Advances in the Management of Hypercholesterolemia - Episode 5
Howard Weintraub, MD: At this point, we’re going to look at guidelines. When doctors think about what they’re going to do, they have historically enjoyed or looked for guidelines. You and I could talk for hours about our affections and disaffections toward some of the guidelines and what each of them have done over the last several decades to either make people more enthusiastic or, in some cases, to disenfranchise. There were guidelines from the ACC [American College of Cardiology] and AHA [American Heart Association] in November 2018, which were followed about 10 months later by European guidelines. This is very important when it comes down to how decisions are made, because a lot of doctors find that this is their blueprint or their recipe for how they want to treat their patients. One of the things that’s important has been consent of shared decision-making. I’m sure when doctors started telling patients about their condition, a lot of the time it wasn’t, “So tell me what you want to do. Do you want to take a drug? Do you not want to take a drug?” Then the patient swears on several Bibles that they’re going to do the very best they can. Depending on the follow-up or absence thereof, people can get lost in the shuffle. Discussion with the patient is so important. I’d love to hear your take on this, because I’ve thought a lot about this myself in the way I treat my patients. How do you get your patients to consider what would be optimal based on your interpretation of guidelines? In addition, we all know that every medicine that’s ever been developed is said to be an adjunct to lifestyle modification, namely diet and exercise. How do you work these things out and what kind of success have you had?
Alan S. Brown, MD, FACC, FAHA, FNLA: Let me start with the lifestyle because that will be a shorter answer. First, many of my patients want to be natural. They often say, “Why do I have to go on medication? How come I can’t be natural?” I explain to them that 100 years ago, everybody was natural, and they lived until about 38 years old, on average. So natural is not all it’s cracked up to be. That’s No. 1. No. 2, we do have some data about the importance of lifestyle modification. We have a lot of data that show you can lower your LDL [low-density lipoprotein] approximately 10% but lower your risk of an event even more than that. That’s true even in patients who are being placed on statin, for example. David Blankenhorn showed that 25 years ago via angiograms in people who were on statin plus niacin vs placebo. The folks on medication had less progression of atherosclerosis on follow-up angiogram. That goes without saying. But when you look at the people who were on medication—those who did well and those who didn’t seem to get the benefit of the medicine—the only differentiator between the 2 groups was the percentage of saturated fat and the diet. When patients say to me, “I’m taking my statin and my numbers are good. Can I go eat pizza?” The answer is no. There is good evidence that you’re going to get the best outcomes when you combine lifestyle modification plus the medication, if the medication is appropriate for you.
As far as the shared decision-making, I’m interested in taking a second on that. They say the most important part of caring for patients is caring for the patient. That is, to really care about them and let them know you care about them. Probably the most important thing that anyone ever said to me in my career is to consider how you influence people. This is not about how you make friends or how you keep your spouse but about how you become influential. The way you influence others has absolutely nothing to do with what they think about you. It has everything to do with how they feel about themselves when they’re in your presence. The first part of the shared decision-making piece is for that patient to understand that you truly care about them and to believe that you have their best interest at heart, which means taking a few minutes to make them feel good about themselves when they’re in your presence. This is true whether we’re dealing with colleagues at a committee or a medical organization or whether we’re dealing with other people. I have found over the years that the biggest impact that leads to a really valuable shared decision-making discussion is to make sure the patient understands that you care about them as a person. After that, it is really important for them to feel as if they were part of the decision of what’s going to happen going forward. Our job is to arm them with the data, explain how much we care about them, give them what we think is reasonable for them, and see if they agree once they have the data in hand. That is really important. It’s important in everything we do. It enhances compliance with our treatment and also reduces conflicts with patients and colleagues.
Transcript Edited for Clarity