Prevention, Treatment, and Control of High Cholesterol

1
Prevention, Treatment, and Control of High
Cholesterol

• Residency educators may use the following slides
  for their own teaching purposes.
• CDCs Primary Care and Public Health Initiative
• September 26, 2012

2
Overview of This Educational Module

• Impact of high cholesterol on cardiovascular
  morbidity and mortality
• Interventions to improve control of high
  cholesterol
• Therapeutic lifestyle changes
• Drug therapy
• System-based initiatives
• Community-based initiatives

3
Lipid Hypothesis of Atherosclerosis

• Circulating cholesterol plays a central role in
  atherogenesis
• Cholesterol levels beginning in childhood predict
  lifetime risk of atherosclerotic coronary heart
  disease (CHD) events
• Statins lower cholesterol levels and reduce CHD
  and cerebrovascular events
• JAMA 201211307(14)1489?90

4
Atherosclerosis A Progressive Process
Pediatrics 2011128 Suppl 5S213?56
5
Prevalence of Cardiovascular Disease Risk Factors
Among US Adolescents, 1999-2008
Pediatrics 2012129(6)1035-41
6
Recommendation for Lipid Screening in Children by
American Academy of Pediatrics
Family history of premature CVD, high
cholesterol, high body mass index, diabetes,
hypertension, smoking, conditions predisposing to
accelerated atherosclerosis, and early CVD
Pediatrics 2011128 Suppl 5S213?56
7
Estimated Number of US Adults with Hypertension
and High Cholesterol, 2005?2008
MMWR 2011460(4)109?14
8
CHD-Related Deaths Prevented in US (2000 vs 1980)

• 341,745 fewer deaths
• 82,830 (24.2) occurred through a 6.1 reduction
  in total blood cholesterol
• 27,765 (8.2) occurred through the use of statins
  

Small Steps Big Impact!
N Engl J Med 20077356(23)2388?98
9
Estimated Benefits of Lowering LDL-C by 1 mmol
(39 mg/dL) Using Statins in Adults
Lancet 201211380(9841)581?90
10
The National Cholesterol Education Program's
(NCEP) Adults Treatment Panel (ATP)
11
Steps in the Management of High Cholesterol

• Screening and Risk Assessment

• Determining LDL-C goal and treatment

• Determine
• Fasting lipoprotein levels (all adults starting
  at age 20 years, each 5 years)
• Presence of clinical atherosclerosis or major
  risk factors
• Patient's cardiovascular disease risk category

• LDL-C goal based on risk assessment
• Therapeutic lifestyle changes if the patient's
  LDL-C is above goal
• Add medication if the LDL-C continues to exceed
  initial levels

12
NCEP, ATP-III Example of Risk Categories and
LDL-C Goals
Risk factors that modify the LDL-C
goal Cigarette smoking hypertension (BP 140/90
mmHg or on antihypertensive medication) low HDL
cholesterol (lt40 mg/dL) family history of
premature CHD (CHD in male first degree relative
lt55 years CHD in female first-degree relative
lt65 years) age (men 45 years women 55
years) HDL cholesterol gt60 mg/dL -1 risk factor
(protective factor)
13
Statins The Magic Bullet?

• Patients believe

• Patients need to know

• I take Lipitor, so I can eat anything I want.
• My mother eats eggs, burgers, fried chicken,
  ice cream, drinks whole milk, and wonders why
  her lipid-lowering medication doesnt work.

• Lifestyle changes should come before and while
  taking the medicine
• How to make these lifestyle changes

14
Medium/High Intensity Diet and/or Physical
Activity Counseling Does It Work?

• Primary outcomes
• ? energy saturated fat 2.83.7
• ?fruit and vegetable 0.42 serving/day
• ?PA 38 min/week

• Secondary outcomes
• ?LDL-C 5.0 mg/dL
• ?BMI 0.3?0.7 kg/m2
• ?SBP 1.5 mmHg
• ?DBP 0.7 mmHg

Ann Intern Med 201226
15
Common Features of All Healthy Dietary Patterns
16
Examples of Healthy Dietary Patterns

• Diet
• United States Department of Agriculture
• Dietary Approach to Stop Hypertension (DASH)
• Mediterranean
• Portfolio

• Reduces risk for
• Coronary heart disease 24?30
• Any stroke 13?29
• Cardiovascular mortality 28?37

17
Therapeutic Lifestyle Changes Overview

• 1. SPA
• Smoking Cessation
• Physical Activity
• 2. Three Ds
• D1 Diet high in fruits, vegetables, and whole
  grains
• D2 Diet low in saturated, trans-fats, and
  cholesterol
• D3 Diet for weight maintenance and reduction

