Let me turn this over to Dr. Hogan and ask her for insight as a practicing interventional cardiologist and cardiologist, how does she optimize secondary prevention in her patients and some tips and tricks to get them the medications they need? Dr. Hogan? Well, thank you for having me. That was a fantastic presentation and I really appreciate this presentation and the toolkit, which I think really will be helpful to clinicians and patients as well, given kind of the complexity of life and medical care these days. So I can just speak, so I'm an interventional cardiologist at Denver Health Hospital, which is in Denver, and we are the safety net hospital for the area. So we actually serve a large minority population and historically underserved population. I would say that one of the advantages of working at an institution like Denver Health is that the institution really does advocate for its patients. So we are able to ensure that most patients who come in, either uninsured or underinsured, we try to supplement their insurance the best we can. And so surprisingly, we are very aggressive with our lipid therapy. Most patients are on high-intensity statins and Zetia by the time they reach us. And we do have a large proportion on PCSK9 inhibitors because our Denver Health Even Medicaid will reimburse. Now we do have to get prior auth for that, but surprisingly, we are able to get a lot of patients onto that therapy and achieve aggressive LDL goals. So that's great. And most patients actually do really want to engage. Now a lot of times you do have to engage the patient, take time with them. We take care of a very large Hispanic population, and we find that family discussions are very important because family members tend to be very close. They live together. Oftentimes children are helping care for their older parents. And so making sure that they're engaged in the process is really important because they will ultimately be the ones kind of helping to ensure that the patient receives the care they need. In terms of PCSK9 inhibitors, again, we were able to successfully get people who need them the medication. The major kind of pushback to the therapy are the side injections, which doesn't happen very often but occasionally. And then even more commonly really is just kind of the polypharmacy issue because these patients are on so many medications already just trying to navigate that and try to minimize, take away things that maybe are less effective. So Zetia statins are very common. We do try to go through three statins before declaring somebody as statin intolerant. And in terms of the newer agents and glycerin and bempedoic acid, we actually have less familiarity with these agents. They're more expensive. And because our pathway with the PCSK9 inhibitors is very successful, we haven't had really as many situations where we'd need to explore those therapies. But I'm sure with time, you know, that will change. And as our reimbursement changes, we expect that those medications will be available as well. So... Thank you so much, Dr. Hogan, for that insight. It's very valuable, practical insight for a practice inclusion. Dr. Paul? Yeah. Thank you, Dr. Hogan. This is really good. I want to ask a few questions to you before I start with Dr. Dahl. So in your practice, I know that you described, but if I ask you one particular barrier that you face, what would be the number one barrier to start the statin or start any non-statin therapy to get our goal? So the number one barrier in our patient population, you know, with the statins, it's not cost, but with everything else in our population, cost really has to be the number one factor. And I would also say, you know, we do have a large population that is unhoused as well. And so consideration for patients that, you know, may have transient housing or how you're going to kind of deal with that and be practical about it. But, you know, when the medications are covered, our participants, our patients are very actually most of the time happy to comply. Thank you. And Dr. Dahl, if you give your perspective from your practice, how do you deal with statin intolerant patients, how to get our guideline goals? So my primary practice location is at a VA and we have an integrated pharmacy group. And there's huge pros and some cons to having that kind of support. I think the pros are if I have a statin intolerant patient, I can send them to pharmacy clinic and they will do the testing and up titration of various statins for me and honestly do a much faster and better job at doing that than I would have as a clinician who's unable to see patients every week in some cases, as they do in pharmacy clinic. The potential downside is they follow and they force us to follow a very strict protocol with regard to attempting at least three statins. And for some patients who have an LDL of 180 and they have severe myalgias with rosuvastatin, I can tell them that they're not going to get to go along 2.5 milligrams of rosuvastatin every other day and some azetamide, but yet we do go through that exercise. I can't complain because they will go through that exercise with me or for me with my patient and that's great. I would say a larger problem I'm seeing more recently is people who are refusing to attempt statin therapy because of concern about side effects and those can be real side effects and those can be side effects that I think are coming from misinformation that they may be seeing online or on social