ASSESSMENT: CARDIOVASCULAR SYSTEM PATIENT CASE, PART 2

1

Patient Case Study Template

Jane Edobor

Walden University

Dr Veleka Grady

Advance pharmacology

May 29, 2026

Patient Case Study Template

1. Patient Profile

· Age: 47 years

· Gender: Male

· Ethnicity: Not specified

· Relevant Genetics (if available): None reported, no familial hypercholesterolemia or markers for statin sensitivity (e.g., SLCO1B1 variants).

· Behavioral Factors (e.g., smoking, alcohol, adherence): Current smoker, approximately 25 pack years; Not specified, alcohol use; Adherence, not documented, lisinopril, liraglutide (which is an herbal supplement used for mood); Current, takes St. John's wort daily.

· Relevant Medical History: Hypertension (on lisinopril 40 mg daily) and type 2 diabetes (on liraglutide 0.6 mg subcutaneously daily).

· Current Diagnoses:

· Severe hypercholesterolemia (LDL 180mg/dL)

· Mixed hyperlipidaemia (total cholesterol = 260 mg/dL, TG = 185 mg/dL)

· Diabetes + hypertension + smoking + obesity is considered to be high-risk atherosclerotic cardiovascular disease (ASCVD) equivalent.

· Overweight/obesity (height 5’9”, weight 204 lbs → BMI ≈ 30.1 kg/m²)

· Pathophysiological Changes (e.g., renal, heart, or liver failure): No renal failure, heart failure or liver failure reported; diabetes causes endothelial dysfunction, accelerated atherosclerosis, and LDL particle retention; smoking causes LDL to oxidize and HDL to decrease; cardiovascular benefit of liraglutide is not fully compensated for by dyslipidemia.

2. Medication Plan

· Medication Name: Atorvastatin

· Dosage and Route: 40 mg orally

· Frequency: Once daily in the evening

· Rationale for Selection (including patient-specific factors): Atorvastatin 40 mg is a high-intensity statin, which lowers LDL by ≥50% (Grundy et al., 2019). The 2018 ACC/AHA cholesterol guideline recommends that persons with diabetes age 40-75 years who have multiple ASCVD risk factors (e.g. hypertension, smoking, obesity, LDL ≥70 mg/dL) should be treated with high-intensity statin therapy, even without the use of a risk calculator (Bhattacharya, 2026). Another risk factor for this patient is his LDL of 180 mg/dL, which is considered severe (LDL ≥190 mg/dL is considered severe; 180 mg/dL is borderline severe with multiple risks). The use of a statin is equally beneficial irrespective of age, gender or ethnicity, as would be further increased at 47 years and male (if applicable) and African American ethnicity (if applicable). Atorvastatin is more commonly used than simvastatin as this is a moderate dose and simvastatin 80mg is no longer recommended as it carries the risk of myopathy. Furthermore, there is greater and more stable LDL lowering with atorvastatin. Most importantly, the patient should stop taking St. John's wort, which is a strong inducer of CYP3A4, and decreases the serum levels of atorvastatin and the reduction in LDL.

· Potential Drug Interactions or Contraindications:

· St. John's wort is an inducer of CYP3A4 which decreases atorvastatin AUC by ~40% and may result in therapeutic failure and ongoing high ASCVD risk (Chan et al., 2025).

· No contraindications with lisinopril or liraglutide.

· Smoking by itself does not interact directly, it does however increase LDL oxidation and decrease HDL.

· Stay away from gemfibrozil (risks of myopathy); good old fenofibrate can be used if triglycerides are still > 500 mg/dL.

· Relative contraindication: Active liver disease (not reported).

· Monitoring Parameters:

· Baseline: Lipid panel, liver function tests (ALT, AST), creatine kinase (CK)

· Repeat lipid profile after 4–12 weeks to evaluate LDL response to treatment and adherence (Bhattacharya, 2026).

· Ongoing: CK only if patient complains of unexplainable muscle pain, weakness or dark urine.

· Once every 6-12 months: LFTs; stop if ALT/AST is more than 3 times the upper limit of normal.

· Behavioral Monitoring: Evaluate smoking status and St. John's wort use at each patient visit.

3. Ethical and Legal Considerations

Several ethical and legal principles apply to KU’s personalized medication plan.

