1. 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

2. 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.

3. 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

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

5. What other labs do you want?

6. Case—LABS Non-traditional CAD risk factors:
Homocysteine mmol/L (NL )
Lp(a) mg/dl
Hs-CRP 0.8
Apo B: mg/dL

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

8. 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

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

10. What else could help in counseling her?

11. Coronary Artery Calcium Score

12. Carotid Ultrasound

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

14. Case—Follow-up 2017 LFT’s, creatinine: NL TSH: 0.92 U/mL
Hemoglobin A1c: N/A
Lipids
TC mg/dl
TG mg/dl
LDL-C mg/dl
HDL-C mg/dl
Non-HDL-C mg/dl

15. Coronary Artery Calcium Score

16. Case—Follow-up 2018 LFT’s, creatinine: NL TSH: N/A
Hemoglobin A1c: 5.3%
Lipids
TC mg/dl
TG mg/dl
LDL-C mg/dl
HDL-C mg/dl
Non-HDL-C mg/dl

17. What else could help in counseling her?

18. Carotid Intima-Media Thickness

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