Familial Hypercholesterolemia: The Difficult to Manage Patient
A 60-year-old asymptomatic, diabetic, overweight woman with Familial Hypercholesterolemia (FH) has been under my care for one year. LDL-C levels have ranged between 250 and 300 mg/dL. She has had side effects (myalgias, headaches, and fatigue) from six of the seven statins. Vitamin D has been repleted and CoQ10 has been tried. Dietary changes, weight loss, and daily exercise have had an inconsequential impact on her lipids.Past Medical History:
- Small Inferior Myocardial Infarction at age 50.
- Coronary artery bypass grafting at age 53.
- Stents to the saphenous vein graft to the right coronary artery and native left circumflex coronary artery at age 57 and 59 respectively.
- Non-valvular Paroxysmal Atrial Fibrillation
- ECHO documentation of moderate valvular and mild supravalvular Aortic Stenosis1
- Vitamin D
- Eicosapentaenoic acid and docosahexaenoic acid
- BP 125/78 mm Hg
- HR 58 BPM
- BMI 30.02 Kg/m2
- Waist circumference at the top of the iliac crest at end-expiration 37"
- 2/6 crescendo-decrescendo systolic murmur
- Bilateral carotid bruits
- Intact peripheral pulses
- Corneal arcus (present by history since age 20)
- Small bilateral Achilles tendon xanthomas
- Total cholesterol 350 mg/dL
- LDL-C 265 mg/dL
- HDL-C 45 mg/dL
- TG 200 mg/dL
ECG: Normal sinus rhythm with old IMI. Borderline LVH.
What are her current treatment options?