A Middle-Aged Woman With Hyperlipidemia, Subclinical Atherosclerosis, and Statin Intolerance

A 53-year-old woman is referred for management of elevated cholesterol. She has a history of obesity, hypertension, and dyslipidemia. She reports a strong family of premature coronary artery disease with both her mother and father suffering myocardial infarctions in their 50s. A calcium score performed prior to this visit showed coronary artery calcium in the proximal left anterior descending with a total Agatston score of 49 (Figure 1). This placed her in the 93rd percentile for her age, race, and gender.

Figure 1: Axial slice from coronary artery calcium CT scan shows area of calcification in the proximal LAD (arrow)   
Figure 1: Axial slice from coronary artery calcium CT scan shows area of calcification in the proximal LAD (arrow)
Her medications include aspirin 81 mg daily and hydrochlorothiazide 25 mg daily. Her physical exam is notable for a body mass index (BMI) of 33 kg/m2, but is otherwise unremarkable. Her blood pressure is 128/88 mm Hg.

Her hemoglobin A1c is 6.2%.

A recent lipid panel shows:

  • TC: 253 mg/dL
  • High-Density Lipoprotein Cholesterol (HDL-C): 51 mg/dL
  • Trig: 150 mg/dL
  • Friedewald-Estimated Low-Density Lipoprotein Cholesterol (LDL-C): 172 mg/dL
  • Non-HDL-C: 202 mg/dL

LDL particle concentration: 3,086 nmol/L (reference lab standard for very high >2,000 nmol/L)

Her estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 3.1% by the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Pooled Cohort Equations.

Coronary artery calcium score: Total Agatston Score 49 located in the LAD (93rd percentile for age, race, and gender)

She was advised to lose weight and referred to a weight loss counselor. She also started rosuvastatin 20 mg daily, but developed aching in her thighs and discontinued the medication with resolution of her aches. She then started atorvastatin 40 mg daily, but again developed aching in her thighs. Similar aches occurred on a red yeast rice/CoQ10 combination and intermittent dosing of simvastatin 20 mg weekly. Her creatine kinase levels were never elevated during her episodes of thigh pain.

She does not wish to try any more statin therapies. Which of the following lipid-lowering agents would be most consistent with the 2013 guideline on the treatment of blood cholesterol?

Show Answer