Closing Thoughts for the Management of CVD



Deepak Bhatt, MD, MPH: Thanks to all of you for this rich and informative discussion. I’ve certainly enjoyed it and learned a lot from all of you. Hopefully the audience has too. Before we conclude, I’d just like to get some final thoughts from each of you. We’ll go in alphabetic order and start with you, Matt.

Matthew J. Budoff, MD, FACC, FAHA: We had some great cases today and a great discussion. At least from my perspective, we have to reprioritize where triglycerides fit into our algorithm of care. We’ve been focused on LDL [low-density lipoprotein] for so long, and that’s appropriate, but we had some interesting cases where the triglycerides were in the 300s mg/dL, and the LDL might have been mildly elevated.

In my algorithm of care, I would add icosapent ethyl first and then later add some of these additional LDL therapies, because the absolute benefit is so much greater in reducing triglycerides, as was discussed with the REDUCE-IT trial and some of the subgroups, than what we’ve seen with some of the LDL therapies to date. It is a changing world, and it will be interesting to see how all these therapies play together in the sandbox, so to speak, as we start using them together in our patients.

Deepak Bhatt, MD, MPH: Great point. Bob, you can go next.

Robert Busch, MD: To highlight what Matt said, looking at the triglycerides is key. The comedian Rodney Dangerfield said he gets no respect. Triglycerides get respect, not just 500 mg/dL or more. If the triglycerides are high—over 135 or 150 mg/dL—that’s an indicator that action must be taken; the patient has persistent cardiac risk. Just because the patient is on a statin and all these other great drugs, you could lower MI [myocardial infarction] stroke death. Look at each individual thing, the composite, and act on that. Don’t ignore triglycerides. Your should focus on not only the blood pressure, the A1C [glycated hemoglobin], and the LDL but also triglycerides and do something about it.

Deepak Bhatt, MD, MPH: That’s good advice. Brett, what are your thoughts in closing?

Brett Nowlan, MD, FACC, RPVI: First, I’d like to say that it was my pleasure and privilege to join all of you today. I certainly learned a lot from this discussion. This is an exciting time to be a practitioner who is prevention focused, because we have a lot of options, we have expanding options, and we have tools to assist with risk evaluation. In my practice and my practice habit—which is taking a plaque-driven approach—1 of the challenges now, because we’re spoiled for choice, is who should get therapy and who shouldn’t. We have a fistful of agents that we could potentially give to everyone.

We need to get better at selecting who is truly going to get the most benefit out of those agents and who should be de-medicated and shouldn’t receive those therapies. Taking a plaque-driven approach with imaging tests like the coronary calcium scan can be helpful to figure out which patients we should be offering the fistful of agents to and which patients we shouldn’t.

Deepak Bhatt, MD, MPH: Great points. Jamie, you can close for us with your thoughts about the future.

James A. Underberg, MD: It’s hard to add much to the eloquent words of my copanelists, and they summarize the discussion well. One point I can end with is the importance of identifying high-risk patients. It’s not just the patients with ASCVD [atherosclerotic cardiovascular disease], but it’s patients with diabetes, multiple risk factors, subclinical atherosclerosis, and elevated lipase protein A. We know that patients with the highest risk are the ones who benefit the most from the interventions that have been documented to show risk reduction.

Therefore, there is an urgency to identify, act, and treat. Too often we get caught up in the issues around watching and waiting. We’ve all heard our patients’ responses when we ask them about their blood sugar, cholesterol, or blood pressure. They respond with, “We’re watching it. We’re following it.” We don’t wait by watching these things. We act, and we treat. Finally, the last part of the equation—and what everyone has so nicely shown around the cases—is don’t just add treatments; simplify treatments. Many times you can use dual therapies that are in 1 tablet or you can add 1 medicine and subtract 2 because you’ve taken away adverse effects. You don’t want to add more drugs and more co-pays. You want to make the regimen simpler and more effective, and you want to do it quickly.

Deepak Bhatt, MD, MPH: There’s a lot of wisdom in what you just said and what all of you said. It is a matter of applying the evidence but also using common sense. We want to make sure that as we are making lifestyle modification recommendations and we’re potentially adding, subtracting, or substituting medicines, we are enhancing the outcomes of the patient and take into account the patient’s preferences as well. I’d like to thank you all and thank our audience as well. Hopefully this was educational, useful, and informative. You’ve been listening to HCPLive® Peer Exchange®. Thank you so much.

Transcript Edited for Clarity

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