The Correct Answer is B!

 

A 66-year-old woman had an NSTEMI 2 weeks ago treated with a DES to the LAD with a pre-dismissal EF of 66%. She has been pain-free since discharge and was released on a beta-blocker, high-intensity statin, and dual antiplatelet therapy. Her only medication on admission was metformin for type II DM, which was continued.

Currently, her BP is 128/70 mmHg, her resting heart rate is 58 bpm, and she has normal renal function. She is tolerating all of her medications well. Lipids on admission prior to starting statin therapy showed total cholesterol of 250 mg/dL, triglycerides of 220 mg/dL, an HDL of 38 mg/dL, and an LDL of 168 mg/dL.

What other medication should be started now?

A. Fenofibrate 145 mg daily
B. Lisinopril 5 mg daily
C. Spironolactone 25 mg daily
D. Ezetimibe 10 mg daily

Rationale:

ACE inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, LV ejection fraction 40% or less, or chronic kidney disease, unless contraindicated. Fibrates are not indicated in patients with mild hypertriglyceridemia and may increase the risk of muscle toxicity in patients on statins. Non-statin medications, such as ezetimibe, could be considered if the patient has a suboptimal response to statin therapy or does not meet goal lipid levels.

However, the patient’s response to statin therapy must be reassessed 4-12 weeks after starting statin therapy before determining the appropriateness of ezetimibe. Aldosterone antagonists such as spironolactone are not indicated in normotensive patients with preserved left ventricular systolic function.

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