Counseling Patients on CVD Risk Factors


Recommendations for establishing relationships and talking with patients about primary and secondary prevention against cardiovascular events.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: Dr Busch, when you think about some of these risk factors that are associated with what Dr Bhatt just mentioned, how are you talking to your patients about these risk factors? I sometimes think about them as modifiable, nonmodifiable. And then, what are the efforts that you are doing, and we’ll maybe go around, of screening these cardiovascular risks? You’re very involved in clinical trial research. I feel like you’re constantly looking at panels and seeing who could potentially be at risk. So maybe talk to us a little about those risk factors and how your practice takes on the screening of these cardiovascular risks.

Robert Busch, MD: For an endocrinologist, most of our patients have diabetes and mainly type 2 diabetes, but they don’t just come in with a diabetes, as Jen and others have said. They come in with diabetes, hypertension, hyperlipidemia, and obesity; they come in with hypertriglyceridemia. So, which one are we going to tackle first? Say they’ve done the lifestyle stuff, they’ve met with the diabetes educator, and you know they’re going to end up on 6 or 7 drugs down the line. Well, visit 1, you’re not giving them the works. You could, but then the patient will put their shoes and socks on and run away. You have to choose your battles first, and what you’re going to be successful with early. Oftentimes, the LDL [low-density lipoprotein] is the easiest thing to control because the statins work, and if they can tolerate the statin, at least you could show success after the first visit, that you got their LDL at a target, and then try to address the other things.

If they come in with an A1C [glycated hemoglobin] over 7.5%, you’re going to give them 2 drugs for diabetes and heart-smart drugs. You give them a statin, or a statin plus something else to get their LDL down. Now we have the REDUCE-IT trial that Dr Bhatt is famous for. You’re going to look at the triglycerides and do something about that as an additional marker. And then of course, their blood pressure. And even if their blood pressure is good, congratulations, you have good blood pressure, here’s your ACE [angiotensin-converting enzyme inhibitor] or ARB [angiotensin receptor blocker] based on the HOPE trial. Congratulations, your LDL is 92 mg/dL, here’s your statin based on the CARDS study, that statins should be in the drinking water of diabetes.

You have to roll out the regimen for the patient, and most of our patients, if you ask them what did they have for breakfast? Their answer is pills, because after a year, they’re on 6 or 7 medications and some injectables as well. So, each thing has to be addressed, because these are risk multipliers, and you want to address each thing. But it takes about 6 months to a year to roll out the full regimen that the patient is going to be on. But you’re not telling them day 1, especially if they come in saying, “I don’t want medications, I want to treat things the natural way,” and you know what you have cooking down the line.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP: Absolutely. It’s a lot, especially as some of these medications start blurring and have cardiac benefits, you have different specialties that normally didn’t use them that are now using them. And we’re going to get to that. Joyce, when we started, you mentioned you spent a lot of time on both preventive cardiology and secondary prevention. From where you sit in the specialty arena, where you get to interact with endocrinologists and pharmacists and cardiologists, how do you go about what Dr Busch just mentioned, with primary prevention and secondary prevention? How do you tackle each of those?

Joyce Ross, MSN, RNC, CRNP, CS, FNLA, FPCNA: Well, I think the first thing I want to say is, I totally agree with Dr Busch that we really can’t just throw everything at the patient the first time we see them. They will run and they won’t come back. And the idea of multiple medications all at one time is something that me is a nurse practitioner, a person who sees the patient on a regular basis, even more than perhaps the physicians in the various settings, I’m kind of a gatekeeper in a lot of ways. At least for our practice, I would be able to make sure that everybody was getting the information. I think communication between the health care providers is critically important, because this is a team. And of course, the most important part of the team is that patient. So, for me, every time a patient is seen by any of a group, and it’s wonderful if you’re all in the same health system, and you can just pick up where you where you want to, but that’s not always ideal. But what happens, what is very important, is for you, as a provider, no matter what your entity is, to communicate with the others about what you saw, what you did, how the patient is doing.

And you know what? The most important thing to me is that patient gets that same letter, because they need the congratulations, they need that idea that, “look what we did.” Again, to go back to what Dr Busch was saying, we’re helping them and supporting them in the decision that they have to make to take a lot of medication. I think that the most important thing is to depend on all the team, communicate, but communicate first with the patient. My opportunities have always been to develop long-term relationships with the patients, because dyslipidemia is not something that’s going to go away. And I’ve taken care of patients from the time they’ve been 6 years old until out of college, married and have children. This long relationship that you have with them is critically important. As a nurse practitioner, I’ve been fortunate to do that, where many specialists don’t have that opportunity. When others communicate with me, I have a great chance of weaving their thoughts and plan into the overall plan. That’s how the team works.

Transcript edited for clarity.

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