Respond to the 2 following posts separately with separate reference lists.
1. Leslie Garcia posted Jul 13, 2022 3:38 PM
The 42-year-old female patient presents for follow up on lab results from her annual physical exam completed a week ago. The lab results are as follows: Triglycerides 225, LDL 170, HDL 22, HgBA1c 8.3%. Patient history reveals a 20 pack-a-year smoking history and type 2 diabetes. The last labs done 18 months ago were normal. What is this patient’s cardiovascular risk based on these lab results? Describe how the FNP would clinically manage and follow up this patient. List the pharmacological and non-pharmacological interventions.
In order to properly manage and follow up this patient, it is important that the FNP do a full assessment of the patient, interviewing the patient as well as to finding out if there have been any changes in her life, and vital signs are all important. This will have an impact in the overall picture. When it comes to her laboratory results, it is recommended by The National Cholesterol Education Program III (NCEP-III), having a target goal of LDL cholesterol at less than 130 mg/dl, triglycerides less that 150 mg/dl and HDL greater than 40 mg/dl (Stanford, 2017). This patient exceeds those number and it needs to be addressed in her visit. This patient also presents with a HgA1c of 8.3% and with a previous diagnosis of type 2 diabetes and 20-pack-a-year smoking history. This means that there has been a drastic change in her health in the last 18 months considering the last labs were normal.
Because all her labs are exceeding the normal range, he her cardiovascular risk has jumped up quite a lot. She now has hyperlipidemia, which is one of the most prevalent risk factors contributing to development of atherosclerosis and cardiovascular disease (CVD) (Hill & Bordoni, 2022). Before the patient develops CVD, it is important to consider that it is the leading cause of death among adults in the United States, and people with hyperlipidemia are at double the risk of developing CVD (Karr, 2017). Also, the patient has uncontrolled diabetes, so if she already is on medication, it is important to adjust it, especially with diabetes being a risk factor in itself. Lastly, smoking is also a great risk factor of CVD. Tobacco smoking, and secondhand smoke, both increase the incidence of atherosclerosis and CVD due to all the chemicals it has such as, nicotine, tar, and carbon monoxide. All these chemicals cause tachycardia, myocardial contractility, inflammation, endothelial damage, thrombus formation, and low HDL, which lead to CVD (Kondo et al., 2019).
According to the American Diabetes Association (2021), It is important to start this patient on moderate-intensity statin therapy in addition to lifestyle therapy. The FNP should order a moderate intensity statin such as Lovastatin 40mg every day. With an A1C of 8.3% it is possible that that FNP may start the patient on Metformin if she is not already taking it, and if she is adjusting the dose may be the next step along with lifestyle modifications and rechecking the A1C in 3 months to see if it is working. Last but not least, lifestyle modifications are the most important thing that the patient needs to learn. Low fat diet, Mediterranean diet, smoking cessation, exercise, and medication compliance are very important. It is important that the FNP follow up in 3 months with labs to find out if her treatment is working appropriately.
References
Hill MF, Bordoni B. Hyperlipidemia. [Updated 2022 Feb 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559182/
Karr, S. (2017). Epidemiology and management of hyperlipidemia. The American journal of managed care, 23(9 Suppl), S139-S148.
Kondo, T., Nakano, Y., Adachi, S., & Murohara, T. (2019). Effects of tobacco smoking on cardiovascular disease. Circulation Journal, 83(10), 1980-1985.
Stanford. (2017, September 11). Hyperlipidemia. Stanford Health Care (SHC) – Stanford Medical Center. Retrieved July 13, 2022, from https://stanfordhealthcare.org/medical-conditions/blood-heart-circulation/vascular-disease/treatments/hyperlipidemia.html
2. Kayla Jones posted Jul 13, 2022 8:14 PM
The 42 year old female patient that presented for a follow up on lab results has a high cardiovascular risk related to her history of diabetes, smoking, and elevated triglyceride and cholesterol levels. The primary cause of mortality for diabetic patients is cardiovascular complications and the risk of coronary heart disease is increased by 20% in females with diabetes (Damaskos et al., 2020). In type II diabetics, cardiovascular disease often manifests as peripheral arterial disease and heart failure. The patient has an extensive 20 pack-a-year smoking history Cigarette smoking greatly increases the risk for cardiovascular disease but also increases the risk for stroke and myocardial infarction. Studies have shown that smoking fewer cigarettes per day for a longer time is more detrimental than smoking more cigarettes per day for a shorter time (Gallucci et al., 2020). For this reason, smoking cessation and not smoking reduction is needed. The patient also has a very high triglyceride and LDL level that increases her risk for stroke, MI, and heart disease. High levels of cholesterol and triglycerides can cause arterial wall hardening, or atherosclerosis, that contributes to hypertension and heart disease (Mayo Clinic Staff, 2020).
There are several tools to calculate cardiovascular risk. The American College of Cardiology has an atherosclerotic cardiovascular disease (ASCVD) risk estimator available on their website. This tool estimates the patient’s 10 year ASCVD risk to help predict how impactful different treatments will be, and the patient’s risk can be reassessed at follow up appointments (American College of Cardiology, n.d.). The ASCVD risk estimator uses the patient’s age, sex, race, blood pressure, total cholesterol level, HDL level, LDL level, diabetes history, smoking history, hypertension treatment, statin treatment, and aspirin therapy to determine if the patient is low, borderline, intermediate, or high risk (American College of Cardiology, n.d.). If we had more information about this patient we could calculate her 10 year risk.
This patient has a high cardiovascular risk due to her multiple risk factors. Her recent hemoglobin A1c is 8.3% which indicates she has poor glycemic control and her blood sugar is too high. She should be educated on lifestyle changes to improve her glycemic control and improve her triglyceride and cholesterol levels. The patient’s goal should be at least 150 minutes of moderate physical activity every week (American Heart Association, 2021). Her diet needs to be many fruits and vegetables, whole grains, healthy proteins, minimal processed food, minimal added sugar, minimal alcohol intake, and reduced salt. The patient will be started on Metformin 500 mg PO BID and atorvastatin 20 mg PO daily. The patient should be seen in a few weeks for a recheck of blood sugar and to verify the new medication therapy is not causing any issues. She will need to be followed regularly after this visit to manage her conditions.
References
American College of Cardiology. (n.d.). ASCVD Risk Estimator Plus. Retrieved July 13, 2022, from https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
American Heart Association. (2021). The American Heart Association Diet and Lifestyle Recommendations. Retrieved July 13, 2022, from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations
Damaskos, C., Garmpis, N., Kollia, P., Mitsiopoulos, G., Barlampa, D., Drosos, A., Patsouras, A., Gravvanis, N., Antoniou, V., Litos, A., Diamantis, E. (2020). Assessing cardiovascular risk in patients with diabetes: An update. Current Cardiology Reviews, 16(4), 266-274. 10.2174/1573403X15666191111123622
Gallucci, G., Tartarone, A., Lerose, R., Lalinga, A., Capobianco, A. (2020). Cardiovascular risk of smoking and benefits of smoking cessation. Journal of Thoracic Disease, 12(7), 3866-3876. 10.21037/jtd.2020.02.47
Mayo Clinic Staff. (2020). Triglycerides: Why do they matter?. Mayo Clinic. Retrieved July 13, 2022, from https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/triglycerides/art-20048186
