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Evolving Strategies for Cholesterol Management and Atherosclerotic Cardiovascular Disease Risk Reduction - Episode 5

Achievement of Goals in ASCVD

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A panel of experts discuss the importance of achieving low-density lipoprotein cholesterol (LDL-C) in patients.

Erin D. Michos, MD, MHS, FACC, FASPC: We’ve talked more in this program about goals, and then we’re going to get into therapies. Jorge, can you tell us a little about patient versus clinician goals? How do we talk to our patients about their goals? Why are achieving goals important? We alluded to that we do have some thresholds, and the slight difference between the European guidelines that talk about goals, where the ACC/AHA [American College of Cardiology/American Heart Association] talks about thresholds, where if you’re above a threshold to intensify therapy. How do you talk to your patients about the numbers?

Jorge Plutzky, MD: It’s an incredibly important point because it has such an impact on patients and their embracing the idea, not fearing it, and understanding the commitment that’s necessary to saying, “Yes, I want to get treated for this.” There are a lot of different approaches to how you convince patients of that. But sometimes when I go through the whole discussion around cholesterol and reducing your risk, and lowering LDL [low-density lipoprotein] with a focus on LDL as opposed to the total cholesterol, I will say to the patient who I think might be resistant, “Let’s imagine we play this conversation back. I start and I change one word, instead of talking about cardiovascular disease, I say cancer, and I have a therapy that’s going to reduce your chances of having cancer by 50%. The tolerability will be the same as placebo.” Most people would say, “Why didn’t you give that to me yesterday?” It’s a mindset of this being important. As doctors, we convey that.

I usually create the context of a continuum of risk and incorporate for the given patient where I’m looking for them to get to. It’s the idea of getting closer to an LDL level of 55 mg/dL if you have very high risk and established cardiovascular disease, and then the gradations from there. One of the aspects of that that’s really important too—and we’re starting to see some movement away from this—is that we do this incremental stepwise approach. When someone’s had an event, they go on to high-intensity, full-dose statin, but even in that situation, it may not be enough. Those conversations can start incorporating the idea for patients that, “We’re starting here, but I’m anticipating needing to add another medicine.” Because if someone’s starting at a very high level, or as I think we see a movement now, is even initiating combination therapy up front, instead of saying, “I’m going to wait for this incremental process.” You get into unfortunate scenarios where patients feel there’s a failure. You started at a low dose, and now they are going to a higher dose. It’s like we need to anticipate that ahead of time, and set the stage for the patient to recognize the importance of this, and that we’re all in. There’s a good chance, or I expect to add a second agent, or I’m adding 2 agents now, because it’s so important. In the same way that for blood pressure, we very often need more than 1 agent to control blood pressure.

Setting that up for patients so they’re not thinking there is some failure, or some danger in escalating therapy, is important. The extent of evidence that we see in our own system, and then nationally, of undertreatment requires us to begin talking about the rationale, and the basis, and the need for therapies that are safe and proven and effective.

Pam Taub, MD, FACC, FASPC: This is where we can learn from our friends in endocrinology. If someone comes in to see Bob with an A1C [glycated hemoglobin] of 8%, no one’s going to just start metformin; it’s going to be multiple drugs. Similarly, if someone walks in with an LDL of 190 mg/dL, we don’t just put them on atorvastatin 20 mg; it’s not going to get us where we need to be. We need to be doing more combination therapy up front.

Robert Busch, MD: Pam, if you ask my patients what they eat for breakfast, their answer is pills, because they’re on 2 or 3 for diabetes and maybe a shot. They’re on 2 or 3 for their blood pressure, and 1 or 2 for their lipids, in addition to the rest of their life with their SSRI [selective serotonin reuptake inhibitor] and PPI [proton pump inhibitor] that they’re taking. We’re selling the science to the patient that you need another medication to get to this goal or threshold that we’ve done with the other disease states, and you have to do all of it. You’re not doing it on day 1. You’re not giving 8 medications the first day, or they’ll run away and never come back. But that’s the long-term plan with the patient.

Alison Bailey, MD, FACC: That is incredibly important, as you’ve all pointed out, but when the patient’s sitting in front of us, this is their only experience. They don’t know what we know. We know they’re going to need 3 or 4 medications down the road. We have to reiterate that up front; “If you do well, this is what I plan to happen. If you don’t do well, we’re going to go this pathway, but hopefully, we go well, and you’re going to be taking more pills.”

Transcript edited for clarity