New Guidance, New Data and New Targets for the Management of Hyperlipidemia - Episode 7
Expert cardiologists discuss data on gender, racial, and ethnic disparities and how to address them in the management of hyperlipidemia.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: We’re going to start now an important part of the conversation, and that’s the fact [that] although we now have these important tools to measure LDL [low-density lipoprotein] cholesterol—we have thresholds—[and] we have different medications, and we’ll go into some of the newer medications in a minute or so, [yet] we still have disparities. We don’t have the utilization of these tools equally across race, ethnicity, sex, gender, geography, and socioeconomic status. Dr Michos, you have been a very strong advocate for treating everyone across those different aspects of our population equally. You want to start that discussion?
Erin D. Michos, MD, MHS: Yeah. Unfortunately, as you mentioned, [there are] a lot of disparities. So even in clinical ASCVD [atherosclerotic cardiovascular disease], which has a class 1 recommendation for high-intensity statins across all guidelines, women are less likely than men to be initiated on a statin, even in the setting of secondary prevention. And if initiated, they’re less likely to be on a high-intensity statin. Women are more likely to discontinue a statin if started, and they’re more likely to report statin-associated muscle symptoms. So there’s already a disparity in secondary prevention.
And in primary prevention, it’s even worse. There is this perception that women are universally lower risk than men because of some premenopausal advantage, but that is not equally true to all women. We’ve been talking a lot about FH [familial hypercholesterolemia]. In the setting of FH, there is no female gender advantage. Women with FH, if untreated, have the same early-onset ASCVD as their male counterparts with FH. Also, things like diabetes and smoking also negate any female premenopausal advantage.
And there are female-specific risk-enhancing factors. We were talking about some of these risk-enhancing factors like South Asian ethnicity, elevated LP(a) [lipoprotein(a)]. But our guidelines also highlight things like premature menopause and adverse pregnancy outcomes, like preeclampsia, that would put a woman in a higher category where they might benefit from initiation of statins for primary prevention. And I think it’s important as clinicians that we take a comprehensive reproductive history in all of our female patients. So women are undertreated.
And then we see significant disparities also by race and ethnicity. There was a series of papers, one by Dr Jacobs in JAMA Cardiology this year in 2023 and one by Dr Aggarwal in JAMA in 2022 that used NHANES [National Health and Nutrition Examination Survey] data, [that] looked at both use of lipid-lowering therapy and LDL goal in primary prevention populations. There’s broadly in the US sort of low use of statins in primary prevention, even in those at high estimated—more than 20% estimated—10-year risk. So high-risk primary prevention use of statins [was] low. And this is even greater among Black adults and Hispanic adults, where the use of statins was less than 25% even in this highest-risk group of more than 20% 10-year risk, which is a class 1 indication for a high-intensity statin. And then if you look at LDL control, again, we see these same patterns that Black adults and Hispanic adults compared [with] White adults are less likely to achieve LDL goals.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr Kohli, I know you’re a strong advocate of patient education, of reaching outside of our little box, our little clinic setting, and talking directly to people. Do you think that may be one pathway where we can start to educate a diverse population based on sex, gender, race, ethnicity, [and] geography? Reach people so that now they demand that their LDL [level] be evaluated and treated appropriately?
Payal Kohli, MD, FACC: I think that’s critical. I think it really has to be a multifaceted approach. Empowering and educating the patients, especially in some of these communities where we know it’s not just their race and ethnicity that put them at higher risk but social determinants of health as well. The fact that they live in a food desert, the fact that they can’t afford high-quality food. The lack of access to health care; they can’t afford their medications. And all of these types of social determinants of health create sympathetic nervous system activation. They create amygdala activation; they activate [their] cortisol levels. And all of that feeds forward into worsening their underlying physiology and biology.
So I think helping the patient to know what their risk is so that they can go to their doctor and say, “I have early onset hypertension” or “I want my LDL cholesterol [level] lower because I have a strong family history of heart disease.” And doing that in a way that appeals to these different groups, doing it in a way that they understand—it’s at their literacy level. These are critical things for us to do as providers, and not doing this, in my mind, is an error of omission. We always worry about doing something to a patient that leads to a bad outcome, an error of commission, but every single day we create errors of omission by leaving LDLs untreated.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr McGowan, I know the [Family Heart] Foundation is very interested in making sure that this disease is identified across all different populations. You want to speak to that?
Mary McGowan, MD, FNLA: Sure. So we are reaching out to all groups. And we feel that it’s incredibly important, just as Dr Kohli pointed out, that people know what their risk is and that they’re empowered to ask for the help they need. We are not afraid to tell people you might need a new provider. If somebody is going to their physician and they have FH and they’re being put off in terms of getting their LDL [level] to goal, it doesn’t matter what race, what ethnicity they are. And, you know, we are also very big proponents of programs across the country that will seek out individuals [who] may not be [getting] treated in a formal setting.
The WISEWOMEN [Well-Integrated Screening and Evaluation for WOMen Across the Nation] program from the CDC, that’s a huge program that we think is really important to educate women who are maybe underinsured or not insured about what their risk is and doing it in a community setting. We talked earlier about the DECIPHeR [Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk] program, which I know you’re involved in, [and] I think is fantastic. I know Baltimore is a recipient—Johns Hopkins. And so we want people to get information any way they can. And the Family Heart Foundation is really seeking to educate people across the country about familial hypercholesterolemia. And certainly now with our expanded mission, elevated lipoprotein(a), which impacts so many people.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Yeah, we do have a major NIH [National Institutes of Health] grant in New Orleans, a very high-risk population. And we’re going directly into the churches using nurse practitioners [and] community health workers [CHWs] to try to control risk factors in the community setting. Thank you for mentioning that.
Mary McGowan, MD, FNLA: Yeah, it’s great.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr Ballantyne, I’m going to have you comment on statin intolerance; that’s the next segment. But before we do that, I know Houston, huge population, very diverse. How do you overcome some of these barriers?
Christie M. Ballantyne, MD, FACC: So, you know, Keith, I think you’re talking about expanding the approach, [and] we’ve all talked about this. We’ve got an NIH grant with a colleague using community health workers, again, in the Hispanic population with diabetes because what you end up [with] is now you have a language [barrier] on top of all the other barriers with it. And you mentioned CHWs, and that’s trying to be expanded from community clinics to also churches.
I think you’re looking at people basically, you know, to communicate. First of all, you got to have a language [for communication], but you also, in addition to English versus Spanish, there’s another language of what’s their situation. Our health care system is complicated. I have a hard time helping my family get through the health care system, much less if I’m someone who maybe is a new immigrant [and] doesn’t speak the language. I mean, it is confusing. How do you get your medications? How do you go through all this stuff? So I think that’s another language, and you need guides who they [can] trust.
Community health workers are more of a trustworthy commodity. The churches can help people get into the system to overcome some of these barriers. I mean, it’s not easy. So we do have to take a broad approach. But our health care systems can help. If you measure lipids in everyone, you’ve got hard data. So now you can look at the disparities. That’s another reason [to go] back to this issue of measuring LDL [levels]. If you measure blood pressure in everybody, you can say, “OK, are we doing worse in certain groups?” Go look at the zip codes, and go look at some of these things. Without the data, you can’t really systematically try to address these issues.
Keith C. Ferdinand, MD, FACC, FAHA, FNLA: So we need to measure LDL [levels], we need to achieve thresholds, [and] we need to use evidence-based medicine regardless of sex, gender, race, ethnicity, geography, or socioeconomic status. If we don’t do that, we won’t have a fair society.
Transcript Edited for Clarity