Discordance documented in Tubby Theory from Topeka patient data

Patients from my Lipid Clinic, Topeka,  Kansas 2009

I culled through the list of  approximately 200 patients from my Lipidology practice in Topeka in 2009.
My list of patients  link.

Look at patients 3 and 4.  I call these the Tim Russert group.
We know they have ASHD from the positive cardiac catheterizations
If advanced NMR Liposcience testing was not done we would have said,
as with Mr. Russert that the goal of less than LDLc of 70 was reached
 or close enough in 2009.
The discordance with LDLc and non-HDLc with LDLp tells us we need to get the LDLp below 750.
 I would add Zetia in patient three who was already on Crestor 5 mg and Enduracin 1,000 mg.
Check LDLp in one month and if not less than 750 I would double Crestor to 10 mg.
Patient four with LDLc 67 is extreme discordance with LDLp 1233. Not even close to goal of LDLp less than 750 with known ASHD on heart catheterization.
Patient already on simvastatin 40 mg (Zocor) and Zetia.  With LDLc 67 no one would add Enduracin 1,000 mg but LDLp 1233 demands it.  In a month if still not at goal I would switch to atorvastatin 40 mg and go up to 80 mg in a month if no side effects and not at goal.

Patient One :

Clearly this patient with a positive coronary cath. needs to start a low dose statin and be checked again.   Perhaps another physician believed a LDLc of 87 did not need to be treated even in a patient with plaque.  The LDLp 1313 shows discordance and should be treated with triple therapy (statin, enduracin and zetia) to LDLp less than 750.

Patient Two:
This patient has a high CAC at 220.  Again he was not started on treatment because the physician thought "why treat an LDLc of 87 in 2010.

Patient Five:

CAC 141.  LDLc 99, why put the patient on lipid lowering agents? Answer: discordance with LDLp 1242.  Patient has atherosclerosis.  We don't know if he has soft inflamed plaque that might break off a clot and cause sudden death  (100,000 deaths a year with death as first sign of disease)  In Patient five we already know he has plaque.  Definitely start low dose atorvastatin 10 mg and check LDLp in one month then consider adding Enduracin 1,000 mg and then Zetia if monthly advanced lipid testing dose not get LDLp down to at least less than 1,000.

Patient Six:

CAC 19.  Many would say not bad.  To me this is the tip of the iceberg of ASHD that has now been documented with positive CAC.  LDLc looks good at 78 on Zocor (simvastatin) 40 mg and Enduracin 1,000 mg. However I would like to get LDLp less than 750 by adding Zetia.

Patient Seven:

CAC Zero.  Perfect right?  The CIMT is at 50% tile for his age and sex which SHAPE task force says "is a positive test for atherosclerosis".  Again with LDLc 87 on Crestor  5mg why would anyone try to get LDLp less than 1,000? This patient had 3 out of 5 criteria for metabolic syndrome.  TG/HDLc was 82/44 after Crestor 5 mg.  I would at least add Enduracin 1,000 mg a day and check advanced lipid profile with Liposcience in one month.

Patient Eight:

CAC zero.  Great but again CIMT was 50% so a positive sign for atherosclerosis. LDLc 111 might lull a general practitioner to not give those "dangerous" statins.
However when I saw big discordance with the LDLp 2007 I knew I wanted to start triple therapy with first step generic atorvastatin (Lipitor).  Very inexpensive and at this dose very few side effects.  Important to check Vitamin D level before giving statin.  Next month add Enduracin 1,000 mg (a over the counter niacin which has a wax matrix pill and does not cause much flush, much cheaper than Zetia.  In a month if still not at goal of less than 1,000 LDLp I would add generic Ezetimibe (Zetia) I might start with just half a pill a day.
This triple therapy very inexpensive  and synergy with low doses very safe.



Patient Nine:

CAC 0.  LDLc 110 on no Lipid lowering drugs.  Okay right?  Until you see the discordance with LDLp at 1439 in a patient with CIMT at 50% tile.  Which SHAPE TASK FORCE say "is a positive sign for atherosclerosis".  Lipitor 10 is very inexpensive and at low dose is very safe.  See Multiplier Effect link.

Patient Ten: 

CAC 12.   LDLc 101 on Lipitor 40 mg (no generic back in 2009) and Zetia.  Again most Doctors in 2009 would have said good enough for government work.  LDLp was 1322,  I would add Enduracin 1,000 mg and try to get LDLp less than 1,000 in a patient with proven atherosclerosis. TG/HDLc ratio 169/52 in female with one criteria for metabolic syndrome(TG 169). Some would say she has positive ratio greater than 3.0 to be diagnosed with metabolic syndrome.  Definitely should add low dose niacin with OTC Enduracin.

Patient Eleven:

CAC Zero.  LDLc 94 on Crestor 5 mg.  All done?  No as there is discordance with LDLp of 1388.  I would like to add Enduracin 1,000 mg.  Her Tg/HDLc is 217/72.  Some would say this might be metabolic syndrome.  If not at LDLp goal in a month I would add Zeta.  Consider Lovaza 4 grams a day to help Niacin lower TG.  In 2018, I would get a 2 hour PP glucose with an Insulin level and start patient on Atkins or Low Carb High Fat diet.