Abstract
A 54-year-old female individual with a history of hyperlipidemia, hypothyroidism, latent autoimmune diabetes of the adult (LADA) with hypoglycemia unawareness, vitiligo, and asthma presented with exercise-limiting pleuritic chest pain and dyspnea. She underwent a full pulmonary and cardiac workup locally and at Mayo Clinic, which were normal and negative for pulmonary embolism and showed no evidence of cardiac ischemia. Her family history and abnormal lipid panels suggested possible familial hypercholesterolemia by Dutch criteria. Lipid fractionation studies were done to further assess abnormal lipid levels and symptoms, as she lives a generally healthy and active lifestyle. Lipid fractionation studies revealed abnormal small, dense (sdLDL) and low-density lipoproteins (LDL) particle numbers. She was started on a triple cholesterol management regimen of ezetimibe, evolocumab, and bempedoic acid, which improved lipid fractionation values and symptoms. This case highlights the utility of using lipid fractionation studies in addition to traditional lipid panels to best treat patients with abnormal lipid panels on lipid-lowering therapy.