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Mhaimeed O, Burney ZA, Schott SL, Kohli P, Marvel FA, Martin SS. The importance of LDL-C lowering in atherosclerotic cardiovascular disease prevention: Lower for longer is better. Am J Prev Cardiol 2024; 18:100649. [PMID: 38576462 PMCID: PMC10992711 DOI: 10.1016/j.ajpc.2024.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/25/2024] [Accepted: 03/09/2024] [Indexed: 04/06/2024] Open
Abstract
Cumulative exposure to low-density lipoprotein cholesterol (LDL-C) is a key driver of atherosclerotic cardiovascular disease (ASCVD) risk. An armamentarium of therapies to achieve robust and sustained reduction in LDL-C can reduce ASCVD risk. The gold standard for LDL-C assessment is ultracentrifugation but in routine clinical practice LDL-C is usually calculated and the most accurate calculation is the Martin/Hopkins equation. For primary prevention, consideration of estimated ASCVD risk frames decision making regarding use of statins and other therapies, and tools such as risk enhancing factors and coronary artery calcium enable tailoring of risk assessment and decision making. In patients with diabetes, lipid lowering therapy is recommended in most patients to reduce ASCVD risk with an opportunity to tailor therapy based on other risk factors. Patients with primary hypercholesterolemia and familial hypercholesterolemia (FH) with baseline LDL-C greater than or equal to 190 mg/dL are at elevated risk, and LDL-C lowering with high-intensity statin therapy is often combined with non-statin therapies to prevent ASCVD. Secondary prevention of ASCVD, including in patients with prior myocardial infarction or stroke, requires intensive lipid lowering therapy and lifestyle modification approaches. There is no established LDL-C level below which benefit ceases or safety concerns arise. When further LDL-C lowering is required beyond lifestyle modifications and statin therapy, additional medications include oral ezetimibe and bempedoic acid, or injectables such as PCSK9 monoclonal antibodies or siRNA therapy. A novel agent that acts independently of hepatic LDL receptors is evinacumab, which is approved for patients with homozygous FH. Other emerging agents are targeted at Lp(a) and CETP. In light of the expanding lipid treatment landscape, this manuscript reviews the importance of early, intensive, and sustained LDL-C-lowering for primary and secondary prevention of ASCVD.
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Affiliation(s)
- Omar Mhaimeed
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Zain A Burney
- Department of Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Stacey L Schott
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Payal Kohli
- Department of Cardiology, University of Colorado Anschutz, Aurora, CO, United States
- Department of Cardiology, Veterans Affairs Hospital, Aurora, CO, United States
- Cherry Creek Heart, Aurora, CO, United States
- Tegna Broadcasting, MD, United States
| | - Francoise A Marvel
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Seth S Martin
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Schott SL, Berkowitz J, Dodge SE, Petersen CL, Saunders CH, Sobti NK, Xu K, Coylewright M. Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability. Circ Cardiovasc Qual Outcomes 2021; 14:e007329. [PMID: 34107740 DOI: 10.1161/circoutcomes.120.007329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients. METHODS A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use. RESULTS The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future. CONCLUSIONS Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.
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Affiliation(s)
- Stacey L Schott
- Division of Cardiology, Johns Hopkins University School of Medicine (S.L.S.)
| | - Julia Berkowitz
- Geisel School of Medicine at Dartmouth, Hanover, NH (J.B.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Shayne E Dodge
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Catherine H Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Navjot Kaur Sobti
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medicine (N.K.)
| | - Keren Xu
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Megan Coylewright
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.).,Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
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Coylewright M, O’Neill E, Sherman A, Gerling M, Adam K, Xu K, Grande SW, Dauerman HL, Dodge SE, Sobti NK, Saunders CH, Schott SL, Elwyn G, Durand MA. The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis. JAMA Cardiol 2020; 5:442-448. [PMID: 31995126 PMCID: PMC7160688 DOI: 10.1001/jamacardio.2019.5719] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022]
Abstract
Importance Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM. Objective To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. Design, Setting, and Participants This mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management. Main Outcomes and Measures Clinician SDM performance was measured using the Observer OPTION5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed. Results Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. Conclusion and Relevance In a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.
