco (current smoker)
Family History: father died from MI at age 50. Mother currently has diabetes
Social History: blue collar worker
Current BP: 120/80 mmHg, HR is 95 bpm, cardiac exam is normal
ECG: v1-v3 ST elevation
Emergent left heart catherization shows occlusion in RCA (treated with stent), 30% stenosis of prior RCA stent
Patient’s total cholesterol on atorvastatin 40 mg daily is 5.2 mmol/L (201 mg/dL), LDL 3.4 mmol/L (131 mg/dL). Ezetimibe 10 mg daily is added. Repeat lipid panel in 3 months shows LDL-C 100 mg/dL (2.6 mmol/L).

17. According to the 2018 ACC/AHA Blood Cholesterol Guideline which of the following is the correct ASCVD risk category for this patient?
Very high risk
High risk
Low risk 

18. What is the goal LDL according to the Chinese Society of Cardiology guidelines?
< 70 mg/dl (<1.8 mmol/L)
>50% reduction in LDL-C
>50% reduction in LDL-C and LDL<70  mg/dL (<1.8 mmol/L)

19. What is the best management strategy to manage this patient’s cholesterol?
Change to simvastatin 40 mg daily and ezetimibe 10 mg daily
Continue current therapy
Discontinue ezetimibe and add PCSK9 inhibitor
Continue atorvastatin 40 mg daily and ezetimibe 10 mg daily. Add PCSK9 inhibitor