Closing the Cholesterol Gap

What keeps Nishant Shah, MD, up at night? Thinking about all the missed opportunities to prevent heart attacks. “Heart disease remains the number one killer across the globe and many of the risk factors, like high cholesterol, are preventable,” said the Duke Health cardiologist.

Cholesterol-lowering drugs can reduce a person’s chances of developing heart attacks and strokes, and vascular dementia, by preventing plaque from building up on the walls of blood vessels. 

But too many patients who could benefit aren’t being treated. Shah, an associate professor of medicine at Duke University School of Medicine, recently led a study following almost 2 million patients at 16 academic health centers and found that less than half of patients with known heart disease and high cholesterol were taking medications to lower their cholesterol.  

“The study shows a problem across multiple health systems,” he said. “We aren’t controlling cholesterol the way we need to.” 

Shah hopes to develop interventions that will help health systems be more effective at controlling cholesterol levels among patients, with the goal of reducing heart attacks across the country.  

New Cholesterol Guidelines 

The topic is especially timely because new cholesterol guidelines have just been released by the American College of Cardiology and the American Heart Association. The new guidelines recommend aiming for lower levels of LDL, commonly known as “bad” cholesterol.  “There is more and more evidence that the lower your cholesterol is, the better it is for you,” Shah said. 

Under the new guidelines, patients at very high risk for heart disease — those with a history of cardiac events and multiple risk factors — should aim for an LDL cholesterol level below 55 mg/dL. High risk patients, including those who’ve had a previous cardiac event, should target less than 70 mg/dL. For everyone else, the goal is below 100 mg/dL.

WATCH: What do my cholesterol results mean? 

To determine risk, the guidelines recommend using PREVENT-ASCVD, a calculator that considers factors such as age, blood pressure, blood sugar and body mass index. When a patient’s risk remains unclear, a coronary artery calcium scan can help guide treatment decisions.  

The guidelines also recommend screening and treating earlier, because the negative effects of high LDL cholesterol accumulate over time — the more plaque builds up, the narrower arteries become. 

Identifying System Level Barriers 

Shah is working with Duke Health preventative cardiologist Neha Pagidipati, MD, MPH, HS’13-’17, to try to understand why so few people with heart disease are taking cholesterol-lowering drugs that could help them.  

The investigators are working with six different health systems to identify barriers that prevent more patients with heart disease from having their LDL tested, receiving a prescription, filling the prescription, or taking the medicine. The researchers are also developing strategies to overcome those barriers.  

To generate the maximum benefit, the strategies have to be system-wide, scalable, and financially feasible, Shah said. “We’re trying to figure out how to make a health system-wide impact to really move the needle at a population level,” he said. 

At Duke, Shah and Pagidipati, an associate professor of medicine, are leading a clinical trial to evaluate the strategy of using a “care champion” to meet with patients while they are hospitalized and stay in touch after discharge. The care champion is responsible for nudging the patient or providers or both in the service of meeting the LDL goal. 

To help educate patients and providers at Duke, Shah said, cholesterol reporting has changed in patients’ electronic health records. In the past, LDL was flagged as abnormal only above 190. That’s been changed to 100. There is also guidance at the bottom of the test result about desirable LDL levels, which will be updated according to the new guidelines. 

“We’re trying to find ways to maximize awareness at the provider side and the patient side so we get to the common goal of improving everyone’s cardiovascular risk,” he said. 

If so few patients with known heart disease are taking cholesterol-lowering drugs, one can imagine uptake is even lower among those who have high cholesterol but haven’t had a heart attack or stroke — yet. 

“The problem with high cholesterol is that you don’t feel it,” Shah said. “It’s just circulating in your body until something happens. You want to prevent that something from happening.” 

Mary-Russell Roberson is a freelance writer living in Durham.