Dr. Deepak Talreja, Elizabeth Vick, BSN, Amy Coleman, BSN and Lori Seaman, BSN discuss the management of their hyperlipidemia clinic and the most important factor of lipid management for reduction of the risk of myocardial infarction.
Welcome everyone to this morning's Centa Heart Hospital, grand rounds, hyperlipidemia and patient management. We've got an impressive list of speakers here. As you can see, this is Deepak Tag and I'm going to start off and then we're going to go through in sequence to everyone who actually did the work behind the project. We're going to talk about today while we're waiting for everyone to filter in. There was a second additional topic that's related that I had wanted to bring up. Many of you remember from our previous announcements that we were going to try out. We have three rehab programs, the traditional rehab program, the Pritikin program and the Ornish program run out of Princess Anne Hospital by DRS Pane Grai and Sharon Henley and their whole team. And many of us have referred patients into each of those programs. And so we thought for providers, it would be helpful to do an example of what the Ornish program was like. And so the Ornish team was amazing. They came in at nights and we did two weeks, four sessions in total where numbers did a taste of Ornish and it was a four hour program each night, we started with exercise for an hour under monitoring, just like our patients would do, then we had nutritional lectures and got to eat together and then did the yoga and meditation sessions. The reason many of us are excited about this is obviously the bar is high to achieve what Ornish wants. But when patients really enroll and become a part of this and do it, we can see tremendous changes in their dietary consumption. These are the end of 2022 metrics. And we see significant improvements in BMI a 5% loss in that quarter. We see decreases in total cholesterol LDL decreases of almost 25% improvements in triglycerides, blood pressure, depression and exercise capacity. And so the group of us that participated in this on the far upper left, you see one of the lectures we're attending. You see a lot of our physicians and aps both eating the diet, learning the nutrition lectures on the treadmills there. On the left, you can see Dr Panny all the way to the left there and on the bottom, you see us in our group therapy session. I think it was tremendous. We'll do a future grand rounds where we talk about what each of us learned from it and how we thought the experience was. Now, let's get to the meat of the presentation. I'm going to take the 1st 10 minutes and give a little background and then turn the floor over to Amy Coleman and then Elizabeth Vick and then Laurie Seaman. There are many more people involved who made this possible. And it's hard to credit everyone with, with the parts they played in this. But I think you'll enjoy seeing what we put together and how we've looked at the metrics that we put together at the beginning of the year. These few slides, I'm going to go through quickly because they are known to all of you. But we know that lipid management is one of the most important modifiable risk factors in reducing the risk of future. There are many factors, alcohol consumption, diabetes, exercise, nutritional consumption of fruits and vegetables, of hypertension, abdominal obesity, psychological factors and tobacco use. But of these, based on the inner heart study, which looks specifically, it's felt that lipids account for the majority of residual risk in patients who have atheros cri cardiovascular disease and their subsequent risk of future events. What it really comes down to is the magnitude and the duration of LDLC exposure. And so as CBD is a simple formula, it's how high your LDL is for, how long it's high. And that really accounts for your total plaque burden. So either we can reduce the years of exposure, which is hard to do without a time machine or we can decrease their LDL for as long as we can to get their, as CBD to ultimately reduce. And we've seen plaque erosion, plaque reduction can occur with appropriate therapy. This is a slide that looks at over 40 years worth of studies and shows that for the red secondary prevention, the group that has as CBD and the darker purple primary prevention group that the lower we get the LDL, the lower the event rate in terms of coronary artery disease death and over a five year period. And so there's no question, there's a clean association between LDL and AROS card cardiovascular disease event rate and reducing LDL clearly is beneficial across any platform. From statins to weight loss to other nutritional type programs, to other medications. Why knowing all this for now, 40 years, why is it? This is still an issue? And the reason is if you look at best available data, many of our patients remain vulnerable to a future CV event. This is patients who've had either an M or a PC or cabbage in the two different colors. And this is at 136 and 12 month intervals. So what we see is after an index event at one month, 2.5 to 5.5% of patients are having another cardiovascular event. And at one year, it's almost 8% and 10% of patients after an mi or after a revascularization are going on to have a second event. So we need to be super aggressive. Once we see these patients have had their first event to prevent that second event and this is, of course, within just one year, you can imagine at five and 10 years, many of these patients are coming back to us with need for additional care. This is a paper in the journal of the American College of Cardiology looking in the US when we've had good guidelines. This is from 2020. So we had our 2018 guidelines at this point on the left, you see that one out of every two patients had an LDLC measured after PC in that 1st 3 to 6 months. What that means is half of our patients are not even getting an LDL measured in that 1st 3 to 6 months after an M across the country. Now, of those that we have measurements for, if you break it down, 57% had an LDL of less than 70 which is what our 2018 guidelines suggested was necessary. 