Joyce L. Ross, CRNP: What’s important, too, is that we talk a lot about lifestyle management, and that is always part of every plan. It’s the first and typical thing that we do with a patient. Finding out what they do is always important. One of my keys was I always like to congratulate the patient on all they’ve done so far, and perhaps even say to that person who has a high score on the CAC [coronary artery calcium], “You know what? You probably saved your life.” Again, that positivity is very important.
Lynne Braun, PhD, CNP: Joyce, let me interject 1 thing. The guideline is so comprehensive and excellent in the stepwise fashion that you can assess someone who is primary prevention, someone with severe hypercholesterolemia, somebody with FH [familial hypercholesterolemia]. Although you don’t need the risk score for somebody with FH, you mentioned obtaining a CT and measuring coronary artery calcium. That’s not necessarily in there for someone with FH, although it absolutely could and often should be done.
But for someone who is strictly primary prevention after you calculate or estimate their 10-year risk, personalize that risk by evaluating their risk-enhancing factors. If the decision to treat is still indeterminate, if either you, the provider, or the patient is still hesitant to start a statin, the next step is to suggest obtaining a coronary artery calcium score. That’s really important.
One other important point that you mentioned as you eloquently talked about the many patients that you saw and treated with familial hypercholesterolemia is that that is a separate category in the guideline. It’s not considered part of primary prevention per se because these patients have severe hypercholesterolemia, typically. It’s very important that they are treated with not only lifestyle but typically with drug therapies. It really speaks to the severity of that problem that they have, not just for them but also their offspring. That’s very important—the notion of cascade screening is even brought out in the guideline, which is very important.
Joyce L. Ross, CRNP: Those are really important things that you bring up, Lynne. I really think we use those guidelines in practice, and the guidelines do have a specific place for familial hypercholesterolemia. But many providers or nurse practitioners out there are not as intimately familiar with the guideline, and I love the fact that the new guideline gave us those 10 avenues or points to really master. What’s important with a patient who has FH is that we do have people to send them to for more thorough evaluation, for more specific treatment regimen. The patient who has familial hypercholesterolemia may be really shocked when they find that, indeed, they’ve got a high score.
Of course, the main thing we tell other nurse practitioners or other providers is that for the patient who you know in your practice, who comes to you for a standard visit, you still should be checking their cholesterol on a regular basis as the normal part of health care. If you see that there is an LDL [low-density lipoprotein] cholesterol greater than or equal to 190 mg/dL, and they have a family history, you know you’ve got familial hypercholesterolemia right there.
Lynne Braun, PhD, CNP: Right.
Joyce L. Ross, CRNP: We do need to emphasize that sometimes it doesn’t take a lot of clinical testing. It takes clinical knowledge, and of course that’s what we hope our nurse practitioner friends out there are going to hear today, that sometimes it’s our gut nursing judgment that helps us work and take care of people.
Transcript Edited for Clarity