BACKGROUND:This observational, quality initiative evaluated the impact of changing from a passive (dismissible) to an active (nondismissible without action) electronic health record alert on guideline-recommended lipid-lowering therapy (LLT) prescriptions in patients with recent myocardial infarction at risk for secondary events. METHODS:We sequentially recruited a retrospective passive-alert (February 2018-July 2019; n=733) and a prospective active-alert (August 2020-January 2022; n=587) cohort of patients who triggered an alert to intensify LLT or order a low-density lipoprotein-cholesterol (LDL-C) test if they had a recent myocardial infarction (within 12 months) and elevated (≥70 mg/dL) or missing LDL-C. Prescribed LLTs and cumulative percentages of patients with missing or LDL-C <70 and <55 mg/dL were assessed in 6-month periods up to 24 months. Reasons for not intensifying LLTs were recorded with the active alert. RESULTS:During 24 months, statin and high-intensity statin use increased from 59% to 87% and from 39% to 69%, respectively, in the passive-alert cohort. In the active-alert cohort, statin and high-intensity statin use were high and changed minimally (79% to 80% and 70% to 73%), but ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor use increased from 12% to 35% and from 2% to 8% (odds ratio, 4.69 [95% CI, 3.22-6.96] and 4.07 [95% CI, 1.92-9.46]), respectively. LDL-C testing and LDL-C goal attainment improved in both cohorts. LDL-C not current (41.7%) was the most common reason for not intensifying LLT. CONCLUSIONS:Continued efforts are needed to encourage guideline-directed LLT intensification for patients with a recent myocardial infarction who are at risk of another cardiac event.

The National Lipid Association (NLA) is currently conducting a study to improve the uptake of evidence-based guidelines into clinical practice through the deployment of case-based online learning modules to participating health systems nationwide. The Translating Evidence-based Approaches into optimal Care of High-risk Atherosclerotic Cardiovascular Disease patients (TEACH-ASCVD) will evaluate the impact of electronic learning modules on clinician practices related to ASCVD management. In the design phase of TEACH-ASCVD, expert lipidologists created a series of 7 cases informed by recent guidelines intended to provide common clinical scenarios that evaluate participant knowledge of evidence-based practices for high-risk ASCVD and familial hypercholesterolemia. In this manuscript, we present 4 primary prevention-focused cases in high-risk patients and discuss pertinent clinical teaching points. These cases are intended for individuals with clinical lipidology training. We encourage lipidologists to disseminate this manuscript and utilize these cases as a teaching tool for nonlipid specialists to hone their knowledge of common clinical ASCVD risk management scenarios.

Atherosclerotic cardiovascular disease (ASCVD) remains a leading global health challenge, with low-density lipoprotein (LDL) cholesterol a pivotal risk factor. While statins are cornerstone therapy for lowering LDL cholesterol, many high-risk primary prevention patients are unable to tolerate statin therapy and do not achieve their guideline directed LDL cholesterol goal. For these patients, non-statin therapies offer complementary and alternative approaches to LDL cholesterol reduction. Recent advancements in non-statin therapies have expanded the options available to clinicians to lower LDL cholesterol in high-risk primary prevention patients. Yet these medications are often under-utilized in clinical practice. Observational studies, Mendelian randomization studies, and randomized clinical trials support the role of non-statin LDL cholesterol lowering therapies in the primary prevention of ASCVD. This review summarizes the evidence supporting their use for the primary prevention of ASCVD and offers practical suggestions as to how clinicians can integrate these medications into their clinical practice.

Typical side effects of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies including influenza-like illness and injection site reactions, are minor and well tolerated. This case, however, highlights a less common but severe reaction, indicating the need for clinicians to understand and manage potential rare side effects noted with biologics.

Although statin therapy is well established to prevent atherosclerotic vascular disease (ASCVD) events in adults 40 to 75 years of age, it is less clear whether older adults benefit from statin therapy. The purpose of this review is to summarize the current evidence and guidelines on statin use for primary and secondary prevention in older patients. Moderate to high intensity statin therapy decreases cardiovascular event rates in older patients with or at risk for ASCVD. Cardiac biomarkers and coronary calcium scoring can identify older patients at higher ASCVD risk who may benefit from statin therapy. Age alone should not be a deterrent to statin therapy in older patients. The decision to initiate statin therapy should occur after a patient to clinician discussion based on the patient's overall ASCVD risk and weighed against other clinical factors that influence the patient's life expectancy and quality of life.

