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CCCP Interactive Case Studies
Certified Cardiometabolic Care Pharmacist (CCCP)
The Scenario: Comprehensive Cardiometabolic Risk Reduction
You are a CCCP in a primary care clinic. You are seeing a 55-year-old male for follow-up. He has a history of hypertension and dyslipidemia, and recent labs show worsening glycemic control. He feels well and has no specific complaints. Your role is to assess his overall cardiometabolic risk and develop a comprehensive, multi-faceted plan to address all of his risk factors according to current guidelines.
Data Sets
Patient Profile & Labs
- Medications: Hydrochlorothiazide 25mg daily, Atorvastatin 20mg daily
- Vitals: BP: 145/92 mmHg (Goal < 130/80)
- Labs: LDL-C: 110 mg/dL (Goal < 100), HbA1c: 6.8%
Cardiometabolic Guidelines (Excerpt)
- Hypertension: An ACE inhibitor or ARB is a first-line agent, especially with diabetes.
- Dyslipidemia: High-intensity statin (atorvastatin 40-80mg) is recommended for high-risk primary prevention.
- Diabetes: An A1c > 6.5% confirms a diagnosis of T2DM. Metformin is first-line therapy.
Your Task
Task 1: Identify the three major cardiometabolic risk factors that are currently uncontrolled in this patient.
Answer:
1. Hypertension: His BP of 145/92 is above the goal of < 130/80.
2. Dyslipidemia: His LDL-C of 110 mg/dL is above the goal of < 100 mg/dL.
3. Hyperglycemia: His HbA1c of 6.8% is in the diabetic range and above the goal of < 6.5%.
Task 2: Is the patient's current atorvastatin dose appropriate for his risk profile? Justify your answer.
Answer:
No. The patient is on a moderate-intensity dose (atorvastatin 20mg). According to guidelines, a patient with his combination of risk factors (HTN, dyslipidemia, new T2DM) is at high risk for a future cardiovascular event and should be on a high-intensity statin (atorvastatin 40-80mg) to achieve his LDL-C goal.
Task 3: Based on his HbA1c, what new diagnosis does this patient have, and what is the first-line medication?
Answer:
He has a new diagnosis of Type 2 Diabetes. The first-line medication is metformin. An A1c ≥ 6.5% is diagnostic for T2DM, and metformin is the guideline-recommended initial therapy.
Task 4: Propose a comprehensive, three-part plan to get all of the patient's cardiometabolic risk factors to goal.
Answer:
- 1. Optimize Hypertension Therapy: Add a second agent. Recommend starting lisinopril 10mg daily. This is a first-line choice that provides renal protection, which is now indicated due to his new diabetes diagnosis.
- 2. Intensify Dyslipidemia Therapy: Increase the statin intensity. Recommend increasing his atorvastatin dose from 20mg to 40mg daily to achieve a >50% LDL reduction from baseline.
- 3. Initiate Diabetes Therapy: Start first-line treatment. Recommend initiating metformin 500mg daily with food and titrating up as tolerated to control his hyperglycemia.
The Scenario: Optimizing Therapy Post-Myocardial Infarction
A 62-year-old female with a new diagnosis of Type 2 Diabetes (T2DM) presents for a follow-up appointment three months after being hospitalized for a myocardial infarction (MI). She is now considered to have established atherosclerotic cardiovascular disease (ASCVD). As the CCCP, your role is to review her current regimen and recommend optimizations based on the latest guidelines for secondary prevention in patients with both ASCVD and T2DM.
Patient Data
Patient Profile & Labs
- PMH: T2DM, Hypertension, Dyslipidemia, ASCVD (post-MI)
- Medications: Metformin 1000mg BID, Atorvastatin 80mg daily, Lisinopril 40mg daily, Metoprolol 50mg BID, Aspirin 81mg daily.
- Labs: HbA1c: 7.8%, LDL-C: 85 mg/dL, eGFR: 55 mL/min.
Guideline Recommendations (ADA/ACC)
- For T2DM patients with established ASCVD, an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit is recommended to reduce the risk of major adverse cardiac events.
- For patients with ASCVD, the LDL-C goal is < 70 mg/dL. If not at goal on a max-tolerated statin, adding ezetimibe or a PCSK9 inhibitor is recommended.
Your Task
Task 1: The patient's diabetes is not at the goal of A1c < 7%. Based on her new ASCVD diagnosis, what is the best-in-class medication to add to her metformin?
Answer:
The best medication to add is an SGLT2 inhibitor (e.g., empagliflozin or dapagliflozin) or a GLP-1 receptor agonist (e.g., semaglutide or liraglutide). Guidelines give a strong recommendation for one of these two classes in any T2DM patient with established ASCVD because they have been proven to reduce the risk of future MACE, independent of their glucose-lowering effects. Given her eGFR of 55, an SGLT2 inhibitor would also be a good choice to provide renal protection.
