A 42-year-old man was admitted to the hospital with severe chest pain that started 2 hours earlier. He was slim, but he smoked 20 cigarettes daily. An electrocardiogram indicated that he might have an acute inferior wall myocardial infarction (MI), which was later also documented by elevated cardiac enzyme levels. The patient was treated successfully with percutaneous coronary intervention and implantation of an intracoronary stent.

The patient's nonfasting lipid levels were measured at the initial blood sample drawn immediately on admittance to the hospital. His total cholesterol level was 255 mg/dL, and his low-density lipoprotein (LDL) cholesterol level was 146 mg/dL; however, his triglyceride level was 378 mg/dL (4.3 mmol/L), and his high-density lipoprotein (HDL) cholesterol level was 27 mg/dL. His blood pressure was 140/80 mm Hg. A plasma glucose measurement showed that he did not have diabetes mellitus.

The relatively modest elevations in LDL and total cholesterol levels together with smoking 20 cigarettes daily would not lead to severe atherosclerosis and MI at such an early age in most cases. However, a nonfasting triglyceride level as high as 378 mg/dL (4.3 mmol/L) means the patient had a remnant lipoprotein cholesterol level of 82 mg/dL (cholesterol in mg/dL: total 255 minus LDL 146 minus HDL 27 equals remnants 82). These high levels of nonfasting triglycerides and remnant lipoprotein cholesterol mean that the risk of MI in this 42-year-old man was 3-fold to 4-fold greater than in men with nonfasting triglycerides below 89 mg/dL (<1 mmol/L).

The patient stopped smoking and was treated with 40 mg of rosuvastatin (Crestor) daily, which reduced the nonfasting triglyceride level to 195 mg/dL, remnant lipoprotein cholesterol level to 38 mg/dL, and LDL cholesterol level to 70 mg/dL. The treatment was well tolerated without muscle pain or elevated alanine transaminase levels, and, hopefully, will prevent this young man from having another MI.