Advances in the Management of Hypercholesterolemia - Episode 3
Howard Weintraub, MD: There are certain issues that I know that you’ve discussed and that we all have to deal with certainly on a day-to-day basis. Those are namely the effects of things that are not in our control, such as age and gender. These are things that we now know have very significant impact. The coronavirus pandemic has shown us that ethnicity, demographics, and socioeconomic status can also have a very big impact on health. The ways people get health care and use health care also ultimately impact whether individuals end up being beneficiaries of this or suffering with it. Please let us know your thoughts.
Alan S. Brown, MD, FACC, FAHA, FNLA: Yes, I certainly agree. Obviously, age is the single biggest risk factor for developing cardiovascular disease. There’s not a lot we can do about it, even though many of us attempt to act younger than we are, much to the dismay of our spouses, in many cases.
What we know is that cardiovascular disease is still the No. 1 killer out of all causes of mortality in the United States. That’s true for both men and women. Years ago, we thought women had a lesser incidence of cardiovascular disease, but we know better than that now. They often have it 10 years later than men. The theory is that they possibly may have some protection from estrogen during their premenopausal period, but they clearly have an equal incidence of cardiovascular disease. It’s still the No. 1 cause of death—more than all the cancers combined.
We’ve spent the past decade educating ourselves and others about the importance of identifying cardiovascular disease in both men and women, and also about some of the gender differences. Women present with different types of symptoms and different risks for procedures. A lot has been done in that arena. As far as the ethnicities go, we know that particularly for hypercholesterolemia, certain ethnic groups have a higher incidence. French Canadians have a higher incidence of familial hypercholesterolemia [FH]. We see that in Lebanese patients and Dutch patients. In fact, FH was first described in South Africa in the Dutch Afrikaners. There are populations—especially those who tend to cluster together and have a founder effect because they live in similar communities—where we see higher incidences of hypercholesterolemia. We know that lower socioeconomic groups, partly because of ethnicity and partly because of status and lifestyle, tend to have a higher conglomeration of risk factors, including hypertension, obesity, and diabetes. Some of that is probably related to ethnicity, but in the lower socioeconomic groups—it’s unfortunate, but the least expensive food, for example, is often the food that’s highest in saturated fat. In many cases, there are what we call food deserts in those localities where they really can’t find a place to get fresh produce or other healthy food, but there’s a McDonald’s right down the street. It becomes less expensive to feed the family and more satisfying to eat a high-fat meal that suppresses your hunger. The amounts of sodium and fat all lead to health issues.
All these things work together. We have to be aware of all of them. When we talk about diversity and inclusion, we mostly think about ethnicity or language, but there are many dimensions of diversity, including socioeconomic group, gender, and age. As we move forward in health care, we’re going to have to consider all those things if we want to be good stewards of the health of our communities.
Howard Weintraub, MD: I agree with you. Actually, the 2018 ACC/AHA [[American College of Cardiology/American Heart Association] guidelines identify Southeast Asians as a group at considerable cardiovascular risk. We at NYU have seen a lot of patients from Central America, South America, and the islands with a particular virial inversion of mixed lipid abnormalities. Many of them have very elevated triglycerides. There is this ethnic predisposition toward certain dyslipidemias. Our cardiology fellows are constantly astounded when they see a small, thin, Indian woman who’s 35 years of age, nondiabetic, and a nonsmoker who comes in with a proximal LAD [left anterior descending coronary artery] infarction. They go, “Wait a minute. This isn’t supposed to happen.”
Alan S. Brown, MD, FACC, FAHA, FNLA: I’m glad you brought that up, Howard. You mean “South Asian,” rather than “Southeast Asian.”
Howard Weintraub, MD: Yes.
Alan S. Brown, MD, FACC, FAHA, FNLA: We actually have a South Asian Cardiovascular Center at Advocate Lutheran General Hospital because we have such a high population of Indian and Pakistani individuals in the Chicago area. You’re absolutely right. They have 3 to 4 times the risk. There’s a lot of theory as to why that is. They tend to have insulin resistance, as well as high incidence of elevated LP(a) [lipoprotein (a)]. The National Lipid Association is about to publish a very comprehensive discussion of that. I’m sorry I left that out. I’m glad you brought that up. That’s very important. It’s important for all physicians to be aware of the high incidence of early heart disease in South Asian patients, so thank you for that.
Howard Weintraub, MD: It’s something that used to be an issue only in urban areas like New York or Chicago, but now as people spread out and there are communities growing in multiple parts of the country, doctors need to recognize where this is from and how it all works. As you pointed out, you have these issues in Chicago. We’ve been seeing them at Bellevue Hospital for years. Jamie Underberg, who I’m sure you know well and is part of our convention center, runs the lipid clinic at Bellevue. We also have a dedicated prevention fellow. He and the fellow are constantly amazed by some of the genetic lipid disorders that come in and those that are there in an ethnicity where there is significant cardiovascular risk. That used to be attributed only to long-standing type 1 diabetes, renal disease, and smoking. This is very important. It’s something that we’re going to need to pay more attention to, particularly with attention drawn to disparities between different socioeconomic groups and demographics. This is something our trainees need to know about, and our colleagues need to be very well educated about this as well.
Alan S. Brown, MD, FACC, FAHA, FNLA: That’s very well said. As you pointed out, the COVID-19 [coronavirus disease 2019] crisis has really emphasized the importance of understanding the effects of disease and health care systems on diverse populations. My suspicion is that all our health care systems are going to change forever based on those experiences. This pandemic really affected certain ethnic and socioeconomic groups with such vigor compared with others.
Transcript Edited for Clarity