1. Clinical Correlations The NYU Langone Online Journal of Medicine http://clinicalcorrelations.org

2. NYU Medicine Grand Rounds Clinical Vignette December 4, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 41 year old woman BIBEMS for one hour of crushing substernal chest pressure Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. The patient is an active smoker who has not seen a primary care physician for many years other than during pregnancy. In the weeks prior to presentation, she noted mild shortness of breath and fatigue with exertion, but no prior chest pain. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: None Past Surgical History: Cholecystectomy Tubal ligation Social History: Smokes 1 pack per day for over twenty years, denies alcohol or illicit drug use U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Family History: Mother- hypertension, diabetes Father- hypertension No known history of early coronary artery disease or sudden death Allergies: No Known Drug Allergies Medications: No medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: Overweight Hispanic woman lying in stretcher in moderate distress Vital Signs: T: 97.7 F, BP: 141/90, HR: 89, RR: 18, and O2 sat: 100% on room air Remainder of Physical Exam was normal other than prominent abdominal obesity U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: WBC 13.8 (53% neutrophils) Remainder of CBC was within normal limits Basic Metabolic panel: within normal limits Hepatic panel: within normal limits Troponin: 0.219, 3.6, >50 Lipid Panel: Total Cholesterol 133, HDL 23, LDL 46, Triglycerides 322 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. EKG U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS ST elevation in v1-v6, I, aVL, ST depressions in III

10. The patient was taken for urgent cardiac catheterization and had a drug eluting stent placed to the mid-LAD with an ejection fraction of 25% On hospital day 3, she was discharged on aspirin 81mg, clopidogrel 75mg, atorvastatin 80mg, metoprolol 12.5mg and lisinopril 2.5mg Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Post-discharge Follow-up In the months following discharge, the patient quit smoking with the use of buproprion and nicotine replacement therapy She became more physically active, but was not able to significantly change her diet or lose weight. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Post-discharge Follow-up Repeat labs one month after discharge on atorvastatin 80 mg Fasting lipids- total cholesterol- 138, HDL 29, LDL- 30, triglycerides 397 HbA1C- 6.6 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Post-discharge Follow-up Based on this data, atorvastatin was decreased to 40 mg daily, fenofibrate 160 mg daily and metformin 500 mg BID were added. Lipid panel after several months of this therapy: Total cholesterol- 143, HDL 30, LDL 82, triglycerides 155 HbA1C- 5.9 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Follow-up Questions Is the patient optimally treated on current therapy based on old and new prevention guidelines? Should any medical therapies be added? Should any medical therapies be removed? U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS