Ask the Experts: What Practice Changes Have You Made Based on the Risk/Prediction/Cholesterol Guidelines?
Editor's Note: ACC.org Diabetes and Cardiometabolic Disease editors, Nathan D. Wong, PhD, FACC, and Michael Blaha, MD, MPH, polled several experts on the following question:
Since the release of the new risk/prevention/cholesterol guidelines, what changes have you made to your practice or your practice system?
Mouaz H. Al-Mallah, MD, FACC: The current American College of Cardiology (ACC) risk/prevention/cholesterol guidelines present a new approach to patients at risk for coronary artery disease (CAD). These guidelines impacted my practice at multiple levels. In this summary, I will focus on a couple of aspects only.
First, the notion that we should treat patients according to their risk rather than their lipid level was new to many practitioners. Many were used to treat patients with statins only if their cholesterol levels were high. In our primary care practice, many patients who have known CAD or at high risk for CAD were treated with low-potency statins due to many reasons, including low serum cholesterol level and potential side effects. However, these patients were really undertreated according to the risk/prevention/cholesterol guidelines. Following these guidelines, we took measures to ensure that all high-risk patents are on high-potency statins at the appropriate dose. Accordingly, these medications were added to our formulary, and their utilization is monitored.
On the other hand, it is still difficult for many practitioners to treat patients without frequently checking their lipid profiles and making sure they are at least meeting the target of the previous guidelines. I feel this is one of the areas of confusion at this point that still needs to be addressed in future iterations of the guidelines.
Andrew P. DeFilippis, MD: In 2013, the ACC and the AHA recommended a new atherosclerotic cardiovascular disease (ASCVD) risk score and cholesterol treatment guidelines to guide preventive therapy decisions.
Unfortunately, the new risk score and three Framingham-based risk scores, all derived from cohorts decades old, were found to overestimate cardiovascular risk, while the Reynolds Risk Score, derived from more modern cohorts, accurately predicted the overall event rate in a modern, multi-ethnic cohort.1-5 These findings have led me to view the ACC/AHA ASCVD risk score with caution and to favor estimates from the Reynolds Risk Score when high-sensitivity C-reactive protein is available or easily obtainable. I consider how risk factors in my patients may be different from those of patients in past decades when the majority of risk score cohorts were developed, as well as other easily identifiable ASCVD risk factors beyond those included in the ACC/AHA ASCVD risk score when making treatment decisions.6 I employ direct measures of subclinical atherosclerosis, like coronary artery calcium (CAC), which has been proven to improve risk prediction beyond risk factor-based calculators when I face difficult therapeutic decisions not adequately addressed with less invasive risk scoring systems.
I practice a simple approach of identifying those at increased ASCVD risk and treating with the proven therapy of diet, exercise, and statin, regardless of baseline low-density lipoprotein (LDL) levels and maximize intensity of statin with respect to patient side effect risk and tolerability. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) results released after the 2013 guidelines have convinced me to consider adding ezetimibe to most high-risk patients who cannot tolerate a high-dose statin. I believe the 2013 ACC/AHA cholesterol treatment guidelines are consistent with this approach.
- Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: The roles of statins, revascularizations, and underascertainment in the women's health study. JAMA Intern Med 2014;174:1964-71.
- DeFilippis AP, Young R, Carrubba CJ, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med 2015;162:266-75.
- Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2935-59.
- Kavousi M, Leening MJ, Nanchen D, et al. Comparison of application of the ACC/AHA guidelines, Adult Treatment Panel III guidelines, and European Society of Cardiology guidelines for cardiovascular disease prevention in a European cohort. JAMA 2014;311:1416-23.
- Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet 2013;382:1762-5.
- DeFilippis AP, Larned JM, Cole JH, Nell-Dybdahl C, Miller JI 3rd, Sperling LS. Clues to cardiovascular risk: An office-based approach. Prev Cardiol 2007;10:36-41.
Seth S. Martin, MD: Since the release of the 2013 ACC/AHA risk/prevention/cholesterol guidelines, I have focused even more attention in my practice on clinician-patient risk discussions. The flexible framework it provides truly allows for personalization in each case. I must admit that, at first, I did not fully appreciate this feature of the guidelines. Only after I more closely examined it, discussed the guidelines with colleagues, and implemented them in my practice did I come to really understand how central clinician-patient discussion is to implementation of the new guidelines. As a result, I wrote an article on the topic with Neil J. Stone, MD, FACC, and other colleagues, and I think other clinicians will find our article useful.
