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50 Year Old Male with Family History of Heart Disease and History of High Triglycerides

50 Year Old Male with Family History of Heart Disease and History of High Triglycerides. Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia

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50 Year Old Male with Family History of Heart Disease and History of High Triglycerides

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  1. 50 Year Old Male with Family History of Heart Disease and History of High Triglycerides 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, Metabolic Syndrome, Low HDL History of present illness: 50 year old male with family history of premature heart disease and history of high triglycerides. Poor tolerance to Lipitor in the past. He has undiagnosed vitamin D deficiency and abnormal thyroid tests. His blood pressure has recently been high and difficult to control with treatment.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Labs Worth Noting on Hypertension Medications

  6. Questions to Consider • Question 1 • Question 2 • Question 3 • Question 4

  7. Labs on Hypertension Medications (1 of 6)

  8. Labs on Hypertension Medications (2 of 6)

  9. Labs on Hypertension Medications (3 of 6)

  10. Labs on Hypertension Medications (4 of 6)

  11. Labs on Hypertension Medications (5 of 6)

  12. Labs on Hypertension Medications (6 of 6)

  13. NMR LipoProfile • Insert NMR Lipoprofile 083011 MF60 Insert

  14. Initial Treatment & Management • Advised to quit smoking to decrease inflammation and help improve lipid profile, specifically HDL. Low HDL is common in those who smoke. • Start Crestor 10 mg/day to lower LDL-P and raise HDL. • Start Lovaza 4 g/day to lower triglycerides and raise omega 3 index. • For metabolic syndrome, start Glumetza ER 1000 mg /day. For the first 2-3 days, take one tablet then increase to 2. • Advise using home blood pressure meter for hypertension. Follow-up with physician for renal artery stenosis. • Increasing exercise with help lower elevated CRP, as well as statin and Lovaza. • Start Synthroid mcg/day. Goal of therapy will be to reduce TSH to around 1.0. • Continue taking 50,000 IU/week of vitamin D2 for vitamin D deficiency. Start vitamin D3 5000 IU/day for 8-2 weeks. Take D3, not D2. Choose an oil based capsule rather than a tablet for better absorption.

  15. Discussion (1 of 6)

  16. Discussion (2 of 6)

  17. Discussion (3 of 6)

  18. Discussion (4 of 6)

  19. Discussion (5 of 6)

  20. Discussion (6 of 6)

  21. Follow Up on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (1 of 2) • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 10 and Lovaza 2 g/day (half the dose advised) due to GI side effects. Also taking flax seed. Only 10% of flax seed is converted to omega 3. • LDL-P lowered from 2223 to 1699. Total cholesterol dropped from 250 to 179. LDL-C reduced to 109 from 131. Triglycerides lowered from 618 to 188. HDL increased from 34 to 42. • Continue therapy. • Insulin Resistance Syndrome / Metabolic Syndrome – Improved. • Currently taking Glumetza 2000 mg/day. (Increased from 1000 to 2000 between visits) • HbA1c dropped from 6.2 to 5.9. • Weight has lowered from 290 to 277. • IR Score lowered from 87 to 73. Insulin has dropped from 151 to 16. • Continue therapy. • Hypertension – Deteriorated. • Blood pressure remains high (160/90). • Continue therapy. • Elevated Transaminases – Improved. • Levels are now normal. • No risks associated with current medications and the liver.

  22. Follow Up on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (2 of 2) • Elevated CRP – Improved. • Improvement with increased exercise and current treatment with Crestor 10 and Lovaza 2. • CRP reduced from 5.0 to 2.3. MPO lowered from 480 to 402. LpPLA2 also decreased to 149 from 171. • Increase exercise and continue therapy. • Hypothyroidism – Improved. • Currently taking Synthroid 50 mcg/day. • TSH lowered from 5.69 to 2.35. Great improvement. • Increase Synthroid to 75 mcg/day to further reduce TSH. • Vitamin D Deficiency – Improved. • Currently taking vitamin D3 5000 IU/day and vitamin D2 50,000 IU/week. • Vitamin D levels increased from 19 to 52. • Continue vitamin D3 5000 IU/day. • Low Omega 3 Index – Improved. • Currently taking Lovaza 2 g/day (half the dose advised) due to GI side effects. Also taking flax seed. Only 10% of flax seed is converted to omega 3. • Omega 3 index increased from 3.9 to 5.3. • Continue therapy.

