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  #1  
Old 06-01-2012
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Question TIA -> drug preventing stroke and CAD ?

A 63-year-old man is evaluated during a follow-up appointment. One month ago, he had a
transient ischemic attack. A carotid ultrasound revealed a 60% left internal carotid artery
stenosis, and a transthoracic echocardiogram revealed left ventricular hypertrophy. He is
currently asymptomatic. He has hypertension and quit smoking 10 years ago. He has no
history of coronary artery disease and no family history of premature coronary artery disease.
Current medications are hydrochlorothiazide and aspirin. An LDL-cholesterol level 6 months
ago was 138 mg/dL (3.6 mmol/L), and he has been compliant with recommended lifestyle
modifications.
On physical examination, blood pressure is 122/78 mm Hg. There are no focal neurologic
abnormalities. Fasting lipid levels are as follows: total cholesterol, 206 mg/dL (5.3 mmol/L);
HDL-cholesterol, 50 mg/dL (1.3 mmol/L); LDL-cholesterol, 128 mg/dL (3.3 mmol/L);
triglycerides, 144 mg/dL (1.6 mmol/L).
Which of the following is the most appropriate management option to reduce the
risk of stroke and coronary artery events in this patient?
(A) Add atorvastatin
(B) Add nicotinic acid
(C) Change hydrochlorothiazide to amlodipine
(D) Change hydrochlorothiazide to carvedilol
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Old 06-01-2012
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Which of the following is the most appropriate management option to reduce the
risk of stroke and coronary artery events in this patient?
(A) Add atorvastatin any patient with LDL>100 is benefited with statin

(B) Add nicotinic acid - HDL is high enough,
niacin does decrease carotid intimal thickness... but i'd still go with statin first


(C) Change hydrochlorothiazide to amlodipine
(D) Change hydrochlorothiazide to carvedilol

both C+D-- his hypertension is well managed doesnt need any change in Rx.
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does he have CHD or CHD equivalent viz DM,PAD,Aortic dx, Carotid DX excluding stroke? yes he has a symptomatic carotid dx i.e the TIA. so his goal LDL is 100. He should be started on meds when his LDl is more than 130, his is 128. His HDl is more than 40 this is good and his TCG is less than 150 so he doesnt need nicotinic acid.
However, in a patient in whom therapeutic lifestyle changes TLC is ineffective in bringing the LDL to the desired less than 100, you can start statins at 100 to 129 mg/dl LDL, i.e dont wait till 130mg/dl LDL
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What he really needs is a beta blocker since he has LVH.

His LDL is falling very well with lifestyle modifications and has fallen by a value of 10 in one month.
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Quote:
Originally Posted by Novobiocin View Post
What he really needs is a beta blocker since he has LVH.

His LDL is falling very well with lifestyle modifications and has fallen by a value of 10 in one month.
Agreed!

His cholesterol has improved greatly, but right now we should be concerned about the LVH.
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Quote:
Originally Posted by Novobiocin View Post
What he really needs is a beta blocker since he has LVH.

His LDL is falling very well with lifestyle modifications and has fallen by a value of 10 in one month.
is BB prescribed even with a normal BP?

and progression of LVH to LVF or prevention of any kind of remodelling is prevented only by ACE/ARBS ?
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Good question... confused between A n D.. anyway will go for (D) Change hydrochlorothiazide to carvedilol.
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Quote:
Originally Posted by nativedoc2 View Post
does he have CHD or CHD equivalent viz DM,PAD,Aortic dx, Carotid DX excluding stroke? yes he has a symptomatic carotid dx i.e the TIA. so his goal LDL is 100. He should be started on meds when his LDl is more than 130, his is 128. His HDl is more than 40 this is good and his TCG is less than 150 so he doesnt need nicotinic acid.
However, in a patient in whom therapeutic lifestyle changes TLC is ineffective in bringing the LDL to the desired less than 100, you can start statins at 100 to 129 mg/dl LDL, i.e dont wait till 130mg/dl LDL

you guys are correct, i totally didnt read the part where his ldl has been dropping!
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Decrease RISK of stroke and CAD answer is A
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Old 06-02-2012
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Quote:
Originally Posted by dryogi View Post
Good question... confused between A n D.. anyway will go for (D) Change hydrochlorothiazide to carvedilol.
ans is A

regarding beta blocker
for hypertension and stroke prevention, preferred drugs are diurectics . i dont think its beta blocker. q ask for both stroke and cad.
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