Case #344: Primary Prevention

I first saw “Angela” when she came to our practice in May 2008 requesting a physical exam. Her father had type 2 diabetes and suffered from strokes. Her mom has hypertension and her brother underwent three-vessel CABG at age 57. Angela, now 50, is a non-smoker, vegetarian, married more than 20 years, very active, has two teens at home and works in the airline industry.

She has a history of anemia and some fatigue and had dermatitis at the time. Otherwise, she is an apparently healthy and active 48-year-old female.

• BP = 102/70
• BMI = 19
• Heart rate = 76

Her SLP on no meds revealed LDLc = 60, HDLc = 85, TG = 52 and TC = 155. Fasting glucose was 80 and her CBC and CMP were both normal. TSH was elevated at 5.844 uIU/ml and ferritin was in the low range (16ng/ml), so she was started on an OTC iron supplement 1-2x/day with vitamin C for better absorption.

Angela was feeling better when I saw her again in November 2008. Her repeat TSH was 2.788 (no meds), T4 was in the normal range at 1.04 ng/dl and T3 was in the normal range at 2.7 pg/ml. Ferritin levels were up to 24 on supplements.

She returned for a complete physical in January 2010, her thyroid was normal and her iron levels were excellent at 54 ng/ml. Her CPE was normal, and she was given the DTaP immunization. Her mammogram and pap test were normal. Angela also told me that her dad had recently passed away at age 72 after suffering another stroke. We ordered a CUS/CIMT, the VAP advanced lipid profile and additional labs.

After her first VAP and CUS/CIMT in March 2010, we started Angela on simvastatin/nicotinic acid combo. March labs also revealed that vitamin D was low at 24, so we started her on 2000 iu/day for life (OTC). Vitamin D deficiency has been associated with an increased risk of coronary artery disease (CAD). At her July 2010 checkup, Angela’s BMD results indicated significant osteoporosis, and we initiated bisphosphonates or selective estrogen receptor modulators (SERMs) and increased her ca/mg/d.

Her March 2010 VAP general lipid numbers overall looked good, but we were worried due to her family history and the elevated Lp(a)-c and elevated VLDL3 remnant numbers. We ordered a CUS/CIMT and results showed a mean CIMT of 0.656 mm and an arterial age of 57 (compared to her actual 2010 age of 50). Her right bulb showed 1.6 mm soft plaque, the left bulb measurement revealed 1.5 mm soft plaque and 1.2 mm calcifying heterogeneous plaque. Recall again that she is a healthy and active nonsmoker.

Labs – Click here to view Angela’s March 2010 VAP Test results, July 2010 VAP Test results and appropriate reference ranges from Atherotech

Lab Results

Angela has made very healthy lifestyle choices her entire life. Her family history and some of her comprehensive lipids, however, were cause for concern. Angela’s March 2010 VAP showing high VLDL3 and high Lp(a)-c combined with a family history of atherosclerosis had me concerned. Her imaging studies confirm her athero risk. HDL is very dynamic, in this case it is quite high, but combined with imaging and family history it appears to be poorly functional or unable to combat her NHDL and high Lp(a)-c and remnant VLDL3. We know that if patients’ HDL is high but they have an event or plaque on imaging, then something isn’t working to clear out the bad cholesterol — known as NHDL and ApoB — from their arteries. These concerns prompted me to start Angela on the simvastatin/nicotinic acid combo therapy.

The patient’s July 2010 labs showed improvement in several numbers, including NHDL, ApoB, LDL, TC, TG, Lp(a)-c and remnant VLDL. The rest of her checkup included a mammogram (normal), pap (normal) and DEXA. We ordered repeat labs in three to six months, a repeat CUS/CIMT in 12 months and another DEXA in 12 months.

Discussion

Angela is a good example of a primary prevention case where appropriate lipid and imaging testing can help me find the patient before the catastrophe. I like to use imaging to find out WHO has disease, especially in patients with family histories of CAD/CVD or people with NCEP risk factors for CAD/CVD; I like advanced lipid and inflammatory testing to find out WHY they have disease. In our practice, we find that imaging tests such as the CAC and CUS/CIMT can actually motivate the patient to be more adherent to lifestyle changes as well as medications to reach goals. VAP UC lipid testing helps me define the pathophysiology of lipid disease and WHAT to target from lifestyle and medication management. Thus, we have the WHO, WHY and WHAT of risk management in this case.

Although Angela is primary prevention, her situation is actually very similar to many of my secondary prevention patients who are on statins. When we draw their VAPs, we almost always find they have residual lipid risks as well, including:

1. Small dense LDL

2. Small dense HDL

3. High Lp(a)

4. High TG remnants (VLDL3/IDL)

5. ApoB, NHDL discordance

In the Patient’s Terms

Bad family history combined with abnormal comprehensive lipids rarely will overcome having a great lifestyle. While lifestyle choices are extremely important for preventing risk and minimizing events, it is also important to gather as much information as possible when trying to prevent the No. 1 killer in America and the world. In our practice, we find combining good lifestyle choices with appropriate screening tests can help us identify people who will need more progressive risk management. Such testing helps motivate myself and my patients for appropriate short- and long-term care needs. After all, preventing the heart attack, the stroke or the stent/bypass is our primary goal.

Abbreviations

BMD = Bone Mineral Density

BMI = Body Mass Index

ca/mg/d = Calcium, Magnesium, Vitamin D

CABG = Coronary Artery Bypass Grafting

CAC = Coronary Artery Calcium Score

CAD/CVD = Coronary Artery Disease/CardioVascular Disease

CBC = Complete Blood Count

CMP = Comprehensive Metabolic Panel

CPE = Complete Physical Exam

CUS/CIMT = Carotid Ultrasound/Carotid Intimal Medial Thickness

DEXA = Dual-Energy X-ray Absorptiometry

DTaP = Diphtheria, Tetanus, and Pertussis vaccine

NCEP = National Cholesterol Education Program

OTC = Over The Counter

SLP = Simple or Standard Lipid Panel/Profile

T4 = Thyroid function test usually ordered with TSH

TSH = Thyroid-Stimulating Hormone

VAP = Vertical Auto Profile