- A 68 years old gentleman who suffers from stable chronic angina for the
past several years came to the cardiology clinic for regular follow up
visit. His coronary angiogram shows triple vessel disease with diffuse
disease involving segments of all the vessels. He is on intensified medical
management and is doing fairly well with occasional Class II angina now and
then. His prescription includes a beta blocker, a nitrate, an ACE inhibitor
and Aspirin. Four weeks back during a visit to his PCP he was started on
Atorvastatin as his LDL was found to be 220 mg/dL. Since the past 2 weeks he
has been experiencing a dull aching pain in the calf region at rest. He
reviewed with his PCP who stopped his Statin in response to his myopathy.
Now the appropriate next step would be any of the following except
- Lipid lowering with aggressive diet and exercise
- Switching over to Pravastatin which has lesser incidence of myopathy
- Using ezetimibe or fibrates
- Referral to a lipid specialist.
Answer: Pravastatin has been shown to be less likely to cause myopathy and so
it is a viable alternative for people who are intolerant to atorvastatin due to
muscle pain. Ezetimibe which is a blocker of intestinal absorption of
cholesterol is effective alone and in combination with statins in lipid
lowering. Aggressive diet and exercise would not be sufficient treatment for
this patient with a significantly high LDL and coronary artery disease.