BACKGROUND:Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death in the United States. Case-based learning using electronic delivery of the modules can educate clinicians and improve translation of evidence-based guidelines into practice for high-risk ASCVD patients.OBJECTIVE:To develop and optimize module design, content, and usability of e-learning modules to teach clinicians evidence-based management in accordance with multi-society guidelines for high-risk ASCVD patients that will be implemented and evaluated in U.S. health systems in the TEACH-ASCVD study.METHODS:Seven e-learning modules were created by a committee of lipid experts. Focus groups were conducted with lipid experts to elicit feedback on case content followed by interviews with a target audience of clinicians to assess usability of the online module platform. Responses from both groups were evaluated, and appropriate changes were made to improve the e-learning modules. Design of the TEACH-ASCVD study is presented.RESULTS:Feedback regarding case content by lipid experts included providing more detailed patient histories, clarifying various diagnostic criteria, and emphasizing clinical best practices based on evidence-based guidelines. The target audience clinician group reported an agreeable experience with the e-learning modules but noted a discordance between the evidence-based guidelines and clinical decision-making in their own practices. Participants felt the modules would help educate clinicians in managing high-risk ASCVD patients.CONCLUSION:Clinicians must be informed of best practices as the field of lipidology continues to evolve. E-learning modules provide a concise, valuable, and accessible mechanism for educating clinicians regarding changes in the field to deliver the best patient care.

Hypertriglyceridemia (HTG) is a prevalent medical condition in patients with cardiometabolic risk factors and is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD), if left undiagnosed and undertreated. Current guidelines identify HTG as a risk-enhancing factor and, as a result, recommend clinical evaluation and lifestyle-based interventions to address potential secondary causes of elevated triglyceride (TG) levels. For individuals with mild to moderate HTG at risk of ASCVD, statin therapy alone or in combination with other lipid-lowering medications known to decrease ASCVD risk are guideline-endorsed. In addition to lifestyle modifications, patients with severe HTG at risk of acute pancreatitis may benefit from fibrates, mixed formulation omega-3 fatty acids, and niacin; however, evidence does not support their use for ASCVD risk reduction in the contemporary statin era. Novel therapeutics including those that target apoC-III and ANGPTL3 have shown to be safe, well-tolerated, and effective for lowering TG levels. Given the growing burden of cardiometabolic disease and risk factors, public health and health policy strategies are urgently needed to enhance access to effective pharmacotherapies, affordable and nutritious food options, and timely health care services.

Despite the availability of effective therapies that lower low-density lipoprotein cholesterol (LDL-C) levels in patients with atherosclerotic cardiovascular disease, many eligible patients are inadequately treated and their LDL-C levels remain suboptimal. Patient nonadherence to lipid-lowering therapy (LLT) is a major contributor to the failure of LDL-C goal attainment. Several factors have been identified as contributing to LLT nonadherence, including healthcare disparities due to socioeconomic status, age, race, sex, and cost; limited access to healthcare; perceived side effects associated with LLT; health literacy; and the presence of comorbidities. Suboptimal LLT use has also been associated with clinician factors, including failure to identify patients who require LDL-C reassessment, insufficient LDL-C monitoring, and clinical inertia such as a lack of therapy intensification. Several strategies to enhance LLT adherence have been shown to be effective, including the implementation of educational initiatives and tools for both patients and physicians, the use of clinical protocols and algorithms to identify patients at risk and optimize treatment, and improvements in electronic healthcare records. Pharmacy-based programs designed to help patients with prescription refills, including reminders or the use of prescription delivery by mail, have also proven effective. Drugs requiring frequent administration can represent a barrier to treatment adherence; therefore, newer, more effective LLTs with lower frequency of administration and lower potential for polypharmacy may improve patient adherence to LLT. Implementation of strategies to identify patients at risk for LLT nonadherence and the use of flexible tools such as telemedicine to overcome geographical barriers may improve LLT adherence.

