LDL Cholesterol as a Performance Measure


The cardiology panelists discuss the importance of screening patients for hyperlipidemia and familial hypercholesterolemia.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: The guidelines really didn’t say don’t measure LDL [low-density lipoprotein]. Is that correct?

Payal Kohli, MD, FACC: No. In fact, they said that’s the only thing that guides your management. Keep checking LDL [level] until you get to your threshold, and even then, you keep checking it. So really you’re supposed to start your medication [and] bring them back in 4 to 12 weeks. What you’re looking at is not just the threshold, but also the δ LDL [level], Dr Ferdinand. That’s one we often forget about, but remember that δ LDL [level] of 50% is what we really want to get our very high-risk patients under. And then once you’re happy with it, then you keep checking every 3 to 12 months afterwards because otherwise you’re flying blind if you don’t check it.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: All right, Christie. I can’t hold you back any longer. I know that you have been very passionate—that it just doesn’t make sense that we have a biomarker that is really predictive. We’ve shown data that it’s causal. Lots of this has been discussed today, but we don’t have a performance measure. What steps are you taking?

Christie M. Ballantyne, MD, FACC: Here’s the issue. We talk about prevention. And [we’re] talking about individualizing therapy. So if somebody comes in, we check their blood pressure, we check their glucose and their [hemoglobin] A1C for diabetes, [and] we weigh them. Those are all quantitative measurements, and you actually can look at this in the EMR [electronic medical record] and see how you are doing for blood pressure, diabetes control, and weight. Then what is the quality metric? Were they prescribed a statin? And then adherence. But if you’re prescribed a statin [and] you can’t take it, that’s a checkbox. I [have] a patient who came [in], just saw me last week. [Their] LDL [level’s] 250 mg/dL. They were prescribed a statin, [but] they can’t take it, so they’re a checkbox. They’re doing OK according to the CMS [Centers for Medicare & Medicaid Services] measure. That’s ridiculous. If someone had a blood pressure of 200 mm Hg and they couldn’t take their medication, would you say they’re under control?

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: No, no, not at all.

Christie M. Ballantyne, MD, FACC: How can you talk about control? And now they mail you your medications. You get a 3-month supply. I don’t know what it means if the pharmacy mailed them the medication. I don’t know if they took it or not. I know when I see someone [in] clinic, and actually, we had a phone visit last week. I looked at the labs—we got a new [patient]—and it said [the patient is] not taking their medicines. [Patients] gets on the consult, and she said “Well, I got to admit, I haven’t been taking my medicines.” I said I already knew that. We already said that before the call started. That’s how you know about adherence. Basically, how can you improve quality if you’re not measuring the right thing? It just doesn’t make sense. We got off. We lost direction with some changes in guidelines and misinterpretation.

We’ve got to get back. If you want to improve management of lipids, it has to be, “Did you achieve [the] LDL level?” It doesn’t make sense, and unfortunately, it’s somewhat of a difficult process. But the Family Heart Foundation/ASPC [American Society For Preventive Cardiology]/National Lipid Association/ACC (American College of Cardiology) CAD [coronary artery disease] pathway just came out. You need to measure lipids and treat lipids. Hopefully, we’ll see it come back [into] the ACC quality metrics. But we’ve got to change it because our health care systems are based upon data. And if you don’t have the right data, you can’t improve anything, and we got to get data. They’re not even measuring lipids. How are you going to improve it if you don’t measure it?

And then it also totally ignores the role of diet and lifestyle. That makes a big difference on people’s lipid controls. Are they not only taking their medications, [but] what’s happening? We saw with [COVID-19]—lady I saw, another one this week, she got off her medicine. She gained 60 lbs during COVID. Lifestyle’s important.

I’m getting a little carried away.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: I know it’s a hot spot for you. Dr McGowan, your data are very, very, very strong. The Family Heart Foundation is patient centered. And I know it must be distressing to you as a physician to have a causal factor for the leading cause of death, atherosclerotic cardiovascular disease, and we’re not using our tools to reach LDL thresholds. You have any ideas on what we can do to do better?

Mary McGowan, MD, FNLA: Well, I have a very strong idea, Keith. One of the things that I think was really disappointing [recently] was the US Preventive Service Task Force came out once again [stating that] it was indeterminate [on] measuring or screening children for lipids at age 2 if they have a family history of FH [familial hypercholesterolemia] or have a family history of ASCVD [atherosclerotic cardiovascular disease] and universal screening between 9 and 11. If we universally screened between 9 and 11, we would find children with familial hypercholesterolemia. In turn, we’d find their undiagnosed parents and be able to initiate therapy.