18
Steps in Therapeutic Lifestyle Changes
SPA Smoking cessation / physical activity (200
kcal/d)
6 wks
4?6 mo
6 wks

• Diet 1 (D1)
• Fruit
• Vegetables
• Whole grain
• Referral to dietician

• Diet 3 (D3)
• Weight loss
• Referral to dietician

• Diet 2 (D2)
• Saturated fat
• Trans-fat
• Cholesterol
• Referral to dietician

19
2010 Dietary Guidelines
http//fnic.nal.usda.gov/dietary-guidance
20
Visit 1 Increase Intake of Fruits, Vegetables,
and Whole Grains

• Simple messages for patients
• Make
• Half of your plate fruits and vegetables
• At least half your grains whole
• Look in ingredients list for
• whole wheat, whole-grain cornmeal, whole oats,
  whole rye, brown rice, bulgur, buckwheat,
  oatmeal, wild rice, quinoa
• gluten-free

21
US Adults in 2006?2007

• Population aged 18?65 years
• Only 30 could name three source of saturated
  fats

J Am Diet Assoc 2009109(2)288?96
22
Visit 2 Decrease Intake of Saturated Fat, Trans
Fat, and Cholesterol

• Simple messages for patients
• Choose lean or low-fat cuts of meat
• Eat seafood in place of meat or poultry twice a
  week
• Try beans and peas, soy products, and nuts
  instead of meat or poultry
• Switch to fat-free or 1 milk and dairy products

23
Major Sources of Saturated Fat and Cholesterol in
the American Diet

• Saturated fat

• Cholesterol

National Cancer Institute, 2010
24
Trans Fats and CVD

• Detrimental effects of trans fat on LDL-C may be
  similar or larger than the effects of saturated
  fat
• Reducing commercial trans fat intake from 2.1 to
  0.1 of energy could prevent up to 22 of CHD
  events in the United States

Trans fats in America a review of their use,
consumption, health implications and regulation.
Journal of the American Dietetic Association
2010110585?592.
25
Trans Fat and Nutrition Facts Label

• Fast facts
• FDA (2006) the amount of trans fat per serving
  is required on the Nutrition Facts panel for all
  product
• Trans fats with lt0.5 g/serving can be listed as
  containing 0 g

Atheroscler Suppl 20067(2)57?9
26
Visit 2 Decrease Intake of Trans Fat

• Trans fat in selected food categories

• Practice tip

• Trans fat can be found in many of the same foods
  as saturated fat
• Check nutritional labels for trans fat content
• Check ingredient list for partially hydrogenated
  oils

J Am Diet Assoc 2010110(4)585?92
27
Visit 3 Intensify Weight Management

• Behavioral interventions face-to-face or
  delivered remotely
• Commercial weight management programs
• Replacement of caloric beverages with non-caloric
  beverages
• All energy-deficient diets (portion control)

• What interventions work for weight loss?

28
Visit 3 Intensify Physical Activity

• At least 150 minutes (2.5 hours) a week of
  moderate-intensity aerobic activityor75 minutes
  (1.25 hours) a week of vigorous-intensity aerobic
  physical activity
• Example a 10-minute brisk walk, 3 times a day, 5
  days a week
• 2 or more days a week muscle-strengthening
  activities that are moderate or high intensity
  and involve all major muscle groups

2008 Physical Activity Guidelines for Americans
29
Visit 3 Intensify Physical Activity Practice
Tips

• Moderate intensity
• Walking fast
• Doing water aerobics
• Riding a bike on level ground or with few hills
• Playing doubles tennis
• Pushing a lawn mower

• Vigorous intensity
• Jogging or running
• Swimming laps
• Riding a bike fast or on hills
• Playing singles tennis
• Playing basketball

30
Physical Activity and CVD Prevention

• Patient who received brief advice (vs. no advice)
  are 42 more likely to increase their physical
  activity
• Regular physical activity is associated with
• 14?20 reduced risk of coronary heart disease
• 12?30 reduced risk of any stroke
• 30?40 reduced risk of cardiovascular mortality

31
Statins and Special Populations

• Gender

• Age

• Both men and women
• Regardless of the type of control, baseline risk,
  or type of endpoint
• Both primary and secondary prevention

• Statins underutilized in the elderly
• Why?
• Uncertainties of risk assessment and
  risk/benefits,
• Polypharmacy
• Costs
• Potential adverse effects