Background: Effective control of risk factors in patients with ASCVD is important to reduce recurrent cardio-vascular events. However, many ASCVD patients do not have their risk factors controlled, and this may have worsened during the COVID-19 pandemic.Methods: We retrospectively evaluated risk factor control among 24,760 ASCVD patients who had at least 1 outpatient encounter both pre-pandemic and during the first year of the pandemic. Risk factors were uncon-trolled if the blood pressure (BP) >= 130/80 mm Hg, LDL-C >= 70 mg/dL, HgbA1c >= 7 for diabetic patients, and patients were current smokers.Results: During the pandemic, many patients had their risk factors unmonitored. BP control worsened (BP >= 130/ 80 mmHg, 64.2 vs 65.7%; p = 0.01), while lipid management improved with more patients on a high-intensity statin (38.9 vs 43.9%; p<0.001) and more achieving an LDL-C < 70 mg/dL, less patients were smoking (7.4 vs 6.7%; p<0.001), and diabetic control was unchanged pre vs during the pandemic. Black (OR 1.53 [1.02-2.31]) and younger aged patients (OR 1.008 [1.001-1.015]) were significantly more likely to have missing or uncon-trolled risk factors during the pandemic. Conclusions: During the pandemic risk factors were more likely to be unmonitored. While measured blood pressure control worsened, lipid control and smoking improved. Although some cardiovascular risk factor control improved during the COVID-19 pandemic, overall control of cardiovascular risk factors in patients with ASCVD was suboptimal, especially in Black and younger patients. This puts many ASCVD patients at increased risk of a recurrent cardiovascular event.

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis Patients with diabetes mellitus (DM) are considered high-risk for ASCVD. Current guidelines recommend a moderate to high-intensity statin for the primary prevention of ASCVD in adult patients with DM and once on a maximally tolerated statin icosapent ethyl if with multiple risk factors and elevated triglycerides. Objective/Purpose To assess adherence with these guidelines among cardiologists in a single large cardiology practice. Methods We identified 8,834 patients (age > 20) with DM and no history of ASCVD who had at least one office visit between December 2019 and November 2020. Patient characteristics, laboratory data and medications were extracted from their electronic health record (EHR). Results The mean age was 67.8 +/- 12.1 years, 50.4% were female and 70.1% were white. In total 1,707 (19.3%) were on no statin therapy, 472 (7.9%) on low intensity statin, and 6,645 (75.3%) on guideline directed statin therapy (moderate to high intensity). Among patients aged 40 to 75, 74.2% were on guideline directed statin therapy. Of the 8,834 patients: 7,213 (81.6%) had an LDL-C in their EHR, of which 1,541 (21.4%) had an LDL-C > 100 mg/dL. Of patients with an LDL-C > 100 mg/dL, only 145 (9.4%) were on either ezetimibe or a bile acid sequestrant. In total 7,194 patients had a triglyceride level in their EHR, of which 2,583 (30.8%) had elevated triglycerides (> 150 mg/dL). In patients with elevated triglycerides, 66.7% were on no triglyceride lowering medication, 10.6% were on a fibrate, 10.4% on over-the-counter fish oil, 5.8% on omega-3 fatty acid ethyl ester, 5.5% on icosapent ethyl (6.1% for triglycerides > 150 and LDL-C < 100 mg/dL), and 1.0% on niacin. Conclusions Over one-fourth of patients with DM without ASCVD in a large cardiology practice are on no statin or on a lower than guideline directed statin intensity and over 1 in 5 have an LDL-C > 100 mg/dL. High triglycerides are common, often not treated and when treated the most common medications are a fibrate or over-the-counter fish oil. The use of icosapent ethyl is low. There is a need to identify strategies to improve the delivery of guideline directed lipid-lowering therapy to reduce residual ASCVD risk in those with DM. Nothing to disclose. None.

