CE / CME
Nurse Practitioners/Nurses: 1.00 Nursing contact hour
Pharmacists: 1.00 contact hour (0.1 CEUs)
Physicians: maximum of 1.00 AMA PRA Category 1 Credit™
Released: August 21, 2024
Expiration: August 20, 2027
How often should we be checking for Lp(a) in our patients?
This is a wonderful question because it is genetically predetermined, in theory. Therefore, you only need to check patients’ Lp(a) once. Of note, there are periods in life where healthcare professionals (HCPs) may recheck it, which often occurs in women since being postmenopausal can raise your Lp(a) levels as well. Beyond that, it is a one-and-done scenario.
As patients are prescribed pharmacotherapy, this practice will be different because HCPs will need to keep track of patients’ Lp(a) levels and ensure the medication is working. From a primary prevention perspective, however, it is now recommended that we are getting our Lp(a) level checked at least once in our lifetime. In this scenario, based on the guidelines, those who would achieve the most success in ensuring that their Lp(a) is checked are those who have a family history of premature ASCVD or who had premature ASCVD themselves. This is because we want to determine if there is anything else beyond the more traditional risk factors that led to them early on in their course getting ASCVD. Patients who are not able to get their LDL-C to the goal that we want despite being on maximally tolerated statins and the addition of nonstatins would be another patient group to check Lp(a). Similarly, it should be considered in people who may have valvular disease, like aortic stenosis. As discussed, there is a correlation with plaque formation and calcification of the aortic valve, too.
How do you order an Lp(a) test? What number is considered elevated and what is the normal range?
It is a simple blood test. Every single lab has access and accessibility to it. One thing that people are often worried about is the cost of it, but the majority of insurance carriers cover it. If they do not, it is very minimal for patients in terms of when you equate the cost to other risk enhancers out there.
With that being said, the goal right now is to be very mindful of the units because there are some labs that use milligrams per deciliter, while others use nanomoles per liter. Universally, they are probably going to be moving to nanomoles per liter to prevent confusion. So, we want to be mindful of the units used right now. If we tell someone that they have an Lp(a) level of 75 nanomoles per liter vs 50 milligrams per deciliter, there is a big difference—one is elevated and the other is maybe something to keep an eye on because it does not meet criteria for where that risk increases.
Where is that cutoff? It is 50 milligrams per deciliter, which equals 125 nanomoles per liter. Anything above is deemed elevated.
We do not have a range because, at this point in time, we know that the higher your Lp(a), the higher your risk is. Further, the higher the number, the higher the risk, but to what degree? This is where research is going to help. What we do know is that when we lower it down to below those ranges, then that risk sort of dissipates, and that is what our hope is—that we are able to prove with the research that patients are actually are seeing improvement in cardiovascular outcomes as well.
Can you explain why the ASCVD recommendation to start a statin lowered from above 7.5 to risk for more than 5?
If we are purely going off the expert consensus pathway, for patients who are already are on a moderate-intensity statin and are unable to achieve the goal (which would be an LDL <100), you do not go back to another moderate-intensity statin. Rather, you go straight to that high-intensity statin. This is because of the likelihood of seeing a marginal improvement when getting them to 20.
Then, when you recheck patients’ bloodwork maybe 4 to 6 weeks later, you are still not going to be at the goal, right? Eventually you will get to that 40. This is where the consensus guidelines are suggesting you go straight to high-intensity statins, particularly in somebody who is in that intermediate range.
If we go back to the 2018 ACC/AHA guidelines, patients at intermediate risk, by definition, would be recommended to initiate a moderate-intensity statin. What we are noticing, though, is that HCPs are often forgetting about our borderline risk patients. And this is where there is opportunity for us to further risk stratify them. So that would be the perfect person where you would look at that risk enhancer list and determine: do they have family history? Is their LDL over a certain range? Did they have preeclampsia with their pregnancy? What is their Lp(a) level? Should I check their Lp(a)? If it is elevated, this would be a perfect candidate to be started on a moderate-intensity statin. Or maybe you would want to do a calcium score.
I think what our expert consensus guidelines are saying is that we want to develop the risk earlier on but, more importantly, we want to better risk stratify these patients and not forget about that borderline range. We are comfortable and confident when patients are at low risk. That is where we just focus on lifestyle, physical activity, and eating healthy. The 2 extremes are easy: the low-risk group and the high-risk group. But gray area remains among the borderline- and intermediate-risk groups.
