CONTACTS
SUBJECTS
Endocrinology Review HDL Failing Rise With Hiking Mileage
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 46 0000. ref SDS 44 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040509 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting this morning follows up telephone meeting with Doctor Kim on
040902 - 230302 1130, ref SDS 46 MJ5I
040904 - ..
040905 - Before meeting this morning, got flu shot for this year. The
040906 - attendant said the upper left shoulder where he made the injection
040907 - contracted because it is well muscled.
040909 - ..
040910 - Met this morning with Doctor Chen in Module 2. After reviewing
040911 - patient history reported in Doctor Kim's progress notes for the
040912 - meeting on 221104 0900, ref SDS 44 PU4G, Doctor Chen left the room
040913 - to consult with Doctor Grunfeld, the attending physician for the
040914 - meeting today. Doctor Chen then returned with Doctor Grunfeld to
040915 - continue the meeting.
040917 - ..
040918 - Very nice to see Doctor Grunfeld still on the job, after the last
040919 - meeting, when he related plans to retire, shown in the record on
040920 - 220526 1030. ref SDS 38 053F
040922 - ..
040923 - Discussed pausing atorvastatin to reduce mounting side effects per
040924 - letter to Doctor Kim on 230927.
040926 - ..
040927 - Doctor Grunfeld proposed changing to a statin, which he feels has
040928 - lower side effects, and in order to maintain progress shown in lab
040929 - this morning showing LDL has dropped to about 100. He wants LDL to
040930 - drop to 70.
040932 - ..
040933 - The doctor said the VA is not recommending PCSK9 in this case, which
040934 - revises discussion with Doctor Grunfeld when he recommended trying
040935 - PCSK9 during the meeting on 220526 1030. ref SDS 38 0540
040937 - ..
040938 - Demurring on prescribing PCSK9, aligns with recent article reporting
040939 - a major clinical trial that found PCSK9 impairs lung function for
040940 - some patients...
040941 -
040942 - Scitechdaily
040943 -
040944 - https://scitechdaily.com/new-cholesterol-drugs-could-harm-lungs-warns-groundbreaking-global-study/
040946 - ..
040947 - A recent study, analyzing genetic data from 340,000 UK Biobank
040948 - participants, has found that PCSK9 inhibitors, a new class of
040949 - cholesterol-lowering drugs, could potentially impair lung
040950 - function. Despite most cholesterol medications effectively
040951 - reducing cardiovascular risks without significant adverse
040952 - effects, the study also found correlations between statins and
040953 - higher BMI, body fat, and reduced testosterone, while
040954 - unexpectedly noting an increase in hippocampus brain volume
040955 - that might lower dementia and depression risks.
040956 -
040958 - ..
040959 - This article references...
040960 -
040961 - BJCP
040962 - British Journal Clinical Pharmacology
040963 -
040964 - Genetically instrumented LDL-cholesterol lowering and multiple
040965 - disease outcomes: A Mendelian randomization phenome-wide
040966 - association study in the UK Biobank
040967 -
040968 - https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.15793
040970 - ..
040971 - First published: 19 May 2023
040973 - ..
040974 - The Principal Investigator for this study is Professor Elina
040975 - Hyppönen
040977 - ..
040978 - What this study adds
040979 -
040980 - ...PCSK9-inhibitor proxy was associated with lower lung
040981 - capacity, requiring further investigation.
040982 -
040983 -
040985 - ..
040986 - Doctor Grunfeld said HDL 51 in lab this morning is very good compared
040987 - to other patients age 78.
040989 - ..
040990 - Scheduled follow up meeting with Doctor Kim in 3 - 4 months to
040991 - evaluate
040992 -
040993 - [On 231228 1111 Rachael called to schedule next meeting at
040994 - VAMCSF on 230426 0900. ref SDS 47 MJ5I
040995 -
040996 -
040997 -
040998 -
040999 -
041000 -
041001 -
041002 -
041003 -
0411 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Progress Notes Meeting Doctor Kim in Endocrinology
050403 -
050404 - Follow up ref SDS 46 PU4G, ref SDS 44 PU4G.