· Informed consent: Provider needs to explain that St. John's wort decreases the effectiveness of atorvastatin in lowering LDL cholesterol, thus the risk of heart attack or stroke (Mefford et al., 2021). The patient can refuse to stop the herb but the provider should record this decision and think about using an alternative statin that is not as reliant on CYP3A4 such as pravastatin (which is less effective).

· Patient autonomy is recognized by offering evidence-based choices, rather than pressuring. When prescribing St. John's wort, the provider may still prescribe atorvastatin, but will have to monitor and counsel for residual risk if KU decides to continue prescribing St. John's wort.

· Cultural sensitivity: Some patients take herbal medicines such as St. John's wort in the context of their culture belief. The provider should enquire about the use of supplements in a respectful way, without using judgmental language, and should recognize that some patients may not be accepting conventional treatment, and have a distrust of it.

· Legal issues: The prescriber (NP or physician) must practice within the scope of practice for statins in their state, and have the power to stop prescribing supplements. Not checking for herb-drug interactions may be a failure to meet the standard of care and be legally liable (Guyton, 2021). Moreover, it's legal to document counselling on smoking cessation, as smoking is a risk factor that can be modified, and statins don't fully counteract it.

· Equity and conformance to guidelines: The ACC/AHA guidelines apply to all ethnicities/genders and the cost and accessibility shouldn't be barriers (atorvastatin is generic and low cost) (Blumenthal et al., 2026).

4. Complete Medication Order

· Medication Name: Atorvastatin

· Dose: 40 mg

· Route: Oral

· Frequency: Once a day in the evening

· Special Instructions:

· Stop St. John's wort because of important drug interaction that decreases the cholesterol-lowering effect.

· May be taken with or without food. Dosage in the evening might be more beneficial to the reduction of LDL.

· Have fasted blood lipid panel and liver function tests repeated in 6 weeks.

· Call a doctor for any unexplained muscle pain or tenderness, weakness, or dark-colored urine or fatigue.

· Strongly recommend smoking cessation counseling – refer to tobacco cessation program.

· Use lisinopril 40 mg once a day and liraglutide 0.6 mg subcutaneously once daily, as needed.

References

Bhattacharya, R. (2026). New cholesterol guidelines | mass general brigham. Massgeneralbrigham.org. https://www.massgeneralbrigham.org/en/about/newsroom/articles/new-cholesterol-guidelines

Blumenthal, R. S., Morris, P. B., Gaudino, M., Johnson, H. M., Anderson, T. S., Bittner, V. A., Blankstein, R., Brewer, L. C., Cho, L., de Ferranti, S. D., Gianos, E., Gluckman, T. J., Gradney, K. F., Isiadinso, I., Lloyd-Jones, D. M., Marrs, J. C., Martin, S. S., McLain, K. H., Mehta, L. S., & Mora, S. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia. JACC, 87(19). https://doi.org/10.1016/j.jacc.2025.11.016

Chan, W.-J. J., Hunter, J., McLachlan, A. J., & Harnett, J. E. (2025). Consumer purchasing behaviour: oral contraceptives with Hypericum perforatum, and atorvastatin with Camellia sinensis: an Australia-wide basket analysis. Drugs & Therapy Perspectives, 41, 354–362. https://doi.org/10.1007/s40267-025-01167-z

Guyton, J. R. (2021). From the editor: Plagues and the ancient legacy of epimenides. Journal of Clinical Lipidology, 14(3), 271–272. https://doi.org/10.1016/j.jacl.2020.05.004

Mefford, B., Donaldson, J. C., & Bissell, B. D. (2021). The immunomodulatory effects of opioids and implications for intensive care unit populations. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 41(8), 668–675. https://doi.org/10.1002/phar.2602

ASSESSMENT: CARDIOVASCULAR SYSTEM PATIENT CASE, PART 2

In Part 2 of the Cardiovascular System Patient Case, you will synthesize your learning into a succinct  elevator speech, presenting your patient plan and reflecting on how new insights from the module inform your clinical approach.

This assignment challenges you to  communicate complex pharmacotherapeutic decisions clearly and concisely, demonstrating your ability to  adapt treatment strategiesbased on evolving evidence and patient needs. Use the study questions to identify key information and ensure your presentation is both comprehensive and focused.

