ASCVD Risk Reduction in a Patient with Familial Hypercholesterolemia

A 39-year-old female presents to the clinic for a follow-up management of hypercholesterolemia.

Past medical history: type 2 diabetes, hypertension

  • No known history of heart disease

Family history:
Mother living with suspected Heterozygous Familial Hypercholesterolemia (not confirmed with genetic testing), myocardial infarction at 43
Father living with type 2 diabetes

Current Medications:
Atorvastatin 80 mg by mouth daily
Ezetimibe 10 mg by mouth daily
Metformin 500 mg by mouth twice daily
Lisinopril 20 mg by mouth daily
Hydrochlorothiazide 12.5 mg by mouth daily

Physical exam:
No visible signs of xanthomas, tendon xanthomas, xanthelasmas, or corneal arcus

BP: 119/77 mm Hg HR: 75 bpm Weight: 64 kg BMI: 24 kg/m2

A1c: 6.1%, TSH: 3.3 mIU/L, Scr: 0.9 mg/dL, GFR: >60 mL/min/1.73 m2, P:C: 0.1 mg/mg, albumin: 4g/dL AST: 30 U/L ALT: 25 U/L, Alk Phos: 90 U/L, Billirubin:0.5mg/dL

9 months ago 370 304 50 320 79 not calculated, since the patient has severe hypercholesterolemia (LDL-C ≥190 mg/dL) at baseline
Today 187 113 57 130 85
TC: total cholesterol, LDL: low-density lipoproteins, HDL: high-density lipoproteins, non-HDL: total cholesterol minus high-density lipoproteins, ASCVD: atherosclerotic cardiovascular disease

The patient reports good adherence to medical therapy and appropriate lifestyle habits.

During today's visit, the patient's labs were assessed, and secondary causes of hypercholesterolemia were ruled out. The patient's Dutch Lipid Score is 6 points (probable FH) and there is concern for residual cardiovascular risk. She is willing to take additional therapy to lower her LDL-C and ASCVD risk.

To reduce her residual cardiovascular risk, which of the following choices is most appropriate based on the ACC/AHA Guidelines?

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