050405 -
050406 - Downloaded progress notes from VA website...
050407 -
050408 - https://www.myhealth.va.gov/mhv-portal-web/track-health
050409 -
050422 -
050423 - 1. Date/Time: 04 Nov 2022 @ 2234
050424 - Note Title: ENDOCRINE-METABOLISM CLINIC F/U (MED)
050425 - Location: San Francisco CA VAMC
050426 - Signed By: KIM,TIFFANY Y
050427 - Co-signed By: KIM,TIFFANY Y
050428 - Date/Time Signed: 04 Nov 2022 @ 2341
050429 - -------------------------------------------------------
050430 - LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC F/U (MED)
050431 - STANDARD TITLE: ENDOCRINOLOGY OUTPATIENT NOTE
050432 - DATE OF NOTE: NOV 04, 2022@22:34 ENTRY DATE: NOV 04, 2022@22:34:51
050433 - AUTHOR: KIM,TIFFANY Y EXP COSIGNER:
050434 - URGENCY: STATUS: COMPLETED
050436 - ..
050437 - ENDOCRINE CLINIC NOTE
050439 - ..
050440 - 2. HPI (Hisotory Present Illness)
050441 -
050442 - Rodney Welch is a 77 yo man with a h/o CAD s/p 4VCABG 2009, AF
050443 - s/p ablations, HTN, HL, achlasia, consult for lipid management.
050444 - Previously seen by Drs Diana Alba, Ken Feingold, Carl Grunfeld.
050445 - See note by Dr Grunfeld 5/26/22 for prior history. H/o very
050446 - high LDL, has decreased LDL and increased HDL but interested in
050447 - increasing HDL further.
050449 - ..
050450 - #. ASCVD: CAD s/p 4VCABG 10-22-09 (LIMA, SVG diag, ramus,
050451 - PDA). Carotid US 9-20- 16 sml plaque R bulb, no stenoses. As
050452 - can be seen below, he has aggressively improved his lipid
050453 - profile in the interim. CTAs in 2015 and 2018 with patent
050454 - grafts. Cath Jan 2020 showed all grafts patent with a severe
050455 - 95% stenosis of the rPL branch which had not been bypassed,
050456 - which was stented. 6/10/21 -
050458 - ..
050459 - "Patent" grafts does not identify findings of angiograms that reported
050460 - 0% stenosis on 200124 0705. ref SDS 10 ME8G and progress notes, 200124
050461 - 0705, ref SDS 10 5G59, whereas 70% stenosis qualifies as "patent,"
050462 - reported on 091022 0700. ref SDS 1 RY6H
050464 - ..
050465 - Progress Notes continue...
050466 -
050467 - Reports Platelet rich plasma made a difference.
050469 - ..
050470 - During meeting today, explained history of PRP treatments enabled
050471 - hiking, which in turn increased HDL 30, at time of CABG, to HDL 83 on
050472 - 181112 1720. ref SDS 8 5C7M
050474 - ..
050475 - Progress Notes continue...
050476 -
050477 - Imaging Jan 2022 with aortic atherosclerosis, luminal
050478 - irregularities representing penetrating atherosclerotic
050479 - ulcers/dissection flaps. Vascular surgery recommended 1 year
050480 - f/u imaging. Was hospitalized June 2020 for intermittent
050481 - abdominal pain and bloating, thought to be ischemic colitis,
050482 - although visualized portions of mesenteric vascular were
050483 - patent. Also h/o diverticulae. Seen by gen surg 9/2022,
050485 - ..
050486 - Cannot find record meeting with General Surgery in Sep 2022. Met with
050487 - Doctor Natile Rodriguez and Doctor Kim in Module 2 on 220503 0900.
050488 - ref SDS 35 LW8H - for some reason, progress notes are dated, 220521.
050489 - ref SDS 35 SP4I
050491 - ..
050492 - Progress Notes continue...
