1. Case 1: A 78-year-old white female with hypertension and hyperlipidemia
Discussion Points:
In that this patient has documented atherosclerotic vascular disease, discussion should focus on prevention of future carotid or coronary events. A patient like this one carries a fivefold to sevenfold elevated risk for developing new or recurrent coronary heart disease.
Treatment goals for lipids should be addressed, with emphasis on meeting NCEP guidelines for LDL-C. Hence the goal in this case is to decrease LDL-C to less than 100 mg/dL.
Immediate institution of nonpharmaceutical therapy is warranted, and cholesterol-lowering drug therapy is often needed.
The patient’s age should be also discussed for its relevance to the questions of initiating drug therapy. In the primary prevention West of Scotland Coronary Prevention Study, treatment with a statin provided the same benefit in patients over age 60 as under age 60.

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7. Case 2: A 58-year-old white male s/p CABG
Discussion Points:
The major issues for this patient are the obvious presence of coronary risk factors, the potential for reducing morbidity and mortality, and the opportunities to reduce risk through nonpharmacologic and pharmacologic therapies.
Despite diet therapy, the patient’s lipids are at a level that requires pharmacologic attention. For instance, according to current guidelines, the goal of therapy in patients with clinical coronary heart disease is to decrease LDL-C to less than 100 mg/dL.
An interesting finding from the West of Scotland Coronary Prevention Study Group (WOSCOPS) is that the “absolute benefit of [statin] therapy was greatest in subjects with the highest baseline risk.”

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14. Case 3: A 38-year-old white male with a family history of coronary artery disease
Discussion Points:
This patient demonstrates what is often a clinical dilemma for the practicing physician ... a patient with no clinical coronary disease, yet presenting with lipid levels and a family history placing him at potential risk.
The AHA Step 2 diet this patient is following seems to be helping lower the LDL-C. However, other lipid levels remain below reference values. With the HDL-C of 31 mg/dL, triglycerides at 250 mg/dL, and total cholesterol at 230 mg/dL, there are opportunities remaining for dietary manipulation and, if necessary, use of pharmacotherapy.
The “high-normal” blood pressure in this patient should also be a point of attention in follow-up visits.

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19. Case 4: A 50-year-old black male with severe hypertension
Discussion Points:
Hypertension develops earlier in life and is more severe in blacks.
This case illustrates common dilemmas for practitioners, and following are major issues for discussion:
-Which therapeutic agent? Even though diuretics and beta blockers are preferred for initial treatment, discontinuation rates due to adverse effects and/or limited efficacy are often more than 50%.
- Inevitably this case requires a multidrug regimen for adequate control and close follow-up for adjustments in drug therapy and life-style.
- Other major discussion issues:
Importance of treating the underlying disease pathology
Life-style modifications

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25. Case 5: A 52-year-old female with 5-year history of “borderline” hypertension
Discussion Points:
Positive family history
Likely involvement of diabetes and the cardiovascular dysmetabolic syndrome
Why “borderline” hypertension deserves treatment and follow-up
The possibility of insulin resistance accelerating the process of atherosclerosis
Links between hypertension, excess weight, and diabetes
Importance of life-style modification
Drug choice for hypertension complicated by diabetes is ACE inhibition

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31. Case 6: A 43-year-old male s/p acute anterior wall MI
Discussion Points:
Therapeutic strategies post-MI
Beta-blockade
ACE inhibition (per JNC VI guidelines)
Lipid management
Life-style modification

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