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Virgie Que from Doctor Unite, Anita Kedia Commented on a Post
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Shared decision-making in treating hyperlipidemia

Cholesterol management has evolved to become increasingly complex and individualized. Newer guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) detail risk assessment, novel non-statin treatment options, concerns centered on patient subgroups, and the value of therapy.

Treatment plans are now highly personalized, and experts recommend shared decision-making to fulfill patient needs. When discussing cholesterol management with patients, 4 tenets to keep in mind include the following:

  1. stress the importance of a heart-healthy lifestyle spanning the patient’s life;
  2. discuss the 10-year risk of atherosclerotic cardiovascular disease per the Pooled Cohort Equations, as well as mitigating risk factors;
  3. explain that although statins are the foundation of treatment, add-on options are available for patients on maximally tolerated statins who need to further lower their LDL-C levels;
  4. address special treatment algorithms in at-risk patient subgroups.

What has worked for you when advising patients on lipid-lowering therapy? What role does shared decision-making play when caring for your patients with hyperlipidemia?

  • from Doctor Unite October 17, 2022
    Shared decision making giving patients an active role in their Rxs is more likely making patients more responsible and compliant, therefore it is a win win situation
  • September 29, 2022
    Shared decision making is critical so that patients feel empowered and are more likely to be compliant. Patients are often reluctant to try statin medications but maybe willing to try a very low dose of rosuvastatin or try non-statin medications such as ezetimibe, Nexletol, or PCSK9I.
  • from Doctor Unite September 28, 2022
    I'm curious what percentage of people in USA would qualify for treatment for dyslipidemia
  • September 20, 2022
    I use the pooled cohort equation when speaking with primary prevention patients (+/- coronary calcium testing for borderline patients), but the majority of my patients are secondary prevention. Through education, I think that we all get on the same page on the goals of LDL and triglyceride management (through diet, exercise, and medication).
  • from Generation NP September 19, 2022
    Shared decision making is important because it empowers patients to take an active role in their health. Additionally, patients are more likely to remain complaint with their medical treatment if they understand the reason for treatment and the benefits. Before starting medication in a patient without clinical ASVCD, I stress the importance of lifestyle modifications, including diet and exercise. If this does not result in improved lipid control, then medication therapy is started.
  • from Doctor Unite September 18, 2022
    The Cholesterol management depends upon if it is Primary Prevention or the Secondary prevention , In Primary prevention the intensity of the LDL and the Triglerides reduction is less than the Secondary prevention , how ever if patient has the diabetes or any evidence of the atherosclerosis on imaging then the intensity becomes the same also another factor is Family history of Premature Atherosceloritic vascular disease then it corresponds to in a way to secodary disease even if thery have not had any CV event , Generally in Primary Prevention with the exclusion of the Diabetes and atherosclerosis the target LDL is less than 130 and generally Diet and exercise the way to go but with the inclusion of the diabetes and atherosclerosis the LDL target is less than 100 and needs to be achieved with statin therapy 10 year risk model of ACC can also be applied in this context for guidance but it does not take in to consideration the Family history of CAD and more pertinent one to follow is Reynolds Risk Score http://www.reynoldsriskscore.org/ and when indicated every effort should be done to institute the Statin therapy if not tolerated well then Ezetemibe or Nexletol should be used Now the USPSTF also ednorses the use of the stain therapy in any case patient needs to be enligtended about the benifits of the statin therapy beyond the Cholesterol /LDL reduction in preventing the primary event while endorsing the other aspects of the healthy life style and other risk factor modifications , In Secondary prevention the stakes are very high and every effort should be done to get the LDL less than 70 or 20-30 % from the base line LDL when the event occured also to get the Triglycerides less than 150 additon of the ezetemibe is imperative in secodary prevention based on IMPROVE-IT trial impressive data , In any event every effort should be done to convince paiient to continue the Statin therapy and other meds for rest of the life once the indication is there to be started on them as it just boils down to the numbers game at the end of the game to prevent the primary or secondary prevention

    Reynolds Risk Score

    Source : https://www.reynoldsriskscore.org/

    If you are healthy and without diabetes, the Reynolds Risk Score is designed to predict your risk of having a future heart attack, stroke, or other major heart disease in the next 10 years.

  • from Generation NP August 14, 2022
    shared decision making is key, otherwise we prescribe and the patient is "non-compliant" because they did not really understand the rationale for the medication. Showing the result of a risk-calculation is very helpful and makes more sense to the patient.
  • from Doctor Unite August 12, 2022
    For starters, shared decision making dramatically improves compliance and patient/provider satisfaction. Improved compliance alone can result in better outcomes, whether compliance is through medications or heart-healthy lifestyle modifications. I will often show the patient their ASCVD risk calculator score and importance of therapy, whether statin-based or not, based on the most recent publications. Demonstrating the increasing complexity on an algorithmic approach helps patients, especially those in at-risk subgroups, see how difficult their disease will be to manage if not managed well early.

