Evolving Strategies for Cholesterol Management and Atherosclerotic Cardiovascular Disease Risk Reduction - Episode 4

Personalized Treatment for Patients with ASCVD

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Experts in cardiology share their thoughts on patient/clinician communication and treatment customized to the individual patient.

Erin D. Michos, MD, MHS, FACC, FASPC: One of the questions we had for you, Dr Busch, what is your approach to treatment goals? How do you personalize it for the individual patient versus following the guidelines with the same rules for everybody?

Robert Busch, MD: American College of Endocrinology makes it easy because if you have diabetes, you’re going to be on a statin. If you have no other risk factors, which is almost nonexistent, the LDL [low-density lipoprotein] has to be below 100 mg/dL. That’s not so difficult unless they start way high. If they’ve had other risk factors, then it’s below 70 mg/dL, if they have hypertension, or the some of the risk factors that Dr Bailey enumerated. If they’ve had an event, they have to be below 55 mg/dL. We don’t have to be very smart; we don’t have to calculate all the stuff that you do. You have diabetes, where’s your statin? Do you have 1 risk factor or 2 risk factors, or if you’ve had an event, and there’s your LDL goal.

Erin D. Michos, MD, MHS, FACC, FASPC: We’re going to talk a lot about drug therapy here in a moment. I’m a lifestyle enthusiast, as many people know. I know Dr Bailey was a coauthor on the cholesterol guidelines. They still have a very important role, talking to patients about lifestyle and diet. Can you tell us a little about what the guidelines say about that, and then your own approach to counseling patients about lifestyle changes?

Alison Bailey, MD, FACC: This is really important because the lifestyle changes, we know do more than just lower your cholesterol. They play a role in lowering cholesterol, though it’s pretty small, I think most of us recognize, unless you make drastic changes. Everybody should opt for an optimal weight, which is a body mass index of less than 25. Everybody should eat a diet that’s high in fruits, vegetables, whole grains, minimizes saturated fat and processed oils, and stays away from processed foods and red meat. Those have all been proven to lower cholesterol levels. We should all be active, 30 to 40 minutes of activity most days of the week. We know that the majority of Americans are overweight or obese; without physical activity, we’re not going to move that metric anywhere either. That’s where we start by telling everyone, and then make sure you don’t smoke. Obviously, that’s in the rules for being a doctor.

Then my personal approach is we do the same things. I have a lot of graphics in the clinic that we talk about. I talk about my experience; I say I don’t know what my calcium score is, but I live like it’s 1000. I optimize everything else in my life; I try to be active, I try to eat a mostly plant-based diet that stays away from processed foods. I try to maintain a healthy weight. There are a lot of ways to do that, there is not one dietary pattern that’s perfect. I think you have to find the one that works best in your lifestyle, and work for that. What we know is all of those healthy patterns avoid processed foods and minimize red meat. We also teach a cooking class…that our patients can come to. It’s offered by our facility in partnership with another group, and all of our patients can come to that for free as many times as they want. We focus on those same concepts; we invite all of our patients with diabetes as well.

Transcript edited for clarity