28% had an LDL of 70 to 100 another 15% had an LDL of greater than 100%. And why does that matter? Why is it not enough just to get them below 100? Well, the answer is on the right side, if you looked at what happened in terms of residual rates of major adverse cardiac events, even those less than 70 had a significant risk of adverse cardiac events. But it goes up in tiered fashion as the residual LDL is higher and higher. So there's clear reasons we need to achieve this. And it's not just to make the numbers look good, it's because of major adverse cardiac events and even the one in addition to five and 10 year risk. So our guidelines have reflected this. In 2018, the American Heart Association and American College of Cardiology came up with the guidelines that for our high risk patients, we wanted to put them on whatever therapy it took to get their LDL below 70. In 2020 the American Association of Clinical Endocrinology and the American Clinical Endocrinology Societies and the European societies suggested an LDL goal of less than 55 was what we needed in the highest risk patients. And in 2022 the AC C followed suit with the expert consensus decision pathways suggesting that patients with as CBD at very high risk should have an LDL less than 55 that is hard to achieve in contemporary practice. You'll see numbers, but we don't get patients there even half the time across this country. And we'll look at some of our numbers in the slides to come. What makes a patient very high risk? It's multiple major as CBD events that patient with a history of m recent A CS history of ischaemic stroke or symptomatic P AD if they have two of those that puts them in the very high risk category. If they have one major risk factor plus one of these other right sided, multiple high risk conditions, age greater than equal to 65 prior cabbage or PC. Besides the event, we're talking about diabetes, heterozygous FH chronic kidney disease, hypertension, smoking, history of CHF or persistently elevated LDL. Then those are things that put them at very high risk. And we need to aim for those targets of less than 70 less than 55. As you'll see, we have a lot of drugs available to us and we saw incredibly impressive rehab programs that can be used to get patients on track. And we've talked about these drugs before to look at one trial. For instance, this is the fourier trial, 27,000 patients on evaluate versus statin. And what we saw was a reduction in baseline entry LDL of 90 to about 30 with 90% of patients achieving their target of less than equal to 70. And that translated into a reduction in hard clinical events. By three years, we saw a 20 percent reduction in mace end points. And this is interesting because now we have five plus years of data. The original trial in which we participated had two groups, the placebo group that received high dose statin and the red group, which is the on treatment group with evaluate. And then at the end of the study, there was an open label extension that we also participated in where everyone was allowed to go on EU cab. And we saw routinely, we could get an average LDL around the 30 range. So we clearly can get there if we use what's in our Armamentarium. The hard part is not having the medications. The hard part is getting patients on diet, exercise, lifestyle changes and getting them to start and stick with these medications. I'm gonna turn the floor over to Amy Coleman. She's our clinical manager for S CS and she'll talk about the guidelines. Good morning. Um, the guidelines that we used once this data came out and we found that there was a need, we kind of looked across the board and one of the ones that Dr Taraia really liked was the American Association of Clinical Endocrinologists. And they did a really good job of kind of breaking it down into a good chart for anyone, any clinician to be able to use to determine what category their patient would be in based on their LDL and their um risk factors. So we're looking at patients in our study um of high risk, extreme high risk and um very high risk. We're not really looking so much at the moderate risk and the low risk. Um but it talks about just like Dr Tarea touched on talks about what the risk factors are based on their LDL and which category to put them in. Um And then here is another thing that the American Association of Clinical Endocrinologists um kind of put out as kind of a pocket guide and it talks about where the patient would go and what the treatment should be. Um And so if you look across the top line across every category of risk, it's lifestyle, lifestyle is consistent across there, which um we've already discussed, you know, diet, um exercise and we are able to offer our patients within Centa the um cardiac rehab. And then the Pritikin and Ornish programs. I know the Ornish program has a referral