Cardiometabolic Risk Summit
The Primary Care Cardiometabolic Risk Summit (October 18-20, 2013, Las Vegas) brought together a mix of physicians, nurse practitioners, and physician assistants for a three-day comprehensive look at the four pillars of cardiometabolic risk—diabetes, obesity, dyslipidemia, and hypertension. For those who couldn’t attend, here is a look at some of the discussions.
Applying Lipid Guidelines in Daily Practice
Colleen Mullarkey, Contributor
Peter H. Jones, MD, opened his lipids discussion by reviewing how to implement recent guidelines that provide risk stratification algorithms to maximize cardiovascular protection without overprescribing or setting unrealistic therapeutic goals.
“Appropriate assessment for the future risk of cardiovascular disease is crucial,” said Jones, associate professor at Methodist DeBakey Heart and Vascular Center at Baylor College of Medicine in Houston, Texas. “Determining whether the patient is high-risk primary prevention or is secondary prevention (known CVD or CHD equivalent) provides guidance on prescribing long-term statin use.”
Evidence-based outcomes trials in high-CVD risk patients support the use of optimal statin dosing for its reduction in events and all-cause mortality, with a very low incidence of side effects. “Statins are first-line lipid therapy for CHD prevention and are combined with targeted healthy lifestyle habits (diet, exercise, weight control, and nonsmoking)—not to be used in place of these habits,” he says.
The target of the statin benefit is a reduction in atherogenic particle number, of which LDL-C has been a good biomarker. “However, LDL-C is not the best marker of atherogenic particle number and hence, the use of non-HDL-C, apo B, or LDL-P measures may be better for some patient groups, such as those with diabetes and those with metabolic syndrome,” Jones says.
While you may be tempted to order all possible biomarkers of CVD risk or to employ imaging techniques, it’s not always necessary—especially in primary prevention cases. Jones recommends using this sort of advanced testing selectively to individualize the decision to initiate intensive therapies.
In selected patients with premature CHD or with a family history of premature CHD, measuring Lp(a) is useful since an elevation is genetically determined. The only nonlipid biomarker validated in risk assessment for statin treatment is hs-CRP in primary prevention men above age 50 and women above age 60. “Although there are other nonlipid biomarkers that can be measured, it is not clear if those really assist in identifying a higher risk than a Framingham Risk Score would tell you,” Jones says.
Addressing additional lipid and non-lipid novel markers might enhance CVD risk identification and possibly predict risk reduction; however, the benefit and any cost effectiveness remains to be established. ■
Heart Disease Among Women Still Under-Recognized
Eileen Koutnik-Fotopoulos, Contributor
Cardiovascular disease is the number 1 killer among women, and is more deadly than all forms of cancer combined, reports the American Heart Association (AHA). Yet, this fatal disease remains an under-recognized health issue for women.
Jeffrey P. Levine, MD, MPH, professor and director of women’s health programs in the department of family medicine and community health at Rutgers Robert Wood Johnson Medical School, said progress has been made in the awareness, treatment, and prevention of cardiovascular diseases in women. However, patients and clinicians “still lack awareness.”
While recommendations for preventing cardiovascular disease are similar for men and women, there are certain risk factors unique to women and they may respond differently to prevention interventions. Cardiovascular disease may also present differently in women. “Very often we spend so much time on gynecologic issues that we don’t address diet, exercise, weight, and blood pressure,” he said.
In 2011, the AHA published updated guidelines for the prevention of cardiovascular disease in women, which outlined approaches to cardiovascular disease prevention for women with hypertension, lipid abnormalities, and diabetes. Levine, who will review the guidelines, said recommendations also include a heart-healthy diet, screening for depression, and using cardiovascular disease risk stratification.
Along with educating women on the importance of healthy lifestyle changes, identifying women at risk for cardiovascular disease and implementing appropriate evidence-based prevention strategies is an important component in treating this patient population, according to Levine. Furthermore, he recommends that clinicians keep up with the latest research regarding the effects of hormone therapy on cardiovascular risk. ■
Diagnosing and Treating Resistant Hypertension
Eileen Koutnik-Fotopoulos, Contributor
Resistant hypertension is a common clinical condition. About 70 million Americans or 1 in 4 adults have high blood pressure. Most estimates suggest that as many as 10% to 15% of those with hypertension actually have resistant hypertension, which means that it probably affects at least 7 million people and 1 in 10 visits for hypertension, according to Michael J. Bloch, MD, associate professor in the department of medicine at the University of Nevada School of Medicine.
Bloch also addresses the importance of implementing treatment regimens aimed at reversing contributing lifestyle factors and maximizing pharmacotherapy. Resistant hypertension is uncontrolled blood pressure despite the concurrent use of 3 antihypertensive agents of different classes, ideally one of which is a diuretic and all used at optimal doses. Furthermore, patients whose blood pressure is controlled but require 4 or more medications should be considered resistant to treatment, according to the 2008 American Heart Association (AHA) consensus statement.