050493 -
050494 - thought to have intermittent ischemic colitis with exertion,
050495 - sequaelae of low flow state. Recommended continued GI f/u,
050496 - avoidance of NSAIDS, routine CTA surveillance, medical
050497 - optimization of CV risk factors. Cardiology: Previously
050498 - followed by Dr Paul Simpson, now Dr Cara Pellegrini and NP
050499 - Rettberg.
050501 - ..
050502 - Doctor Monto diagnosed ischemic colitis reported on 200612 0700.
050503 - ref SDS 11 LY3G
050505 - ..
050506 - On 200613 0519 at 1135 discharge instruction progress notes cite
050507 - vasodilation from hiking, together with 4 heart ablation procedures,
050508 - as causing reduced blood flow to heart causing ischemic colitis.
050509 - ref SDS 12 PP9T
050511 - ..
050512 - Progress Notes continue...
050513 -
050514 - #. Dyslipidemia: Many of his early labs were not at the San
050515 - Francisco VA, so may not be available to us. His highest LDL
050516 - here was 243 in 2015. His LDL before 2009 was 192 to 203. His
050517 - HDL before his CABG was 30-32 in 2005-2009. In the years after
050518 - his CABG, his HDL ran in the 40s. His triglycerides are mostly
050519 - below 100. He has trouble with statins but after working with
050520 - Dr Feingold he was able to tolerate atorvastatin 10 mg every
050521 - other day and ezetimibe 10 mg daily. This regimen brought his
050522 - LDL down to the 90s and low 100s.
050524 - ..
050525 - Ezetimibe 10 mg is also every other day, taken with Atorvastatin,
050526 - prescribed by Doctor Alba during meeting on 131219 0930. ref SDS 4
050527 - 6H6K
050529 - ..
050530 - Progress Notes continue...
050531 -
050532 - He was significantly overweight and began hiking. This raised
050533 - his HDL level so he began hiking more and hikes about 20 miles
050534 - per day many days a week. This hiking regimen brought his HDL
050535 - mostly into the range of high 50s to 60s in our lab.
050537 - ..
050538 - VAMCSF lab reportedL...
050539 -
050540 - HDL 70............ 150209 1012, ref SDS 5 5C7M
050541 - HDL 69............ 160202 1220, ref SDS 6 5C7M
050543 - ..
050544 - Progress Notes continue...
050545 -
050546 - His HDL has been as high as 83. His HDL was lowered during
050547 - bouts of AF.
050549 - ..
050550 - HDL lowering after onset of AF best seen in spreadsheet...
050551 -
050552 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
050554 - ..
050555 - Progress Notes continue...
050556 -
050557 - He also gets NMR measures of his lipids. He reports that he
050558 - has mostly large fluffy LDL.
050560 - ..
050561 - HDL 83 reported NMR lab at Labcorp on 181112 1720. ref SDS 8 N64J
050562 - This lab further reported....
050563 -
050564 - LDL and HDL Particles
050565 - HDL-P (Total) 45.9
050566 - Small LDL-P 310
050567 - LDL Size 20.7
050569 - ..
050570 - Progress Notes continue...
050571 -
050572 - In the past, he has had elevated CRP: It was as high as 20.6
050573 - in 2016 and during that time it ranged between 3.8 and 5.1.
050574 - When his CRP was 4.5 his sedimentation rate was excellent at 7.
050576 - ..
050577 - He has lost significant weight since then due to his hiking so
050578 - unlikely he has the inflammation of obesity. See note on
050579 - 8/5/21 by Dr Grunfeld:
050581 - ..
050582 - We had a long discussion, in which I explained:
050583 -
050584 - 1) Losing weight was likely the most important factor for
050585 - getting HDL into the 50's and he did that by exercising, so
050586 - exercise is good.
050588 - ..
050589 - Do not recall discussion during the meeting that losing weight
050590 - increases HDL 30 to 50+, per above. ref SDS 44 MJ5I
050592 - ..
050593 - Previously, research indicated hiking raises HDL and EPCs, reported on
050594 - 131125 0005. ref SDS 3 6O9M, which in combination regress plaque
050595 - buildup in blood vessels with return collesterol transport (RCT),
050596 - reported on 131125 0005. ref SDS 3 R44O more specifically. ref SDS 3
050597 - 186Y
050599 - ..