media. And I have not figured out a good strategy for that. showing them their angiograms, giving them my professional expertise. I do think this is a role that an interventional cardiologist can step into in a way because a patient is never more teachable, unfortunately more vulnerable, but also more able to change is that first time you show them their coronary arteries or when they come in with a mild cardial infarction and that is the time they may be most willing to accept your expertise and try a new medication that they otherwise their uncle or their second cousin told them is going to kill them. So I don't know the answer there, but I actually am having more problems with people who refuse statins than I am with people who try them and then have intolerances at the present moment. Excellent. So you think that in our panel, everybody thinks that I was thinking that adding a pharmacist in a team or extra pharmacist, like, or maybe like, you know, we have the diabetic educator, so we might need a statin educator, a cholesterol educator in the, or like the people who does the lifestyle modification education, all of this, if they are involved, I think it will be more compliant, you know, or they can spend more time basically. I think though we tell what are the indication, we tell that we should be on, but I think that if someone else also tell behind the physician, I think that might be helpful. So Dr. Lotip, you, there are two recent studies came out, very big studies also, you also mentioned that in your first gap, that half of the patients does not even have after PCI or even within six months, they don't have any LDL level. And that's, that's from the study. So how do you approach that? Like what strategy would do to decrease that scenario? So I'll start with my own example. I'm as guilty of that as anybody else. I think I have, I have missed out on checking LDLs on a regular basis. I think the purpose of this webinar first and foremost is to educate myself that, you know, like, like what the recent consensus from ACC says that we should be checking cholesterol every four to 12 weeks until we get to target. So I think I do check it frequently, but I was not checking as frequently as six weeks. And many times, you know, the patients are also a little bit hesitant to get their blood draws. But, you know, I think the focus of our webinar was on secondary prevention. So most of the patients have had an event. So when, when patients have had an event, they, they tend to be a little bit more pliable to taking these medicines, which are lifesaving. So I think I have personally changed my practice for the better. I check lipid profiles much more frequently and try to use all the options that are available. Although we have, I must admit that my office has to go through hurdles trying to achieve that. Thank you. What we are doing in our practice, anybody come to the cath lab, everybody gets by default a lipid panel with the BMP and CBC when they do the cath. We make that a strategy and it's really improved our utilization of statin and getting the LDL goal. We have some data for the last two, three years. So we've been doing this. So that might be strategies as they are coming to the lab for even the diagnostic thing or any kind of procedures that come, that's the one time they're already fasting, you're getting the other labs, one draw, at least you get the baseline and you can act on it. I think that's a good strategy. Dr. Mukherjee, I face some questions to the patients all the time and I'm struggling with that, that they are starting intolerance, they have a lot of side effects and they are concerned about their memory issues. Even today I saw a patient in the clinic and he said, oh, I had a history of Alzheimer's in my family. He had a stent and he said, no, I don't want to start because I think that I will get Alzheimer's. He and his wife read about it, dementia, Alzheimer's, memory issues, diabetes is one of the things they read about it. And how do you convince the patient that, oh, these are not the issues? Because they have pre-occupied, kind of pre-occupied their head that those are the other side effects behind the muscle, muscle, muscle pain. Oh, fair question. And I think Dr. Doll touched on this a little bit, there is perception and if you Google, which most of our patients do, I think you read more about side effects, there is robust data that the mild elevation in glucose or some of the side effects, the benefits significantly outweigh the risks. There's mortality benefit, there's reduction in heart point, that doesn't mean you're going to convince a patient. One of the strategies we do, we do a lot of cardiac rehab, post-TMI, post-heart failure, post-CCU admission, and we incorporate that teaching with a pharmacist during their cardiac rehab. We have had some success, but some individual patients are completely convinced that the risks outweigh the benefits and you're not going to convince them one way, but it works on most of the patients, I would think, given, you know, you show them slides, you show them figures that the magnitude of benefit, including making them live longer, I think we can convince appropriately based on evidence that these are life-saving medications. There are good things for the patient who is completely against having read about all the side effects, about memory reduction, they're going to get diabetes, and all these bad things are going to happen. We do have agents. Unfortunately, they're