TITLE

Coronary artery disease with high LDL cholesterol, diabetes, chest burning, back pain, and right-ear hearing loss

ONE SENTENCE SUMMARY

Your LDL and non-HDL cholesterol are high, diabetes control is good, kidneys and liver are normal, potassium runs borderline high, and hearing and back symptoms need planned follow up.

PATIENT CONTEXT

Age 58, male.

Main symptoms, chest burning at rest for 3–4 months, long-standing mid-back pain with flares, right-ear hearing loss that is getting worse for 3 years, dark skin patches on hip and low belly.

Goals, LDL cholesterol under 1.4 mmol/L [55 mg/dL], non-HDL cholesterol under 2.2 mmol/L [85 mg/dL], ApoB under 0.65 g/L [65 mg/dL].

Lifestyle, 184 cm, 85 kg, waist 80 cm, about 2,000 steps per day, no alcohol, vapes nicotine, high work stress, sleeps 6–7 hours.

Current medicines, Repatha 140 mg every 2 weeks, tirzepatide 5 mg weekly, dapagliflozin 10 mg morning, Cosyrel nightly [fixed tablet with bisoprolol, a beta-blocker, and perindopril, an ACE inhibitor], duloxetine 30 mg night, CoQ10 total 1,000 mg daily, tadalafil 5 mg night, pantoprazole 40 mg night, levothyroxine 25 micrograms morning.

Stopped due to pain 2 months ago, ezetimibe 10 mg, pitavastatin 2 mg.

Missed Repatha for about 2 months while trying inclisiran, now back on Repatha.

Key yes/no symptom checklist already answered above is used in this report.

KEY FINDINGS FROM PRIOR RESEARCH

10 Aug 2025, guideline verification message, confirmed targets, LDL <1.4 mmol/L, non-HDL <2.2 mmol/L, ApoB <0.65 g/L, and drug effect sizes, evolocumab about 60 percent LDL drop, ezetimibe about 18–22 percent, pitavastatin 2 mg about 35–40 percent, bempedoic acid about 15–20 percent.

10 Aug 2025, earlier clinical report in this chat, plan to keep strict Repatha, consider ezetimibe re-trial with a pain plan, consider bempedoic acid if pain recurs, and use physiotherapy for thoracic pain.

10 Aug 2025, research summary, tirzepatide often raises amylase/lipase a little without raising pancreatitis risk, monitor symptoms not numbers alone.

10 Aug 2025, research summary, unilateral hearing loss needs audiology and MRI of internal auditory canals to rule out vestibular schwannoma after audiogram confirms sensorineural loss.

10 Aug 2025, interaction review, avoid NSAIDs with ACE inhibitor plus SGLT2 when possible, watch potassium, never combine tadalafil with nitrates.

WHAT CHANGED SINCE LAST REPORT

You shared new lab screenshots dated 09 Aug 2025.

You shared older King’s College Hospital labs dated 11 Jun 2025.

You confirmed no exertional chest pain, burning happens at rest.

You confirmed progressive right-ear hearing loss with ringing.

You confirmed gallbladder removed in the past.

You stopped ezetimibe and pitavastatin 2 months ago for back pain, and you restarted Repatha after a 2-month pause on inclisiran.

TEST RESULTS SIMPLIFIED

Definitions in brackets, LDL [“bad” cholesterol that clogs arteries], HDL [“good” cholesterol], non-HDL [all atherogenic cholesterol], ApoB [number of atherogenic particles], eGFR [kidney filter rate].

Test Value Unit Lab range Date Simple meaning

Total cholesterol 231 mg/dL 100–199 09 Aug 2025 High

LDL cholesterol 143 mg/dL 0–99 09 Aug 2025 High heart risk

HDL cholesterol 38 mg/dL ≥39 09 Aug 2025 Low protection

Triglycerides 205 mg/dL 0–149 09 Aug 2025 High

VLDL 61 mg/dL 5–40 09 Aug 2025 High

Non-HDL cholesterol 193 mg/dL “Desirable <130” (lab) 09 Aug 2025 High vs lab target, far above CAD goal <85

