Paradigm Shifts in Lipid Lowering - Episode 3

Identifying Patients at High Risk for CV Morbidity and Mortality

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Norman Lepor, MD, FACC, FAHA, FSCAI, shares how he would identify and monitor patient populations at high risk for CV morbidity and mortality.

Keith C. Ferdinand, MD: Norm, the patient who comes in front of you now has risk. I already mentioned the lipid profile; it could be average, especially between the African Americans, the LDL might be 113, 120, HDL 50, triglycerides 80. It does not look that bad. Blood pressure is a little high, smokes, has some obesity. How do you then determine what patient really is at high risk, not just in terms of the simple metrics that we use in the conventional visit. What type of tools do you use to tease out those very high-risk patients?

Norman Lepor, MD, FACC, FAHA, FSCAI: What you are describing is the patient who has a little bit of this and a little bit of that, and I think that first off, in my evaluation of the patient, I am interested in really getting a detailed family history. Because genetics are such a strong component. And they always say you must know history because history repeats itself, and it is incredibly important to get really a feel for the genetic predisposition, which I think accounts for the predisposition to some of the other comorbidities you mentioned beyond lipids, hypertension.

Even a patient I saw today, I had to convince her to take her blood pressure medication, and then she tells about her sister who is also hypertensive and also I think when a patient presents, particularly a new patient, it's kind of like putting the pieces of a puzzle together, and what you're doing is you're getting the genetic information, then you're defining other risk factors, their history of perhaps tobacco use, and their tobacco use could be smoking or it could be -- probably more likely where you live, more like chewing tobacco. And then we get into some of the comorbidities.

But I've always felt that imaging plays a critical role. And I certainly early on took a lot of bullets, because early on you would hear people talking about how cost ineffective it would be to do calcium scoring and these other assessments. But as a cardiologist, I prefer living in a world of absolute risk rather than relative risk, and I think I would like really, at the end of the day, find out how all these risk factors that we know about, plus the others that we do not frankly know about, and see what it does in terms of defining phenotype. And how do you define phenotype? Well, you could define phenotype if the patient has had a history of an event. Have they had an MI [myocardial infarction], have they had a stroke, do they have PAD [peripheral artery disease], have they had a coronary stent?

But oftentimes I am seeing these patients before they manifest these secondary complications of disease, and I will be very aggressive about calcium scoring, and even in the diabetic patient I am very aggressive because even though diabetes is considered a cardiovascular disease equivalent, I know, and I see a very amount of heterogeneity even within the type II diabetic patient.

What I really try to do is define absolute risk, and then once I have defined that patient as being absolute -- at a high relative risk and high absolute risk, I'm very aggressive with a little bit of hypertension. I normalize their blood pressure. I try to make an effect with education on lifestyle modification, such as the salt in the diet, activity, alcohol use. I am very aggressive about getting my patients to lose weight by virtue of trying to minimize the development of diabetes and perpetuation of the metabolic syndrome, and yes, I will even use pharmacology as a cardiologist. We do have some good pharmacology; unfortunately, it is not that available to the Medicare population because of insurance issues. For some reason Medicare does not consider -- it does not take seriously obesity as a disease state, so I do not have as many tools. 

What I do is, I use imaging in a large extent, carotid ultrasound, I will use calcium scoring, and I'll use that to really, I think do a better job of defining the risk of disease in this population, and then the more malignant the risk. And we can talk about that later because it is not cookie cutter for me. The more malignant the presentation, just like cancer, and I have been quoted as saying atherosclerosis is like cancer of the arteries. And the more malignant the presentation, the more aggressive I am going to be in terms of goals for treatment.

Keith C. Ferdinand, MD: I agree with you. Coronary calcium scoring now is readily available. In fact, the cost is down. In most places you can get it for $100 or less. The amount of radiation is not more than a mammogram with the new techniques, so it is a way of looking and discerning those high-risk patients who have the various risk factors, you put them together, it does not really impress you, but then with a strong family history you pick up something.

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Transcript Edited for Clarity