The clinician-patient risk discussion has shared decision making at its core. It is a thoughtful conversation between the clinician and patient about the potential for ASCVD reduction benefits, adverse effects, drug-drug interactions, and patient preferences. Ultimately, the result is a coherent decision that fits with the patient's personal values and preferences while being informed by the best available scientific evidence and clinical experience/judgment.
It seems like common sense that we should talk with rather than at patients, and strive for shared decisions rather than take charge and dictate therapy, but sometimes common sense may be lost in medical care. Sometimes physicians may feel pushed towards being more authoritative in prescribing medicines in general and in using lipid-lowering therapies like statins, perhaps because it may be felt to show competence and confidence. While I have always tried hard to elicit and take into account patient preferences, and work towards shared decisions, I feel like I am doing a significantly better job now, inspired by the 2013 ACC/AHA guidelines. As a result, I think I am seeing more "buy-in" from my patients and that I am providing even better care.
- Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
- Martin SS, Sperling LS, Blaha MJ, Wilson PW, Gluckman TJ, Blumenthal RS, Stone NJ. Clinician-patient risk discussion for atherosclerotic cardiovascular disease prevention: importance to implementation of the 2013 ACC/AHA guidelines. J Am Coll Cardiol 2015;65:1361-8.
Michael D. Miedema, MD: The ACC/AHA guidelines have provided me with strong reinforcement in explaining to patients that the most important prevention question they should be asking their doctor is not, "What is my cholesterol?" but rather "What is my risk of having a heart attack or stroke?" This concept was previously somewhat difficult to get patients (and their primary care providers) to buy into. I have adopted consistent use of the ASCVD Risk Estimator with my primary care patients as a starting point for our discussion about the risks and benefits of statin therapy (I use it for a discussion about aspirin as well). I am a strong proponent of CAC scoring and use it frequently in my primary prevention patients. The fact that the risk calculator is largely dominated by age has led me to adopt frequent use of CAC scoring as a method of personalized risk stratification. The new guidelines do not give CAC scoring a strong recommendation; I was disappointed to see it lumped together with other tools that I don't feel have as strong of evidence for risk stratification. However, I do think the risk-based approach adopted by the new guidelines does intuitively create value for the personalized risk assessment provided by CAC. I fully agree with the recommendation to generally avoid follow-up testing of liver and muscle enzymes, and I have significantly reduced the frequency with which I obtain these follow-up labs.
Overall, I think the controversies surrounding the new guidelines (the accuracy of the calculator, the potential increase in statin eligibility, etc.) have created a distraction from the fact that the prior guidelines had flaws that, in my opinion, were much more significant than the current guideline criticisms. The ACC/AHA guidelines have provided a framework for a risk-based approach to the treatment of cholesterol, a framework that I apply to all my prevention patients as I believe it is evidence-based and clearly a step in the right direction.
Ronald Scott, MD: Kaiser Permanente Southern California (KPSC) is implementing KP guidelines that are based on the 2013 ACC/AHA cholesterol guidelines among our 4 million members. There is a large gap in statin treatment nationally, especially in primary prevention for which treatment rates are approximately 41%. In the Centers for Medicare & Medicaid Services Healthcare Effectiveness Data and Information Set (HEDIS) 2013, KPSC achieved LDL cholesterol (LDL-C) <100 control rate of 83% among members with ASCVD. Since then, KPSC has shifted focus from LDL-C <100 in ASCVD, towards more optimal statin use across all four statin benefit groups in the ACC/AHA guideline. We changed our decision support and registries to promote statin starts and adherence across a range of LDL-C. For example, a member overdue for initial statin fill or refill receives automated calls, then potential live calls, and outpatient pharmacist interventions. Many members with LDL-C levels 70-99 were started on statins or increased to higher-intensity statins. In a proposed National Committee for Quality Assurance (NCQA) metric on patients with diabetes filling statin in the last year, 2015 national field sample data showed 46%, while our KPSC rate is about 75%. For members with LDL ≥190, an alert will prompt and stage laboratory work-up and statin start. The 10-year ACC/AHA ASCVD Risk (A-Risk) result on a member with prefilled variables, and coupled with concrete prompts, is available at the point of care to providers. For example, a provider reviewing lipid panel results may see the prompt "A-Risk 16%, start atorvastatin 40 mg daily, start aspirin 81 mg daily." Members on www.kp.org can also see updated guidance, including their personal A-Risk, near lipid panel results. In adults age 40-79 who have not had a lipid panel in the last five years, we are starting to systemically facilitate lipid panels. We test the untested to facilitate treat the untreated. KPSC is implementing cholesterol guidelines to reduce downstream heart attacks, strokes, and revascularizations.
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