J Am Coll Cardiol 2012759(6)572?82 Clin
Interv Aging 2011627?35. 2011 N Engl J Med
200820359(21)2195?207
32
Statins and Side Effects

• Fast facts

• Practice tips

• 10?15 experience myopathy
• Higher risk
• Patient characteristics
• Higher dosage higher risk

• Low dose statins
• Alternate daily dosing
• 2 dosing per week with longer half-life statins
  or Other non-statin lipid-lowering drugs

• Curr Atheroscler Rep 201012(5)322?30 Clin
  Pharmacol Ther 201292(1)112?7 Expert Opin Drug
  Saf 201110(3)373?87 Lancet 2012380(9841)565?7
  1

33
Side-Effects Cognitive Function and Diabetes

• February, 2012, FDA safety label changes for
  statins
• Generally non-serious and reversible cognitive
  side effects
• Increased risk of diabetes
• Overall 9
• High intensity statins 12

Cardiovascular benefits of statins outweigh small
increased risks
Lancet 201211380(9841)565?71
34
Practice Tip Stopping Statins and Intermittent
Use

• Discontinuation of statin may be detrimental
• This seems to be especially true after an acute
  event
• Intermittent use may be worse than no use

• Curr Opin Cardiol 200924(5)454?60 Arch Intern
  Med 2009 9169(3)260?8

35
Prevention of CVD Statins, Diet, and Physical
Activity
36
Provider Strategies to Improve Adherence

• Simplify regimen
• Impart knowledge
• Modify patient beliefs and human behavior
• Provide communication and trust
• Leave the bias
• Evaluate adherence

• MedGenMed 200574

37
Evidence-based Methods to Improve Lipid-Lowering
Medication Adherence
Cochrane Review, 2010
38
Statins and Cost-Effectiveness

• QALY

• 50,000 per QALY
• Drug price is the primary determinant of statin
  cost-effectiveness
• Framingham risk
• 25 90 per month
• 10 70 per month
• 5 50 per month
• Generic statins 4 per month

Quality adjusted life-year

BMC Res Notes 20125(1)373
39

• Medicare beneficiary sees a median of 7
  physicians per year
• 12 undergo 3 or more outpatient measurements of
  serum lipids per year
• Multiple lipid testing is associated with the
  presence of multiple providers

• Cochrane Database Syst Rev 201017(3)CD004371
  Med Care 201149(2)225?30

40
Meaningful Use of EHR Overview
From payment per service to payment per
performance
Arch Intern Med 2012172(9)731?6
41
Does E-Prescription Improve Attainment of
Cholesterol Goals?

• Provider information for on drug costs specific
  to each patient
• Patient for each 10 increase in prescription
  price 5 decrease being at goal

• Low co-pay
• Medium co-pay
• High co-pay

Clin Cardiol 201134(4)254?60
42
Meaningful Use and Clinical Quality Measures (CQM)

• 2 reporting systems
• Medicare and Medicaid EHR Incentive Programs
  Web-based Registration and Attestation System
• Physician Quality Reporting System-Medicare EHR
  Incentive Pilot

• Meaningful use objectives CQMs reporting
• 6 core BMI (2), smoking, BP, immunization (2)
• 38 optional lipid screening, LDL-C control, etc.

43
Clinical Quality Measures for Lipid Management by
National Quality Forum (NQF)

• At a minimum the prescription of a statin

44
Med Care 201048(10)923?33

• 300 studies support the pharmacist's role in
  primary care
• Medication therapy management will be
  reimbursable for all at-risk Medicare
  beneficiaries in January 2013
• Individuals who have multiple chronic diseases,
  are taking multiple Part D drugs, and are likely
  to incur 3,000 in annual costs for covered Part
  D drugs.

45
Pharmacist Care

• 2011 meta-analysis
• Effective tool in management of patients with
  major CVD risk factors

Arch Intern Med 201112171(16)1441?53
46
All Hands on Board To Improve Community Health!
(Clinical Trial)

• Patients
• Counseled by a nurse practitioner or community
  health worker
• Have significant improvements (in intervention
  vs. the usual care group)

Circ Cardiovasc Qual Outcomes 20114(6)595?602
47
Home-based Secondary Prevention

• 2010 meta-analysis
• Comparing usual care and home-based interventions
• Home-based interventions significantly improved
• Quality of life, systolic blood pressure, smoking
  cessation, total cholesterol and depression
• Low cost (average 300)

Eur J Cardiovasc Prev Rehabil 201017(3)261?70