Expert Perspectives on Novel Treatment Options for Atherosclerotic Cardiovascular Disease and Hypercholesterolemia - Episode 5
Expert endocrinologists and cardiologists review the role of DCRM multispecialty practice recommendations and the use of combination therapy for patients with ASCVD and hypercholesterolemia.
Yehuda Handelsman, MD: I would like to address what Erin mentioned, the DCRM [Diabetes Cardiorenal & Metabolism Institute] released cardiorenal, metabolic practice recommendations. A group of endocrinologists, nephrologists, and cardiologists get together with experts on every aspect, heart failure, lipids, and blood pressure. We have everybody involved and are asking, can we address this complex patient in a different aspect than how we do it? We looked at lifestyle and control, individual risk factors, and the combination of people with heart failure and CKD [chronic kidney disease]. Erin, you worked on the combination and how we approached them both, and everybody here was involved, for full disclosure. Matt, you were very much involved in the atherosclerosis and testing, can you share a little of what we have there?
Matthew J. Budoff, MD: Yes. We wanted to go beyond the basic, know the LDL [low-density lipoprotein], know the blood pressure. Things like EGFR [estimated glomerular filtration rate], knowing their renal status and hemoglobin A1c [glycated hemoglobin] to try to get things done. Looking at their plaque burden, coronary calcium scanning in those low- to intermediate-risk patients for better risk stratification, to get a better handle on their global risk, and knowing where they are so that you can better target where they need to go.
Yehuda Handelsman, MD: Some of us were also involved in the glucose control, and we were very progressive in how we did glucose control. We defined a goal that you can choose, take 6%, 6.5%, or 7%, whichever you choose, just get to that goal. If you are 1 to 2 percentage points away from that goal, go with combination therapy. Just like with blood pressure, if you are 10 or 20 mm Hg away from the goal, go with combination therapy. We have done similarly on the lipid side. Erin, do you want to address it?
Erin D. Michos, MD, MHS: We are very comfortable with combination therapy with blood pressure. There are data suggesting adherence is optimized when you use single-pill combinations. We want to get to these new targets for these high-risk patients, an LDL less than 70 or 55 mg/dL. If you know where your starting LDL is and where you want to go, and if you already need more than a 50% LDL reduction, you are going to need more than a high intensity statin, so we should think about combination therapy up front. We also need to be intensifying every 6 to 12 weeks if we are still not at goal. Often people get started on a low-dose statin, they come back in 6 months to a year, and maybe it’s doubled, and people never get to goal. Then the Gold registry, in over in a 2-year period, only 12% of these patients with high-risk ASCVD [atherosclerotic cardiovascular disease] had their therapy intensified. We need to use combination therapy up front. The most common is statins with ezetimibe, but we also have other combinations, certainly adding PCSK9 inhibitors and bempedoic acid, which can be combined with statins. Bempedoic acid has a combination pill with ezetimibe, which will have ease of dosing. So we have a lot of different combinations that we can use to get our patients to goal quicker.
Yehuda Handelsman, MD: We like that we further highlighted the need to get to goal, to get to lower than 50%, to get combination therapy when we need it. Paul and I were involved with a practice recommendation from AACE [American Association of Clinical Endocrinology] in late 2020, where we addressed many of those issues. I thought in the DCRM, when we worked together, we got it even clearer that we need to use these guidelines.
Paul S. Jellinger, MD, MACE: I would like to pick up on a comment that Erin made in reference to every 6 to 12 weeks. I like to push it closer to 6 weeks, even 4 weeks. Doctors who double the statin dose or add an agent and say come back and see me in 3, 4, or 6 months, it’s inappropriate. We need to look at it as a race, we need to get that LDL burden down, and to take 3 or even 6 months to come back, and I see it all the time, it’s inappropriate. To answer one of the questions that I believe was coming up, how frequently should you check lipids? When you start someone on therapy, 4 to 6 weeks, no question about it, until you get to goal. I would choose 6 weeks, but others I have spoken to would choose 4 weeks. Once the patient is at goal, it becomes more difficult to assess. Once or twice a year I would be comfortable with, unless they gain a lot of weight, have a new risk factor that develops, become obese, diabetic, are on a new drug known to affect lipids, or any number of qualifiers that would make us want to check lipid levels in between. But let’s get into an every 4-to-6-week pattern till you’ve reached the goal, and then I would suggest perhaps twice a year.
Yehuda Handelsman, MD: Paul, I think it’s great, and it’s a great goal if we can do that. But Christie will tell you that after these 2013 ACC [American College of Cardiology] guidelines that you mentioned, we were checking a lipid panel every few months with a grade A recommendation. There still was a whole initiative against managing lipids, and you tried to do a counter initiative to it.
Christie Ballantyne, MD: We are still working on this. It’s ridiculous. If you look at the quality metrics right now—and those are very important in terms of health care organizations, CMS [Centers for Medicare & Medicaid Services]—obviously for diabetes, measurement of A1c is in there.
Paul S. Jellinger, MD, MACE: Every 3 months.
Christie Ballantyne, MD: For blood pressure, you are supposed to check blood pressure. For lipids, the ACC was saying that the person recommended a high intensity statin. Not even were they were taking it, it was recommended; that’s not a quality metric. People can put whatever they want, they will just check the box, yes it was recommended. The issue is, were you effective in their management? That’s a quality metric. As you said, the only way I can know if someone’s control is good is if I measure their lipids. First of all, were they taking the medications, because frequently they are not. Did they gain weight, what happened, psychosocial stressors? This is ridiculous; you cannot manage lipids without measuring lipids. Just like you can’t treat blood pressure without measuring blood pressure, or diabetes without measuring A1c. That hopefully will be addressed by the next ACC quality metric that is in progress.
Yehuda Handelsman, MD: Let’s hope it will go back into the guidelines.
Christie Ballantyne, MD: It’s supposed to. We are working on that. But you are right that guidelines did not come down in commandments in stone that are written forever. You have this issue, these are guidelines, it’s a patient-physician discussion, or health care provider or nurse practitioner. But in setting a plan for implementation, I like to get lipids in 4 weeks because the sooner they get the information, the more likely they are to keep taking the medicine. That’s the data on that.
Yehuda Handelsman, MD: This is a problem, and we need to go forward. The problem is, can you do it? Paul, you can order it in your practice, as you are in private practice. In large places, let’s say I talk to people from Brigham and Women’s Hospital, because it’s not part of the metrics, they cannot order it.
Christie Ballantyne, MD: You can if you have changed…that it is uncontrolled, there are ways of putting it in your note, once again. And if you’ve added a medication, you can always check it.
Yehuda Handelsman, MD: But then will they get paid?
Christie Ballantyne, MD: They will if you changed the medication.
Paul S. Jellinger, MD, MACE: I can’t underestimate the benefit of frequent lipid checking in terms of adherence. Patient adherence and physician reaching goal, it’s so powerful.
Yehuda Handelsman, MD: We agree.
Transcript Edited for Clarity