We are not using the tools we have, and we are having people find out that they have familial hypercholesterolemia at the time of a first cardiac event. So the one thing I think we could do a whole lot better [on]—and there are lots of things—[is] aggressively screening children. And that is something that we really need a lot of education of both families and providers. And I think that the current data [are] somewhere between 8% and 20% of children are screened, and it really does depend geographically on where you are whether or not you’re screened.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: In these patients [whom] the [Family Heart] Foundation [is] trying to put a focus on, when you say the first heart attack or their first event is when they find out that they have disease, we’re not talking about 60-, 70-, 80-year-old people.

Mary McGowan, MD, FNLA: No, we are not, Keith. We are talking about people in their 30s and 40s and even younger. One of the things that the US Preventive Service Task Force says is that HoFH, homozygous familial hypercholesterolemia, is out of scope. Why is it out of scope? It should not be out of scope for this recommendation because kids with HoFH, and even adults with HoFH, don’t wear a sign that says they have it.

We just published a paper in the [Journal of the American Heart Association] looking at our HoFH data. And unfortunately, people get diagnosed with HoFH at the time of a cardiac event. We have children [who] have had bypass surgery at age 6. We had a child [who] was found because her older brother, who she’ll never meet, died at 1 [year of age] of a cardiovascular event. So not screening children really puts us behind the eight ball. We don’t know what we don’t know until they’re seeing adult cardiologists.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: Dr Michos, I’m going to ask you to comment on some of the disparities in LDL threshold attainment. But before you do that, let’s stick with this screening issue. If you have a young person [with a] family history, they may have FH. It’s a blood test. Why not check?

Erin D. Michos, MD, MHS: Well, certainly all our guidelines recommend that all adults have a lipid panel to identify those individuals who may have familial hypocholesterolemia. If the cholesterol values are normal, young adults may have it repeated in 5 years or something like that. But it’s already in our guidelines that everybody should have a lipid panel for screening.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: What about younger people?

Erin D. Michos, MD, MHS: I don’t take care of [the] pediatric population, but I agree completely with Dr McGowan that we absolutely should because we know that if we can identify FH in children and we start them on a lipid-lowering therapy, we can change the whole trajectory compared [with] their parents. There are studies [showing] if you can start statin therapy in these youth, they don’t develop the early onset of ASCVD as their parents. You can change their whole trajectory or their life by identifying them early and starting early treatment. So absolutely, I agree completely [that] we should be screening children.

Keith C. Ferdinand, MD, FACC, FAHA, FNLA: We’re going to initiate that therapy, initiation across populations—[a] disparities conversation. And I’m going to come right back to you, but I wanted to give Dr Kohli a chance to talk about what she thinks is important in terms of screening.

Payal Kohli, MD, FACC: I think, Dr Ferdinand, there‘s a cultural bias. We believe that in order to have high cholesterol, we need to be overweight or we need to have medical problems. And I think that’s where we really need to talk about educating parents—that even if their child is not heavy, [is not] obese, [and doesn’t have] childhood diabetes or any of those other risk factors, they could have a genetic condition that leads them to have high cholesterol levels.

That’s why I think screening even de novo. Let’s say you don’t even have a family history of high cholesterol. Even then we need to encourage our parents and empower them to ask their pediatricians for this type of screening so that they can really identify their children.

Christie M. Ballantyne, MD, FACC: Keith, let me say one thing to our audiences, so cardiologists. If your patient has a premature event or if you have a patient with a very high LDL [level], make sure their kids get screened, OK? Make sure to screen the children because starting [screening] earlier [causes me to] notice it [earlier]. To me, one of the saddest cases I’ve ever had is—we used to start a little later, we’d wait until later in life—I remember having a woman I started [as] a child, so, you know, the whole family had many relatives with FH. And unfortunately, [we] didn’t start the statin until about the end of high school going off to college. Well, what happens when people go to college? It’s a rebellious time for many people. [She] quit taking [her] medications [and] thought [she] could do it all naturally. [At] age 26, [she] dies [during] competitive ballroom dancing, sudden death. Now, if I started [her] at age 10 when [she] was living with [her] parents, [then she would have been] in the habit of taking that medication every day. Screen them and start early. Start when they’re at home so that they’re used to taking these medications. Young people, when they’re in their early college years is not the time to be trying to start. For someone with FH, it’s late. So it’s really a critical issue. Screen their children.

Transcript Edited for Clarity

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