First Video Conference of New Project Year for the OHSU/BDMS Collaboration Jan 16, 2018 Global Office at OHSU in Portland and BDMS Locations in Thailand

Agenda Welcome and Introductions Discussion about format of the newly approved project for 2018 Discussion about format and scope of the monthly video conferences Recent case managed at the Center for Preventive Cardiology Case from BDMS? Other issues and conclusions

Case 54 yo female, of Asian Indian ethnicity but on western diet and lifestyle, referred by PCP for CVD risk evaluation in the context of progressively increasing LDL levels over time, seen in clinic on January 9, 2018. History of severe inflammatory bowel disease with colic resection and placement of stoma (9 years prior). History of chronic obesity with bariatric surgery (6 years prior) leading to weight loss (40 lbs) followed by weight gain (60 lbs) No known or suspected CAD, no diabetes or dysglycemia, three normal pregnancies without GD.

Case She also has history of: • LFT elevations and fatty liver • Depression   • GERD   • Gout       • Hypertension   • Migraine     • Severe anxiety   • Sleep apnea What is her dyslipidemia?  

Medications Metoprolol and amlodipine for HTN Anti-TNF alpha and Methotrexate for RA Lexapro (escitalopram) for depression High dose vitamin B complex and folic acid, and 50,000 IU of vitamin D with calcium carbonate supplementation No lipid modulators. Reports prior exposure to atorvastatin with development of severe leg pain and generalized fatigue after a few weeks on therapy. Absolutely unwilling to try another statin.

Findings BP 141/86 Pulse 107 Ht 1.588 m (5' 2.5") Wt 103.6 kg (228 lb 6.4 oz) SpO2 97% BMI 41.11 kg/(m^2) 

Lipid Panel

Lipid Panel

Other Labs

Chest CT w/o Contrast EXAM: CT CORONARY ARTERY CALCIUM SCORE 01/10/18 10:32:53 FINDINGS: The coronary arteries arise in normal position and have a normal course. There is moderate coronary artery calcification, resulting in an Agatston score 147 (38 in the left main, 2 in the LAD, 12 in the LCx, and 95 in the RCA). The right and left ventricular chambers are of normal position in size. Aortic valvular calcifications noted. There is also minimal mitral annular calcification. IMPRESSION: Moderate evidence of coronary artery calcification resulting in an Agatston score = 147. This corresponds to the 96th percentile for age and gender.

Impressions and Plan Chronically obese patient affected by a severe form of dyslipidemia, characterized by LDL levels recently above 200 mg/dl (today's value 231) and mildly elevated triglycerides with normal HDL and borderline Lp(a) levels. She has intolerance to statins with severe myalgia on atorvastatin. She is unwilling to try statins again. Her LDL is in the range of FH. CT of the chest for coronary calcium scoring showed multiple calcified plaques, mostly in the RCA but also including left main, LAD, and LCx. It may be appropriate to perform a stress echo if the patient discloses any symptoms upon additional questioning. Her LDL target is <70 mg/dl, a very long distance from the current value. Considering her unwillingness to try another statin, I recommend starting ezetimibe 10 mg and initiate paperwork for PCSK9 inhibitor. In addition, today the patient saw our dietitian as part of the first visit package. Dietitian’s notes are produced separately. She has elevated blood pressure in office, and thus agrees to monitor values for a week at home and report back to us for medication adjustment if needed.

Discussion Points What would have been done differently in your hospital? What else does this patient need for maximum CVD risk control? ASA? TG management beyond fish oil supplements? Does HbA1c of 5.9% require action?

Agenda Welcome and Introductions Discussion about format of the newly approved project for 2018 Discussion about format and scope of the monthly video conferences Recent case managed at the Center for Preventive Cardiology Case from BDMS? Other issues and conclusions

Agenda Welcome and Introductions Discussion about format of the newly approved project for 2018 Discussion about format and scope of the monthly video conferences Recent case managed at the Center for Preventive Cardiology Case from BDMS? Other issues and conclusions