Case-Based Evidence for Cardiovascular Risk Reduction - Episode 1
Deepak Bhatt, MD, MPH: Hello, and welcome to this HCPLive® Peer Exchange® titled “Case-Based Evidence for Cardiovascular Risk Reduction.” I’m Dr Deepak Bhatt from Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts. Today, to review various trial data investigating the lowering of atherosclerotic cardiovascular disease [ASCVD] event risk and to discuss real-world patient scenarios, I’m joined by Dr Matt Budoff from the David Geffen School of Medicine at UCLA in Los Angeles, California and Dr Bob Busch from Albany Medical College in Albany, New York. I’m also joined by Dr Brett Nowlan from Cottage Grove Cardiology in Bloomfield, Connecticut, and Dr Jamie Underberg from NYU Langone Health in New York, New York. Welcome, and let’s get started with today’s program.
Brett Nowlan, MD, FACC, RPVI: Thank you.
Deepak Bhatt, MD, MPH: First, let’s talk a little about cardiovascular risk. You can never say enough about cardiovascular risk. Let’s start with you, Bob, discussing the burden of cardiovascular disease out there and the challenges of multiple morbidities along with the need for interdisciplinary research in the first place.
Robert Busch, MD: I’m pleased to be surrounded by cardiologists and lipidologists, but even as an endocrinologist, my entire day is spent trying to lower cardiovascular risk. We know that cardiovascular disease is the No. 1 killer in the United States, the No. 1 cost in the United States. This is despite great drugs being available over the last 2 or 3 decades with statins and RAS [renin angiotensin system] blockers, and there is an uptick of cardiovascular deaths perhaps because of an increase in diabetes and obesity.
Smoking seems to have leveled off, but maybe people are not taking statins from some of the hype about statins. We’re very fortunate that we have a lot of great drugs to treat patients, but there is a high residual risk despite those drugs. We can always do 1 better.
Deepak Bhatt, MD, MPH: That’s really terrific. Matt, for our audience, what exactly is the pathophysiology of hypercholesterolemia, and what risk factors are associated with it?
Matthew J. Budoff, MD, FACC, FAHA: When we think about our high cholesterol as our risk, we have to remember that there are multiple factors that go into that. Their LDL cholesterol, the low-density lipoprotein, is clearly associated both as a marker of risk and as a direct pathogen. It causes the macrophages to become foam cells, and that starts the process of atherosclerosis.
We know that triglycerides are also related to atherosclerosis as a separate risk factor, and genetics tie that in quite tightly with that same story. When we talk about risk factors, obviously the people who have high cholesterol are those who have diabetes, renal disease, metabolic syndrome, among others—those that have the highest comorbid conditions with hypercholesterolemia.
Deepak Bhatt, MD, MPH: Terrific. Brett, perhaps I can ask you something that comes up all the time. When should patients be screened for cardiovascular risks? Who is it that’s actually classified as high risk?
Brett Nowlan, MD, FACC, RPVI: Yes, absolutely. As you mentioned, this is an absolute fundamental that we do in our office every day. If we referred to the 2019 ACC [American College of Cardiology]/AHA [American Heart Association] Guideline, that’s for the primary prevention of cardiovascular disease. If I had to boil that down, it’s very reasonable to start from quite a young age, such as from the age of 20 years old, and ask someone about their family history of premature ASCVD and certainly about any tobacco product use.
You would want to measure blood pressure. It’s very reasonable at that time to send someone for either a fasting or nonfasting lipid panel. If someone has other risk factors such as diabetes, you certainly may be inclined to measure their blood glucose. If all that looks completely normal, then you probably should do that roughly every 5 years until you get to the age of 40 years old, according to the guidelines.
You should do those things routinely. At that stage, you really want to calculate a formal 10-year ASCVD risk using some of the risk-scoring systems out there, such as the pooled cohort analysis. If someone is at a borderline or an intermediate risk, you would move beyond those conventional risk factors to consider other things. For example, this may be metabolic syndrome, chronic inflammatory conditions, looking at other lipid risks, such as the lack of protein levels or inflammatory markers, like high-sensitivity CRP [C-reactive protein]. In my practice, I’m very swayed by a plaque-driven approach to risk assessment.
If there is any uncertainty looking at those basic factors—about whether someone is at increased risk or if there is uncertainty about low risk—then something like a coronary calcium scan can be very helpful as an adjudicator.
Deepak Bhatt, MD, MPH: Those have been a little more popular in recent years, you’re right.
Brett Nowlan, MD, FACC, RPVI: Absolutely. As a tiebreaker, particularly in that borderline and intermediate-risk group of patients, it is exceedingly helpful. We know that it also drives patient engagement—engagement and lifestyle modification, engagement and keeping up with therapies and their visits. If you look at all those risk factors, you consider someone to be high risk if they had an LDL cholesterol of 190 mg/dL or above, and certainly if someone had had a clinical ASCVD event, that would be high risk.
Most adults in the 40-to-75-years-old age range with diabetes will be at least intermediate risk. If they have any additional risk factors, certainly that would be likely high risk. If you were older than 75 with diabetes, you’re almost automatically high risk. Certainly if you have chronic kidney disease, stage III or IV, that would put you in a high-risk category. If you’ve gotten to the point of measuring a 10-year ASCVD risk and that risk is more than 20%, those are high-risk people. If you’ve taken a plaque-driven approach and you have a calcium scan, Agatston score of more than 400 Hu or worse than 75th percentile for age, gender, or race-matched cohorts. Those will be considered high-risk people.
Deepak Bhatt, MD, MPH: Yeah, that’s very useful for our audience.
Transcript Edited for Clarity