Hypertension & Hyperlipidemia inquiry

Medical Q&A [Moderated]
1

Good morning,

I am a 33 y/o male of Asian-pacific islander heritage, non-smoker, occasional ETOH use (x1 8oz glass of wine/week) active duty military member with concerns for hypertension and dyslipidemia. My lipid panel from August 2017 displayed the following results:

Triglycerides- 67 mg/dl
HDL- 67mg/dl
Cholesterol- 327 mg/dl
LDL direct- 247 mg/dl

LFTs normal (sorry don’t have the numbers)

This was following 8 months on a ketogenic diet for the purported cognitive benefits with approximately 70% of my daily intake coming from some form of saturated fats, with roughly 2200-2500 calories total daily based on my activity level for the day. Within the past year, I have become more liberal with my intake, no longer track my macros daily, though still very conscientious of what I eat (rarely eat out, do most of my cooking at home with single ingredient type-food choices) and try to time my carbohydrate intake with work outs. After visiting with my PCM following the above results, she immediately recommended Simavastatin 80mg, to which I declined opting to attempt some form of dietary modification. My most recent lipid panel as well as an Hgb a1c completed in October 2018 displayed the following results:

Hgb a1c- 5.4

Cholesterol- 288
HDL- 72
LDL- 204
Triglyceride- 59

Over the past week, I’ve begun routinely monitoring my blood pressure (morning, noon, and just before going to bed) in preparation for my next PCM visit and my average is 127/65.

I consider myself a pretty active individual, regularly maxing my Army Physical Fitness Test, though only recently diving into strength training with NLP. Prior to this I was an avid runner/rock climber and grew up swimming competitively. Currently I am 6’, 190lbs, 13% body fat, 32 inch waist for what it’s worth.

Family history includes father with HTN & HLD, mother has no comorbidities, paternal grandmother: CAD, DM II, HLD, CHF, CKD, HTN.

The only medications I take routinely are an omega-3 supplement and multivitamin, with occasional Zyrtec for seasonal allergies.

Should I be concerned with the above data? Is a statin at that dose warranted with more recent lab data? Would further diagnostics such as calcium scoring and/or CRP be of any utility (would it change the plan of care)? Any guidance would be greatly appreciated. Thank you for all you do, I find your podcasts entertaining and informative. They make my daily commute to work much more enjoyable.

2

Hey! Welcome to the forum.

Yes, your old lipid panel was quite concerning, particularly the non-HDL-C of 260. This appears to have improved significantly to 216, though this is still substantially above the usual non-HDL-C goal of <130. Most of the current CVD risk calculators (like the pooled cohort equation) are applicable starting at age 40 – so we technically can’t use those to forecast your risk. However, an LDL-C > 190 is automatically considered to be a higher risk situation, particularly when you consider that your vascular system would be exposed to that concentration in a cumulative fashion over the next 40-50 years, assuming a normal life expectancy.

It sounds like you’ve made some improvements by getting off the ketogenic-style diet. Remaining nutritional factors would be to increase the proportion of dietary fiber intake to above 30-35 grams per day, and to shift the composition of your typical dietary fat intake towards unsaturated sources (e.g., olive oil, nuts, avocado, etc).

If this produces further improvements in your lipid panel, that’d be great. However, if your non-HDL-C remains in a high risk range despite all your efforts, I’d wonder if there are some genetic predispositions at play here. A minority of individuals are particularly sensitive to dietary fats and cholesterol (termed “hyper-absorbers”) and may see benefit from further reduction in dietary lipid intakes, though this certainly doesn’t work for everyone. And if it were me at that point - I’d probably use a form of lipid-lowering therapy (e.g. statin with or without ezetimibe, as needed to reach goal targets).

I will say that I strongly disagree with the idea to use Simvastatin 80 mg – and don’t recommend anyone be on this dose of simvastatin, ever, given the alternative statin options we have nowadays. Starting with something like atorvastatin 10-20 mg and monitoring the response would be perfectly reasonable at first. hs-CRP or CAC score should not be used routinely, but may be helpful in patients whose risk estimate is near a threshold to initiate preventive therapy. For example, if you had a CAC score of zero, it would be reasonable to not use lipid-lowering therapy until another re-assessment down the road.

It sounds like you have most of the other modifiable risk factors under control (no obesity, diabetes, or smoking). Your b mood pressure is mildly elevated but not in the hypertensive range that would merit medication therapy, and your lifestyle habits sound pretty good as well.

Hope this helps.

3

Thank you helpful information.

4

Thank you for the helpful information. If statin therapy is still warranted despite improvements with increased dietary fiber and unsaturated fat, what effect, if any, will this have on training volume or intensity with the doses proposed (I am aware of the possibility of myalgias)? What would be a good timeline as far as a follow up lipid panel following further dietary modification and/or initiating medications?

5

I would not assume this will have any effect at all. In fact, having the knowledge regarding myalgias and any other expectations you may have pertaining to the medication increase the chances that you’ll experience adverse effects, compared to not knowing / not worrying about such things.