- In 2013, new guidelines were issued for managing cholesterol to reduce the risk of developing atherosclerotic cardiac disease (ASCVD)
- In a new study, researchers analyzed data from the National Ambulatory Medical Care Survey from 2006 to 2016, which looked at 11,033 outpatient visits from adults with ASCVD.
- Less than half of the people seen with ASCVD were prescribed statins and aspirin or received lifestyle counseling in 2016.
- Healthcare professionals were less likely to prescribe ASCVD prevention treatments for female and non-Hispanic Black people.
In 2013, the American Heart Association and the American College of Cardiology issued new guidelines for managing cholesterol to reduce the risk of developing atherosclerotic cardiac disease (ASCVD).
ASCVD is a collective term referring to disorders of the heart and blood vessels, including coronary artery disease, ischemic stroke, transient ischemic attack, and peripheral artery disease. More than 400,000 deaths annually are attributed to ASCVD in the United States.
The 2013 revamped guidelines expanded the groups eligible for statin therapy to all adults with known ASCVD regardless of individual low-density lipoprotein cholesterol levels.
Some experts described the 2013 guidelines as a fundamental shift in how doctors treat high cholesterol.
Under the new guidelines, one study estimated the number of adults eligible for statins, drugs that can lower blood cholesterol, would increase by 12.8 million. ,
However, in a recent study published in JAMA Network Open, researchers found less than half of the people seen with ASCVD were prescribed statins or received lifestyle counseling, which includes recommendations to exercise more, stop smoking, and eat a healthy diet.
Since treatment with low dose aspirin had been previously recommended for secondary prevention in patients with ASCVD, the researchers also looked at the percentage of patients who were prescribed aspirin. They found less than half of the patients were prescribed the treatment.
“When guidelines change, it’s always interesting to see how well they are being implemented,” Dr. Ambar Kulshreshtha, associate professor at the Emory University School of Medicine and a co-author of the study, told Medical News Today.
Data from ASCVD-related doctor’s visits
For this cross-sectional study, researchers analyzed data from the National Ambulatory Medical Care Survey (NAMCS), an annual survey of visits at office-based physicians, like primary care and internal medicine doctors and cardiologists, as well as at health centers.
Researchers analyzed the years 2006 to 2016 in the survey. For their data, they looked at patients who were age 21 and older and who had been diagnosed with ASCVD, which included anyone diagnosed with myocardial infarction, angina, ischemic stroke, transient ischemic attack, peripheral artery disease or who had undergone coronary revascularization. This procedure unblocks or widens a vessel that supplies the heart to restore blood flow.
Data were separated into two groups — before and after the 2013 recommendations. Researchers looked to see whether health practitioners prescribed statins or aspirin or offered lifestyle counseling to the patients.
Researchers conducted a statistical analysis of the data in March 2021.
Little increase in statin prescriptions
From 2006 to 2016, researchers identified 11 ,033 visits involving adults with ASCVD, representing a total of 275.3 million visits.
The median age of these patients was 70. Female patients made up 40.7% of the visits. Of the visits, 9.2% were from Hispanic patients, 9.9% were non-Hispanic Black patients, and 90.1% of visits were among non-Hispanic white patients.
Of the visits, 69.5% of patients had hypertension, 57.5% had hyperlipidemia, and 29% had diabetes. The researchers considered about 11% of the patients to be obese.
Among the ASCVD patients, about 50.0% used statins, 46.8% took aspirin, and 20.2% received lifestyle counseling.
The number of prescriptions for statins increased from 45.3 in 2006 to 60.3 in 2014, shortly after the new guidelines were released. However, they decreased to 46.5% in 2016.
In 2006, 41.3% of patients received an aspirin prescription. That number jumped to 47.5% in 2016. Meanwhile, in 2006, about 33% of patients received lifestyle coaching. That number decreased to 22.3% in 2016.
