Patient Knowledge of Heart Risk Profile May Help Improve Cholesterol Management

Patients who discuss their coronary risk profiles with their physicians may respond better to treatment for cholesterol disorders, according to a report in the November 26 2007 issue of Archives of Internal Medicine, one of the JAMA/Archives journals1.

Dyslipidemia, or cholesterol problems that may include combinations of high total cholesterol, high levels of low-density lipoprotein (LDL, or “bad” cholesterol) or low high-density lipoprotein (HDL, or “good” cholesterol), is a risk factor for cardiovascular disease. Treatment is most effective when targeted to high-risk individuals, according to background information in the article. However, these patients sometimes do not adhere to recommended lifestyle changes or pharmacotherapy. One study suggested that one-third of patients who stop taking lipid-lowering medications do so because they are not convinced they need treatment.

Steven A. Grover, M.D., M.P.A., F.R.C.P.C., of McGill University, Montreal, Quebec, Canada, and colleagues followed 3,053 patients undergoing treatment for dyslipidemia with lifestyle changes and statin medications when necessary. A group of 1,510 patients was randomly assigned to also receive a one-page computer printout of their probability for developing heart disease at the beginning of the study and at follow-up visits three, six, nine and 12 months later.

A total of 2,687 patients completed the 12-month study. After adjusting for beginning cholesterol levels, individuals who received their risk profile had small but significantly greater reductions in their LDL levels and their total cholesterol to HDL ratio. “Patients in the risk profile group were also more likely to reach lipid targets,” the authors write.

The risk profile included a summary of each individual’s cardiovascular age, calculated by subtracting the difference between life expectancy and the average life expectancy from the individual’s current age. “For example, a 50-year-old with a life expectancy of 25 more years (vs. 30 more years for the average Canadian) would be assigned a cardiovascular age of 55 years,” the authors write. “Individuals without cardiovascular disease were also given their cardiovascular age, their actual age and the resulting ‘age gap’ (cardiovascular age minus actual age). This variable seemed to modify the degree to which patients responded to the risk profile.” Patients with a larger gap between their cardiovascular and actual age had greater reductions in LDL cholesterol levels than those with a smaller gap or no gap.

Given the public health burden of cardiovascular disease, preventive steps must be taken, the authors note. “Communicating risk is consistent with many of the recommendations to improve adherence, including enhancing self-monitoring and using the support of family and friends,” the authors conclude. “Informing patients of their coronary risk may also increase the effectiveness of primary prevention by identifying individuals most likely to benefit from treatment while reassuring those at low risk. This information may also assist physicians in treatment selection while improving patient adherence.”

Understanding and treating patients’ overall cardiovascular risk may have advantages over focusing on individual risk factors such as high blood pressure and cholesterol, write Rod Jackson, M.B.Ch.B., Ph.D., and Sue Wells, M.B.Ch.B., M.P.H., of The University of Auckland, New Zealand, in an accompanying editorial2.

“The distinction is far more than a subtle difference in wording; cardiovascular risk factors are individually poor predictors of a patient’s risk of a cardiovascular event, the only outcome that matters to patients,” they write. “For most patients, their actual blood cholesterol level or blood pressure becomes clinically meaningful only when considered in combination with other risk factors and when the cardiovascular risk is calculated.”

A patient-centered approach to cholesterol management that includes the concept of cardiovascular age appears effective, writes Charles B. Eaton, M.D., M.S., of the Warren Alpert School of Medicine at Brown University and Memorial Hospital of Rhode Island, Providence, in a second accompanying editorial3.

“The results of this study are for the most part promising, but it should be pointed out that only 45 percent to 66 percent of these high-risk cardiovascular patients had reached their respective lipid targets after one year, and thus, a large treatment gap still persisted,” Dr. Eaton writes. “More research testing the systematic identification of high-risk patients (e.g., a dyslipidemia disease registry) combined with a calculated coronary risk strategy using the cardiovascular age paradigm seems to be warranted.”

References:

1. Arch Intern Med. 2007; 167(21):2296-2303.  

2. Arch Intern Med. 2007; 167(21):2286-2287.  

3. Arch Intern Med. 2007; 167(21):2288.