very expensive still. Bempedic acid is an oral agent for somebody who doesn't want to take injectables. It's not as effective, still 10 to 15% reduction. PCSK9 inhibitors and glycerin are extremely effective. There is less, I would say, outcome data still with glycerin, more robust data, and Dr. Hogan mentioned it's been around longer. What I'm seeing in my own practice, it's getting a little easier to get pre-authorization. I think insurance companies are figuring out that preventing an event eventually will save them more money if they pay for that medication upfront. I think it's a real problem, but I think we're working with their cardiac rehab, patient educator, and particularly a pharmacist talking to them about the risk and benefits and showing the data. Having said that, one of the things let me ask you and the rest of the panelists, we're all interventional cardiologists. How do you deal with prescribing this medication if the patient is referred by a PCP or a cardiologist? Are you prescribing them yourself? Are you calling the referring physician? Are you telling the patient, giving them a note? How do you avoid stepping on the toes of your referring physician, but at the same time, optimize secondary prevention because they're as much your patient as the referring physicians? I'm personally managing those lipids. Even the PCP referred to us for other reason or I just check the lipid panel if available. If not available, I just try to get the last lipid panel. If it's not successful, sometimes I'm not successful after multiple communications, so I just check in our lab and I just go from there because with the robust data and definitely decrease all these cardiovascular events. So I'm managing and then I just call them, say I started this medication and I'm increasing the dose or adjusting based on this lipid panel. But I'm also at the same time, I do go to some outreach clinic and it's a real challenge to get the baseline lipid panel or follow-up lipid. It's really, really a challenge for me. Even if I want to be aggressive, that's why I start with the highest dose and then we go from there. If they don't tolerate, then decrease. But honestly, multiple attempts, I was failed to get the lipid panel because they don't want to come always in the bigger center and the labs. Anybody else have any follow-up? A follow-up question to that is, you know, basically I know we have always talked about a fasting lipid profile and I know there is some data that maybe fasting is not as important, particularly when you're looking at LDL and stuff. So many times if the patients come to my clinic and even if I'm seeing them in the afternoon and I have concerns that this patient is not going to show up for their lab later, I have told them, you know, just go and get your lab done today so that you don't have to make an extra trip. And that way I think I have been successful to some extent. That is correct. So I also do, there is no need for fasting anymore. So as soon as I see the patient, my lab is right there. So I get the lipid panel. I have one more experience. I think it's a major one that I felt and I've been seeing that everybody I talked about want to start the cholesterol. First thing patient told me that, oh, my PCP told me that my cholesterol is fine. So then it's very hard and I have many patients because they are so close to the PCP and you want to change the doses or anything you want to do. They say, I want to talk to my PCP and PCP said, I just checked the lipid a couple of months ago, very recently, and they said my lipid is fine. So what is happening that if LDL is 130, whatever the normal value in the parentheses, they said, oh, your cholesterol is good. They don't think about other ACVD, ADC scores or others. So I think there is still room for education to the primary care community or primary care area. What do you think in that? I think there is still lack of education guidelines. I think one of the slides I showed is empowering the patient, showing them the data, asking them or showing them the ACVD risk and what the target LDL. You're absolutely right. Depending on the PCP, sometimes, you know, they're looking at what the lab says is normal and they come back to you saying, why do you want to put me on this? It's a challenge and, you know, involving pharmacists, involving other ancillary individuals and showing them the data is probably the best way. But still, it can be challenging if they, you know, most patients trust their physicians, they trust their PCP. They may think that is not necessary. Thank you. Dr. Dahl, there is a recent study just published last year, and it's a big study, 14 countries, European countries, 9,000 patients. The name of the study is Santorini study, done by Dr. Koshikre, published in Lancet. And it shows that there is a significant lack of utilization of the study, like more than 50%. And do you think that it is underestimation of the risk and or underutilization of the combination therapy like this? Everybody probably starting some doses of starting to just get the checkbox, like, you know, the metrics, hospital metrics and everything. As long as you're starting is 5, 10 milligrams, it doesn't matter, your box is checked. But are we not using the combination therapy either statin plus ezetimibe or statin plus PCSK9 inhibitor upfront? What do you think and what we should do? I think it's a, we see kind of slow uptake of utilization of every drug once it hits