Level 1: No AI Permitted

· AI tools may  not be used at any stage

· Common for clinical documentation or performancebased work

RESOURCES

Be sure to review the Learning Resources before completing this assessment.

Required Resources

To prepare:

· Complete the Cardiovascular System Patient Case, Part 1

· Consider the important information to present from your patient plan

BY SUNDAY OF WEEK 2

Submit a 3-minute elevator speech recording using a slide deck to highlight the important information from your patient plan.

Imagine you are giving your preceptor an update on the case. In your presentation, explore how your treatment plan would change based on what you learned this week. This presentation should be no more than 3 minutes.

1

Patient Case Study Template

Jane Edobor

Walden University

Dr Veleka Grady

Advance pharmacology

May 29, 2026

Patient Case Study Template

1. Patient Profile

· Age: 47 years

· Gender: Male

· Ethnicity: Not specified

· Relevant Genetics (if available): None reported, no familial hypercholesterolemia or markers for statin sensitivity (e.g., SLCO1B1 variants).

· Behavioral Factors (e.g., smoking, alcohol, adherence): Current smoker, approximately 25 pack years; Not specified, alcohol use; Adherence, not documented, lisinopril, liraglutide (which is an herbal supplement used for mood); Current, takes St. John's wort daily.

· Relevant Medical History: Hypertension (on lisinopril 40 mg daily) and type 2 diabetes (on liraglutide 0.6 mg subcutaneously daily).

· Current Diagnoses:

· Severe hypercholesterolemia (LDL 180mg/dL)

· Mixed hyperlipidaemia (total cholesterol = 260 mg/dL, TG = 185 mg/dL)

· Diabetes + hypertension + smoking + obesity is considered to be high-risk atherosclerotic cardiovascular disease (ASCVD) equivalent.

· Overweight/obesity (height 5’9”, weight 204 lbs → BMI ≈ 30.1 kg/m²)

· Pathophysiological Changes (e.g., renal, heart, or liver failure): No renal failure, heart failure or liver failure reported; diabetes causes endothelial dysfunction, accelerated atherosclerosis, and LDL particle retention; smoking causes LDL to oxidize and HDL to decrease; cardiovascular benefit of liraglutide is not fully compensated for by dyslipidemia.

2. Medication Plan

· Medication Name: Atorvastatin

· Dosage and Route: 40 mg orally

· Frequency: Once daily in the evening

· Rationale for Selection (including patient-specific factors): Atorvastatin 40 mg is a high-intensity statin, which lowers LDL by ≥50% (Grundy et al., 2019). The 2018 ACC/AHA cholesterol guideline recommends that persons with diabetes age 40-75 years who have multiple ASCVD risk factors (e.g. hypertension, smoking, obesity, LDL ≥70 mg/dL) should be treated with high-intensity statin therapy, even without the use of a risk calculator (Bhattacharya, 2026). Another risk factor for this patient is his LDL of 180 mg/dL, which is considered severe (LDL ≥190 mg/dL is considered severe; 180 mg/dL is borderline severe with multiple risks). The use of a statin is equally beneficial irrespective of age, gender or ethnicity, as would be further increased at 47 years and male (if applicable) and African American ethnicity (if applicable). Atorvastatin is more commonly used than simvastatin as this is a moderate dose and simvastatin 80mg is no longer recommended as it carries the risk of myopathy. Furthermore, there is greater and more stable LDL lowering with atorvastatin. Most importantly, the patient should stop taking St. John's wort, which is a strong inducer of CYP3A4, and decreases the serum levels of atorvastatin and the reduction in LDL.

· Potential Drug Interactions or Contraindications:

· St. John's wort is an inducer of CYP3A4 which decreases atorvastatin AUC by ~40% and may result in therapeutic failure and ongoing high ASCVD risk (Chan et al., 2025).

· No contraindications with lisinopril or liraglutide.

· Smoking by itself does not interact directly, it does however increase LDL oxidation and decrease HDL.

· Stay away from gemfibrozil (risks of myopathy); good old fenofibrate can be used if triglycerides are still > 500 mg/dL.

· Relative contraindication: Active liver disease (not reported).