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis Four US organizations (AHA/ACC, ADA, NLA, and AACE/ACE) have guidelines on statin and other lipid-lowering medication use for the primary prevention of ASCVD in patients with diabetes mellitus (DM). While all four guidelines recommend moderate to high-intensity statin as first-line therapy, the NLA and AACE/ACE have LDL-C goals based on risk and advocate non-statin LDL cholesterol lowering drugs for patients who need additional LDL-C lowering. Objective/Purpose To compare the four major guidelines in a contemporary cohort of patients with DM in a large cardiology practice. Methods We identified 8,834 patients (age > 20) with DM and no history of ASCVD who had at least one office visit between December 2019 and November 2020. Patient clinical characteristics, laboratory data, and medications were extracted from their electronic health record (EHR). Patients were considered to have met the AHA/ACC and ADA guidelines if they were aged 40 to 75 and were on a moderate or high-intensity statin. Adherence to the NLA and AACE/ACE guidelines was assessed among the 7,212 patients with DM (81.6%) who had an LDL-C value recorded in the EHR. Patients were stratified into high (LDL-C goal < 100 mg/dL) and very high-risk (LDL-C goal < 70 mg/dL) groups based on additional risk factors. Results The mean age of the study patients was 67.8 +/- 12.1 years, 50.4% were female and 70.1% were white. Among the 7,212 patients with an LDL-C in the EHR, 90.2% were stratified as very high-risk by the NLA and 98.8% by the AACE/ACE guidelines. Of the very high-risk patients not at their LDL-C goal, 69.9% were not on a high intensity statin and 92.6% not on any intestinal blocking agent. Conclusions In a contemporary cohort of primary prevention patients with DM seen in a cardiology practice almost all are very high risk and almost 60% have not achieved their NLA or AACE/ACE guideline directed LDL-C goal. Although the AHA/ACC and ADA guidelines are less stringent, over 25% have not met these goals. The use of non-statin LDL-C lowering drugs was low. Strategies are needed to improve guideline directed lipid lowering therapy in these high-risk patients. Nothing to disclose. None.

Telehealth services have been implemented to deliver care for patients living with many chronic conditions and have expanded greatly during the COVID-19 pandemic. Little is known about the current or future impacts of telehealth on lipid management practices. The PubMed database was searched from inception to June 25, 2021, with the keywords "lipids or cholesterol" and "telehealth," which yielded 376 published articles. Telehealth was defined as a synchronous visit between a patient and clinician that replaced an in-office appointment. Studies that solely used remote monitoring, mobile health technologies, or callbacks of results, were excluded. Articles must have measured lipid values. Review articles and protocol papers were not included. After evaluation, 128 abstracts were included for full text evaluation, with 55 full-text articles eventually included. Of the articles, 29 were randomized clinical trials, 15 were pre-post evaluations, and 11 were other study designs. Telehealth had positive to neutral impacts on lipid management. Reported facilitators include easier implementation of multidisciplinary approaches to care, and utilization of patient-centered programs. Reported barriers to telehealth services include technological barriers, such as various skill levels with technology; systems barriers, such as cost and reimbursement; patient-related barriers, including patient non-adherence; and clinician-related barriers, such as difficulty standardizing care. Clinicians reported improved satisfaction among patients but had mixed feelings regarding their ability to deliver quality care. Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID-19 pandemic, but more research is needed to determine its potential as a sustainable tool for lipid management.

