CVD risk reduction: How do you get this done?
There is a new addition to the Healio Rheumatology site that has allowed me to review all of my past editorials since our inaugural issue in November 2015. My first editorial topic was biosimilars, which sounds, well, so incredibly retro in the COVID-19 era.
I invite you to take a look and peruse this long, strange trip I have tried to lead you on, reflecting with you on topics ranging from empathy to precision medicine: Healio.com/LCalabrese. I strongly suggest an adult beverage to accompany you on this effort but — considering the times — you probably are bored to tears anyway.
This month, we again address the topic of cardiovascular risks and prevention in patients with rheumatic diseases and we are privileged to have such a great faculty, including Jon T. Giles, MD, MPH, M. Elaine Husni, MD, and Ted R. Mikuls, MD, MSPH. The themes are familiar: The science is compelling in that the risks are real, and we can reduce these risks through aggressive cardiovascular risk management, but the question lingers as to how to get this done.
It is a story quite similar to wellness behaviors and how healthy eating, exercise, sleep hygiene, stress reduction and smoking cessation can benefit our patients; the rejoinder is also similar, namely, how can we get this done? In fact, in 2019, I wrote about the very question of what exactly is the role of the rheumatologists in the holistic care of our patients — check out “Rheumatology and Primary Care: What is the 95% Confidence Interval of Scope of Practice?” from February 2019. I am sorry if I appear to be repeating myself, but these problems are not solved and that is not fake news.
Since I wrote that editorial on scope of practice, new guidelines have been published by the American College of Cardiology and the American Heart Association. These guidelines emphasize the interprofessional nature of this tall task of CVD risk management while explicitly identifying rheumatic diseases, such as rheumatoid arthritis, as accelerators of risk that demand more aggressive assessment and management.
Then the real question is, given the clarity of the data, why are we doing so poorly in addressing these needs as so many studies have shown over the past decade? I know the knee-jerk response is that “it’s not my primary job, which is controlling the rheumatic disease.”
On the other hand, we are all concerned and, I believe, doing a much better job of protecting our patients from secondary infections while on immunosuppressive therapies. Why is this? More immediate consequences vs. more silent but relentless risk of harm? I have the same struggles with CVD prevention even though we have a preventive cardiology referral service at the Cleveland Clinic that is very aggressive with our patients and I am privileged and fortunate to have them.
In this era of ever-lowering LDL targeting and new drugs for achieving these targets, I have concerns that many PCPs may be not confident in how to optimally manage CVD prevention in patients with rheumatic diseases. So just saying that “the PCP can do it,” may not be adequate.
I was recently involved in an advisory board discussion of cardiovascular risks in RA with a group of some of the world’s leading authorities on the disease and was blown away by the differences in opinion; not regarding the magnitude of the problem, nor recognizing that our primary responsibility is to control the inflammatory disease state, but rather on how to solve this problem and practically just how to get it done!
We also now have several classes of drugs (for example, IL-6 inhibitors and JAK inhibitors) that tell us to monitor lipids, which makes me wonder what is being done about this and if anything is actually being done. I have not seen anyone writing about what a great job of CVD risk mitigation is being done in rheumatology and there are copious data documenting that CVD risk is not only rarely discussed in rheumatology visits, but also that our patients are not optimally treated in terms of risk factor modification and lipid-lowering therapies.
In closing, I ask you: what do you do and what are your best practices to ensure our patients are getting the best in CVD risk reduction? Do you contact the PCP personally? Do you use statins? In other words, how do you get this done? Send me your answers through Twitter at @LCalabreseDO or email me at firstname.lastname@example.org.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.