Optimal Management of Lipid Disorders: Expert Nurse Practitioner Perspectives - Episode 4
Joyce L. Ross, CRNP: That brings up something important to me that I want to ask you about. Do you find today that patients are much better at taking their statins, or do you think it’s still such a resistance type of a thing?
Lynne Braun, PhD, CNP: My answer is that it depends; it really does. I have found that establishing an excellent relationship with the patient, answering all their questions honestly, listening to them, explaining what the data show, and also stating up front, “I’m recommending this medication. Not necessarily to lower your cholesterol, but to lower your risk for having a heart attack or a stroke,” often resonates with them. They go home and read, then they call or come back or message me, and we talk again. But I have felt that spending more time up front with the patient is well worth it instead of a quick visit of, “Here’s your medication.” The patient may or may not go home and fill that prescription.
The clinician-patient risk discussion is critical, and that really comes out loud and strong in the guideline. Some patients may see a physician and a nurse practitioner or a nurse and may have a discussion with the pharmacist. This is certainly a team approach, but no matter who writes that prescription, it is well worth having a thorough discussion. This is because the lifestyle component fits into this as well. We don’t ever want to be in the business of just prescribing a drug to lower cholesterol, to treat blood pressure, and so forth, because lifestyle is often very critical.
Certainly, for our very high-risk secondary prevention patients, our guidelines direct us to prescribe high-intensity statin therapy, using a threshold of 70 mg/dL, to consider adding nonstatin medications. But with primary prevention, there is a little more wiggle room sometimes. It’s so critical to hear out that patient to clarify any misconceptions they may have and then perhaps see them back or speak to them even in 2 weeks to see where their head is at that time, what their thought processes are. Nine times of 10, we’ll be able to work this out together. The patient after all is our most important partner.
Joyce L. Ross, CRNP: Exactly. What’s so important, and I’m so happy you brought that up, is part of the next thing I want to talk about. We just don’t treat LDL [low-density lipoprotein] anymore. It’s not just about lowering a number. We know that we want at least a 50% reduction in the LDL cholesterol when we prescribe a statin therapy. We know they have specifically, in the guidelines, pointed out which statins those are. But I also found that with my patients, it was very important to talk about what else a statin does. Do they just lower a number? No, they actually can stabilize plaque, which is huge.
I always talk about the theory of grapes and raisins. When you have unstable plaque, what you have is a bunch of grapes. We all know how thin the skin is on a grape and how good and juicy the inside is. We love the wine that comes out of it. But you don’t want good, gooey grapes in your vascular system, because they will burst 1 day and cause the cardiovascular event.
Plaque stabilization is really important to the patient and maybe has an important thing you already brought up: decrease inflammation. That’s not just from the plaque; it’s from everything else you mentioned. Why do people have inflammation? Well, we have it because we have rheumatoid arthritis, we’ve got other problems that are going on. So what’s really important is we talk about what else it does, and that is sometimes the tip that helps the patient understand this is not just about a number.
I also think what you just talked about, and the part I’m adding, is about the respect for the patient and respect of what they want to do, what they need to do, and that type of thing. As nurse practitioners, we have the best of both worlds in helping diagnose and manage these patients who really are going to lead to a lifetime of treatment, and that’s what we’re talking about today. We’re not saying we’re going to give you something, you’re going to take it for 10 days, and go and sin no more.
No, we’re talking about the rest of your life. You brought up the issue with screening the entire family, the cascade screening. Of course, for that gentleman who I dragged into the office, it’s important to say, “You have children, and they’re going to have the chance to inherit that risk as well.” The earlier we know about children, the better off they are. We’re not going to treat all the children with a bunch of statins or anything, but maybe they should be started when they’re teenagers because of genetic disorders.
Transcript Edited for Clarity