So this is it, this is the last lecture. So I'm going to try to keep everybody awake for the next 10 minutes, see if I can do this. And I'm going to chat about championing strategies for secondary prevention in your calf patients. These are my disclosures. So you've literally just heard this over and over again for the last 45 minutes that we know the patients who've got known atherosclerotic cardiovascular disease, they've got high risk for subsequent cardiovascular events. And despite the fact that there's evidence-based guidelines saying, hey, you need to lower their cholesterol, you need to lower the blood pressure, you need to give them good glycemic control, implementation of secondary prevention has just remained absolutely poor. This is a cross-sectional study. It's over 5,000 patients from the NHANES database who had known atherosclerotic CVD. And basically what you can see is that treatment rates have improved over time. But even in the most recent era, we still have 25%, 30% of patients who aren't getting their cholesterol or their high blood pressure treated and got low rates of anti-glycemic treatments as well. And well, it's great. Maybe those patients didn't need treatment. But for those patients who are being treated, we're not even doing a good job at getting good control. I mean, you can see here almost 20% of patients didn't have their lipid thick goal, 30% of patients were still hypertensive, and 40% of patients still had suboptimal hemoglobin A1Cs. And this was, again, recent, 2017 to 2020. And I think this is really important for us to note that the rates of secondary prevention are significantly worse for underrepresented minorities. This is the use rate of statins. You can see here it was lower by about 20% for black and Hispanic individuals. And the use of an optimal treatment regimen, so this is cholesterol, glycemic control, blood pressure, anti-platelets, was lower by about 8% in black and Hispanics when we compared them to white patients. So what can we do about this? The reality is that there are many barriers to achieving optimal implementation of evidence-based cardiovascular care. And they exist at multiple levels, the patient level, the provider level, the health system, and the societal level. And the reality is that we're not going to fix health care. I'm certainly not going to fix it in the next eight minutes. It's well beyond our control as individual practitioners. We're seeing individual patients. But some of these provider and patient barriers you do have the ability to affect. And they often, fortunately, involve education, counseling, and resources, things that we are often limited on. So patient education and counseling, it takes a whole lot of time. So does keeping up with the most up-to-date guideline recommendations, and going to talks, and going to the conferences. And as busy interventionalists, we're taking care of more and more complex patients. We're working in systems that have limited resources. And it can seem really overwhelming, even if we acknowledge that this is an incredibly important thing for us to do. So I'm going to spend the next 15 or so slides going over some key strategies that hopefully will improve secondary prevention for your patients. They're both effective. They've been shown to be effective by research. But they're also efficient. And they can be implemented with, hopefully, minimal time impact to you. So strategy one, consider using polypills. I came out of fellowship, and I was like, I don't like polypills. I don't like the fact that if I want to change a dose of one med, I have to change all of it. It's just annoying. But here's the deal. This strategy actually really works. And this was shown in the UMPIRE trial. So the UMPIRE trial randomized 2,004 patients. They had known CVD, or they were at high risk for CVD. And they either got a polypill, which was aspirin, statin, and two different antihypertensive agents. Or they just got usual care, which was whatever multiple different pills they needed for cardiovascular risk factor management. Primary outcome was rate of medication adherence, as well as changes in how well they did getting their risk factors controlled. And you can see here on the right that patients who were treated with the polypill, this is called a fixed dose combination pill. That's why it says FDC. They had significantly higher rates of medication adherence at 12 months. And that extended out to those patients who were followed for two years. And not shockingly, if you take your meds, it works. Patients who took the polypill had lower systolic blood pressures. They had lower LDL levels when you compared to the usual care group. OK. Two, try to encourage your patients to engage in behaviors that are going to simplify their medication acquisition. So one of the ways I do this is I encourage the use of a mail-order pharmacy. Most health insurances offer access to this. And the theory behind this, it's pretty intuitive, right? You're more likely to forget to go to CVS every month or every three months to pick up your meds if they're not. If they're just sent to your door or you just have to click a button on your computer, it might be a little easier. And again, studies have shown that this is true. This was a study that researchers, they used propensity score matching that was performed between patients who had diabetes. And they were either getting their meds at their local pharmacy or at a mail-order. And essentially, you can see that mail-order pharmacy use was associated with greater medication adherence, better hemoglobin A1C controls, and actually rates of hospitalization all the way out to four years. Another way to help