HbA1c 5.6 percent 4.8–5.6 09 Aug 2025 At goal for diabetes

Creatinine 0.97 mg/dL 0.76–1.27 09 Aug 2025 Normal kidney

eGFR 91 mL/min/1.73 m² ≥60 09 Aug 2025 Normal kidney

Sodium 143 mmol/L 134–144 09 Aug 2025 Normal

Potassium 5.1 mmol/L 3.5–5.2 09 Aug 2025 Borderline high

Bicarbonate 27 mmol/L 18–29 09 Aug 2025 Normal

Chloride 105 mmol/L 97–108 09 Aug 2025 Normal

Troponin I Unknown — 0.00–0.16 09 Aug 2025 Value unreadable on image

Total cholesterol 214 mg/dL 100–199 11 Jun 2025 High

LDL cholesterol 145 mg/dL 0–99 11 Jun 2025 High

HDL cholesterol 48 mg/dL ≥39 11 Jun 2025 Fair

Triglycerides 182 mg/dL 0–149 11 Jun 2025 High

Non-HDL cholesterol 166 mg/dL “Desirable <130” (lab) 11 Jun 2025 High

Fasting glucose 116 mg/dL 65–99 11 Jun 2025 Mildly high

HbA1c 5.7 percent 4.8–5.6 11 Jun 2025 Near goal

Creatinine 0.89 mg/dL 0.76–1.27 11 Jun 2025 Normal kidney

eGFR 99 mL/min/1.73 m² ≥60 11 Jun 2025 Normal kidney

Potassium 5.3 mmol/L 3.5–5.2 11 Jun 2025 High

AST 17 IU/L 0–40 11 Jun 2025 Normal

ALT 18 IU/L 0–44 11 Jun 2025 Normal

Urine albumin/creatinine ratio 8.55 mg/g 0–30 11 Jun 2025 Normal kidney filter

Trend

• LDL stayed high and above goal on both dates.

• HDL fell from 48 to 38 mg/dL.

• Triglycerides rose from 182 to 205 mg/dL.

• Non-HDL rose from 166 to 193 mg/dL.

• HbA1c improved from 5.7 to 5.6 percent.

• Potassium stayed borderline high, 5.3 then 5.1 mmol/L.

Conflict to flag

• The lab “desirable” non-HDL target is <130 mg/dL for the general public. Your coronary disease goal is stricter, <85 mg/dL. This is not an error, it reflects different targets for high-risk patients.

QUESTIONS FOR MY DOCTOR BY CATEGORY

Diagnosis

• Does my chest burning match reflux or angina? Do I need a stress test now?

• Does my mid-back pain look mechanical [muscle, joints] or nerve-related?

• What type of hearing loss do I have on the right, sensorineural [inner ear/nerve] or conductive [middle ear]?

Tests

• Order fasting lipids with ApoB and non-HDL 6 weeks after on-time Repatha.

• Order Lp(a) once to define inherited risk.

• Recheck potassium, creatinine, and sodium in 1–2 weeks.

• Audiology and tympanometry, then MRI internal auditory canals if sensorineural loss is confirmed.

• Thoracic spine X-ray. Consider MRI if red flags.

Medicines

• Confirm Cosyrel strengths, bisoprolol mg and perindopril mg.

• When to re-try ezetimibe 10 mg with a pain plan?

• If pain returns, should we use bempedoic acid or increase Repatha frequency?

• Keep tirzepatide 5 mg or increase dose?

• Safe pain plan that limits NSAIDs?

Side effects

• Could pantoprazole move to pre-breakfast for better reflux control?

• How to prevent low blood pressure with Cosyrel plus tadalafil?

• Do I need magnesium check with long-term PPI?

Lifestyle

• What diet steps will lower triglycerides fast?

• What walking and physio plan fits thoracic pain?

• Is vaping harming artery healing, and how do I quit?

Follow up

• Set dates for labs in 1–2 weeks and 6 weeks.

• Book ENT and physio.

• Define LDL goal date and success checks.

MEDICATION SCHEDULE RECOMMENDATIONS

Notes in brackets for clarity. “Separate” means take at different times.

