Clinical Pearls on Lipid Management


A panel of expert cardiologists share their clinical pearls for managing patients with hyperlipidemia.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: I’m going to give each of you about a minute or so to give what we call a take-home message: a clinical pearl for the physicians, nurse practitioners, physician assistants, [and] pharmacists who may be listening, something that will motivate them to do better. We’ve heard from the Family Heart Foundation that we’re not recognizing these patients early enough and that those patients at high risk are not getting high-intensity statin. We heard from Dr Michos that there is a whole world of alternatives. Christie, you suggested [that] we combine these agents [to] reach lower [lipid] levels vs pushing [the dose of] a drug to toxicity level. Dr Kohli, you’ve been very persistent that education, culturally appropriate [and] literacy-appropriate education, is one of the linchpins to success.

Christie M. Ballantyne, MD, FACC: We’ve talked about education, but it starts with [this]: “You can prevent heart attacks and strokes.” Patients need to know their numbers; that’s an education process. We help them get there. We’re their guides to get there. One thing that is a frustration, a practical point in terms of when you use some of the nonstatin therapies, [is] the approval process. It turns out—we have fellows coming [in] every year—if you say this patient has a family history of very high cholesterol [level] and premature heart disease, [you’re] denied. You [have] to say heterozygous familial hypercholesterolemia [FH]. There’s an ICD-10 [International Classification of Diseases, Tenth Revision] code for that. Put those words in there. If you say [the patient] “has heart disease or ASCVD [atherosclerotic cardiovascular disease] with MI [myocardial infarction]”…put the right information. Have a lipid measurement within a month, [provide] the LDL [low-density lipoprotein] cholesterol [level], [and state], “It was unacceptably high; therefore, [I’m] using this agent.” Some pragmatic steps will reduce the frustration for both [patient and provider], because if the patient doesn’t get it and you don’t get it, it’s frustrating. But you can do it. It’s easier.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr McGowan, thank you for your great work with the Family Heart Foundation. Can you give us some clinical pearls to help our clinicians out there do better?

Mary McGowan, MD, FNLA: When you screen patients, and hopefully you’ll screen all your patients, [but] when you screen patients with a lipid profile, if it’s an adult person and you see an LDL [level] greater than 190 mg/dL, you want to think familial hypercholesterolemia. With that in mind, you want to have a conversation with the patient [that] this is unlikely to be chance. This is your genetics, and, therefore, your children need to be screened, your siblings need to be screened, and it’s important. People who hear that it might [affect] their children are more likely to take action. So take action. The other big thing, [because] I’m coming from the Family Heart Foundation, [is] don’t forget to measure lipoprotein(a) [Lp(a)] [level]. Don’t think it’s unactionable. I’m going to tell you one quick story about a patient of ours who’s an advocate for Lp(a). This young woman was 44 years old [with a] completely normal lipid profile. [She] did have a history of cardiac disease [and] attributed her father’s early cardiac disease to his type A behavior. She waited 18 hours with chest pain before going in and finding that she was having a cardiovascular event: a myocardial infarction. What she said to us was, “If I had known I had such a high Lp(a) [level], I would have gone in earlier.” That was important information to me. So even if you feel like there aren’t agents currently [available], as everybody else has said, you can reduce other risk factors. Measure that Lp(a) [level] and then take action. And educate your patients about it.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Very important messages. Dr Kohli?

Payal Kohli, MD, FACC: There’s so much burnout in medicine. It is so hard, what we do on a day-to-day basis. But the thing that keeps me most engaged is knowing that I made an impact on somebody’s life. If you could take 2 or 3 minutes at the end of every visit, no matter what it’s for (eg, knee pain, urinary tract infection, back pain), to look at those lipid [levels and] focus on prevention, [then] you are going to have a tremendous impact on [a] number of lives out there that you won’t even realize. That will give you the highest degree of engagement: knowing their numbers, not just knowing your numbers, but knowing your patients’ numbers and phenotyping at every visit so [that] you’re delivering a personalized care plan. You’re not lumping every secondary prevention to less than 70 mg/dL or less than 55 mg/dL. You’re using your risk modifiers to reclassify that risk in an iterative fashion at every visit for your primary and secondary prevention. So if Mrs Jones had a stroke since the last time you saw her, her risk just changed. You bump her down to the next level, δ LDL of 50%, and get [her level] below those thresholds. If you can work it into your busy practice, just spend 2 minutes at the end of each visit looking at those lipid [levels] and making a little plan. It’ll be tremendous how many lives you’ve changed and how many trajectories of atherosclerosis you’ve modified.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: That’s a wonderful message. Dr Michos, you have the last take-home [message].

Erin D. Michos, MD, MHS: I want to circle back to something that Dr Kohli said at the beginning about cholesterol years. This is something that might resonate with patients and other clinicians when they’re familiar with pack-years of smoking. It’s not only the magnitude of elevation; it’s the duration [that] one’s [had] that value. There’s been some modeling thinking that the theoretical onset of clinical ASCVD may be around 5000 mg/dL-years. Individuals who have had high cholesterol [level] since birth—our patients with FH—if left untreated, they’ll cross that threshold of clinical ASCVD very young in life. Whereas individuals who have favorable genetics, healthy lifestyle, or early treatment may never cross that threshold for clinical ASCVD. [And] don’t forget about those with mild to moderate hyperlipidemia. The LDL [level] is [in the] 130s mg/dL [or] 160s mg/dL. A lot of these patients are ignored. But [if] left untreated for a sufficient number of years, those individuals will have earlier onset ASCVD than their counterparts who have had lifelong low LDL [levels]. The message is [that] we want to get LDL [levels] lower for longer and get there faster.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Wonderful message. Thanks to you all for this rich and informative discussion. And thank you for watching this Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchange [videos] and other great content right in your inbox.

Transcript Edited for Clarity

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