Cardiovascular, Family Medicine Board Certification Examination - Full Vignette with Extended Explan

Описание: A 31-year-old man with known tricuspid regurgitation, hereditary antithrombin deficiency, and a recent non-ST-elevation myocardial infarction is recovering in the cardiac ICU after transient instability. Despite appropriate initial therapy, you review his evolving lipid profile, family thrombosis history, and current medications. How do these factors influence the optimal prevention strategy in a high-risk acute coronary syndrome patient? What patient and laboratory features should guide your approach?

VIDEO INFO
Category: Cardiovascular, Family Medicine Board Certification Examination
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Prevention - Preventive measures and screening
Case Type: Critical Condition

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QUESTION
A 31-year-old man with tricuspid regurgitation and genetically confirmed antithrombin (SERPINC1) deficiency is admitted after a non-ST-elevation myocardial infarction complicated by transient hypotension and nonsustained ventricular tachycardia requiring short vasopressor support. He is now hemodynamically stable in the cardiac ICU on hospital day 2. He previously smoked 0.5 pack/day for 10 years and quit 5 years ago. He works construction, keeps several exotic pets, and has no recent travel....

OPTIONS
A. Add ezetimibe 10 mg daily now with high-intensity statin; recheck lipids in 4-8 weeks to guide intensification toward less than 55-70 mg/dL.
B. Defer any nonstatin therapy now; add later only if LDL-C is still =70 mg/dL, and recheck a lipid panel at 12 months instead of 4-8 weeks.
C. Start bempedoic acid now with continued statin in place of ezetimibe as the first add-on therapy in a statin-tolerant post-ACS setting.
D. Initiate a PCSK9 monoclonal antibody now and omit ezetimibe, with no planned lipid testing for 3 months given expected potency.

CORRECT ANSWER
A. Add ezetimibe 10 mg daily now with high-intensity statin; recheck lipids in 4-8 weeks to guide intensification toward less than 55-70 mg/dL.

EXPLANATION
The best answer is "Add ezetimibe 10 mg daily now with high-intensity statin; recheck lipids in 4-8 weeks to guide intensification toward less than 55-70 mg/dL." In very-high-risk ACS, guidance supports adding a nonstatin when on-statin LDL-C is 55-69 mg/dL (Class 2a) and mandates it at =70 mg/dL (Class 1). This patient s LDL-C is 62 mg/dL after 36 hours of rosuvastatin 40 mg with about a 52% drop from baseline, meeting the threshold to reasonably add ezetimibe now, with reassessment in 4-8 weeks to decide on further intensification (e.g., PCSK9 mAb) toward a goal below 55-70 mg/dL depending on framework.

Deferring any nonstatin for 12 months ignores early secondary prevention. Bempedoic acid has outcome data in statin-intolerant patients but is not first add-on in a statin-tolerant post-ACS ICU patient when ezetimibe and PCSK9 are available. Jumping directly to a PCSK9 mAb and omitting ezetimibe can be reasonable in select extreme-risk scenarios but typically follows an ezetimibe step, and lipid testing should occur at 4-8 weeks to confirm effect.

In summary, adding ezetimibe now and repeating lipids in 4-8 weeks best matches contemporary post-ACS intensification guidance at LDL-C 62 mg/dL on maximal statin.

Key teaching points: After ACS, initiate high-intensity statin and add nonstatins when on-treatment LDL-C is =70 mg/dL (Class 1) or 55-69 mg/dL (Class 2a); recheck lipids in 4-8 weeks; consider PCSK9 mAb if targets are unmet after ezetimibe.


Further reading:

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