Gregory M. Weiss, MD

The enormous importance of cholesterol management for reduction and prevention of 

atherosclerotic cardiovascular disease (ASCVD)

While ample evidence exists that reductions in low-density lipoprotein cholesterol (LDL-C) reduce the risk of cardiovascular events and death in patients with ASCVD, data gathered by the American College of Cardiology (ACC) from the PINNACLE registry reveal that 21.1% of these patients had no history of lipid-lowering therapy use and 84.5% did not meet LDL-C goal of less than 70mg/dL.

Patients with ASCVD least likely to achieve LDL-C goals while on a statin include younger patients, African Americans, and hypertensive patients.

 These facts underscore the importance of determining and overcoming barriers to achieving optimal cholesterol management.

Timothy Attebery, DSc, MBA, FACHE, Chief Executive Officer of the American College of Cardiologists states, “Management of lipid disorders has become more complex as new data, drugs and clinical standards around lipid management are introduced. The College has many successful tools and initiatives that have helped our members provide the most advanced and effective lipid management strategies for their patients, but there is more work to be done.”

In 2019, the American College of Cardiology in cooperation with the American Heart Association (AHA) issued updated guidelines, made simple, for management of blood cholesterol. In these guidelines they highlight ten take-home messages to reduce the risk of ASCVD through cholesterol management.

Clinicians should always emphasize a heart-healthy lifestyle throughout life with particular focus on avoidance of developing the metabolic syndrome.

High-intensity statin therapy (if tolerated) should be instituted in patients with clinical ASCVD with the goal of lowering LDL-C levels by greater than or equal to 50%.

Consider adding a non-statin cholesterol lowering agent (such as ezetimibe) in very high-risk ASCVD with a LDL-C threshold of 70mg/dL.

Clinicians should begin high-intensity statin therapy in patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]).

Moderate intensity statin therapy should be instituted in patients 40-75 years of age with diabetes mellitus and LDL-C levels greater than 70mg/dL.

Clinicians should have a discussion with their patients about primary ASCVD prevention before starting statin therapy.

Moderate-intensity statin therapy should be considered in non-diabetic adults 40-75 and LDL-C levels greater than 70mg/dL.

Statin therapy should be considered in non-diabetic adults with a 10-year risk of 7.5% to 19.9%.

If a decision about statin therapy is uncertain in Non-diabetic adults with LDL-C levels greater than 70mg/dl to 189 mg/dL and a 10-year risk for ASCVD of greater than 7.5%-19.9% a Coronary Artery Calcium (CAC) Score should be calculated to aid in the decision.

Four to twelve weeks after statin initiation clinicians should assess adherence and percentage response to LDL -C lowering medications and lifestyle changes with repeat LDL levels and then every 3 to 12 months as needed.

These guidelines are concise and should be easily attainable with the tools we possess. However, being armed with a primer for good care clearly is not enough. The American College of Cardiology in conjunction with Sanofi and Regeneron Pharmaceuticals Inc. have developed an initiative called the TRANSFORM LDL-C trial aimed at addressing the gaps in treatment for ASCVD patients with regards to cholesterol-lowering therapy. 

Dharam Kumbhani, MD, SM, FACC is a senior author of the TRANSFORM LDL-C trial. Dr. Kumbhani states, “Large groups of patients with ASCVD are not achieving low enough LDL-C levels, which puts them at greater risk of recurrent cardiovascular events and death.”

The TRANSFORM LDL-C initiative aims to optimize patients’ access to the latest evidence-based treatments for LDL-C lowering and cardiovascular event risk reduction based on the ACC/AHA guidelines.

 Dr. Kumbhani goes on to say, “It’s apparent that large gaps exist and that more efforts are needed in implementing the cholesterol guidelines. Next steps are examining what barriers exist in achieving these treatment goals and how to address these barriers.” These barriers, once identified, will need to be addressed if the gaps in treatment, access, and goal achievement are to be eliminated.

In general, before the results of the TRANSFORM LDL-C initiative are known, things can be done to reduce barriers to achieving the recommended LDL-C targets in patients with ASCVD. Simplifying treatment regimens can increase adherence especially in patients with several comorbidities such as hypertension and hyperlipidemia. Prescribing single-pill combinations containing treatment for both conditions makes it more likely the patient will comply with their regimen.

Further, initiating treatment early with regular follow up and positive reinforcement from clinicians at each office visit are a good first step toward reducing cardiovascular risk in patients with hyperlipidemia. Together we can take the evidence and guidelines at our disposal and eliminate barriers to achieving the results our patients deserve improving outcomes and the quality of their lives.

Articles

With September recognized as National Cholesterol Education Month, Dr. Weiss reflects on the importance of cholesterol management as part of mitigating risk of events in patients with ASCVD. 