The AHA guidelines recommend a 7-step diagnostic and treatment algorithm when evaluating patients for resistant hypertension. “It is well known that patient’s with apparently resistant hypertension have a higher risk of cardiovascular events,” said Bloch. “But, our experience suggests that many of these patients actually can get their blood pressure under control. Their care team just needs to be more knowledgeable in how to approach this common, but under-appreciated condition.” ■
A Dietitian’s Perspective on Nutrition inCardiometabolic Risk
Colleen Mullarkey, Contributor
Nutrition is a crucial piece of the puzzle in reducing cardiometabolic risk. Linda M. Delahanty, MS, RD, LDN, shared evidence-based nutrition and lifestyle interventions for reducing cardiometabolic risk, as well as nutrition counseling strategies.
“Nutrition and lifestyle changes can help patients achieve targets for weight loss, glycemic control, blood pressure, and lipid levels with less medication,” said Delahanty, who is the chief dietitian and director of nutrition and behavioral research at Massachusetts General Hospital Diabetes Center in Boston. “Evidence shows that diet and lifestyle modifications have the potential to reduce LDL cholesterol levels by up to 20% to 30%, systolic blood pressure by 19 mm Hg to 50 mm Hg, and diabetes incidence by 58%.”
Delahanty said too often patients are overwhelmed by the number of diet and lifestyle changes that they’re asked to make to improve various elements of their cardiometabolic risk profile. “Then they become so discouraged, frustrated, and confused that they make little to no progress at all,” she explained. “We need to simplify our messages about nutrition and lifestyle, and help patients to prioritize their focus on the health behaviors that will give them the most of what they want—better health outcomes, less medication, better quality of life, and an ability to enjoy eating in the process.”
She recommended a streamlined approach physicians can use to support patients in creating a nutrition plan and implementing lifestyle changes that work for them:
• Tailor discussions with patients based on an assessment of their medical profile, nutrition, and lifestyle habits, and readiness to make nutrition and lifestyle changes.
• Based on that assessment, help each patient to prioritize which health behaviors to focus on.
• For patients who want to lose weight, focus on reducing calories and portions to lose 5% to 10% of body weight, which will simultaneously reduce diabetes and other risk factors.
• For those who are not ready to lose weight, talk to them about focusing on increasing activity or on making a few specific diet changes.
• Try to agree upon 1 to 3 SMART (specific, measurable, achievable, realistic, time-sensitive) goals for each patient.
“When possible, refer patients to meet with a dietitian-nutritionist who has the time and expertise to provide this type of individualized medical nutrition therapy,” Delahanty said. “Telling patients what to do (lose weight and increase activity) is not enough—they need to learn the skills to know how to do it in a sustainable way.” ■
The Impact of Primary Care on Cardiometabolic Risk
Pooja Shah, Managing Editor
John E. Anderson, MD, an internist in Nashville and the president of the American Diabetes Association, delivered a keynote address that said primary care has made a significant impact on the spread of cardiovascular disease—to the tune of 1.1 million deaths averted between 1970 and 20101—but that diabetes is on the rise globally and we need to stay vigilant in early detection and managed care.
Anderson outlined several challenges that primary care practitioners face including lack of time, competing interests at the time of visit, an episodic/acute care model, absent reimbursement for care coordination, limited resources, and evolving treatment options. In addition, there is an overall decline in the number of residents, physician assistants, and nurse practitioners choosing to go into general internal medicine versus subspecialties that pay more. In 1998, 54% of internal medicine residents went to internal medicine general practice versus 21% in 2009.2 Conversely, in 1998 there was no such thing as a hospitalist and today, there are 20,000 hospitalists and the number is projected to reach 40,000 in the near future.
Despite all that, we are seeing a 19% to 35% decline in cardiovascular deaths across the country.1 Emergency room visits have also declined. Anderson acknowledged better medications and better treatment options played a role, however, “I would argue that this is you and me.”
Reductions in complications from diabetes over the last 15 years include a 50% decrease in amputations, 34% reduction in end-stage kidney disease, and a 24% drop in 10-year coronary disease risk.
In 2007, $174 billion was spent on diabetes treatment. In 2012, that number jumped by 41% to $249 billion.3 “I don’t know of any other disease that is growing at a rate of 8.1% per year,” said Anderson. And what’s the driving force? The prevalence of diabetes, particularly in an older, ethnically diverse society, is today’s reality and a major concern for primary care. ■
1.National Institutes of Health. 2012 Chart Book. Available at: http://www.nhibi.nih.gov/resources/docs/2012_ChartBook_508.pdf. Accessed August 22, 2013.
2.Weissman A. Internal medicine in-training examination survey. Office of Research, Planning and Evaluation. American College of Physicians. Personal communications between John Anderson, May 2010. ITE Exam Survey.
3. American Diabetes Association. Diabetes Care. 2013;36(4):917-932,1033-1046.