USMLE Step 3 - Question 20

A 55 year old male with a history of hypertension has the following fasting lipid profile:

Total cholesterol 240 mg/dL
LDL cholesterol 98 mg/dL
HDL cholesterol 35 mg/dL
Triglycerides 140 mg/dL

Which of the following is the most appropriate treatment?

A. Diet and lifestyle modifications

B. Start niacin

C. Start gemfibrozil

D. Start an HMG-CoA reductase inhibitor

E. No therapy is needed

For men the goal HDL is > 40 mg/DL, thus diet and lifestyle modifications should be tried for 6 months prior to initiating niacin, which is the preferred drug used to raise HDL levels, although recent data from the AIM-HIGH trial and the HPS-3 Thive trial have not shown a mortality benefit. His LDL level is normal according to ATP III guidelines. Other interventions that raise HDL levels include exercise (part of diet/lifestyle modifications), alcohol, omega-3 fatty acids, HMC-CoA reductase inhibitors (although only small effect), and estrogen.