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54 Year Old Male with Peripheral Vascular Disease and Elevated Lipoprotein (a)

54 Year Old Male with Peripheral Vascular Disease and Elevated Lipoprotein (a). Case Category: Primary Prevention

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54 Year Old Male with Peripheral Vascular Disease and Elevated Lipoprotein (a)

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  1. 54 Year Old Male with Peripheral Vascular Disease and Elevated Lipoprotein (a) Case Category: Primary Prevention History of present illness: 54 year old male with PVD on post trauma x-ray based on extensive calcium in arteries. No prior CAD, no history of symptoms, no history of dyslipidemia, and recent abnormal lipoprotein (a). Interested in recommendations for primary prevention. 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

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Labs Worth Noting on Vitamin D3 2000 and Omega 3 Fatty Acids 2400

  6. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (1 of 7)

  7. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (2 of 7)

  8. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (3 of 7)

  9. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (4 of 7)

  10. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (5 of 7)

  11. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (6 of 7)

  12. Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400 (7 of 7)

  13. Other Labs on Vitamin D3 2000 and Omega 3 Fatty Acids 2400

  14. Initial Treatment & Management • Start Niaspan 500 mg/day to lower Lp(a) and LDL-P. Take 325 mg noncoated aspirin before meal and Niaspan after meal to avoid flushing side effects. Increase to 1000 mg/day if tolerating. • Continue taking vitamin D3 2000 IU/day for low vitamin D level. • Recommend Carotid Intima Media Thickness testing to identify increased thickening in the artery walls which suggests early plaque formation.

  15. Discussion (1 of 2)

  16. Discussion (2 of 2)

  17. 2 Month Follow-Up • Elevated lipoprotein(a) – Improved. • Started Niaspan 1000 mg/day. • In just 2 months, Lp(a) lowered to 59 from 79, Lp(a) cholesterol lowered from 13 to 9. • Tolerating Niaspan. • Dyslipidemia – Improved. • In just 2 months on Niaspan, LDL-P is now 759 compared to 1415. Total cholesterol reduced from 192 to 161. LDL-C down from 101 to 74. Non-HDL-C down to 96 from 127. Apo B lowered to 64 from 84. HDL stable at 65, and may increase. • Inflammatory markers are normal (MRO, LpPLA2, CRP). • Vitamin D Deficiency – Improved. • Levels are up to 70 from 48. • Continue supplementation. • Omega 3 Index – New. • Omega 3 level is low at 5%. • Currently taking 2400 mg fish oil. Increase fish oil or increase fish consumption.

  18. Follow Up Labs on Niaspan 1000 (1 of 3)

  19. Follow Up Labs on Niaspan 1000 (2 of 3)

  20. Follow Up Labs on Niaspan (3 of 3)

  21. NMR LipoProfile • Insert NMR Lipoprofile 07252011 AM56 Insert

  22. Clinical Pearls – Niaspan as Monotherapy • Niaspan is a very effective LDL–Particle (LDL-P) lowering agent as well as one of the only therapies that lowers lipoprotein (a). It can be used as monotherapy in cases such as this one or women of child bearing age as an agent to lower LDL. It is also a great option for statin intolerant patients with or without bile acid sequestrate. • Niaspan’s effect on lipoproteins is to lower LDL-P, which is does more than any effect on LDL–Cholesterol. It is possible that these other benefits of Niaspan are what ultimately provide cardiovascular benefit versus HDL cholesterol raising which is what is traditionally associated with Niaspan therapy. HDL cholesterol increases due to increase in size of HDL particles however Niaspan (nicotinic acid) does not actually increase the HDL Particle number as measured by NMR.

  23. Case Summary Note: At 6 month follow-up, treatment providing maintained benefit.

  24. References • Nordestgaard B, Chapman M, Ray K, et al. Lipoprotein(a) as a cardiovascular risk factor: current status. European Heart Journal. doi:10.1093/eurheartj/ehq386. • Marcovina SM, Kennedy H, Bittolo Bon G, et al. Fish intake, independent of apo(a) size, accounts for lower plasma lipoprotein(a) levels in Bantu fishermen of Tanzania: The Lugalawa Study. ArteriosclerThrombVascBiol, May;19(5):1250–6. • Cromwell WC, Otvos JD, Keyes MJ, et al. LDL particle number and risk of future cardiovascular disease in the Framingham offspring study – implications for LDL management. J ClinLipidol2007 Dec;1(6):583-92. • Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. Jul 13 2004;110(2):227-39. • OtvosJD. The surprising AIM-HIGH results are not surprising when viewed through a particle lens. J ClinLipidol. 2011 Sep;5(5):368-70. • Jafri H, Alsheikh-Ali AA, Mooney P, et al. Extended-release niacin reduces LDL particle number without changing total LDL cholesterol in patients with stable CAD. J ClinLipidol. 2009;3:45-50. • Airan-Javia SL, Wolf RL, Wolfe ML, et al. Atheroprotective lipoprotein effects of a niacin-simvastatin combination compared to low- and high-dose simvastatin monotherapy. Am Heart J. 2009;157:687-688.

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