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  • from Doctor Unite August 11, 2022
    With the advent of telehealth I do alot of these discussions remotely. I share my screen to show the patient the risk calculator results and then I show them the Mayo Clinic Statin Decision Aid. These tools really help the patient make a decision about treatment.
  • August 11, 2022
    I go into detail about diet. It is surprising that so many patients are not fully aware of what foods to avoid and then give them a chance to make a change. If they do need medication I explain the benefits that surpass the numbers.
  • from Doctor Unite August 10, 2022
    Thank you for the opportunity to talk about cholesterol treatment. Many people are very surprised when they learn of their increased cholesterol levels. I have many older patients for which I use the ASCVD and they understand better when you show a specific number. Something that has worked for me is using the rainbow related to food intake. I tend to mention all fruits and vegetables (colorful) and avoid white foods (cookies, tortillas, rice, potatoes). Something that has also worked is to ask people who still watch TV with commercials to have some physical activity during the commercials.
  • from Doctor Unite August 10, 2022
    Encourage healthy diet and exercise habits, inform about risks associated c high lipids, atherosclerosis, have regular blood test , try to get to lipid goals
  • from Generation NP August 10, 2022
    I have detailed conversations about the impactful nature of dietary and lifestyle modifications. Through ground-breaking work of Dr. Dean Ornish, we have definitive data that lifestyle modifications, particularly plant-centric diets and stress management, play an impactful role in reduction of coronary plaque burden. I find ASCVD risk score to be very helpful in patient conversation. The data is easy to understand and patients can clearly see where they fall within a 10 year risk timeline. We discuss the risks and benefits of statins as well as long term implications of statin effects. My job is to educate the patient on current guidelines and then we work together to make decisions which are best for their long term health.
  • from Generation NP August 10, 2022
    I find counseling in low fat diet and appropriate exercise that someone is willing to do is important to start with. I also use the 10year risk calculator and show patients their risk. Maybe it is just my population, but I don't always find the calculator impactful. I do find discussing family history impactful especially if there is a lot of cardiovascular disease in the family. Small changes a patient can make and their willingness to make change is important. I have a large under served population of patients with not a lot of resources for proper nutrition and safe exercise so we discuss that also on how to work around these disparities.
  • from Doctor Unite August 10, 2022
    Besides evaluating for risk factors and lifestyle, I like to do an advanced lipid panel to evaluate the LDL particle size and phenotype , besides other things. I also like to get a CT coronaries for a calcium score and then finally discuss and explain to the patient . Usually works . Thanks
  • from Doctor Unite August 10, 2022
    I like using the 10 year ASCVD risk estimator plus from the American College of Cardiology: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
    This is a good tool to demonstrate the risk in mathematical/percentage format. Lipids is one of several factors included in this calculation. Of course, lipid lowering medications are one option, but I do like to start with recommending diet modification and exercise to see if that helps. I have a lower threshold of recommending medications for those with other risk factors such as diabetes, family history of ASCVD, personal history of ASCVD, tobacco use, etc. Shared decision making plays a significant role when making decisions regarding hyperlipidemia since patients have different preferences with regard to treatment modalities (lifestyle modification vs. OTC medication vs. prescription medications. One of the significant factors to consider is side effects from medications.
    ASCVD Risk Estimator +

    ASCVD Risk Estimator +

    Source : https://tools.acc.org/ascvd-risk-estimator-plus/

    This calculator only provides 10-year risk estimates for individuals 40-79 years of age. to view brief suggestions for younger patients. Current 10-Year ASCVD Risk** Previous 10-Year ASCVD Risk Lifetime ASCVD Risk: Lifetime Risk Calculator only provides lifetime risk estimates for individuals 20 to 59 years of age.

  • from Doctor Unite August 10, 2022
    I first counsel on fitness, diet and exercise. I use a risk calculator on either my or preferably the patient’s phone as a more tangible tool and motivator. This works better than words alone. I usually add a dietary consult then a recheck and labs two months down the road. If at least some progress is not made then. As statin is discussed and added without abandoning fitness and dietary goals.
    Statin therapy is usually started at a dose likely not thought to reach goal but this mitigates side effects and when labs repeated in two months some progress can be a motivator and may allow the patient to accept a larger more therapeutic dose more easily.
  • from Doctor Unite August 10, 2022
    I’m pushing olive oil, physical activity and increased vegetable/fruit consumption. If pts need to take statins then education is provided until statin or another cholesterol lowering medicine can be provided.
  • from Generation NP August 10, 2022
    Patients who could benefit from lipid lowering therapy but are resistant to medications. I think of it as a process. Through discussions, patients often say they will try diet and exercise over the next 3-6 months. If still no change and still resistant to medication agent, I discuss role of calcium score as add on option. If patients willing to pay co-pay or co-insurance (our practice has a discounted imaging center we collaborate with). Patients can get a CT of heart for calcium score. If positive, I go over image with patient which often sets in the reality of atherosclerotic disease and I get buy in.
  • from PA Unite August 10, 2022
    I use the ASCVD app on my phone, with them providing the data and then. They can see what the results and risk levels are. Seeing things in black and white makes a difference for people.
  • from Generation NP August 10, 2022
    I still use the ACC/AHA risk score calculator show them it step by step. My practice also uses PAD screening tools and atherosclerosis that shows on x rays to show them it is not all about the numbers. The goal is reduction of the inflammation on irregular plaques and plaques evidenced on the X-rays so we don’t have emboli and occlusions.