Gregory Weiss, MD: Meeting the Challenges of Cholesterol Management

ESC Congress 2020 Hot Line Review

Slideshows

Dr. Gregory Weiss compiles thoughts and perspective on hot line trials presented at ESC Congress 2020.

ESC Congress 2020 Hot Line Reviews

The COVID-19 pandemic has fundamentally changed society as a whole. It is clear that this pandemic will alter human behavior and propel the adoption of novel methods for scientific information-sharing among healthcare professionals.

From social distancing to widespread mask-wearing, social interactions have already been drastically altered. Physicians and other clinicians are not only faced with caring for patients in a perilous environment, but they must also maintain their competency and continue to network in an effort to improve their practice and meet the rapid changes in healthcare today and into the future.

In addition to continuing education, collaboration across great distances often facilitates breakthroughs in medicine that are often born of traveling to international conferences and society meetings. Travel bans and distancing practices have made scholarly meeting attendance virtually impossible.

The medical community has relied on conferences, congresses, symposiums, and other live meetings as the foundation for advancements in medicine. To date, 64% of this year’s conferences have been canceled, moved online, or postponed.

 Without our primary source for education and networking, we as clinicians must improvise, adapt, and overcome to meet the demands of a rapidly changing environment.

So how can we continue to collaborate and learn during a global pandemic?

Without being instantly aware, the tools we would need to stay current and collaborate were right in front of us every day. Luc Rubinger and colleagues from Canada and the UK looked at ways physicians can meet without traveling. They found that virtual conferences with an online platform can offer more than just an alternative to conventional face-to-face events. Online meetings save time, money, and other resources consumed by planning and holding in-person meetings.

 In addition to providing continuing education and collaboration, virtual meetings allow universities and healthcare associations to increase their outreach and position their research on an international stage.

So, what are the attitudes of conference organizers and participants with regards to meeting cancelations and virtual conferencing? Some worry that organizations may suffer financially due to a sizable reduction in exhibitor sponsorship.

 Laura Shelters, a director of content research and development states, “We are nimble enough to quickly convert any of our in-person education to a virtual offering.”

Most of the physicians I speak with have mixed feelings. On the one hand, virtual meetings offer flexibility and reduced cost to attendees, while on the other we lose substantive networking opportunities and the chance to see friends and colleagues we are separated from by distance.

The American College of Cardiologists (ACC) have already held their annual meeting online. Janice Sibley, the executive vice president for education and publications for the ACC states, “As horrible as the situation is right now and as much focus as our members need to put on the care of their patients, we can’t stop the science from moving forward.”

There are clear benefits to attending conferences online. I share the sentiment of many clinicians that in-person meetings limit my ability to go to the sessions I want to on my schedule. On-demand meeting sessions and discussions that can be viewed and reviewed at any time of day provide far more flexibility than a set meeting schedule. Further, many clinicians find traveling great distances to be time-consuming and expensive in addition to the ever-increasing conference fees. Virtual conferencing allows the participant to spread the content over longer periods of time with minimal interference in their busy work schedules.

The ACC virtual annual meeting was seen by most as an example of what the new normal will look like for medical conferencing for the foreseeable future. The COVID-19 pandemic has changed how humans interact with each other, and these changes are likely to persist, at least for some years. If scientific societies wish to remain relevant to their members and successful, they must adapt to this new reality.

In a press release from the European Society of Radiology (ESR) Boris Brkljacic, MD, PhD, chairman of the ESR board of directors states, “The mold is broken; the new, online ECR 2020 will be a different meeting, with a different structure and different outcomes. It will be the first, and the best (so far) of a new generation.”

Brkljacic goes on to say, “When we decided to convert ECR 2020 into an online-only congress, there was a lot of uncertainty about how this would look and whether it would still be possible to capture the magic of ECR in a digital format. After an incredible congress week, I am extremely pleased to say, there are no longer any doubts”.

Attitudes like these will allow us to move forward with optimism and innovation. We will continue to educate, collaborate, and persevere in these troubled times.

A cardiologist offers his perspective on the pros and cons of virtual medical conferences as a result of the ongoing COVID-19 pandemic.

Face Time: Virtual Conferencing in the COVID-19 Era

Check out the slideshow below for a review of a recent scientific statement from the American Heart Association outlining the need for diet assessments as a screening tool for cardiovascular disease. 

Importance of Diet Assessments in Cardiovascular Disease

Gregory Weiss, MD, offers his perspective on a recent scientific statement from the American Heart Association underlining the importance of dietary assessments in patients seeing a cardiologist. 

Author | Gregory M. Weiss, MD

Articles

Gregory Weiss, MD: Meeting the Challenges of Cholesterol Management

ESC Congress 2020 Hot Line Reviews

Face Time: Virtual Conferencing in the COVID-19 Era

Physician's Perspective: Role of Dietary Assessment in Cardiovascular Disease Screening