pathway. Um Pritikin does as well. So if that's something you're interested in, there is a referral cue that you can um refer your patients to then based on the category that they're in after they're educated on the lifestyle changes and given the information. Um if Ornish and predict isn't something that they feel that they can do or want to do, we also give them information on Daesh and then uh keto diet and also Mediterranean, then um if you look at the bottom, it talks about checking lipids every three months or more frequently, we've actually kind of narrowed that down to a 4 to 6 week range with our patients. Um we had started with 6 to 8 weeks, but as new studies came out and new information, um it was found that the four week time frame is best and it talks about what to put your patients on. And um the PC Ks nine P sorry P CS K nine inhibitor that we mostly use is R paha. It has about a 95% of the market share. Um So when we add that to our patients, that is what is being added to their um regimen, here's our similar guidelines um for diagnosing and treating patients um from the AC C and the A H A and it is a similar pathway and it talks about their risk factors and when to add certain classes of medications. Um and then this is the job aid that we came up with as a group to kind of start our process. And it talks about how to refer the patients into the hyperlipidemia clinic. Right now. We are just focusing on um Dr Tara's care team. So we can kind of get a understanding of the best workflow to go with. And then in 2024 we hope to have um a nurse driven protocol where the nurses can make a lot of these decisions independently of the provider. And now I'm going to pass the floor to Elizabeth Vick, who is um one of the Virginia Beach Nurses and also the nurse for doctor Ta Tauras Care team. Hi, good morning. Thank you, Amy. So excited to be here, I'm going to start off this morning with just a few numbers from CTERA just focusing in right now on a study health management report from January 2016 to May of 2020. And if you look on the right hand side of the screen, we're looking at patients a total within ctera of 178,000 patients that we know had were identified as having cardiovascular disease of those patients. Roughly 40,000 of them experienced in M I and could have been um definitely benefited from aggressive um lipid therapy. So this is a huge opportunity to make an impact on these patients. Next, we can look at again honing in on Centa. Um Numbers is what I'm showing here towards the bottom of the screen. Our patients um on low to moderate intensity statin with Zetia and we're compared against the national and Virginia and we're about 38%. So we're OK. In that category, it can do definitely much better. Then we look at patients who are on a high intensity statin with Zetia and we're about 50% still better than national in Virginia. But here's where we can definitely do much better. These are patients who are on no lipid therapy at all and we're at almost 24 percent and oh my gosh, we could do so much better with that. Imagine if we could get to like 2% there with so all patients being on lipid therapy therapy within Centa. Imagine that that would be fantastic. So next, um as Amy mentioned earlier, we're looking at patients who are extreme risk. So category of LDL is less than 55 and are very high risk patients keeping their LDLs than 70. These are the patients I primarily focused on in the lipid group. So what what is our lipid group? We started this in an August through November. We had a total patients enrolled of 98. We had two patients who just wanted to work with their PC P based on location. Completely understand. And one patient who died during the entire clinic for these patients, there were 20 that were not even on a statin that got added. We did 22 dose changes with their statin. We had adding Zetia to 12 of them for patha to 14 patients. And then another medication, Bendo acid and glycerin, four patients had that medication added to them. So at our baseline, we started, there were about 4% of patients who were already at goal. And why does that matter? They're already at goal. The takeaway on that is they are at goal, but we want to make sure that they stay at goal. So for those patients, I was monitoring them and at the four month mark to make sure that they still were at their goal LDL. Post enrollment from August to November. I'm I wanted this number to be so much better. But as I was reminded by Dr Tara, we started at zero. So at 35% of patients that started in this clinic made goals so that I am very excited about that. Our baseline LDL. Another impressive number, we were started at 113 and our post LDL for our patients was 62. So it's still really, really impressive. But of course, I wanted, I wanted more um some of the interventions here and we need to address what our goal was for. This was to reduce these patients LDL based on their individual risk factors. And I can't stress that enough. It's an individual risk factor that decides which um do we need to be below 55? Do we need to be below 70? Um So what did we do to get there? The big thing is to support the patient, they're understanding their condition and help them manage it. Most of these patients could not make the connection between having a lower L and the fact that they just had a heart attack. So, and I discovered that with people that they believed that they were fixed with the stent and that they were sent out