Bob’s Problem with High Cholesterol

Bob is a 60-year-old retired engineer who developed guidance software for the Space Shuttle program. He came to my clinic for a routine check-up. Bob reported no significant symptoms but mentioned feeling slightly more fatigued than usual over the past few months. He denied experiencing chest pain, shortness of breath, palpitations, or dizziness. His primary concern was managing his cholesterol levels, which had been elevated in the past.

Bob had a past medical history of high blood pressure, diagnosed ten years before and well-controlled on captopril. He also had type 2 diabetes mellitus, diagnosed five years before and managed with lifestyle modifications and metformin. Bob’s high cholesterol had been diagnosed seven years before and was managed with dietary changes and intermittent trials of medications.

Family History and Medications

Bob’s father had a history of high cholesterol and blood pressure and died at 75 of a heart attack. His mother had diabetes and high blood pressure and died at 80 of a stroke. Bob has a 62-year-old brother with high cholesterol and a 58-year-old sister with type 2 diabetes.

For medications, in addition to captopril and metformin, Bob takes a baby aspirin every day for cardiovascular protection and a multivitamin.

Physical Examination and Laboratory Tests

Bob’s physical examination was within normal limits except for a blood pressure of 130/80 mmHg (slightly high) and a body mass index of 27.5 kg/m² (overweight range). Bob’s laboratory tests were notable for the following results: total cholesterol of 260 mg/dL (normal: < 200 mg/dL), LDL cholesterol of 170 mg/dL (normal: < 100 mg/dL), HDL cholesterol of 40 mg/dL (normal: ≥ 40 mg/dL), triglycerides of 150 mg/dL (normal: < 150 mg/dL), and HbA1c of 7.0% (normal: < 5.7%; goal for diabetes: < 7.0%). Other tests, including liver function tests, were within normal limits.

Assessment and Plan

My assessment of Bob is that he has uncontrolled hypercholesterolemia with elevated LDL (the ‘bad cholesterol’) despite previous dietary modifications. His high blood pressure is well-controlled on his current regimen. Based on his HbA1c screening test, I also determined that he has type 2 diabetes. Given his age, family history, and coexisting conditions, I believe Bob is at an increased risk of a cardiac event similar to the one that took his father’s life.

I started Bob on simvastatin 20 mg daily at bedtime to lower his LDL and total cholesterol. I reinforced the importance of a heart-healthy diet, regular physical activity, and weight management. Bob does not smoke tobacco regularly but did admit to occasionally smoking marijuana, which is legal in our state. If Bob were a regular smoker, I would have recommended ways to quit to reduce his cardiovascular risks.

Follow-up

I explained that simvastatin has some possible side effects, which we should discuss at a follow-up appointment in six weeks. These include muscle pain or weakness, headache, stomachache, and liver damage that could result in elevated liver function tests. I made a note to consider referring Bob to a dietitian for detailed dietary counseling and a cardiologist for further cardiovascular risk assessment if needed.

Victory Over High Cholesterol

Bob reported feeling well at the follow-up appointment, with no significant side effects from the medication. He adhered to a heart-healthy diet and maintained a regular exercise routine. His lipid panel showed substantial improvement: total cholesterol decreased to 180 mg/dL, LDL cholesterol to 90 mg/dL, and HDL cholesterol increased to 50 mg/dL. Bob's liver function tests remained within normal limits, indicating good tolerance to simvastatin. He reported no muscle pain or weakness, and his overall energy levels had improved. I congratulated Bob on his commitment to lifestyle changes and medication adherence and advised him to continue his regimen. A six-month follow-up appointment was scheduled to ensure ongoing management and monitor for any potential long-term effects of the medication.

Regular physician visits are critical, particularly for individuals with risk factors for cardiovascular disease, such as hypertension, high cholesterol, diabetes, smoking, or a family history of heart disease. These appointments allow for early detection and management of potential health issues, significantly reducing the risk of severe complications like heart attacks or strokes. Your healthcare provider monitors vital signs, conducts necessary tests, and adjusts treatment plans based on the most recent health data. Regular check-ups also provide opportunities for personalized advice on lifestyle changes, such as diet, exercise, and stress management, which are essential for cardiovascular health. These visits foster a proactive approach to health, encouraging patients to stay informed about their conditions and compliant with their medications. Overall, consistent medical supervision helps maintain optimal health, improves quality of life, and enhances longevity by reducing the risks associated with cardiovascular diseases. Contact your healthcare provider if you have any questions or concerns.