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Affiliation(s)
- Megan Coylewright
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Elizabeth O’Neill
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Robert Larner, M.D. College of Medicine, University of Vermont, Burlington
| | - Ariel Sherman
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Megan Gerling
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Kaavya Adam
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
- Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Keren Xu
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Stuart W. Grande
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Harold L. Dauerman
- Robert Larner, M.D. College of Medicine, University of Vermont, Burlington
| | - Shayne E. Dodge
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Navjot Kaur Sobti
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Catherine H. Saunders
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Stacey L. Schott
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Glyn Elwyn
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
| | - Marie-Anne Durand
- The Dartmouth Institute for Clinical Practice and Health Policy, Lebanon, New Hampshire
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Schott SL, Dannenberg MD, Dodge SE, Schoonmaker JA, Caisse MM, Barr PJ, O'Malley AJ, Bruce ML. Heart sounds: a pilot randomised trial to determine the feasibility and acceptability of audio recordings to improve discharge communication for cardiology inpatients protocol. Open Heart 2019; 6:e001062. [PMID: 31363416 PMCID: PMC6629402 DOI: 10.1136/openhrt-2019-001062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/24/2019] [Accepted: 06/13/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Ineffective hospital discharge communication can significantly impact patient understanding, safety and treatment adherence. This may be especially true for cardiology inpatients who leave the hospital with complex discharge plans delivered in a time-pressured discharge discussion. The goal of this pilot trial was to determine if providing supplemental audio-recorded discharge instructions is feasible and to explore its impact on cardiology patients' ability to understand and self-manage their care . Methods and analysis We will conduct a parallel-group, randomised controlled trial in adult cardiology inpatients with balanced blocking by a physician. Patients (n=50) will be randomised to usual care (verbal discussion and written summary) or intervention (usual care, plus audio-recorded discharge discussion provided to patients on a portable electronic recording device). Enrolled patients will complete study assessments immediately prior to the discharge discussion, immediately postdischarge discussion and 1 week after hospital discharge by telephone. Primary outcomes include the proportion of eligible providers and inpatients who agree to take part in the trial, the proportion of inpatients who receive the audio recording in accordance with a fidelity checklist, and the proportion who use the audio recording. We will analyse preliminary data about the impact of audio recording on patient activation, health confidence, provider communication ability, adherence and 30-day readmissions. Ethics and dissemination This trial was approved by The Committee for the Protection of Human Subjects (CPHS) at Dartmouth College (CPHS# 00031211). Findings will be disseminated in scientific journals and at meetings. Trial registration number NCT03735342 Protocol version 1.0
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Affiliation(s)
- Stacey L Schott
- Department of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michelle D Dannenberg
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Shayne E Dodge
- Department of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jesse A Schoonmaker
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Molly M Caisse
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - A James O'Malley
- Department of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Martha L Bruce
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
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Schott SL, Xu K, Berkowitz J, Petersen C, Saunders C, Sobti N, Coylewright M. TIMING OF ELECTRONIC HEALTH RECORD INTEGRATED DECISION AID (IDEA) FOR STROKE PREVENTION IN ATRIAL FIBRILLATION MATTERS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Schott SL, Carreiro FP, Harkness JR, Malas MB, Sozio SM, Zakaria S. Exertional dyspnea as a symptom of infrarenal aortic occlusive disease. Tex Heart Inst J 2014; 41:316-8. [PMID: 24955052 DOI: 10.14503/thij-13-3301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Advanced atherosclerosis of the aorta can cause severe ischemia in the kidneys, refractory hypertension, and claudication. However, no previous reports have clearly associated infrarenal aortic stenosis with shortness of breath. A 77-year-old woman with hypertension and hyperlipidemia presented with exertional dyspnea. Despite extensive testing and observation, no apparent cause for this patient's dyspnea was found. Images revealed severe infrarenal aortic stenosis. After the patient underwent stenting of the aortic occlusion, she had immediate symptomatic improvement and complete resolution of her dyspnea within one month. Twelve months after vascular intervention, the patient remained asymptomatic. In view of the distinct and lasting elimination of dyspnea after angioplasty and stenting of a nearly occluded infrarenal aortic lesion, we hypothesize that infrarenal aortic stenosis might be a treatable cause of exertional dyspnea. Clinicians should consider infrarenal aortic stenosis as a possible cause of dyspnea. Treatment of the stenosis might relieve symptoms.
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Affiliation(s)
- Stacey L Schott
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - Fernanda Porto Carreiro
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - James R Harkness
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - Mahmoud B Malas
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - Stephen M Sozio
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - Sammy Zakaria
- Departments of Medicine (Drs. Harkness, Porto Carreiro, Schott, Sozio, and Zakaria) and Vascular and Endovascular Surgery (Dr. Malas), Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
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