Clinical Assessment: Mr. Rajaram Hadawale, 58M

• Total Cholesterol: 203 mg/dL (borderline high)
• LDL: 134 mg/dL (borderline high - needs urgent attention given his risk profile)
• HDL: 44 mg/dL (low normal)
• Non-HDL: 159 mg/dL (desirable range 130-159)
• TG: 121 mg/dL (normal)
• Fasting Glucose: 86 mg/dL (normal)

Key Issues to Address

1. BETA-BLOCKER - Should you start one?

• A resting HR of 54/min is already bordering on bradycardia (< 60 bpm)
• Starting a beta-blocker on a HR of 54 risks symptomatic bradycardia (HR may drop to 40s), especially since he is already experiencing dizziness (though likely labyrinthine given response to betahistine/vertin)
• Echo is normal and ECG is within normal limits - no heart failure or reduced EF to drive beta-blocker use

• Do NOT start a beta-blocker at this time given HR of 54/min
• Verify whether the 54 bpm is his baseline resting HR or whether he has been on any rate-slowing drug
• If the dizziness was cardiac in origin (vasovagal, sinus bradycardia), beta-blockers would be absolutely contraindicated
• If and when beta-blocker is needed for MB symptoms (angina, ischemia), start at the very lowest dose (e.g., metoprolol succinate 12.5 mg OD) under HR monitoring
• Ivabradine (5 mg BD) is an alternative heart rate-reducing agent that avoids negative chronotropy-related bradycardia risk and is particularly useful in MB with normal EF - worth considering if HR-reduction is clinically needed
• Consider a 24-hour Holter to rule out sick sinus syndrome, pauses, or AV block before making any HR-modifying decision

2. DYSLIPIDEMIA MANAGEMENT - Is his LDL adequate? Should Rosuvas 5 be converted to Rosuvas-EZ?

• Known dyslipidemia
• CAG 12 years back showing myocardial bridge (a structural coronary anomaly, though not atherosclerotic, places him in a monitored category)
• Age 58, male
• LDL currently 134 mg/dL on Rosuvastatin 5 mg

• ACC/AHA: LDL < 70 mg/dL (high-intensity statin recommended) - per Harrison's 22E
• ESC 2019/2023: LDL < 55 mg/dL for very high risk, with ≥50% reduction from baseline
• His current LDL of 134 is far above either target. He is on a low-intensity statin (Rosuvas 5 mg).

• Rosuvastatin 20-40 mg is preferred first step (high-intensity statin; reduces LDL by ~50-55%)
• Atorvastatin 40-80 mg is the alternative
• Per Harrison's 22E: "Current recommendations are to use high-intensity statin therapy in patients with ASCVD or deemed at high risk of ASCVD"

• Ezetimibe adds a further 18-25% LDL reduction on top of statin (Harrison's 22E)
• The IMPROVE-IT trial showed statin + ezetimibe combination significantly reduced major CV events vs statin alone
• The combination is safe and well-tolerated; monitor LFTs when combining

3. OTHER CONSIDERATIONS

• Dizziness / Vertin: The resolution with betahistine (Vertin) strongly suggests benign positional vertigo or labyrinthine etiology, not cardiac (no syncope, no HR drop noted, normal ECG/echo). Reassuring. Follow Dix-Hallpike if recurs.
• Non-HDL 159 mg/dL: Still elevated (desirable < 130). This will improve with statin intensification.
• HDL 44 mg/dL: Low-normal. No drug indicated for isolated low HDL currently; lifestyle (exercise, smoking cessation) is key.
• Fasting glucose 86 mg/dL: Normal. No diabetes risk currently.
• Lifestyle: Emphasize Mediterranean diet, regular aerobic exercise (30 min/day), avoid smoking - all lower LDL and improve HDL.

Summary Advice