ABSTRACT
Though cardiovascular risk is of lower urgency, this patient does have several other risk factors that suggest that he may indeed have more risk than his peers.There are several guidelines that use scoring systems to arrive at a quantitative prognosis for incident heart disease; for BH, I used the Framingham risk score (FRS).1 The ATP-III guidelines would count only one major risk factor, low HDL, and his FRS was 8%, suggesting low risk.This means that among a group of nonsmoking men living in Framingham, MA in the 1970s around his age with similar cholesterol and blood pressure, 8% of them had died or had a myocardial infarct by the next decade. A strict reading of the ATP-III report would lead one to consider him low risk. However, the FRS likely underestimates his risk, since it does not consider several softer risk factors, including obesity, ominous family history (albeit, out of the age range), elevated hsCRP, hypertriglyceridemia, and the metabolic syndrome. In practice, it is quite common to see patients whose FRS doesn’t seem to match the warning signs from the rest of their history. For this reason the NCEP encourages the physician to modulate the risk upward in the presence of these emerging risk factors.1,3
Given that the primary goal is to protect BH from pancreatitis, the physician must appreciate that the statins are among the weakest drugs for lowering triglycerides. Inefficacy of the high-dose statin is not surprising.Three types of nonstatins are preferred by the NCEP, based on their triglyceride-lowering prowess: fibrates, niacin, and fish oil.The bile acid sequestrants are contraindicated because they may raise the triglycerides.The fibrates lower triglycerides between 25 and 50%, niacin 20-40%, and fish oil 30-40%, while statins may lower triglycerides between 7 and 30%.1