050600 - After the meeting, research found...
050602 - ..
050603 - Very Well Health
050604 -
050605 - Follow up ref SDS 46 E29G, ref SDS 44 E29G.
050606 -
050607 - https://www.verywellhealth.com/exercise-and-hdl-cholesterol-1745833
050609 - ..
050610 - Losing weight: For every 6 pounds lost, HDL may increase
050611 - by 1 mg/dL.Mar 26, 2022
050613 - ..
050614 - Perhaps the most interesting finding from this study is
050615 - the observation that it was the duration of exercise
050616 - sessions and not the frequency or intensity of
050617 - exercise that best correlated with increased HDL levels.
050618 - The investigators reported that in research subjects
050619 - exercising for at least 20 minutes, each additional
050620 - 10-minute increase in exercise duration was associated
050621 - with an additional 1.4 mg/dL of HDL.
050623 - ..
050624 - This aligns with Harvard study reported on
050625 -
050627 - ..
050628 - Progress Notes continues...
050629 -
050630 - 2) Values of HDL are not comparable by different methods
050631 - and hence different laboratories.
050633 - ..
050634 - Experience in this case show increased hiking to mile 11 - 15 raised
050635 - HDL 60 - 70 with blood tests at VAMCSF, Labbcorp and Quest labs
050636 - consistently yielded HDL between 60 - 70.
050638 - ..
050639 - Progress Notes continues...
050640 -
050641 - 3) His values are not significantly different with the
050642 - exercise induced inflammation.
050644 - ..
050645 - Have not encountered "exercise induced inflammation" affecting HDL -
050646 - how is this identified and measured?
050648 - ..
050649 - Progress Notes continues...
050650 -
050651 - 4) So don't focus on levels.
050653 - ..
050654 - Is there a study that correlates plaque in blood vessels with
050655 - "inflammation"?
050657 - ..
050658 - Progress Notes continues...
050659 -
050660 - 5) He should work on eliminating the inflammation with
050661 - exercise by working with podiatry and consider splitting
050662 - his hikes (which he was thinking of doing).
050664 - ..
050665 - Significant work has been done by Doctor Tang and Doctor Hewitson in
050666 - Podiatary to reduce inflammation from feet injuries over the past 10
050667 - years. Most recently today, reported on 221104 0830. ref SDS 43 L83K
050669 - ..
050670 - Progress Notes continues...
050671 -
050672 - He will continue do Platelet rich plasma on his own. In the
050673 - past, has had bad reactions to rosuvastatin and simvastatin:
050674 - shoulder aches, neck aches and worsened. Had worsening
050675 - neuropathy so he stopped atorvastatin, resumed May 2022 b/c his
050676 - athersclerosis was stable while on atorvastatin and while off
050677 - atorvatatin his LDL is too high at 189.
050679 - ..
050680 - This is dependent on availaility of funds, currently withheld by VA
050681 - and on appeal, for reasons in David Ames letter on 221019 0854.
050682 - ref SDS 39 LR5H
050684 - ..
050685 - Progress Notes continues...
050686 -
050687 - Subjective:
050688 - No acute issues. We had a discussion about HDL and LDL, role
050689 - of telomeres in aging. He may be a good candidate for clinical
050690 - studies of aging given his interest. He was disappointed I did
050691 - not have anything to add for abdominal pain.
050693 - ..
050694 - Seems like abdominal pain (bloating) that mostly occurs during
050695 - hiking, but sometimes otherwise, would be an "acute" issue.
050697 - ..
050698 - Progress notes continue...
050699 -
050700 - Reviewed history further after visit, he has been evaluated by
050701 - vascular surgery, general surgery, also GI as per above.
050703 - ..
050704 - References above. ref SDS 44 CP7K
050705 -
050706 -
050707 - Lipid medication:
050708 - Atorvastatin 10 mg QOD
050709 - Ezetimibe 10 mg QOD
050710 -
050711 -
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0508 -