Case—History 75 year old woman referred for statin intolerance in 2016

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Presentation transcript:

Case—History 75 year old woman referred for statin intolerance in 2016 Non-smoker Heart disease in mother and father Mother had high cholesterol HTN on losartan, metoprolol Atrial fibrillation treated with apixaban 5 mg BID, flecainide 50 mg BID, metoprolol Hypothyroidism: 125 mcg levothyroxine No history of: Diabetes, CAD, PVD

Case History of hyperlipidemia “for as long as I can remember” Lipid lowering therapy history starting 2015-stopped in 2016: Statin intolerance (myalgias/arthralgias) to 5 different statins (atorvastatin, simvastatin, pravastatin, rosuvastation, pitavastatin). Currently only on omega-3 fatty acids 2 g daily.

Case—Physical Exam BP: 144/73, pulse 77 (irregularly, irregular) BMI 34.8 kg/m2 Waist Circumference: 111 cm PE, including CV system otherwise normal

Case—LABS LFT’s, creatinine: NL TSH: 0.79 U/mL Hemoglobin A1c: 5.6% UA: no protein Lipids TC 269 mg/dl TG 202 mg/dl LDL-C 175 mg/dl HDL-C 54 mg/dl Non-HDL-C 215 mg/dl

What other labs do you want?

Case—LABS Non-traditional CAD risk factors: Homocysteine 7.5 mmol/L (NL 3.4-10.8) Lp(a) 10 mg/dl Hs-CRP 0.8 Apo B: 133 mg/dL

Diagnosis Familial Combined Hyperlipidemia Confirmed by an Apo B level (> 120 mg/dl)

No Lp Partical Size: I already know she has small, dense LDL  VLDL-TG Liver CETP  HL FFA Large, buoyant LDL, HDL Small, dense LDL, HDL  IAF

What are your treatment options? Intensive Lifestyle Management 10 year ASCVD risk 28.7% ? Statins—Intolerant, does not want medications

What else could help in counseling her?

Coronary Artery Calcium Score

Carotid Ultrasound

What Do You Recommend? Trial of lovastatin? Begin ezetimibe? Begin fenofibrate? Do nothing?

Case—Follow-up 2017 LFT’s, creatinine: NL TSH: 0.92 U/mL Hemoglobin A1c: N/A Lipids 2016 2017 TC 269 243 mg/dl TG 202 281 mg/dl LDL-C 175 149 mg/dl HDL-C 54 38 mg/dl Non-HDL-C 215 205 mg/dl

Coronary Artery Calcium Score

Case—Follow-up 2018 LFT’s, creatinine: NL TSH: N/A Hemoglobin A1c: 5.3% Lipids 2016 2017 2018 TC 269 243 251 mg/dl TG 202 281 193 mg/dl LDL-C 175 149 165 mg/dl HDL-C 54 38 47 mg/dl Non-HDL-C 215 205 204 mg/dl

What else could help in counseling her?

Carotid Intima-Media Thickness

What Do You Recommend? Trial of lovastatin? Begin ezetimibe? Begin fenofibrate? Do nothing?