Medication Dose Time With food Interaction notes Reason Missed dose plan Monitoring

Levothyroxine 25 mcg Wake-up Empty stomach, water only Separate all other pills by 30–60 min Steady thyroid If same day, take when remembered on empty stomach, else skip TSH in 6–8 weeks after any change

Pantoprazole 40 mg 30–60 min before breakfast Water PPI works best before first meal Reflux control If missed, take next morning Symptom log

Dapagliflozin 10 mg With breakfast Yes Watch BP with Cosyrel and tadalafil Glucose, kidney-heart help Take same day if remembered, else skip eGFR and potassium in 1–2 weeks, then every 3–6 months

Cosyrel [bisoprolol/perindopril] strength unknown Evening With or without food Additive BP drop with tadalafil; perindopril can raise potassium BP and heart protection Take when remembered same day; if next day, skip Home BP; potassium and creatinine in 1–2 weeks

Duloxetine 30 mg Night With snack if nausea Higher bleed risk with NSAIDs Nerve and muscle pain Take next scheduled dose, do not double Mood, BP

Tadalafil 5 mg Night With or without food Do not use with nitrates; extra BP drop with Cosyrel Prostate and sexual function Take same day, else skip Dizziness/BP

CoQ10 1,000 mg total Split AM and PM With meals None important Comfort with statin re-trial Take when remembered None needed

Tirzepatide 5 mg Weekly, same weekday With or without food Slows stomach emptying Diabetes and weight If missed, take within 4 days; if >4 days, skip and take next scheduled Weight, glucose, digestive symptoms

Repatha 140 mg Every 2 weeks — No major drug interactions LDL lowering If <7 days late, inject and keep schedule; if >7 days, inject and set new 2-week cycle from that day Lipids at 6 weeks after consistent dosing

Storage reminders

• Repatha and tirzepatide, keep in refrigerator, protect from light. Do not freeze. Check each box for allowed time at room temperature.

DRUG INTERACTIONS SUMMARY

• Duloxetine + NSAIDs (ibuprofen, naproxen, diclofenac). Mechanism, both increase bleeding from stomach. Risk, moderate. Action, use acetaminophen first, if NSAID needed use lowest dose and shortest time, add food, monitor for black stools or stomach pain.

• Perindopril in Cosyrel + potassium trend. Mechanism, ACE inhibitor raises potassium. Risk, moderate. Action, repeat potassium and creatinine in 1–2 weeks, avoid potassium salts, avoid dehydration.

• NSAID + ACE inhibitor (Cosyrel) + SGLT2 (dapagliflozin). Mechanism, “triple whammy” reduces kidney blood flow. Risk, moderate to high during illness or dehydration. Action, limit NSAIDs, hydrate, hold NSAID and consider “sick day” hold of dapagliflozin and perindopril during vomiting or diarrhea, check kidney tests after any NSAID course.

• Tadalafil + nitrates. Mechanism, large blood pressure drop. Risk, high. Action, never combine. Keep at least 48 hours gap if ever given nitrates in emergency.

• Cosyrel + tadalafil. Mechanism, both lower blood pressure. Risk, moderate. Action, keep tadalafil at night, rise slowly, hold tadalafil on dizzy days.

• Levothyroxine + all other pills. Mechanism, food and medicines reduce absorption. Risk, moderate for under-treatment. Action, take levothyroxine alone at wake-up with water.

• Pantoprazole + clopidogrel. Not on your list now. If you ever take clopidogrel, prefer pantoprazole rather than omeprazole.

KEY HIGHLIGHTS

• HbA1c is 5.6 percent on 09 Aug 2025, good control.

• Kidney function is normal, eGFR 91–99 mL/min/1.73 m².

• Urine albumin/creatinine ratio is 8.55 mg/g, normal.

• Liver enzymes are normal.

• You restarted Repatha, the strongest LDL-lowering agent you use.

KEY CONCERNS WITH REMEDIATION PLAN

1. High LDL and non-HDL cholesterol

Risk, higher heart and stroke risk. Reason, LDL 143 mg/dL and non-HDL 193 mg/dL while off ezetimibe/statin and with a PCSK9 gap. Plan, keep Repatha on time, tighten diet, discuss ezetimibe re-trial in 6 weeks, consider bempedoic acid if pain recurs, target LDL <55 mg/dL and non-HDL <85 mg/dL. Owner, you and cardiologist. Due date, 21 Sep 2025 labs. Success check, LDL and non-HDL at or under goals.