on medications, but they had no idea what the medications were for. Um, came in with an standing as well. He ran out at all. I think we're hearing some background noise. If everyone can mute, you're not a so on. He Ibex line direction medical therapy. You have to eat in the background. There we go. Ok. Um So teaching with these patients is helping them understand the difference between their LDL and total cholesterol. A lot of patients said, oh, my total cholesterol is great but their LDL was extremely elevated or they just had AMI and they thought their numbers were ok. So helping them understand that food choices was a huge one as well. Which on the next slide, you'll see what I used for that teaching. But mostly the heart, healthy eating brochure from Sana. And I did mail these brochures also to the patient to help, to support and drive that, uh, medications we talked about, uh, with the patient to discuss the different medications statins versus, or pa or peret, um, touched on that as well. Um, I was trying to drive change in our patient's behavior to help them understand why they were on statins or cholesterol medications and helping them to drive down their LDL. So that also helped with compliance with their medications, understanding that if a medication wasn't working for them, that they, there were other options out there that they didn't have to stop the medication, we could change to something else that was a huge teaching point with a lot of patients who would just stop their cholesterol medication because it was causing them some muscular skeletal pain. Um, interest in the process and engagement is not just from the patient's point of view, it's also from the nurse or the patient or the person driving the clinic, um, showing an act of interest, not only helps the patient stay compliant, it helps trust and build that, um, patient nurse relationship and this is a, uh, food, um, choices it, within the brochure that I helped use uh to help with these patients talk about fruits and vegetables, protein. Also, we talked about, you know, the differences between saturated non saturated fats. And so just the basics of helping a patient even go to the grocery store and understand what is, you know, a good healthy choices to um be at the grocery store. So that was also used. So here we're going to get into our data and this is really, really exciting. So this got broken out into six groups. You can see LDL less than 55 all the way to the right hand side of the screen with LDL greater than 60. So you can see that are primarily the two groups in the middle, your LDL greater than 70 but less than 129 was the bulk of the patients around 25% of each in each of those categories. It was a little daunting to think that I actually had. So this is where we started um with hopefully focus of uh changing some of the LDLs greater than 130 see if we can reduce those. So remember now, this is from August to November. And as you can see, um the this group, now, if you look on the right hand side of the screen, I do not have any more patients in the greater than 161 130 range. So it is all shifted to the left which is amazing. So most of the patients now are with an LDL of less than 100 or right around that 100 mark. And this and if you look to the very far left, I have made a significant improvement of patients with an LDL less than 55. That's about 25% of patients in that category now. So this data is, is excellent. I was so pleased to see this, Still have some more work to do in the 70 to 129 range. But it was, it was great to see that a lot of patients moved out of the greater than 130 LDL. So um still more to go and these are patients that I have and I've only seen the one time and we're still working on pulling their LDL down. So, but great improvement here with these patients. Now, this, this slide is so amazing. It's just so exciting to see this. So these are um our goals, patients uh um of achieving goals in our percentage of it of less than 100 less than 70 less than 55. So in the less than 100 range, we doubled the patients in the LDL category of less than 100 and they're at 85% of gold that just is so exciting. And then in the category of less than 70 we tripled the patient in this category with their LDL, about 55% so, so, so exciting. And then this 10 just, just such great news is that we quadrupled the patients less than 55. 0 my gosh. I was so ecstatic when I saw this graph. So and it wasn't just me, it was the excitement with the patients too when they achieved goal. So such such an amazing graph to see. So a couple of examples of patient cases that I have, I can share you too. Uh One of the patients that came through had an LDL of 127 did not have an event yet uh but was counseled by their PC P who is trying did a great job trying to get this patient on medications. Um By September, the patient had a non sty um and was did receive PC and they were started on atorvastatin 40 mg and I had been following them and we just now got their LDL down to 64. So it was a great accomplishment by them and helping them understand, you know, again, another intervention that might have been prevented. And then one that we were super excited about was a patient who was a cardiac patient for a long time and actually was maxed out on atorvastatin 80 Zetia 10, lots of counseling to go on A P CS K nine inhibitor patient was very reluctant, didn't want to do it and then has an interior stemi. She not only got a PC, she had to