your patients simplify getting their meds is to encourage them to engage in refill synchronization. So this actually refers to patients being on a schedule. They only have to go to the pharmacy one time a month to pick up all of their maintenance meds. Again, this is something that's actually available at most pharmacies or CVS or Walgreens. It's supported by many prescription drug plans, and it works. This study, patients with over 7,000 patients, propensity matched were taking two or more drugs for chronic conditions. And you can see that synchronized refills was associated with significant improvement in med adherence in patients who were using retail pharmacy, as well as using mail-order pharmacy. Mail-order is on the right. And actually, what you can see here is that the effect in patients using mail-order pharmacies was less dramatic. But that's likely since we already got the medication acquisition being made easier with that whole mail-order pharmacy. This is an easy thing to do. Tell your patients to ask the pharmacist about how to opt into the synchronized refill. It will take you 10 seconds in a clinic visit. Next strategy, don't be afraid to re-challenge previously rejected medication classes. So we know this. Patients experience tons of side effects from cardiac drugs. Many of these side effects might be related to a specific formulation, or some of them are just not even related to the drug class, right? Someone's like, my hip hurts because I'm on a statin. I'm like, well, no, you have bursitis. So this study found that the vast, vast majority of patients who had experienced a side effect leading to statin discontinuation were actually able to tolerate either another statin, or even the same statin when they were re-challenged with it. And interestingly, of almost half the patients who were re-challenged with the same statin, not only were they taking the same dose that they had initially discontinued, or even a higher dose at one year. But that said, some patients may say, hey, I don't want to take that med. It made me feel bad. And that's totally understandable. So be open to working with the patient, trying different approaches, even if it's not what the class one recommendation is. So this, we say you have to take your statin every day. Well, consider intermittent dosing of statins. So in this study, patients who got intermittent statins, they got them every other day, they had a significantly higher LDL reduction when compared with no statin at all. And there was actually a strong trend towards a decrease in all-cause mortality at eight years with both daily and intermittent statin dosing as compared to no statin. Or be willing to consider treatment with moderate intensity statins. Yes, the guidelines recommend the use of high intensity statin formulations. That's what we should try to do. But if your patient can't tolerate it, the Lodestar study showed that a treat-to-target strategy with any statin was non-inferior to high intensity statin treatment when we take into account a three-year composite endpoint of death, MI, stroke, or coronary revascularization. So be flexible. Strategy number four, utilize non-physician resources. This stuff doesn't require you to take any time. These are your advanced provider proteins. These nurses, your nurse practitioners, your PAs, they are great resources to help with education and counseling as well as with dosage adjustments for your patients. And again, this is the COACHE study that was shown here. And it showed that aggressive pharmacologic management, educational behavior counseling, problem solving to address barriers to adherence, all can result in significant improvement in blood pressure control, lipid control, and glycemic control. OK, well, maybe you're like, great, Suze. I don't have an army of available NPs or nurses to work with my patient panel. Well, cardiac rehab, it's a wonderful thing. Cardiac rehab addresses risk factor control. And this is a meta-analysis of 33 studies that included almost 17,000 patients. And what you can see here is that cardiac rehab programs increased medication adherence by 14%. All of your post-PCI, post-MI, post-CABG patients should be referred to cardiac rehab anyway. So this is another good way, another reason why you should do that, but also another good way to kind of help get your patients taking the right meds. There's actually also beyond hospital or health system community-based programs can also help by making treatment convenient and providing it with the endorsement of community members. This is data from the randomized study. It was 320 patients, black male barbershop patrons who had hypertension. And barbershops were actually assigned either a pharmacist-led intervention in which barbers encouraged meeting in barbershops with pharmacists who prescribed the drug therapy with a collaborative practice agreement with the patient's doctor or to an active control approach. Primary endpoint was systolic blood pressure reduction at six months. And you can see here, folks who had the intervention had substantially greater drops in their systolic blood pressure, the diastolic blood pressure. And frankly, the majority of patients have achieved a blood pressure goal of 130 or 80 or less. So these programs are out there. You just need to know about them, and you can share them with your patients. So I Googled Miami-Dade Senior Center Activities because this is where we are right now. And look what I found, which is, here we go, controlling high blood pressure, free blood pressure screening with registered nurses. It will take a little bit of legwork to find out about existing community-based programs that are near your