Purpose This study was designed to evaluate the change in loop diuretic dose at three months post-initiation of a sodium-glucose cotransporter-2 inhibitor (SGLT2i) in patients with heart failure with reduced ejection fraction (HFrEF). Methods This was a retrospective cohort study including 69 patients from January 2020 to September 2021. Patients were included if they were ≥ 18 years old, had an ejection fraction (EF) of ≤ 40%, were prescribed a loop diuretic, and were initiated on a SGLT2i as an outpatient. Patients were excluded if the SGLT2i was discontinued prior to follow-up or if there was insufficient data available in the patient's chart such as missing loop diuretic dose or lack of follow-up visit after SGLT2i initiation. The primary outcome was the change in loop diuretic dose from baseline to 3 months after SGLT2i initiation. Secondary outcomes included change in other diuretic medications, change in the patient's heart failure status based on the New York Heart Association (NYHA) classification, and the incidence of adverse effects at 3 months after SGLT2i. The primary outcome was analyzed using the Wilcoxon signed-rank test with a p-value <0.05 considered significant. Results This cohort was primarily male (69.6%) with a median age of 64 years, a median EF of 20%, and a median loop diuretic dose of 40 mg (22.8-80.0) of furosemide equivalents at baseline. The majority of patients had NYHA class II or III at baseline (79.7%). Most patients were on guideline directed medical therapy at baseline with 63 patients (91.3%) on a renin-angiotensin inhibitor, 67 patients (97.1%) on a beta blocker, and 45 patients (65.2%) on a mineralocorticoid receptor antagonist. At a median of 94 days after initiation of a SGLT2i, 26 patients (37.7%) required a reduction in their loop diuretic dose. The median loop diuretic dose at 94 days was 40 mg (20.0-60.0) of furosemide equivalents which is a significant change from baseline (p = 0.001). No significant differences were noted in the secondary outcomes (p >0.05). Conclusion While the median loop diuretic dose was similar before and after SGLT2i initiation there was a statistically significant number of patients who had their loop diuretic dose reduced. This study provides a real-world experience on the additional diuresis obtained with a SGLT2i and a potential guide to loop diuretic dose adjustments in HFrEF patients.

BACKGROUND:Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein (LDL) cholesterol and cardiovascular event rates, yet due to their high price remain underutilized and difficult to prescribe in clinical practice. In March 2018, their price was significantly reduced. We evaluated whether the price reduction would improve prescribing patterns of PCSK9 inhibitors in eligible patients with atherosclerotic cardiovascular disease (ASCVD).METHODS:We identified the number of eligible ASCVD patients and those prescribed a PCSK9 inhibitor for each year between July 2015 and December 2019. Patient demographics and clinical characteristics for those prescribed a PCSK9 inhibitor were extracted from their electronic health record.RESULTS:In total 1059 patients of eligible patients received a new prescription for a PCSK9 inhibitor. From 2015 to 2019, the rate of new prescriptions among eligible patients increased from 0.5 to 3.3% (p < 0.001) and continuation rates increased from 18 to 60% (p < 0.001). Following the price reduction, patients who were prescribed a PCSK9 inhibitor were younger and more likely to be female, but less likely to have Medicare insurance.CONCLUSIONS:Despite the reduction in the cost of PCSK9 inhibitors, most eligible patients are not prescribed one. The reduction in cost has improved adherence, primarily in patients with commercial insurance. Older patients and those on Medicare still face significant barriers in accessing a PCSK9 inhibitor. Further reductions in the price of the PCSK9 inhibitors are needed as is further study of the barriers that exist in prescribing one.

Background: HeFH is a common inherited disorder that leads to markedly elevated LDL-cholesterol from birth and premature cardiovascular disease. HeFH is frequently underdiagnosed and undertreated. Objective: To compare how well primary care physicians and cardiologists recognize and treat HeFH. Methods: The National Lipid Association surveyed 500 primary care physicians and 500 cardiologists in the US who have patients with baseline LDL-cholesterol >= 190 mg/dL. The survey was conducted between August 29 and September 30, 2019. Results: For a hypothetical case of HeFH, 57% of cardiologists versus 43% of primary care physicians made the correct diagnosis (P<0.001). Among respondents, 21% of cardiologists versus 29% of primary care physicians have never made a diagnosis of HeFH in a patient with an LDL-cholesterol >= 190 mg/dL (P<0.004). Only 7% of cardiologists versus 5% of primary care physicians would refer to a lipid specialist (P=0.05). For additional LDL-cholesterol lowering after statins, 58% of cardiologists versus 48% of primary care physicians would prescribe a PCSK9 inhibitor (P=0.004); however, 30% of cardiologists versus 53% of primary care physicians have never prescribed a PSCK9 inhibitor in an HeFH patient (P < 0.001). Conclusion: Although cardiologists compared to primary care physicians are somewhat more likely to recognize and treat HeFH patients according to guidelines, both physician specialties do not adequately recognize or treat HeFH. There is a need for more education and training in recognizing and treating HeFH, greater access to lipid specialists, and fewer barriers for PCSK9 inhibitor use. (C) 2021 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Heterozygous familial hypercholesterolemia (HeFH) creates elevated low-density lipoprotein cholesterol (LDL-C), causing premature atherosclerotic cardiovascular disease (ASCVD). Guidelines recommend cascade screening relatives and starting statin therapy at 8–10 years old, but adherence to these recommendations is low. Our purpose was to measure self-reported physician practices for cascade screening and treatment initiation for HeFH using a survey of 500 primary care physicians and 500 cardiologists: 54% “always” cascade screen relatives of an individual with FH, but 68% would screen individuals with “strong family history of high cholesterol or premature ASCVD”, and 74% would screen a child of a patient with HeFH. The most likely age respondents would start statins was 18–29 years, with few willing to prescribe to a pediatric male (17%) or female (14%). Physicians who reported previously diagnosing a patient with HeFH were more likely to prescribe to a pediatric patient with HeFH, either male (OR = 1.34, 95% CI = 0.99–1.81) or female (OR = 1.31, 95% CI = 0.99–1.72). Many physicians do not cascade screen and are less likely to screen individuals with family history of known HeFH compared to “high cholesterol or premature ASCVD”. Most expressed willingness to screen pediatric patients, but few would start treatment at recommended ages. Further education is needed to improve diagnosis and treatment of HeFH.

