Jorge Plutzky, MD

In our last few minutes, we’re going to go around the table. What’s 1 key takeaway point that you want to drill home to our audience? I’d like to have everyone get a chance to give their takeaway. I’ll start with Pam. What’s the message you want to emphasize?

My takeaway is to look for subclinical atherosclerosis. That’s where we can make a huge impact. Once somebody has had a heart attack or a stroke, the cat’s out of the bag. We know what we have to do. We know we have to be aggressive. But look for subclinical atherosclerosis, whether it’s through coronary calcium scoring or other biomarkers, and treat those patients aggressively.

My point is around LDL [low-density lipoprotein] lowering and achieving that we know that what the drugs do and the LDL lowering they achieve. As caregivers, we have to be committed to getting patients to appropriate LDL levels because it will change outcomes. Creating the rationale, explaining the rationale, and educating around that is essential. We use the tools we have to achieve those LDLs. It’s important to do it. We just have to be fully committed to it.

Use the tools. We have terrific tools. If you started out with nothing 20 or 30 years ago, look what we have to prevent heart disease. We have a potpourri of drugs, whether it’s for blood pressure, lipids, or diabetes, to help the patient. Looking at the patient with type 2 diabetes, think of that patient as a heart attack waiting to happen. I heard a very wise cardiologist say, “Having an event is 1 bad day.” In primary prevention and secondary prevention, for patients who have high cardiac calcium scores, it’s a bad day that they had the event. Treat them as someone who had an event. Be aggressive with that patient. Outline to them that you want to prevent the first event.

I have 2 takeaways. When we see patients struggling with lipids, sometimes we don’t take as much time on top to talk about lifestyle. It’s important to reiterate the importance of exercise and healthy diet in every visit with every patient. My second takeaway is that it’s also important to use all the medicine we have in our armamentarium to get to an LDL of less than 55 mg/dL to address diabetes. To address weight, we have many options that help patients lose weight. That’s key with addressing lipids: addressing every risk factor that we can think of.

My takeaway is that I like thinking about LDL years and minimizing the total duration of exposure to these atherogenic particles. We need to lower LDL for longer and get there faster. We need to think about combination therapy up front earlier because these patients are very high risk. We need to intensify therapy every 4 to 12 weeks to overcome some of this inertia.

Thank you all for this rich and informative discussion. Thank you for watching this 

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Drs Erin Michos, Pam Taub, Robert Busch, Alison Bailey, and Jorge Plutzky offer key takeaways in the management of hypercholesterolemia and ASCVD.

Key Takeaways for Lipid Lowering in Hypercholesterolemia and ASCVD

 Alison, you’re in a very busy cardiology clinical practice. With a lot of these barriers we face, with co-pays and prior authorizations, what’s your approach in trying to overcome some of those barriers? Do you have advice for other practices?

It’s important. What Bob said is probably the most important thing we can take away: you have to have bidirectional communication with other members of the care team. Sometimes physicians, other nurse practitioners, and PAs [physician assistant] are afraid to start a medicine because they’re afraid it will insult another member of the team—the cardiologist, the endocrinologist, the primary care doctor. I don’t think that ever happens. I’m glad when an endocrinologist starts a medicine in 1 of my patients. I also have a large heart failure practice. We do a lot of SGL2 inhibitors. I don’t think anybody ever calls and says, “I’m sorry you tried to help this patient.” That’s the first key: to do the right thing for the patient that’s in front of you.

It’s important to have templated clinic notes, like for PCSK9 inhibitors. When they first came out, they were challenging to get for our patients. If you had that templated note and you knew how many statins they had failed, what the adverse effects were, what their current LDL [low-density lipoprotein] is, their initial LDL, then your nurse or whoever helps you with prior authorizations could easily go through and do that. It’s the same thing with SGLT2 inhibitors, GLP1 receptor agonists, and some other drugs outside the lipid realm. We’ve done the same things with templated notes. We know what our prescribers or insurers need to get that prior authorization.

The ACC [American College of Cardiology] and other professional societies are working on prior authorization reform. That’s important too because that takes a lot of our time. We know these medicines work, and our patients should have access to medications. That probably requires more than what we can do with prior authorization in our offices. It requires reform on a higher level.

