Scenario

A 40-year-old Maori man came for routine review concerned because his 38-year-old brother, who was a smoker, died suddenly of a heart attack. The patient was athletic, previously played professional rugby, without clinical risk factors.

- BMI 28

- LDL 4.9; TC/HDL ratio 4

His calculated cardiovascular risk on these parameters was low. A reasonable approach would include

1) reinforcing healthy living and reassessing in 5 years

2) reinforcing healthy lifestyle and starting a statin

3) reinforcing healthy lifestyle, getting a CTCA, starting a statin

4) all of the above

Discussion

Being Maori with an immediate first degree relative having proven cardiovascular disease will adjust the calculated cardiovascular risk from low to moderate. However, this adjustment remains arbitrary. Because of his young age, his calculated 5-10 year cardiovascular risk is underestimating his lifetime cardiovascular risk.

Reinforcing lifestyle approach may seem adequate based on risk figures alone, though it is not unreasonable to start a statin on the LDL alone, notwithstanding the significant family history. (ACC/AHA Guidelines 2013)

A more comprehensive approach may be that he gets a statin and a CTCA to delineate his coronary anatomy and may be reinforce compliance. However, evidence for routine CTCA in this situation is currently less robust.

Author

Dr Seif El-Jack