· Monitoring Parameters:

· Baseline: Lipid panel, liver function tests (ALT, AST), creatine kinase (CK)

· Repeat lipid profile after 4–12 weeks to evaluate LDL response to treatment and adherence (Bhattacharya, 2026).

· Ongoing: CK only if patient complains of unexplainable muscle pain, weakness or dark urine.

· Once every 6-12 months: LFTs; stop if ALT/AST is more than 3 times the upper limit of normal.

· Behavioral Monitoring: Evaluate smoking status and St. John's wort use at each patient visit.

3. Ethical and Legal Considerations

Several ethical and legal principles apply to KU’s personalized medication plan.

· Informed consent: Provider needs to explain that St. John's wort decreases the effectiveness of atorvastatin in lowering LDL cholesterol, thus the risk of heart attack or stroke (Mefford et al., 2021). The patient can refuse to stop the herb but the provider should record this decision and think about using an alternative statin that is not as reliant on CYP3A4 such as pravastatin (which is less effective).

· Patient autonomy is recognized by offering evidence-based choices, rather than pressuring. When prescribing St. John's wort, the provider may still prescribe atorvastatin, but will have to monitor and counsel for residual risk if KU decides to continue prescribing St. John's wort.

· Cultural sensitivity: Some patients take herbal medicines such as St. John's wort in the context of their culture belief. The provider should enquire about the use of supplements in a respectful way, without using judgmental language, and should recognize that some patients may not be accepting conventional treatment, and have a distrust of it.

· Legal issues: The prescriber (NP or physician) must practice within the scope of practice for statins in their state, and have the power to stop prescribing supplements. Not checking for herb-drug interactions may be a failure to meet the standard of care and be legally liable (Guyton, 2021). Moreover, it's legal to document counselling on smoking cessation, as smoking is a risk factor that can be modified, and statins don't fully counteract it.

· Equity and conformance to guidelines: The ACC/AHA guidelines apply to all ethnicities/genders and the cost and accessibility shouldn't be barriers (atorvastatin is generic and low cost) (Blumenthal et al., 2026).

4. Complete Medication Order

· Medication Name: Atorvastatin

· Dose: 40 mg

· Route: Oral

· Frequency: Once a day in the evening

· Special Instructions:

· Stop St. John's wort because of important drug interaction that decreases the cholesterol-lowering effect.

· May be taken with or without food. Dosage in the evening might be more beneficial to the reduction of LDL.

· Have fasted blood lipid panel and liver function tests repeated in 6 weeks.

· Call a doctor for any unexplained muscle pain or tenderness, weakness, or dark-colored urine or fatigue.

· Strongly recommend smoking cessation counseling – refer to tobacco cessation program.

· Use lisinopril 40 mg once a day and liraglutide 0.6 mg subcutaneously once daily, as needed.

References

Bhattacharya, R. (2026). New cholesterol guidelines | mass general brigham. Massgeneralbrigham.org. https://www.massgeneralbrigham.org/en/about/newsroom/articles/new-cholesterol-guidelines

Blumenthal, R. S., Morris, P. B., Gaudino, M., Johnson, H. M., Anderson, T. S., Bittner, V. A., Blankstein, R., Brewer, L. C., Cho, L., de Ferranti, S. D., Gianos, E., Gluckman, T. J., Gradney, K. F., Isiadinso, I., Lloyd-Jones, D. M., Marrs, J. C., Martin, S. S., McLain, K. H., Mehta, L. S., & Mora, S. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia. JACC, 87(19). https://doi.org/10.1016/j.jacc.2025.11.016

Chan, W.-J. J., Hunter, J., McLachlan, A. J., & Harnett, J. E. (2025). Consumer purchasing behaviour: oral contraceptives with Hypericum perforatum, and atorvastatin with Camellia sinensis: an Australia-wide basket analysis. Drugs & Therapy Perspectives, 41, 354–362. https://doi.org/10.1007/s40267-025-01167-z

Guyton, J. R. (2021). From the editor: Plagues and the ancient legacy of epimenides. Journal of Clinical Lipidology, 14(3), 271–272. https://doi.org/10.1016/j.jacl.2020.05.004

Mefford, B., Donaldson, J. C., & Bissell, B. D. (2021). The immunomodulatory effects of opioids and implications for intensive care unit populations. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 41(8), 668–675. https://doi.org/10.1002/phar.2602