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61 Year Old Female with Premature CAD and Normal LDL-C Cholesterol

61 Year Old Female with Premature CAD and Normal LDL-C Cholesterol. Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia

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61 Year Old Female with Premature CAD and Normal LDL-C Cholesterol

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  1. 61 Year Old Female with Premature CAD and Normal LDL-C Cholesterol Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia Elevated Lipoprotein (a) Statin Intolerance Case category: Familial Combined Hyperlipidemia, Diabetes, Metabolic Syndrome History of present illness: 61 year old female with history of diet controlled diabetes. Diagnosed with CAD with recent CABG and stent placement. Current treatment includes Pravachol 40 and Zetia 10, prescribed by her PCP. She just started metformin 500, but plans to discontinue if she can control with an organic diet. She has high triglycerides, but never treated. She is concerned about her diabetes and new heart issues and here to discuss treatment of lipids and cardiometabolic risk.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Lipid Profile on Plavix 75, Pravachol 40, Zetia 10, Metformin 500, and Vitamin D3 1000 Fasting: NF NT = Not Tested

  6. Other Labs Worth Noting on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 Fasting: NF NT = Not Tested

  7. Labs on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 (1 of 5)

  8. Labs on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 (2 of 5)

  9. Labs on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 (3 of 5)

  10. Labs on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 (4 of 5)

  11. Labs on Plavix 75, Pravachol 40, Zetia 10, Metformin 500 and Vitamin D3 1000 (5 of 5)

  12. NMR LipoProfile Insert NMR Lipoprofile 040611 SR49 Insert

  13. NMR Interpretation When LDL-C and LDL–P are discordant, risk tracks with LDL-P.

  14. Questions to Consider Question 1 Question 2 Question 3 Question 4

  15. Initial Treatment & Management Currently taking Plavix, metoprolol, and HCTZ for CAD and HTN. Continue therapy. Monitor BP with a home BP meter. Goal is to be below <120/80. For familial combined hyperlipidemia, stop Pravachol and Zetia. Start Crestor 20 mg/day and Niaspan 1000 mg/day to lower LDL-P and triglycerides. Niaspan will also help raise HDL and lower Lp(a). Currently taking metformin 500 mg/day. Increase to 1500-2000 mg/day for diabetes and lipid benefit. Metformin will also help lower Lp(a). Start Lovaza 4 g/day to help lower triglycerides, CRP and for the antithrombotic benefits. Increase vitamin D3 to 2000 IU/day for vitamin D deficiency.

  16. Discussion (1 of 9) Risk Factors: Heart Disease, Elevated Lp(a), Apo E3E4 Assessment: CAD and HTN

  17. Discussion (2 of 9) Assessment: Familial Combined Hyperlipidemia

  18. Discussion (3 of 9) Assessment: Metabolic Syndrome / Diabetes Type 2

  19. Discussion (4 of 9) Assessment: Elevated Lipoprotein(a)

  20. Discussion (5 of 9) Assessment: Elevated CRP

  21. Discussion (6 of 9) Assessment: Vitamin D Deficiency

  22. Discussion (7 of 9) Assessment: Apo E3E4 Genotype

  23. Discussion (8 of 9) Assessment: Platelet Genetic Testing – Abnormal CYP2C19

  24. Discussion (9 of 9) Assessment: Myalgias

  25. 2 Month Follow Up on Plavix 75, Crestor 10, Niaspan 1000, Metformin 2000 and Vitamin D3 2000 (1 of 3) • CAD and HTN – Unchanged. • Currently taking Plavix 75. • Recommended Lovaza 4 last visit, but not started due to cost. Lovaza is preferred over OTC omega 3 fish oil as it has antithrombotic benefits and reduces for risk of sudden death by 45% as seen in GISSI trial. Also, Lovaza is the only omega 3 prescription that is FDA regulated. An alternative is Carlson Liquid Fish Oil. Fish oil can increase bleeding time, so monitor for any issues. • Recommend switching from Plavix to Effient due to abnormal CYP2C19. • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 10, Niaspan 1000 and metformin 2000. Crestor was reduced to 10 from 20 for better tolerability. • LDL-P lowered from 1485 to 510. Small LDL-P reduced to from 1000 to 245. LDL-C dropped from 55 to 40. Total cholesterol lowered from 133 to 107. HDL increased from 38 to 47. Triglycerides lowered from 285 to 101. Excellent response. • Increase Niaspan to 2000 mg/day. Continue therapy.

