Advanced Lipid Clinic
I am fortunate (and blessed) to be enjoying a long and successful career in Cardiology and participated in its evolution that started in 1980 from the early days of balloon angioplasty to stenting to heart bypass to aggressive and highly effective heart attack and stroke prevention using evidence-based optimal medical therapy.
The COVID-19 pandemic drastically changed the way we conduct our lives. I switched to using Telehealth technology for 14 months to provide the care my patients needed. I am back in the office for a few months now.
Just recently, one of my patients reminded me that I have been his cardiologist since he was 31 years old when he had his first and only heart attack and thanked me for the care I provided and that he never had any other cardiac hospitalizations or procedures - no stents or heart bypass surgery. He is now 74! We have enjoyed a close doctor-patient relationship for 43 years. I forgot how old we both are. Many cardiologists my age have either retired, developed disabilities, or died - I am excited about my work, about helping others and pursuing a new and challenging project - Save Your Heart Campaign, after the pandemic ends.
My personal and professional journey to heart attack prevention started in 2001. I acquired the knowledge needed, developed care innovations, and succeeded where most failed. Treating a 50-year-old patient with a very high calcium score whose likelihood of suffering a heart attack is 30% to 50% within the next 5 to 10 years and now at 70 years old, raised a family and enjoying retirement without having angina, heart attack, heart failure, stroke and without needing stents or heart bypass - this, I believe, is the highest level of cardiac care. That's what we do and I hope others will follow to save more lives.
Heart attack kills more Americans (more than COVID-19 in 2020) than any other disease. Before 2001, like many practicing cardiologists, I helped save many lives but always wished I could do more. That's the reason I pursued heart attack prevention.
The first evidence that a new specialty might be emerging was the publication of the first landmark placebo-controlled statin clinical trial in 1994 - the 4S trial. Here is the summary.
I tell my high-risk patients that as an expert in heart attack prevention (preventive cardiologist) and cholesterol management (lipidologist), there is no single intervention, medical or surgical, that can match or even come close to the benefits achieved by optimal lipid (cholesterol) therapy. Read the quick summary of the benefits of lowering LDL cholesterol from 188 mg/dL to 128 mg/dL listed above. That was in 1994. Since then, there are many more clinical trials showing that the lower LDL cholesterol, the better - all the way down to 30 mg/dL. And sustained LDL cholesterol levels in the 30's, even 20's, are proven safe.
The Scientific Advances
Here is a composite slide showing the benefits of statin therapy and statin combination therapy - greater and greater reductions of cardiovascular events with lower and lower LDL cholesterol levels - all the way down to LDL cholesterol levels less than 30 mg/dL (IMPROVE-IT). And that is what I see in my practice.
Providing leadership and guidance to the largest professional organization of cardiologists in the world, Dr. Wolke, then the president of the American College of Cardiology, posed this question to its members in 2004: So, why aren't all cardiologists preventive? He was trying to lead the organization to more aggressive prevention and less aggressive intervention (stents).
He identified financial investments and financial incentives that work against heart attack prevention as obstacles.
Three years later, the COURAGE trial became the game-changer that we had hoped for. We had always assumed without proof that placing a stent to open a partially clogged artery is a good thing and benefits patients. The COURAGE trial tested that assumption. Our assumption was wrong - there are no additional benefits in patients with stable heart disease and already on optimal medical therapy!
Unnecessary stenting dropped quickly and this trend continues.
Patients having an acute major heart attack need to dial 911 and get to the ER without delay. Emergency stenting is done as speedily as possible - less than 90 minutes from the time of arrival is the target. Faster care should save more lives and reduce in-hospital mortality (NEJM September 5, 2013) but it did not.
That was a very reasonable assumption. Another WRONG assumption!
So what now.
STOP. THINK. Why not just prevent most heart attacks before they happen.
In 2015, the president of the American College of Cardiology, Dr. Williams, told us what to do:
"It is time to turn off the faucet (of heart attacks) instead of just mopping the floor".
In just one year, there could have been nearly 300,000 fewer deaths from heart disease if 60% of eligible patients received appropriate medical therapies. That was the year 2000. For the 2000 -2010 decade = 300,000 x 10!
The Other Major Obstacle: The Wide Treatment Gap
In 2000, a nationwide survey was made to determine if physicians to treating patients with proven heart disease to an LDL cholesterol level of less than 100 mg/dL. Only 18% were; 82% were not.
One attempt was to use PDAs for faculty members and resident physicians involving 2,884 patients over an 18 - month period. Failed to close the treatment gap.
Another attempt comparing a lipid clinic in a teaching hospital with conventional care - no difference. Another failed attempt.
The American Heart Association launched a "Get With The Guidelines" campaign in 2008 to encourage physicians to treat more patients to recommended LDL cholesterol treatment goal. The data showed most patients who can benefit from statin therapy were treated inadequately or not treated at all.
We Closed The Treatment Gap and Turned Off The Faucet
We developed care innovations - PaKS Approach and ACCEPT Clinical Management System and made continuous improvement on it. We published our performance data in 2006. We were able to get 85% of high risk patients to LDL cholesterol goal, compared to 18% in the L-TAP study.
By then, it was clear that patients were doing better with much fewer heart attacks and stents. We closed the treatment gap in our practice.
In 2016, we analyzed our data and published our performance. 89% were below 100 mg/dL; 51% were below 70 mg/dL.
We kept the faucet closed and there is no need for floor moppers.
Patient outcomes were much better. MEDICARE saved many thousands of healthcare dollars per year per beneficiary.
When a 40 or 50 year old patient comes in for heart attack prevention, the initial evaluation involves clinical cardiology expertise.
After the initial evaluation, preventive cardiology expertise determines how most accurately determine the risk for cardiovascular events within the next 5 to 10 years.
Advanced Lipid Clinic
Once the severity of risk is known, medical therapy is optimized to the level of risk. Advanced lipid therapy is the foundation of prevention in high risk patients.