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A patient with CAD has high triglycerides (300-500 mg/dL), and therefore his LDL is reported as “unable to calculate.” If he fails lifestyle modification, should he start a fibrate (or niacin) for the high triglycerides, or would it be better to start a statin? The statin might lower triglycerides enough to calculate the LDL, not to mention treat the LDL, which is probably high as well and significantly more concerning. Using a statin at this point might avoid the later need to use a more toxic combination of two medications, i.e., a fibrate and an added statin.
—Steven M. Schwartz, MD, New Haven, Conn.

Dr. Schwartz is right to try a statin first in this man with CAD if, in addition to the elevated triglyceride level, the total cholesterol level is also high. One could then conclude that the LDL level is high as well. On the other hand, if the total cholesterol is <200 mg/dL, the LDL is probably not worrisome, and a fibrate would be preferable as initial therapy.
—Peter F. Cohn, MD (99-2)

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