2. Borderline high potassium

Risk, heart rhythm issues if level rises. Reason, ACE inhibitor effect and occasional NSAIDs. Plan, repeat potassium and creatinine in 1–2 weeks; hydrate; limit NSAIDs. Owner, you and primary doctor. Due date, 24 Aug 2025. Success check, potassium 3.6–5.0 mmol/L.

3. Chest burning at rest

Risk, reflux discomfort, small chance of angina. Reason, no link to walking, long duration. Plan, move pantoprazole to pre-breakfast, start reflux steps, schedule a stress test to be safe. Owner, you and cardiology. Due date, book by 24 Aug 2025. Success check, symptom relief and a negative test.

4. Right-ear hearing loss with ringing

Risk, hearing decline, rare tumor. Plan, audiology and ENT, MRI internal auditory canals if sensorineural loss. Owner, you and ENT. Due date, book by 07 Sep 2025. Success check, audiogram completed and next step set.

5. Thoracic back pain flares

Risk, function limits and poor sleep. Reason, long history, worse with sitting, morning stiffness. Plan, thoracic X-ray now; start physiotherapy for posture, thoracic mobility, and scapular strength; heat, topical diclofenac; keep NSAIDs rare. Owner, you and physio. Due date, start by 17 Aug 2025. Success check, average pain ≤3/10 and more daily steps.

LIFESTYLE AND MONITORING

• Steps, build to 6,000 per day by 21 Sep 2025, add two 10-minute walks after meals.

• Diet, Mediterranean style, more vegetables, legumes, whole grains, nuts, and fish, less sweets and refined starch, keep sugary drinks at zero, fiber ≥30 g/day, avoid late eating after 19:30.

• Weight, aim loss 0.25–0.5 kg per week.

• Sleep, 7–8 hours nightly, winding down at a set time.

• Home blood pressure, goal 120–129/70–79 mmHg, check morning and evening for 7 days then 3 days per week.

• Glucose, fasting 4.4–7.2 mmol/L [80–130 mg/dL]; if higher, log food and timing.

• Pain log, record triggers, sitting time, and relief methods.

NEXT STEPS WITH DATES

• Today, move pantoprazole to 30–60 minutes before breakfast. Keep levothyroxine alone at wake-up.

• By 17 Aug 2025, book physiotherapy and thoracic spine X-ray; start daily walking plan.

• By 24 Aug 2025, repeat potassium, sodium, creatinine; share results.

• By 24 Aug 2025, schedule cardiac stress test.

• By 07 Sep 2025, audiology and ENT visit; follow with MRI if audiogram shows sensorineural loss.

• 21 Sep 2025, after six weeks of on-time Repatha, repeat fasting lipids with ApoB, non-HDL, and Lp(a); decide on ezetimibe re-trial or bempedoic acid.

• Ongoing, avoid routine NSAIDs; use acetaminophen first; if NSAID needed, shortest time, take with food, hydrate.

SOURCES

• Chat messages, “Guideline verification and medication effects,” 10 Aug 2025.

• Chat message, “Structured report with labs and plan,” 10 Aug 2025.

• Lab screenshots, 09 Aug 2025, pages labeled 3–5 of 5, lipid panel, HbA1c, electrolytes, kidney tests.

• King’s College Hospital London lab screenshots, 11 Jun 2025, pages labeled 2–7 of 7, CBC, chemistry, fasting glucose, HbA1c, potassium, UACR, lipid panel.

• PDF, “Lab Result Report,” Dr Sulaiman Al Habib, dated 11 Jul 2025 (values unreadable in parts, so not used for numbers).

• Cosyrel product information (bisoprolol plus perindopril), verified externally.

MISSING INFO LIST

• Exact Cosyrel strengths per tablet (bisoprolol mg and perindopril mg).

• Troponin I numeric value on 09 Aug 2025 image.

• ApoB, non-HDL (reported as 193 mg/dL but ApoB not measured), and Lp(a) labs.

• Any audiogram or thoracic imaging reports.

END OF REPORT