the market, obviously. And I think it's a little bit interesting to watch statins that had that same curve, and now have plateaued. And I would argue, although I don't know the data perfectly, that we've now started to have more challenges getting patients started on statins. I also think some of these other medications get tarred by the same brush as the statins. In patients' minds, they've heard these things about statins, and then you start talking about other cholesterol medications. And they also have concerns about that. So I do think there's patient level barriers to get people not only on a statin, but getting them on combination therapy, where you can actually get them to a goal of less than 70 or less than 55. All that being said, I think there's a responsibility for us as well as physicians. And I think a lot of us, and I'll talk about myself here, I think when I started in independent practice, if you looked at my procedure notes, I would write aggressive secondary prevention. And that was the extent of what I was doing in this area. And it turns out that people are actually reading those notes. And when I started writing high intensity statin with goal of less than 70, and then better when I started actually ordering the statin, the atorvastatin of 80 milligrams for the patient, and then sending them back to my partner, those patients got put on more medications. I can't cure the whole world, but the people who come through my lab at this point are getting put on the right medications. And I'm adding ezetimibe. And now I'm adding a lot of PCSK9 inhibitors. Although, as I mentioned before, that's within the context of an algorithm that I don't have full control over. I think in order to get this more broadly used, you got to get to primary care physicians because we still see a relatively small slice of the at-risk population. And your guess is good in mind what the best interventions are, but I do think thinking of all of us as a community and as a group, and again, in the VA, that's really easy. Like I see these people every day, we have all the same electronic medical record, just knowing that we collectively take care of these patients. It's not your problem. It's not my problem. Like we all need to get them on the right therapy. Dr. Hogan, so when you order the PCSK9 inhibitors, like how do you in the clinic first time? Because in my experience, I'm trying to enroll some patients for one of the trial. We need 5,000 patients for PCSK9 inhibitor in ACS patients. And every time I talk to the patient, they're a little afraid of the needle. And they said, no, I don't want to take any injection. And then, of course, it's a trial. But in the real situation, do you show the actual, like as Dr. Mukherjee showed in a slide, I think that slide is very important, the patient education with the needle, with the cost. I think that's the money slide. And it tells everything about all the statin, all the non-statin therapy. So I think that that should be handy to all cath lab or all in our practice from our Skype toolkit. But my question to you, that how do you, have you ever faced this needle, fear of needle and they don't want to? Yeah, absolutely. I think it's being patient and sometimes, you know, kind of anticipating that a patient may need to be on a PCSK9. And so kind of preparing them for that and saying, okay, let's, you know, talk about anything else we can do in terms of diet, you know, whatever else we can do to try to get the deal down. But if, you know, if you're still not reaching goal, like really, you know, to decrease time in the hospital and events and improve your life, this is really the next recommendation. And yes, we do have, you know, we show the patients the first time and, you know, that can be a barrier for some patients for sure. But most of our patients are willing to go down that route if we recommend it. So, and I think, you know, the fact that the dosing is less frequent also, that can also be seen as an advantage. Thank you. I think we have two minutes left. Maybe we can wrap up with a very specific summary. So with this, today's webinar, I think the most important part that we all know as cardiologists statin is important. On top of the statin, we should use the PCSK9 inhibitor or any kind of non-statin therapy to reduce further LDL to reach our goal. But there is no brainer because we know all the guidelines, but issue are how to convince patients, how to tell the patients to, hey, we have some randomized trial that showed that even the muscle pain, the placebo patient does not have any, they have more muscle pain than the patient actually taking the statin. So we should convince any way that we can, we should involve the pharmacy, as Dr. Dahl mentioned, that the thing that will increase the more compliance and more patients will be convinced. Those things, and of course, the appeal form is, I think is very important that everybody should use that appeal form. There's three important points that statin intolerant or tried maximally tolerated doses. We, patients have established SCVD or coronary artery disease. And then if still they refuse, then we just do PR to PR. And I think from our community, as interventional cardiologists or cardiologists, we should be very aggressive to lower our LDL goal. And upfront, like combination therapy is very important.

secondary prevention

medication access

patient engagement

PCSK9 inhibitors

barriers in statin therapy

comprehensive approaches