Risk-Enhancing Factors for Lipid Disorders



Joyce L. Ross, CRNP: Welcome to this HCPLive® Peers & Perspectives® presentation titled “Optimal Management of Lipid Disorders: Expert Nurse Practitioner Perspectives.”

Hi, I’m Joyce Ross. I’m a nurse practitioner with specialized training in cardiovascular risk reduction and lipid management. I’m a certified clinical lipid specialist and diplomate of the Accreditation Council for Clinical Lipidology. My clinical work has been with the University of Pennsylvania in Philadelphia. I am a past president of the Preventive Cardiovascular Nurses Association as well as a past president of the National Lipid Association. I was a founding board member of the Familial Hypercholesterolemia Foundation.

I’m joined today by a dear friend and colleague Lynne Braun, professor emeritus at Rush University in Chicago, Illinois. Her clinical and research interests include cardiovascular risk reduction, exercise, cardiac rehabilitation, hyperlipidemia, and hypertension management. She is the immediate past president of the Midwest Affiliate Board of Directors and Preventive Cardiovascular Nurses Association and a past chairperson of the Illinois Advocacy Committee. Nationally, she is the a past chair of the American Heart Association Council on Cardiovascular and Stroke Nursing.

Our discussion today focuses on team-based, patient-centered care. We will provide insight into various treatment options for the management of lipid disorders, thereby helping to reduce the risk of cardiovascular events.

Lynne, I’m so happy to have you here to work with me today. I’m sure we’re going to have a great discussion. The 1 thing we have to start our discussion with is how it’s a great time to be a nurse practitioner, especially in the world of all these changes that we have surrounding cardiovascular risk and dyslipidemia. What’s really important is to talk about how the patient is the center of care today. As nurse practitioners, we’ve always wanted it to be, and we’re really happy that is the major part of what we’re going to talk about.

We also have these new guidelines, and for the first time these multisocietal guidelines putting us in a wonderful situation where every part of the team is recognized. That falls into concert with how the nurse practitioner works to begin with. We’ve got some new medications coming up, some in the works, and we’ve got much more to offer patients than when I started in this field 20-plus years ago.

We have to emphasize that we are a team, and as the nurse practitioner part of this important team, we’re the ones who see the patient most often—we’re often the one who’s going to hear the complaints or problems. We’re also going to be the one who is going to identify patients who need further care because of our ongoing part that we have. Lynne, let me start with a question. How do you feel about these new guidelines?

Lynne Braun, PhD, CNP: Joyce, first of all, thank you for inviting me to participate in this program with you. You and I have worked together closely in the past, and I’m thrilled that we’re doing this again. How do I feel about these new guidelines? I must say, I am a little biased about this because I was a coauthor of the 2018 AHA [American Heart Association]/ACC [American College of Cardiology] Guideline on the Management of Blood Cholesterol.

You mentioned team, and that’s so important. That came through loud and clear in the new guidelines. I was the only nurse representative. We had PharmDs as representatives, and of course we had physicians, all who were coauthors. It was a wonderful experience to work together with this team on these guidelines. I was able to deliver the nurse practitioner perspective on these guidelines, and we were led by Drs Scott Grundy and Neil Stone.

Joyce L. Ross, CRNP: They are wonderful, and we were so happy to have you represent the nurse practitioner group in those guidelines. We’re so proud of the work you’ve done. What’s important to talk about when we talk about cholesterol, though, is that sometimes we just get down to thinking about cholesterol: all about our lifestyle, everything we eat, and everything we do.

But there is that other component that raises our cholesterol such as genetics and what happens with people because of their ethnicity, race, or other people who are likely to have problems with lipids because of who they are. Of course, the environment does play a huge role. Lynne, if you could spend a minute and talk about the genetic piece.

Lynne Braun, PhD, CNP: Certainly, but I’d also like to mention what we put in the guidelines are risk-enhancing factors. As you know, when you first see a patient for primary prevention, the first thing you do is you estimate their 10-year risk for ASCVD [atherosclerotic cardiovascular disease]. That’s limited because it includes only traditional risk factors like the presence of hypertension or diabetes, smoking, their cholesterol level, their blood pressure level, their age, whether they’re a man or a woman, and so forth. However, there are so many other factors that contribute to cardiovascular disease risk. There’s a very important table in the guideline called risk-enhancing factors, and the first risk-enhancing factor is a family history of premature cardiovascular disease.

That’s very important, and we recognize that some individuals have very few traditional risk factors, but they have a terrible family history. These individuals may go on and also have early events.

Being of a high-risk ancestry, such as being South Asian, is considered a risk-enhancing factor. Then there are other conditions like metabolic syndrome, the presence of chronic kidney disease, having inflammatory type conditions such as lupus or rheumatoid arthritis. We know that inflammation is part and parcel with the development of atherosclerosis. Then there are laboratory parameters that are not part of the initial risk assessment such as having an elevated lipoprotein (a) level that is included as a risk-enhancing factor.

I would like to say 1 more thing about the risk-enhancing factors, and this is something that many people aren’t aware of. There is a very useful supplement to the guideline, and in that supplement, there is a table that has the relative risks for each of the risk-enhancing factors as they relate to the development of ASCVD. If you want to know the contribution of early menopause or having preeclampsia to the development of cardiovascular disease, you can see what that relative risk is. This is so important because of the clinician-patient risk discussion. First, we calculate their 10-year risk. Secondly, we personalize that risk by discussing any risk-enhancing factors that they may have. This could really dictate whether we recommend drug treatment at this point with the patient.

Joyce L. Ross, CRNP: Thank you, Lynne. That is really important information that you bring up. That’s what sets all these new guidelines apart from where we had practiced in cardiovascular risk intervention in the past. For a long time, we knew that things like triglycerides were problematic, but I couldn’t say to you exactly why. Today we have new knowledge, and we have new ability to take a look at those other risk factors that contribute to cardiovascular disease. We’re not quite as LDL [low-density lipoprotein]–centric, which we used to be.

Transcript Edited for Clarity

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