It’s relevant for people in practice who say, “I’m not in an academic setting. I’m not going to have all those resources.” Consolidating expertise in the process can help with picking someone in your practice—an admin or someone working with patients—and let that 1 person handle your requests and your authorization. They very quickly come up to speed and help facilitate instead of asking everyone to do it piecemeal. It’s the same thing with advanced practice providers who can do titrations, spend more time with patients, and often have a very good relationship with them to create a rationale to push on. You need combination therapy, you’re at high risk, and we want to keep you out of trouble. It’s helpful that consolidating integrates efficiency for physicians, who can contribute to the inertia, either because they’re busy or the next patient is waiting. Here comes that flood of things to do to parse that out to people who can help move the ball down the field.

Bob, do you have any tips about overcoming a nursing practice?

 The prior authorization is the bane of our existence other than the electronic record and pointing and clicking. Many specialty pharmacies—you can find 1 in your community, like a hospital-based 1—have prior-authorization people who specialize in that. They know all the buzzwords and everything that’s needed. We’re very spoiled working in a medical center. They have 2 people in our practice, and it’s their entire job to do the prior authorizations. If it’s the nurse, who’s not usually doing it, they might find other tasks that are more interesting and more patient focused. Remember, helping the patient get the drug approved is a key obstacle, especially with any nonbranded drug—GLPS, SGLT2, PCSK9. Whatever it is, get that drug to the patient. Usually, that can be accomplished with someone who’s good at the prior-authorization process.

There are some patient-assistance programs. Some companies have coupons to get discounts for medications. It’s important to be familiar with those and to reach out to the companies for these patient-assistance programs.

An expert panel discusses challenges and provides solutions to managing patients with hypercholesterolemia.

Barriers and Solutions for Lipid Management in Clinical Practice

In our next segment, I wanted to get into how we can address these unmet needs. One thing that’s important is we need all hands-on deck: we need a team-based approach. I’m happy that we’re here with our endocrinology colleague. I was wondering, Bob, if you could tell us a little bit about the team-based approach to care; how you, as an endocrinologist, interact with cardiologists in co-management of your pts.

: The question is, who’s going to do it? Well, it’s each of our responsibilities. Whether you’re the primary care clinician, the endocrinologist, or the cardiologist, someone has to do it. Don’t just say, “Oh, I’ll defer to my cardiologist to get you down.” Define with the patient the whole goal is lowering heart disease, and the different manifestations of ASCVD [atherosclerotic cardiovascular disease] that Pam outlined. We’re very spoiled where we are. We have nutritionists and dieticians to cover what Alison covered. We have Pharm.D.s to have the in-depth discussions as your other drug interacts with- if you’re on amiodarone as a P50 inhibitor- switch statins. We have the clinician there. My job as an endo[crinologist] is I must do the ABCs. Get your A1C down, blood pressure down, which takes combination therapy. To give a combination for cholesterol, we’ve been there, done that. We know what our target is and discuss it with the patient. The whole goal is I’m trying to avoid a heart attack, stroke, death, peripheral vascular disease. We know about eye, kidney nerve disease, we’ve accomplished that by lowering your A1. But the macrovascular disease is what kills you. Those are the big morbidities we want to avoid, and that’s why we’re doing that. We have a team. Whoever the clinician is that they’re seeing should at least initiate the conversation and try to put their toe in the water, not just pass the buck.

I agree completely in involving all team members, including pharmacists, and nurses, and nurse practitioners, and exercise physiologists, and nutritionists. I know, in our prevention practice, I’m very delighted to work with an excellent cardiology nurse who helps with a lot of this management. This includes teaching about injections and helping with some of these burdens, helping with some of the preauthorization paperwork. I know this recent conference we were at. Pam, I got to meet your wonderful nurse that helps you in the lipid clinic. Why don’t you tell us a little bit about your lipid clinic, and how you utilize other team members in co-management of your patients, such as your nurse that I met?