A recent rise in atherosclerotic cardiovascular disease (ASCVD) mortality in women warrants a heightened focus on the cardiometabolic risk factors that are closely tied to increasing trends in obesity and suboptimal lifestyle. Polycystic ovarian syndrome (PCOS), adverse pregnancy outcomes (APOs) and nonalcoholic fatty liver disease (NAFLD) are often manifestations of cardiometabolic disease that convey cardiovascular risk requiring recognition foremost, as well as a targeted approach to treatment. Similarly, menopause is a time to reflect on a woman's cardiovascular risk as multiple cardiometabolic changes occur during this time. Contraceptives and menopausal replacement therapy (MRT) should be considered along with a woman's individual thrombotic and cardiovascular risk. Clinicians should be attuned to cardiometabolic risk factors throughout a woman's lifespan and familiar with strategies to reduce cardiovascular risk.

Heterozygous familial hypercholesterolemia (HeFH) results in significant elevations in LDL-C and premature atherosclerotic cardiovascular disease (ASCVD). Current guidelines recommend add-on proprotein subtilisin/kexin type 9 inhibitor (PCSK9i) therapy for additional LDL-C lowering beyond statins. Data are sparse, however, regarding treatment patterns and barriers relating to PCSK9i in HeFH patients. We examined physician attitudes, use, and barriers for treatment in patients with HeFH. We surveyed 1,000 physicians (500 primary care providers [PCPs] and 500 cardiologists in the US regarding their preferred treatments, experience and barriers associated with using PCSK9is. Cardiologists compared to PCPs were more likely to rank a PCSK9i as most important for an HeFH patient needing additional LDL-C lowering (68.6% vs. 64.8%; p < 0.05), as well as prescribing and having a patient on a PCSK9i. PCPs vs. cardiologists were less likely (odds ratio [OR] [95% confidence interval] = 0.46 [0.34-0.63]), private vs. academic practice more likely (OR = 1.53 [1.02-2.28]), and those who would prescribe a PCSK9i in an HeFH patient with (OR = 3.86 [2.57-5.78]) or without (OR = 1.96 [1.40-2.72]) ASCVD needing additional LDL-C reduction beyond a statin were more likely to actually prescribe a PCSK9i. Those practicing in an urban vs. rural setting were less likely (OR = 0.56 [0.34-0.93]), and those indicating they would prescribe a PCKS9i in an HeFH patient with (OR = 2.80 [1.74-4.49]) or without (OR = 1.43 [1.02-2.02]) ASCVD needing additional LDL-C lowering beyond a statin were more likely to face difficulty prescribing a PCSK9i (all p<0.05 to p<0.01). Greater physician education and assistance among both cardiologists and PCPs are needed to address the gaps in understanding and treatment regarding PCSK9is. (C) 2021 Elsevier Inc. All rights reserved.