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A 66 year old female college professor is seen in your office after undergoing an ‘executive physical’ which included an EKG, GXT, and coronary calcium score. She is asymptomatic, exercises regularly, and is a lifelong non-smoker. She has well-controlled hypertension and takes Losartan/HCTZ 100/25mg daily. Her coronary calcium score is 843 with diffuse distribution of calcification. GXT was normal at a high achieved workload. Weight is 73 kg. BP 130/74. Fasting glucose is 99.

She has been told she has high cholesterol dating back to her 50s. Currently on therapy her total cholesterol is 254, HDL 51, LDL 171, triglycerides 160. Both of her parents had "borderline” cholesterol. She has no siblings. She eats a mostly plant-based diet with occasional ‘indulgences’. Ethanol use is modest: 2-3 glasses of red wine per week. She typically spends 2 months every year on remote field research trips with her students.

She has been on bile acid sequestrants, niacin, ezetimibe, and several statins. She is currently on only simvastatin 40mg every other day. She has had significant myalgias with daily dosing of numerous statins and good relief with drug holidays. Her current regimen is tolerable and she has minimal myalgias. She experiences cramps and diarrhea with ezetimibe.

She is naturally concerned about the elevated coronary calcium score and wishes to know how she can get her lipids to goal. She is willing to make more improvements to her diet and to step up her exercise regimen.

Does her elevated coronary calcium score change your goals for treating this patient’s lipids?

Besides lipid-lowering therapies, what other interventions are appropriate?

What is the next step in bringing her closer to her target LDL level?