  23. Clinical Pearls

  24. Case Summary

  25. Follow Up Labs on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (1 of 5)

  26. Follow Up Labs on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (2 of 5)

  27. Follow Up Labs on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (3 of 5)

  28. Follow Up Labs on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (4 of 5)

  29. Follow Up Labs on Crestor 10, Glumetza 2000, Lovaza 2, Synthroid 50 and Vitamin D3 5000 (5 of 5)

  30. NMR LipoProfile • Insert NMR Lipoprofile 083011 MF60 Insert

  31. References (1 of 3) Familial Combined Hyperlipidemia • Mora S, Szklo M, Otvos JD, et al. LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2007 May;192(1):211-7. • 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 ClinLipidol. 2007 Dec;1(6):583-92 • BrunzellJD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008 Apr;31(4):811-22. • Nicholls SJ, Ballantyne CM, Barter PJ, et al. Effect of two intensive statin regimens on progression of coronary disease. N Engl J Med. 2011 Dec 1;365(22):2078-87. • Talayero BG, Sacks FM. The role of triglycerides in atherosclerosis. CurrCardiol Rep. 2011 Dec;13(6):544-52. • Roth EM, Bays HE, Forker AD, et al. Prescription omega-3 fatty acid as an adjunct to fenofibrate therapy in hypertriglyceridemic subjects. J CardiovascPharmacol. Jul 10 2009. • Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet. 1999 Aug 7;354(9177):447-55. • Otvos JD, Mora S, Shalaurova I, et al. Clinical implications of discordance between low-density lipoprotein cholesterol and particle number. J ClinLipidol. 2011 Mar-Apr 5(2):105-13.

  32. References (2 of 3) Metabolic Syndrome • Rosenson RS, Otvos JD and Hsia J. Effects of rosuvastatin and atovastatin on LDL and HDL particle concentrations in patients with metabolic syndrome: a randomized, double-blind, controlled study. Diabetes Care. 2009 Jun;32(6):1087-91. • Orchard TJ, Temprosa M, Goldberg R, et al. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med. 2005 Apr 19;142(8):611-9. • ADA Standards of Medical Care in Diabetes - 2012. Diabetes Care. Jan 2012 35(1)11-63. • DeFronzo RA, Abdul-Ghani M. Assessment and treatment of cardiovascular risk in prediabetes: impaired glucose tolerance and impaired fasting glucose. Am J Cardiol. 2011 Aug 2;108(3 Suppl):3B-24B. • Goff DC Jr, D'Agostino RB Jr, Haffner SM. Insulin resistance and adiposity influence lipoprotein size and subclass concentrations. Results from the Insulin Resistance Atherosclerosis Study. Metabolism. 2005 Feb;54(2):264-70. Hypothyroidism • Taddei S, Caraccio N, Virdis A. et al. Impaired endothelium-dependent vasodilation in subclinical hypothyroidism: beneficial effect of levothyroxine therapy. J ClinEndocrinolMetab. 2003 Aug;88(8):3731-7.

  33. References (3 of 3) Vitamin D Deficiency • Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008;168(12):1340-1349. • Cannell J, Hollis B, Zasloff M, et al. Diagnosis and treatment of vitamin D deficiency. Pharmacotherapy. 2008;9(1):1-12. • Giovannucci E, Liu Y, Hollis B, Rimm E. 25-hydroxyvitamin d and risk of myocardial infarction in men. Arch Intern Med. 2008;168(11):1174-1180. • Holick M. Vitamin D Deficiency. N Engl J Med. 2007;357:266-81. • Michos E and Blumenthal R. Vitamin D Supplementation and Cardiovascular Disease Risk. Circulation. 2007;115(7):827-828. • Hathcock J, Shao A, Vieth R, et al. Risk assessment for vitamin D. Am J ClinNutr. 2007;85:6-18. • Jockers B. Vitamin D sufficiency: An approach to disease prevention. The American Journal for Nurse Practitioners. 2007;11(10):43-50. • Perez-Castrillon J, Vega G, Abad L, et al. Effects of atorvastatin on vitamin D levels in patients with acute ischemic heart disease. Am J Cardiol. 2007;99(7):903-4.

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