Case Studies in the Management of Hyperlipidemia Case #1 Case ...

Case Studies in the Managementof HyperlipidemiaDaniel E. Wise MD, FACC, FNLACardiology Specialists of theCarolinas PACase #1• 53 year old male who presents for preventionevaluation for coronary artery disease due to the factthat his closest friend recently died of sudden deathand was found to have severe CAD at autopsy.• He has no symptoms of CP or DOE.• PMH: positive for hypothyroidism• FH: Adopted• SH: History of smoking for 20 years at a PPD, quitat age 38, eats reasonably well but does eat out a lotand has fast food 4-5 times per week, exercisesregularly, jogging 20+ miles per weekCase #1• PE: BP 138/88, P 68 and regular, Weight 210,Height 70 inches, otherwise unremarkable• Medications: Multivitamin and Synthroid 50 mcgdaily• Baseline Labs: TSH 3.801, Free T4 1.1, FBS 109,TC 219, HDL-C 41, LDL-C 124, TG 270, UricAcid 7.9, Urine analysis unremarkableWhat Information Would HelpYou Assess Risk MostA. Nuclear Stress TestB. Advanced Lipid TestingC. Cardiac Calcium ScoringD. Carotid IMTWhat Lifestyle Therapy WouldYou Have Him AdoptA. Mediterranean DietB. Dash DietC. Adkins DietD. AHA Step II DietGoals of TherapyA. LDL < 70 mg/dLB. Non-HDL Cholesterol < 100mg/dLC. Apo B 100 < 80 mg/dLD. LDL-P 40 mg/dL ?

What Therapeutic ApproachWould You Start WithA. Rosuvastatin 20 mg dailyB. Atorvastatin 40 mg and Fenofibrate 160 mgDailyC. Simvastatin 40 mg and Niaspan 1000 mgDailyD. Rosuvastatin 20 mg and Omega-3 Fish Oil4 g DailyFollow-Up Labs at 3 MonthsA. FBS 118B. TC 156, HDL-C 49, LDL-C 79,TG 140C. TSH 4.020, Free T4D. Uric Acid 9.1What Therapeutic Approach isNextA. Increase Simvastatin to 80 mg andNiaspan to 2000 mg dailyB. Add Zetia 10 mg dailyC. Add WelChol 6 tablets dailyD. Switch to Rosuvastatin 40 mg andadd Omega-3 fish oil 4 g dailyCase #2• 55 Year old female who has a strong family historyof coronary artery disease and Diabetes Mellitus buthas no known disease herself. She denies anycardiovascular symptoms. She went throughmenopause at 49 and has been on HRT since.• PMH: History of elevated BS not treated, elevatedcholesterol not treated• FH: Father died sudden death at 46, brother 48 s/pPTCA and stent, sister 52 with DM andHyperlipidemiaCase #2• SH: Smokes ½ PPD, 1-3 beers per day, noexercise, diet high in meat, fat, sugar and salt• Medications: Prempro 0.45/1.5 mg daily andmultivitamin daily• PE: BP 148/96, P 78, Weight 224, Height 64inches, Fundi show mild arteriolar narrowingand increased light reflex, soft right carotidbruit, Gr 3/6 harsh SEM at the LLSB thatradiates to the base, S4, bilateral decreaseddistal pulsesCase #2• Baseline Labs: FBS 136, TSH 5.208, Cr 1.3,BUN 26, Uric Acid 9.1, TC 256, HDL-C 36,TG 564

What is 1 st PriorityA. Assess subclinical diseaseB. Lower TriglyceridesC. Lower Non-HDL-C to < 100 mg/dLD. Work hard on Therapeutic LifestyleTherapy to Modify Overall RiskProfileWhat Test Would You Like NextA. Repeat Thyroid StudiesB. Carotid U/SC. Nuclear Stress TestD. Cardiac Calcium ScoreWhat Non-PharmacologicIntervention Would You Start With ?A. Smoking CessationB. Stop AlcoholC. Mediterranean /Dash DietD. All Of The AboveGoals of TherapyA. Reduce TG < 250 mg/dLB. Control BP < 130/80 ?C. Control BS, Reduce Hgb A1c < 6.5 ?D. TSH 1-2 mcIU/dLE. Non-HDL < 100 mg/dLWhat Therapeutic ApproachWould You Start WithA. Atorvastatin 40 mg and Fenofibrate160 mg dailyB. Rosuvastatin 20 mg and Omega-3 fishoil 4 g dailyC. Synthroid 50 mcg, Metformin XR1000 mg, Simvastatin 20 mg dailyD. Synthroid 50 mcg, Atorvastatin 10 mg,Fenofibrate 160 mg dailySix Weeks Later Returns To TheOffice With New SymptomsA. Myalgias and Nocturnal Leg CrampsB. NightmaresC. Hair LossD. Weight Gain of 8 PoundsE. Labs: FBS 142, TSH 4.106, TC 182,HDL-C 39, LDL-C 70, TG 365, Non-HDL-C 143

Goals of TherapyA. LDL < 70 mg/dLB. Non-HDL Cholesterol < 100mg/dLC. Apo B 100 < 80 mg/dLD. LDL-P 40 mg/dL ?What Is The Next Step??A. Increase SynthroidB. Stop StatinsC. Switch to a different StatinD. Switch Fenofibrate to Omega-3 fishoil 4 g dailyE. Change A, C and D