How do you address managing lipid profile in keto diets?
Response: Avoid saturated fat, keep close track of apoB (or non-HDL-C)

How often do you start PCSK9 inhibitors for patients? Many times, when referring patients fo poorly controlled DLP despite max statin dose and ezetimibe, very rarely PCSK9 are added despite being recommended by the guidelines. Question of cost?
Response: Frequently. If they are above thresholds, I use them

CRP Vs Ultrasensitive CRP how de we interpret them differently ans use them for Dx
Response: hsCRP

Can you comment (broadly) on the costs of ordering an Lp(a) or an Apo-B compared to that of a standard NFLP?
Response: About 15$

Is it worth it to order ApoB over NonHDL (already on the lipid profile) or is there a specific clinetele that we would privilege to oreder the ApoB
Response: Definitely in overweight/central obesity/DM2/metSyn but useful in all

Where can get get the coronary CT scan? If we see calcification on the CT, do we need to start aspirin?
Response: Most clinics do them. No need for ECASA unless score is extremely high

Can Lipoproteine(a) change if measured at age 40 vs at age 70?
Response: Yes. It goes up in menopause

If we are advised to use Apo B as our preferred method of risk assessment instead of LDl then why do we still target treatment to ldl less than 1.8 ? Why not target treatment for Apo B levels less than ? Also why do labs have different upper limits of normal for Apo B levels ?
Response: apoB >0.7 is threshold in secondary prevention

Guideline overload! Recent PEER lipid guidelines (October 2023 CFP journal) have different recommendations (not testing Lpa, apo-B, not using a treat-to-target approach). How to navigate all of this, especially when receiving specialist reports that ask us to treat <1.8 LDL, etc...
Response: I think the goal of PEER is to simplify but that won’t necssarily lead to opitmal care. The data is clear with regards to more aggressive therapy

Is PCSK9 inhibitor covered by RAMQ for secondary prevention?
Response: Yes if above intensification thresholds and receiving statins + ezetimibe

Do you have recommendations as to what to do in patients with a low FRS but an exceedingly high lipoprotein a?
Response: Optimize all risk factors. Get apoB < 0.8 at minimum

What can be done for high Lp(a) if young ex 20 yrs old and very positive family history - other than lifestyle? Any therapy to reduce Lp(a)?
Response: Optimize all risk factors and get apoB < 0.8 at mimimum with statins. Lp(a) lowering therapy are in development

When ordering regular lipid profile and ApoB, can we only use Apo B cutoffs if this is the best marker, or should we be looking at all values Apo B, nonHDL, LDL?
Response: ApoB supersedes all the other info

In primary prevention do you treat to target LDL?
Response: If start statins, I try to get LDL-C < 2.0 or apoB < 0.8 or non-HDL-C < 2.6

Where do we refer and what is the typical wait time?
Response: Our clinic is at the new GCSM clinic at 5100 de Maisonneuve. Send to prevention clinic Fax 514-384-8134

Should you send pt to lipid clinic or genetics for genetic testing in familial dyslipidemia?
Response: You can send to our prevention clinic fax 514-384-8134

Can we drop the lipid panel and only do Apo B once we are monitering response to statin therapy? Any disadvantage to this approach?
Response: Yes. There is no disadvantage.

Should we suspect familial hypercholesterolemia in anyone with LDL > 5 even if it was previously lower (ex. 4) but went up with age / poor lifestyle etc?
Response: If they also have a family history of premature ASCV disease or dyslipidemia, yes

Can you comment on primary prevention for non frail/vigorous 80 years-old + patients, when is primary prevention too much?
Response: A robust 80 year old may have 10 yrs+ of life to life, and evidence suggests beneficial. Avoiding a stroke is key to QoL

Other guidelines do not suggest repeating lipids in primary prevention once a statin is initiated. Your thoughts?
Response: As long as you are using a moderate intensity dose of statin or if the initial LDL was not > 4.0

What is your starting dose of statin for primary and secondary prevention?
Response: Rosuva 20 or Lipitor 40

What is aim for ApoB in treatment?
Response: In primary prevention < 0.8 In secondary prevention < 0.7

If a patient has mild elevation in CK after starting a statin but patient is asymptomatic, do you stop the statin, change or decrease?
Response: No, if mild and no Sx, continue and monitor

Sorry, this is off topic, but what do you recommend for pts with incidental finding for vascular atheroscleosis on imaging the in heart of brain vessels - do you recommend starting them on ASA for “subclinical” condition in abscene of chest pain, Hx of CVA? thanks
Response: No