practice. But encouraging your patient to use them probably takes very little time, and it might pay dividends for them. And lastly, strategy number five, and Peter kind of alluded to this, start as many meds as possible when the patient's in the hospital. This is good for multiple reasons, but not the least of which you've got a captive audience. They're in the hospital. They just had a cardiac event. They've got nowhere else to be, and they're freaked out. So hammer in your message. And again, it won't just be you. They're in the hospital. So there's going to be repeated education opportunities by all members of the health care team who are going to say why they're taking these meds and how important it is. Again, this strategy, also supported by research. There have been multiple studies that have shown that medication initiation in the hospital is a strong predictor of longer term medication adherence. This is in the ACS population as well as the heart failure population. And then the concordance registry found that patients were 10 times, 10 times, 10 times. We never have an odds ratio of 10 times, but 10 times more likely to be adherent to a medication regimen at six months if they were discharged on that med regimen. So in summary, secondary prevention patients with ASCVD is imperative, but we are still not doing a great job about it. It remains suboptimal. There are multiple patient, provider, and system barriers to achieving adequate secondary prevention in this population, but there are several potential efficient strategies that have been shown to be effective. And that includes considering polypills, simplifying medication acquisition by encouraging your patients to use mail order pharmacies, synchronized refills, medication re-challenges while also being flexible, utilization of non-physician resources, and initiation of medications as an inpatient. Thank you very much. Thank you. Suzanne, maybe kind of a wrapping up question. So what's the role for interventional cardiologists in all this? I know we faced this in our hospital where certain prevention measures were being evaluated and lipid therapy measures were being considered, and it almost happened without the interventionalists talking about it. So I actually think we should take a pretty big role. We spent all that time putting that teeny, tiny stent into that teeny, tiny artery, and you know what? I want that stent to stay open. And it makes me really, really mad that if we fail on the flip side of not actually getting our patients on the meds that are going to actually help improve their mortality. We stent for stable angina all the time. We know that does not improve cardiovascular mortality. All of the things that you heard in the last hour, all of the lipid-lowering strategies, that improves cardiovascular mortality. We need to be part of this. We owe this to our patients, but frankly, totally selfishly. I feel like we owe it to ourselves after all the hard work that we've done becoming interventional cardiologists. Question? So in a lot of our patients that come in with, let's say, ACS, and now have ischemic cardiomyopathy, unfortunately, they have low risk as well. When our needs are becoming standard of care for the elderly at heart, how do we incorporate those holy grail prescriptions? I don't think it comes with that. So fair question. I'm just going to repeat it in case anybody didn't hear it, because I know that's what Tara wanted me to do. So she was saying a lot of our patients, the question was a lot of our patients are coming with low EF and they need to be started on GDMT, which now is primarily is including ARNIs or Entresto. So unfortunately, there's not one great polypill that includes your beta blocker, your L-dactone, your ARNI, your statin, your aspirin, your Plavix. I mean, that would be cool. We should probably think about making that. Patent pending, patent pending. She's copyrighted it right here. Look, you're not going to get everything into one polypill, but if you can get some of it, I think that's going to help. So your joint antihypertensives, your joint lipid lowering medications, anything that makes pill burden less, and I didn't show that, but that's been shown as well. Anything that makes pill burden less for patients, less for them to remember to take, less for them to be like, I'm just tired of swallowing 8 million pills, will help. So it's not perfect. There's not one great pill until you patent this idea, which you should do. Aspirin, Aspirin, if you're here, come talk to her. The right one, Aspirin. Yes, but right now, there isn't. But I think that's a really good point, though, is it may take multiple polypills. So in that, friends, we're going to wrap it up. This is the end of 2024 Sky Fellows course. Thank you all so much. Do not run away. I mean, I guess you guys can leave if you want to, but I prefer you stay, but you do you. Don't run away, because we're going to do some feedback. Before we get into some feedback, I cannot say enough how much I want to extend our thanks to the Sky staff. would be possible without the Sky staff. They are amazing. You've seen them floating around. But I cannot, I'm going to just call out people I see in the back of the room, Tara, Eric, Rob, Rachel. I don't know if she's here. She's not. Sandy. I mean, there are a ton of folks who make this happen. This is something we work on all year, and it would not happen without the incredible dedication of the staff. So I really want to give you guys a huge shout out and a huge round of applause. Thank you so much. Thank you.

ASCVD prevention

cardiovascular events

medication adherence

healthcare disparities

interventional cardiology