  26. 2 Month Follow Up on Plavix 75, Crestor 10, Niaspan 1000, Metformin 2000 and Vitamin D3 2000 (2 of 3) • Metabolic Syndrome / Diabetes Type 2 – Improved. • Currently taking metformin 2000. • IR score lowered to 48 from 67. HbA1c increased from 6.1 to 6.4. It’s likely this increase is due to starting Niaspan and is of no clinical significance (ADMIT/ADVENT trials). • Continue therapy. • Elevated Lp(a) – Unchanged. • Not tested today. • Currently taking Niaspan 1000. Increasing dose to 2000 mg/day. Lp(a) can be lowered with niacin therapy. • Elevated CRP – Improved. • Currently taking metformin 2000. Recommended to start Lovaza 4 last visit but not started due to cost. • CRP lowered from 26 to 3. • Reassuring that LpPLA2 and MPO are normal.

  27. 2 Month Follow Up on Plavix 75, Crestor 10, Niaspan 1000, Metformin 2000 and Vitamin D3 2000 (3 of 3) • Vitamin D Deficiency – Improved. • Currently taking vitamin D3 2000 IU/day. • Levels increased from 41 to 58. • Continue supplements. • Myalgias – Improved.

  28. 2 Month Follow Up Labs on Plavix 75, Crestor 10, Niaspan 1000, Metformin 2000 and Vitamin D3 2000

  29. NMR LipoProfile Insert NMR Lipoprofile 062111 SR49 Insert Page 1 Insert NMR Lipoprofile 062111 SR49 Insert Page 2

  30. 8 Month Follow Up on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (1 of 2) • CAD and HTN – Unchanged. • Recently stopped Plavix and switched to Effient 10. • Currently taking Lovaza 4. • Continue therapy. • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 10, Niaspan 2000, metformin 2000 and Lovaza 4. • LDL-P and small LDL-P are optimal at 639 and 367. LDL-C is normal and lowered from 40 to 37. Total cholesterol is normal at 120. HDL increased from 47 to 57. Triglycerides decreased to 98 from 101. • Continue therapy.

  31. 8 Month Follow Up on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (2 of 2) • Metabolic Syndrome / Diabetes Type 2 – Improved. • Currently taking metformin 2000. • IR score lowered to 15 from 48. HbA1c lowered from 6.4 to 6.0. • Continue therapy. • Elevated Lp(a) – Unchanged. • Not tested today. • Currently taking Niaspan 2000. Lp(a) can be lowered with niacin therapy. • Elevated CRP – Improved. • Currently taking metformin 2000 and Lovaza 4. • CRP is normal at 1.2. • Vitamin D Deficiency – Deteriorated. • Currently taking vitamin D3 2000 IU/day. • Levels decreased from 58 to 39. • Increase vitamin D3 to 4000 IU/day.

  32. 8 Month Follow Up Labs on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (1 of 4)

  33. 8 Month Follow Up Labs on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (2 of 4)

  34. 8 Month Follow Up Labs on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (3 of 4)

  35. 8 Month Follow Up Labs on Effient 10, Crestor 10, Niaspan 2000, Metformin 2000, Lovaza 4 and Vitamin D3 2000 (4 of 4)

  36. NMR LipoProfile Insert NMR Lipoprofile 011212 SR49 Insert

  37. Clinical Pearls Niacin in any form has potential to transiently increase insulin resistance but no long term effects seen in clinical trials. When LDL-C and LDL –P are discordant, risk tracks with LDL-P. (See MESA data slide) When patients have residual risk based on elevated LDL–P and are already on combination drug therapy (Pravachol and Zetia), options are to add therapy or to simply change to more potent statin. Crestor is most potent for LDL-P reduction. With evidence of insulin resistance on NMR could titrate to higher dose of metformin and adjust diet further. A lower dose statin in combination with medications like Niaspan will be very efficacious at getting patients to goal when higher dose statin is not tolerated. Combination therapy is more effective than monotherapy for LDL-P reduction.

  38. LDL-P and LDL-C DiscordanceMulti-Ethnic Study of Atherosclerosis (MESA) Otvos JD et al. J ClinLipidol. 2011 Mar-Apr 5(2):105-13.

  39. Case Summary

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