Optimal Management of Lipid Disorders: Expert Nurse Practitioner Perspectives - Episode 2

Practical Management of Patients at Risk for CVD

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Joyce L. Ross, CRNP: I know we have had similar experiences with clinical work in our clinical experiences, and I think about the patient who comes in to see you or me in a clinical setting. If you think back, Lynne, could you think about 1 of the patients who had come to you because they needed to have the enhancement of this expertise that you can offer for bringing that person to the idea that they needed to be treated, why they need to be treated, and perhaps what should be treated for them?

Lynne Braun, PhD, CNP: Sure. A lot of my background is treating women with risk factors or concern that they have elevated risk because my background has been primarily in the Rush Heart Center for Women. I saw men as well, but mostly I saw women. I had a lot of patients directly referred to me because my arrangement with my collaborating physician is that she really wanted to see and thought she should see more of the secondary prevention patients and that I was highly qualified to treat the primary prevention patients. My typical patient would be a woman who’s probably reached middle age, and she either has a strong family history of premature cardiovascular disease or multiple risk factors, and she really wanted to know how to address those risk factors and how to specifically reduce her own risk.

Typically, she had young or even adult-age children, and she was concerned about them as well. Some of these came by referral of the FH [familial hypercholesterolemia] Foundation. I also had younger patients, men and women who have heterozygous familial hypercholesterolemia. I have actually been 1 of the few providers in our practice to see these patients until now. Some of that’s a little different. Joyce, you’ve had tremendous experience with patients who have FH. Why don’t you tell us about some of your typical patients?

Joyce L. Ross, CRNP: Sure. Thanks, Lynne, for that. Most of my career has been centered on the work with familial hypercholesterolemia. When you are born, you actually inherit something. No matter how well you’re doing your diet, your exercise, all those wonderful things that are part of the lifestyle intervention, you are not going to escape what God gave you. What’s problematic is that most of these patients feel wonderful. They have no idea that they are really high risk, no symptoms. They just know that their father had a heart attack maybe at age 45, but he smoked and didn’t exercise. So we have a way of falling back. A typical patient for me could have been someone who has a family history of familial hypercholesterolemia who is now being encouraged strongly by their spouse to get an evaluation to find out if indeed they are high risk and how do we treat you, so that they are around to help them raise their children.

My patient would often come in very hesitant: “I don’t need any medication. I’m not taking any medication. I don’t have these risk factors.” There are many things that we have to do. As you mentioned earlier, these enhancing risk factors are something that is so important to talk about, because the patient with familial hypercholesterolemia very often has other high-risk things: Apolipoprotein B that makes that LDL [low-density lipoprotein] cholesterol even more dense or high lipoprotein(a), which causes clot formation and is even more problematic for this patient with FH.

It takes a ton of education. For this particular patient, I would start out and say, “I know you’d really not be here, but it’s great that your family loves you. I know you want to be there to see your daughter down the aisle on her wedding day.” I always found that if you get to the heart of the dad for his little girl, then maybe you have a chance to start that dialogue. It’s important to start the dialogue, as you talked about, doing your risk assessment, and having an open conversation: “OK, this is where I see you. How do you see yourself?” Of course, because we’re nurse practitioners, we have the time that we weren’t constantly worrying: “Oh my gosh, I’ve got to get the next patient in here.” What I found out is it took the next visit before we actually got down to the planning because we had to establish trust, and that patient had to absorb what was really happening.

Oftentimes, what I did with that patient was getting an electron beam CT scan or a coronary artery calcification, because I call it the crystal ball. We can look inside the coronary arteries into the heart between heart beats, and you can see plaque starting to develop. It doesn’t tell stenosis or anything like that, as you’re aware, but what it does is show that there’s cholesterol in there and it’s unstable plaque.

Lynne Braun, PhD, CNP: Yes, and not just cholesterol. There’s disease.

Joyce L. Ross, CRNP: Exactly. If they reach a certain score, then we tell them, “You actually have subclinical disease now.” The idea is to halt the progression. You can’t go back and fix what’s broken already. Basically, with that patient we would establish that there is a need to treat, then we would go on to talk about the myths they have for any of the medication. We would establish that, “No, if you take a statin, your liver is not going to fall out. No, it’s not going to kill you.” As a matter of fact, the biggest risk factor for taking a statin is it will save your life. That was the typical type of a patient.

Transcript Edited for Clarity