New Guidance, New Data and New Targets for the Management of Hyperlipidemia - Episode 5

Reasons for Not Reaching Thresholds

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The reasons many patients do not reach LDL-cholesterol thresholds.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: The Family Heart Foundation should be congratulated for showing such powerful data on how we’re not achieving LDL [low-density lipoprotein] thresholds. We’re not using appropriate therapy. Dr Kohli, what’s up? Why is this? What’s going on?

Payal Kohli, MD, FACC: This is obviously very eye-opening for me. But it’s not all that surprising if you think about it because hyperlipidemia is an asymptomatic condition. When it comes to us as providers and us as patients, it doesn’t tap us on the shoulder and say, “Treat me.” We really have to go sort of looking for trouble. And that’s where the patient education piece, I think, really comes in because a lot of patients have a reluctance to take medications. And it’s because they don’t realize that leaving their cholesterol untreated could potentially lead to these types of outcomes. I have patients every single day who come to me, and they’ll be happy to take red yeast rice, which is a low-potency statin essentially, because they think it’s a nutritional supplement. But there’s the sort of cultural bias against taking a medicine for the rest of my life that could potentially be something I have to do every day.

So I think the first piece of it is patient education, and what ties into that is a lot of misinformation, especially online. When it comes to statins, they’ve gotten a bad reputation even though they’re lifesaving medications. People worry about muscle aches. They worry about dementia. They worry about their hemoglobin A1C. All the things that you can find out there. So it behooves us as clinicians, I think, to really dispel some of that misinformation.

And then the final patient perspective piece is the [adverse] effects. There are patients who can have perceived or real [adverse] effects [and] just can’t tolerate statins for whatever reason. That’s when we start to reach in our toolbox, talk about what Dr Michos mentioned, some of the nonstatin agents that could potentially help to reduce their risk.

Now that’s the patient piece, Dr Ferdinand, but there’s also something on us as providers where we need to step it up. I think the first piece of that is really a knowledge gap. We’re drinking from a fire hydrant when it comes to the number of guidelines that are coming out, so keeping up with the latest sometimes can be challenging, especially as a busy primary care physician. And we worry about driving their LDL [level] down too low, which is a misinformation that primary care physicians and a lot of internists and cardiologists have.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Hasn’t been shown to be a real problem.

Payal Kohli, MD, FACC: Not at all. In fact, the opposite. A lot of the data [are] really encouraging us that lower is better and there’s no such thing as a floor. You really just can keep going lower and feel very comfortable doing that. And then the final piece of it is, I think, that perceived lack of time. We’re so busy. We’re pulled in so many directions, and so we put out the fires that we see. We don’t reach for the fires that we don’t yet see.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Boy, that’s really true. Dr Michos, you’re on the East Coast, Baltimore. [There are] high-risk patients in Baltimore. Many of them are not reaching the thresholds, as Dr McGowan has shown in [data from the] Family Heart Foundation. What’s been your experience? Why are we not doing better?

Erin D. Michos, MD, MHS: I think it’s so many of the issues that Dr Kohli brought up that kind of lead to clinical inertia. Unfortunately, we often have very limited time in practice, especially for busy primary care providers [who] have so much to cover in a visit. And this is where I really think we need a team-based approach to care, [so] that we can identify patients not at goal if we leverage our data from our electronic health record system. We can identify patients who have a clinical ICD-10 [International Statistical Classification of Diseases, Tenth Revision] code for atherosclerotic cardiovascular disease whose LDL [levels] remain above our target thresholds. You can look at [their] medications [and] see, do they have a statin prescribed at the appropriate high intensity? You can even identify which patients likely have probable FH [familial hypercholesterolemia] just from [the] EMR [electronic medical record] based on their LDL values above 190 mg/dL. Enlisting help from pharmacists, nurses, and other parts of our [health care] team [who] can help identify these patients [who] are not at their LDL goals and using these flowcharts that are so clearly, nicely outlined in our statements help support our clinicians to work together to get our patients to goal.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr Ballantyne, I know you’re going to tell us about some action that the American Society [for] Preventive Cardiology and National Lipid Association are taking to look at LDL as a performance measure. But before you do that, you’re in Houston. High-risk patients not getting to goal or not reaching the thresholds. That’s what Dr McGowan’s data [show] us. What’s been your experience?

Christie M. Ballantyne, MD, FACC: It’s very frustrating, Keith, because we have all this knowledge. We [have] cancer and cardiovascular disease as the 2 major causes of death. A lot of the cancer is [due to] the fact that we don’t really know how to prevent a lot of cancers; we [know] smoking cessation, better diet. But we could prevent most cardiovascular disease. We know how to do it, but we’re just not doing it. I think there’s a major gap between our science and our implementation. This is like at the knowledge level, and we have efficacy versus effectiveness in clinical practice. And I think that’s, hopefully, where we need to focus, the things we mentioned. Erin mentioned some of the opportunities when you have an EMR and a health care system. That kind of leads into what you mentioned afterwards, [which] is that the issue is, to be honest with you, our guidelines and our quality metrics don’t take advantage of that. Our guidelines are a little confusing.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: I’m going to hold you back. I want you to talk about what you’ve been doing in that area. It’s very powerful, and it’s really important.

Transcript Edited for Clarity