Task 2: The patient's LDL-C is 85 mg/dL. Is this at goal for a secondary prevention patient? If not, what is the next appropriate step?
Answer:
No, an LDL-C of 85 mg/dL is not at goal. For a patient with established ASCVD (secondary prevention), the goal is an LDL-C of < 70 mg/dL. Since she is already on the maximum dose of a high-intensity statin (atorvastatin 80mg), the next appropriate step is to add a non-statin agent. The first-line choice per guidelines would be to add ezetimibe 10 mg daily.
Task 3: Her current regimen includes four medications for cardiovascular protection (statin, ACEi, beta-blocker, aspirin). What is this combination of post-MI therapies commonly called?
Answer:
This is commonly referred to as Guideline-Directed Medical Therapy (GDMT) for secondary prevention post-MI. The four pillars are a high-intensity statin, an ACE inhibitor/ARB, a beta-blocker, and antiplatelet therapy.
Task 4: What is the primary role of the CCCP in managing a complex secondary prevention patient like this?
Answer:
The primary role is to ensure the patient is on an optimized, evidence-based regimen that addresses all aspects of their cardiometabolic risk. This involves moving beyond single-disease management and integrating therapies. For this patient, it means not just controlling her A1c, but doing so with an agent (SGLT2i or GLP-1RA) that also reduces her cardiac risk, and not just lowering her LDL, but intensifying therapy to get her to the stringent secondary prevention goal. The CCCP ensures that all opportunities to reduce risk via GDMT are identified and implemented.
The Scenario: Interpreting Challenging Lab Results
A 60-year-old female with T2DM and hypertension comes to your clinic for a routine follow-up. Her primary care provider is concerned about her latest lipid panel, specifically her severely elevated triglycerides, and asks for your recommendation as the CCCP. The patient has been trying to improve her diet but struggles with consistency.
Patient Data
Patient Profile & Meds
- PMH: T2DM, Hypertension
- Medications: Metformin 1000mg BID, Lisinopril 20mg daily, Atorvastatin 40mg daily.
Lipid Panel & A1c
| Lab | Result | Goal |
|---|---|---|
| Total Cholesterol | 250 mg/dL | < 200 |
| LDL-C | 95 mg/dL | < 100 |
| HDL-C | 35 mg/dL | > 50 |
| Triglycerides (TG) | 600 mg/dL | < 150 |
| HbA1c | 9.5% | < 7.0% |
Your Task
Task 1: What is the most likely cause of this patient's severe hypertriglyceridemia (TG > 500 mg/dL)?
Answer:
The most likely cause is her severely uncontrolled Type 2 Diabetes, as indicated by her HbA1c of 9.5%. Poor glycemic control is a major secondary cause of hypertriglyceridemia. While her diet may contribute, the magnitude of the elevation is most strongly linked to her hyperglycemia.
Task 2: What is the most immediate health risk for a patient with triglycerides this high, and how does it change your treatment priority?
Answer:
The most immediate risk is acute pancreatitis. While high triglycerides are a long-term cardiovascular risk, levels above 500 mg/dL significantly increase the short-term risk of this painful and potentially fatal condition. This shifts the immediate treatment priority from solely focusing on LDL-C for ASCVD risk to also aggressively lowering triglycerides to prevent pancreatitis.
Task 3: Would you add a fibrate (e.g., fenofibrate) to her current statin therapy right now? Justify your answer.
Answer:
No, you would not add a fibrate at this time. The first and most important step is to aggressively control her blood glucose. Improving her A1c will have the most significant impact on lowering her triglycerides. Adding a fibrate before addressing the underlying hyperglycemia would be premature. The best practice is to first optimize glycemic control and then re-evaluate the lipid panel in 3 months to see if additional triglyceride-lowering therapy is still needed.
Task 4: What two interventions should be prioritized to address the root cause of her hypertriglyceridemia?
Answer:
The two highest priorities are:
- Intensify Diabetes Therapy: Her A1c of 9.5% on metformin monotherapy indicates a need for additional medication. Adding a second agent, such as an SGLT2 inhibitor or GLP-1 receptor agonist, is the immediate pharmacologic priority to improve her glycemic control.
- Medical Nutrition Therapy (MNT): Provide a "warm handoff" referral to a registered dietitian or certified diabetes care and education specialist. MNT is crucial for addressing both the hyperglycemia and hypertriglyceridemia through targeted dietary changes (e.g., reducing refined carbohydrates and saturated fats).