come back for another staged PC. And her LDL on admission was 279. And here is the, the heartbreaking part of it. She actually left the hospital with Repatha and didn't even start it. Um came into the for office visit and um brought her Repatha with her. Um And luckily I was there that day and we did lots of cal slain on that. I showed her how to use the repatha. I explained to her what it, what it was all about, what it meant. She left, went home, gave herself the repatha. She came back to me in a LDL of 52. So she was a great success story, but also one that we could show that lack of education for her LDL and using these medications to help drive that LDL down was definitely missing some of our um challenges that we had for this program was lack of patient adherence. Um This last patient was a perfect example of that. We've addressed the problem. We have a, we haven't addressed the problem. We address the one consequence of the problem and the patient thinks it's fixed is helping the patient understand that driving down their LDL is helping to prevent another event. So a lot of times these patients just don't understand, it's not that they don't want to take their medication. They just need further education, absence of dose transition. I've had a lot of patients say Oh, I've been on this dose for years yet. They can't tell me when their last lipid panel was drawn or what their LDL was. So helping them understand that a lot of times when I was talking with this patient, there was a lot of confusion who's managing what. So there not really a good standardization. And so the education there was, this is your LDL and this is what it needs to be. So let's help to get you there and help educate the PC P or endocrinology. If they are following them, lack of follow up appointments or lack of LDL discussion at the follow up appointment, um uh was a huge challenge. These patients would have an event in the hospital and then we wouldn't see them for 3 to 6 months. And then when we did, there was no LDL discussion. Um talking about getting repeat labs, know your LDL goal. Why you're taking this medication to help patient compliance. The fasting restriction on the lab was also a challenge for me in getting patients to go back to the lab and get their LDLs drawn as something I had to work through patient preference. Some patients were stuck on, I don't want to be on this med or I don't like statins because of this, but they wouldn't try other meds. So working through counseling with them on that cost of medications was also a challenge. Not only the cost of it, but if you put in a prescription for rep disconnect and having to do prior off and then you find out they can't afford it. So that was a huge challenge that I had to work through to try to get patients on the effective therapy. So my takeaway points for this is screening and testing. Obviously very important risk assessments need to be done. Patients need to understand what their LDL is. Are they below 55 below 70 interventions in lipid lower therapy to make sure patients understand there are options out there for them and close follow up. I can't stress this enough to help reduce cardio vascular events. Being highly proactive, helps drive and change the behavior in our patients in regards to their LDL therapy, not only save lives, but it also helps to reduce the cost of health care. So, thank you very much. I'm gonna hand this uh next over to Laurie, who's our regional director of from Caro cardiology. Good morning, everybody. What an honor and a privilege to work with these wonderful folks on this great program and look at all the accomplishments, accomplishments they've achieved with our patients. I just wanted to go through a couple of things that we've achieved. Not only with our medical group initiatives, which is where this all started. We started in 2023 talking about this as a co management metric with our Cento cardiology specialist CPMC group. Happy to announce that we did receive 10 points for our 2023 metrics in this and it was develop and implement RM protocols, hyperlipidemia for RN visits beginning in Q three. As you can see from all the data, Elizabeth and Dr Talreja achieved that and are going to continue on. This was also a part of a cento one wave initiative which I'm sure you all have heard multiple things about in this one. We're assessing the opportunity for RN clinic visits to allow for the RNS mds to work at the top of their license. We also hope to increase RN retention and recruitment. These RN visits are protocol driven and they are disease management based which includes a large part of education. This then can help us open up opportunities on our provider to either see our more complex or our new patients to get further patients into our clinics, checkmarks, we've achieved them all. Um but good news, we are not done there. We are going forward in our next step of 2024 onto our co management metrics and our care delivery. As you can see here, we are going to work towards quarter of four to have this be an independent hip hyperlipidemia RN clinic. So much like we have our anticoagulation clinic today. This will be the same sort of thing. We're going to work towards putting this out throughout cardiology and not just here with Dr Tara's patients. This we have seen great evidence based with Elizabeth's presentation of how these resources help our patients. And at the end of the day, that's what we're here for excellent patient care.