Cardiovascular Case Analysis

69-year-old Hispanic male with history of STEMI, hypertension, and reduced ejection fraction

Patient Overview

Demographics

Age: 69 years

Sex: Male

Ethnicity: Hispanic

Cardiovascular History

STEMI episodes: 2 (both stented)

Last MI: 2 years ago

Hypertension: Controlled (135/85 mmHg avg)

Cardiac Function

Ejection Fraction: 45% (moderately reduced)

Stress Test: Normal exercise tolerance

NYHA Class: Likely I-II

Current Medications

Medication Analysis

The current medication regimen is appropriate for secondary prevention in a post-MI patient with reduced EF. The use of carvedilol, valsartan, aspirin, and atorvastatin follows current ACC/AHA guidelines for STEMI management. Amlodipine is likely being used as adjunctive therapy for blood pressure control.

Consider assessing for need of SGLT2 inhibitor (empagliflozin or dapagliflozin) given the reduced EF, and possible eplerenone if EF remains ≤40% despite current therapy.

Laboratory Results Analysis

Tier 1 Abnormalities (Requiring Immediate Attention)

Vitamin D deficiency (24.54 ng/mL), Elevated triglycerides (201 mg/dL), and Low HDL (32 mg/dL) indicate residual dyslipidemia despite statin therapy.

Elevated urea (60 mg/dL) and BUN (28 mg/dL) suggest possible prerenal azotemia or mild dehydration requiring evaluation.

Tier 2 Abnormalities (Monitor/Follow-up)

MPV (10.1 fL) and eosinophilia (8%) may indicate platelet activation or mild allergic/inflammatory process. Note: Carvedilol can sometimes cause eosinophilia.

Direct bilirubin (0.31 mg/dL) slightly elevated - consider liver function monitoring given multiple medications.

Hematological Profile

Parameter Value Reference Analysis
Hemoglobin 14.7 g/dL 13.5-17.5 Normal
Platelets 288 x10³/mm³ 140-400 Normal
MPV 10.1 fL 7.5-10.0 Slightly elevated (monitor)
Eosinophils 8% (560 abs) 2-4% (100-500) Mild eosinophilia

Metabolic Panel

Parameter Value Reference Analysis
Sodium 141 mEq/L 136-146 Normal
Potassium 4.97 mEq/L 3.5-5.1 Normal (watch with ARB)
Urea 60 mg/dL 10-50 Elevated
BUN 28 mg/dL 6-23 Elevated
Creatinine 1.07 mg/dL 0.5-1.2 Normal
eGFR 69 mL/min - Stage 2 CKD

Lipid Panel

Parameter Value Reference Analysis
Total Cholesterol 116 mg/dL 50-200 Well controlled
HDL 32 mg/dL 40-55 Low (risk factor)
LDL (calculated) 43.9 mg/dL - Excellent control
Triglycerides 201 mg/dL 10-30 Markedly elevated
VLDL 40 mg/dL 0-100 Elevated

Clinical Assessment & Recommendations

Cardiovascular Risk Assessment

This patient remains at very high cardiovascular risk due to:

  • History of two STEMIs
  • Reduced EF at 45%
  • Residual dyslipidemia (low HDL, high triglycerides)
  • Stage 2 CKD (eGFR 69 mL/min)

Despite current therapy, annual cardiovascular mortality risk remains ≈5-10%.

Recommendations

  1. Lipid Management:
    • Consider adding omega-3 fatty acids (4g/day of icosapent ethyl) for persistent hypertriglyceridemia
    • Discuss possible fenofibrate trial if triglycerides remain >200 on follow-up
  2. HFrEF Optimization:
    • Given EF 45%, consider SGLT2 inhibitor (dapagliflozin/empagliflozin) per recent guidelines
    • If symptoms develop or EF drops ≤40%, consider adding MRA (eplerenone)
  3. Metabolic/Vitamin:
    • Vitamin D supplementation (1000-2000 IU daily)
    • Regular monitoring of renal function
  4. Follow-up:
    • Repeat echocardiogram in 6-12 months to monitor EF
    • Consider cardiac rehab referral if not previously completed

Risk Factors Addressed

Hypertension controlled LDL at goal Anti-platelet therapy Beta-blocker therapy RAAS inhibition

Residual Risk Factors

Low HDL High triglycerides Vitamin D deficiency Moderate CKD Moderately reduced EF

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