As Bob mentioned, the multi-disciplinary approach is critical. It takes a village. We sometimes only spend a very small portion of time with the patient. The patient gets to spend a lot more time with the dietician. If they’re in cardiac rehab, our staff gets to spend 36-72 sessions with the patient. We have to utilize these other points of contact in the patient’s journey. In our clinic, we utilize advanced practitioners to see the patients, especially after discharge, because they can see the patient quickly. We also use dieticians, and pharmacists, to educate the patient about the drugs. You had mentioned my nurse. Our nursing staff is critical in the prior authorization part of the equation. A lot of these drugs are not going to get to the patient unless somebody takes time to do the prior authorizations, and the proper documentation is there. We have to be really working with our medical assistants and our nurses to get this prior authorization done. It can be done if we just put in the right documentation. We have an up-to-date LDL [low-density lipoprotein]. We can get these medications. One thing I wanted to mention about inclisiran; Alison had mentioned this before. For Medicare patients who have a supplement, the way inclisiran is structured, their copay is $0. It’s very accessible to our Medicare patients, which some of the other drugs historically have not been as accessible. We need to work in a multi-disciplinary team, and also, we need to work on access.

Our panel highlights the importance of a team-based approach to care in the management of hypercholesterolemia.

Multidisciplinary/Team Based Approach for Lipid Management

Ezetimibe, unfortunately, is not the most potent LDL [low-density lipoprotein]-lowering medication. It’s only around 18% or so LDL-lowering but in combination with bempedoic acid, you can get up to 40%. Then, with the other PCSK9 inhibitors, you can get 50% to 60% LDL-lowering. While we usually try ezetimibe in these very high-risk patients, we often need more, which is why I want to get back to what you brought up earlier: blood pressure. Somebody comes in and their blood pressure is above 160, you’re thinking combination therapy from the get-go. In clinical practice, we waste a lot of time starting with these low doses. Patients come back in 6 months, in a year. If they’re lucky, they get their dose increased; there’s a lot of inertia. In the GOULD registry that Alison had referred to, over these patients with ASCVD [atherosclerotic cardiovascular disease], these high-risk patients, over a 2-year period, only 17% actually have their lipid-lowering therapy intensified. Tell us about the approach for combination therapy. When should we be thinking about combination therapy? What do the guidelines say about combination therapy for lipids?

The broad message is to push on and to achieve the numbers that we need to achieve in patients, using the tools available and at our disposal. For many patients, that will be combination therapy. The ezetimibe trial is to show someone over 2-4 weeks that, “Yes, you’re not reacting.” We almost never do that in secondary prevention when the risk is higher. Even primary prevention in high-risk, we’ll say, “Well, we don’t want to spend that time waiting.” We’re really pushing on to additional therapies, using combination therapy, and doing it earlier especially in patients at very high risk; we’re going right to combination therapy, especially when patients start off with much higher LDL levels. We have a very low threshold for starting those agents, especially attending on inpatients services. If someone’s having a recurrent event on a statin alone, they need to aggressively move on, and to tailor that to the given patient using the tools you have available with these adjunctive medicines. We do that very early and aggressively, and after having established the rationale for the patient. I think anyone who practices prevention ends up doing motivational interviewing. When someone said to me, “Oh, that’s interesting. You’re really into motivational interviewing,” for the first time, I said, “Well, what is that?” I went back and then realized, well, gosh, this what we’ve been practicing for a very long time, creating a construct where you’re recognizing what the patient is bringing to the discussion. One of those fundamental tenets is that no patient is trying to hurt themselves. No one’s saying, “I was really hoping for a heart attack. I was really hoping you would place a stent.” They’re coming to this point where there may be a wrestling with a question about LDL lowering. Not because they want to harm themselves, but because they don’t fully understand the data, the evidence, and the options for pushing on and tailoring that to the patient. Explaining why they need combination therapy in the context of, “Well, then consider the alternative. If you’re having an event, to not being around. Or being compromised, or being on even more medicines, or having an interventional surgery.” I think that context really says, “Of course, I’ll take 2 medicines, because I need to do this, because the alternative is really dangerous.”

Thinking about combination therapy very early, in these very high-risk patients; to be intensifying therapy rapidly every 4-12 weeks, if they’re not at goal, to be intensifying to help overcome some of this inertia.

Erin D. Michos, MHS, FACC, FASPC; Pam Taub, MD, FACC, FASPC; Robert Busch, MD; Alison Bailey, MD, FACC; and Jorge Plutzky, MD; share benefits of combination therapy for lipid lowering in ASCVD and hypercholesterolemia.

Jorge Plutzky, MD

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