Of the female patients surveyed, about 43.3% were prescribed statins. Meanwhile, 52.7% of the men received statins. About 40% of female patients were prescribed aspirin, compared to 48.5% of male patients. Health practitioners provided lifestyle counseling to 22.9% of women compared to 23% of men.
Among non-Hispanic Black patients, 41.6% received statins, 41.1% were prescribed aspirin, and 24.2% received lifestyle counseling. Among white patients, 49.8% received statins, 45.9% were prescribed aspirin, and 23.3% received lifestyle counseling.
About 47% of patients seen at family medicine practices were prescribed statins, and about 33% were prescribed aspirin. Of patients seen at internal medicine offices, 51.7% were prescribed statins, and 43.1% were prescribed aspirin. Of patients seen at cardiology offices, 55.6% were prescribed statins, and 56.2% were prescribed aspirin.
Statins underused for ASCVD
When new guidelines for treating patients come out, some doctors are hesitant to change their recommendations, Dr. Kulshreshtha told MNT. “So whenever guidelines come out, especially if they’re controversial, there’s a huge clinical inertia to you know, to go by these guidelines,” he said.
Dr. Kulshreshtha told MNT there are currently “several quality improvement initiatives going on” designed to get providers on board about ensuring the guidelines for secondary treatment of ASCVD are followed. “But what our data suggests is more needs to be done,” he told MNT.
Lifestyle counseling for heart health
MNT also spoke with Anthony Mufarreh, a 2021 graduate of the master’s of the public health program at Emory University and a current student at the Central Michigan University College of Medicine who co-authored the study. Mufarreh said there are several reasons why primary care providers are not providing lifestyle coaching more frequently to their ASCVD patients.
For one thing, medical students don’t receive enough education in nutrition and exercise, according to Mufarreh. “We get very little … training, and very little implementation of that in the clinical sense,” he said.
The amount of time offices allows for patient visits in the United States also makes it difficult for health providers to discuss nuanced topics like making changes to exercise and eating habits, according to Dr. Kulshreshtha. “You only get a 15-minute window, sometimes less for a lot of cases, to do everything,” he said.
One option to remedy this problem, according to Dr. Kulshreshtha, would be to have someone else on the medical team handle lifestyle coaching. “Does it all have to depend on the physician?” he asked. “Or can, as we’re all working like in a team-based practice, can one of the physician assistants take over that part?”
Dr. Kulshreshtha has found motivational interviewing, a counseling approach where the patient’s individual needs, as well as their conflicting feelings regarding their need to change, are taken into consideration can be a successful technique for motivating patients to alter their exercise and eating habits.
Talking with patients about their personal motivations and the barriers to making a change, gets them invested, he explained to MNT.
“They want to take ownership and change something,” Dr. Kulshreshtha said. “[But] that whole conversation is not something, like you hand them a paper at the end of it — ‘You need to exercise 150 minutes a week and eat this and that.’ Yes, we hear it, but it goes out the other ear. I think what really needs to happen is time to talk about and understand where the patient is coming from.”
Health disparities and next steps
Prior to launching the data, Mufarreh expected to see disparities in the treatment of female and Black patients with ASCVD. However, he was surprised by the extent of the disparities revealed by the study.
“One of the big things is honestly just awareness of these disparities existing,” Mufarreh told MNT.
Having data that shows female and Black patients are not being treated equally allows public health officials to launch targeted interventions, he said.
Another way to remedy the problem, Dr. Kulshreshtha believes, is training health providers on implicit bias, which is when an individual doesn’t consciously recognize that he or she harbors stereotypes about a group of people
“I think providers need to be universally trained on it,” he told MNT. “It should be taught, in my opinion, in all med schools and it should be emphasized again and again throughout the course of training.”
Since the researchers identified that less than half of the patients with known ASCVD were prescribed statins, aspirin or received lifestyle counseling in 2016 and that there are disparities in the management of ASCVD, the next step is to research how these problems can be remedied, Dr. Kulshreshtha told MNT.
“I feel like that is the way we make progress, right?” he said. “We identify gaps and then figure out ways to solve them.”
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