Are there any risk calculators that integrate with EMR systems?
I think every EMR should have it. Within my own health system, the team completed a process to implement a risk calculator in it to the degree we needed it, including a reminder feature. We are often in the midst—especially for our primary care colleagues out there—of dealing with a million and one topics and this may not necessarily be a focus. But if there is a reminder built in, it makes a huge difference.
There are calculators that the ACC and AHA felt would better suit one's additional risk. There has been development of a newer calculator that ties in a lot of the risk enhancers that the ASCVD risk pooled cohort equation does not have.
We are waiting for these new guidelines from the ACC, which will be coming out very soon. I'm enthusiastic about the fact that we probably will have a calculation that includes all of those other really important risk enhancers. But getting back to the basics, we should use what we have access to. The ASCVD pooled cohort equation gives us a good understanding, but we also must be mindful of the fact that there are some limitations. Even if we looked at it from a race and ethnicity perspective, it was only studied among Black and White individuals, so that is very limited because we know that our world is a lot more diverse than that. This is why we have to use those other risk enhancing tools, possibly calcium scores, to better assess patients’ risk.
What do you say to patients who are concerned about side effects like muscle cramps?
I think it is really important to acknowledge that the side effects of these medications are very minimal. I will not dismiss the fact that myalgias exist; they obviously do. But we have actually studied this, it is the act of knowing that a medicine can cause muscle pain that one ends up having muscle pain. It's like a placebo effect, so I prepare my patients for those possibilities. I tell them that we scale back if you encounter that issue.
This is why there is no downside to slowly titrate up because there have been some data to support patient tolerance with titration. However, we want to tell patients what our end goal is, so they mentally are prepared as well.
And I will say that these theoretical adverse effects of statins are less of a concern because of their benefits, right? We know that they do a phenomenal job in preventing strokes, heart attacks, and death. And these are the conversations that we have with patients.
I also am very mindful of which types of statins I am choosing. The older patient and female populations, do better with hydrophilic statins. This includes rosuvastatin as an example.
Even though guidelines do not include, propose, or support the utilization of supplements, there has been some debate on using coenzyme Q10. Anecdotally seen in one third of people, when combined with statins, coenzyme Q10 can lower feelings of myalgias. I am not necessarily suggesting that every patient needs to be on it, but it could be beneficial. There could be a trial of adding coenzyme Q10 and later discontinuing if it does not help them.
What do you tell a patient who is concerned that statins cause dementia?
This topic takes up a lot of my clinic, but that is okay because this is where we are educating patients about how everything we read is not always accurate. Let us go back to the science of it. There have been a lot of studies that have debated this issue. What we do know is that statins have a higher likelihood of helping, given the predominance of vascular dementia vs the benefits of statins.
I am mindful of these concerns because we have patients that have an extensive family history of Alzheimer's disease, and they may not want to be on a statin because of that. Therefore, we need to discuss the different types of statins and success we have seen. For example, studies on hydrophilic statins have shown a potentially small risk of developing dementia. This risk was less in those taking hydrophilic statins vs lipophilic. And because of that, this is where shared decision-making comes in. HCPs should discuss why you put patients on a statin and work together to ensure patients understand any risk involved vs the benefit. This allows the opportunity for patients to see the light and follow the recommendations of their HCP.
What is the cost of checking calcium scores?
A lot of commercial insurance carriers now cover CAC score testing, but it still poses a challenge. For example, CAC score requires prior authorization and/or peer-to-peer, which could take time. The patients who are often not covered are the ones that have an intermediate or high ASCVD risk, and HCPs need more information on terms of how low their LDL should be.
It is not universally covered, even though we are advocating and lobbying for it. I am a huge proponent of advocacy, and I have gone to Capitol Hill to advocate for this because I think it is such an important tool.
What I have seen is that most health systems, as well as our standard diagnostic outpatient testing, are charging patients a pretty nominal fee. Examples range anywhere from $75 to $90. Even though, for me, that may seem nominal, I am also mindful of the fact that for others it is not. Fortunately, the vast majority of people will opt into this testing when you explain to them the benefits of it.
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