September 17, 2025 • 25 mins
Cardiovascular expert Colleen Walsh-Irwin returns to NP Pulse for an in-depth look at hyperlipidemia and the importance of controlling LDL-C levels. Walsh-Irwin also walks us through lipid panels, risk scoring and the many tools NPs have at their disposal to keep patients healthy and informed.
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Episode Transcript
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Sophia (00:12):
From the American
Association of Nurse Practitioners,
I'm your host, Dr. Sophia Thomas,
and this is NP Paul, the voice.
Of the nurse practitioner.
Welcome to NP Pulse, a P'S
official podcast, bringing you
unique nurse practitioner voices
and expertise on issues that
matter to NPS and our patients.
(00:36):
Many of you may remember our guest
for today, Colleen Walsh Irwin,
who joined me earlier this year to
speak about the updated treatment
guidelines for hyperlipidemia.
And today we're going to be continuing
that discussion, digging a little
bit deeper into what NPS and patients
should know about testing medications.
(00:56):
And we'll also bust some
myths while we're at it.
And so before we get started, I wanna
thank you, Colleen, for joining us today.
And for our listeners who
may not know you, could you
please reintroduce yourself?
Colleen (01:08):
Sure.
Always a pleasure to
speak with you, Sophia.
So my name is Colleen Walsh.
Rowan, I have, I've been a nurse
practitioner for nearly 30 years
working for the Department of
Veterans Affairs in cardiology.
I am also running a national program
for evidence-based practice for
the Department of Veterans Affairs.
I am a very proud member of A A
(01:30):
NP and a fellow with the American
Association of Nurse Practitioners.
And I'm really excited to be here
today to talk about hyperlipidemia.
I've written some articles.
I've been in textbooks
presented nationally.
I sit on VA and DOD guidelines
for hyperlipidemia, and I'm
just very passionate about it
and happy to be here today.
Sophia (01:51):
You are truly an expert, and I
know this and I've known you for years.
There are so many components of the
lipid panel, but today we're gonna
really be focusing on the LDLC, and
I wanna begin by discussing what
has changed since we last scope.
What do you believe is
different in the way.
Providers should approach
LDLs risk factors and testing.
Keeping in mind that I think half of all
(02:11):
Americans are affected by cardiovascular
disease and while cardiovascular
disease was previously on the decline,
it's actually an increase, right?
Colleen (02:22):
Yes, that's true.
After 40 years of it decreasing,
it's actually on the incline.
25% of deaths in the United States are
attributed to cardiovascular disease.
And sadly, not only is it increasing,
but it's increasing among younger people.
And I think it's really appropriate
that we're discussing this.
'cause September is National
(02:42):
Cholesterol Education Month.
So I think as people
listen to this podcast.
They should not only be thinking of
their patients, but thinking of their own
health and their loved one's health too,
because I think it's really, truly not
recognized enough the impact that high
cholesterol can have on our outcomes.
Sophia (03:03):
Absolutely.
And this June, the National Lipid
Association shared some new clinical
guidelines, which really concluded that
lowering the LDLC early intensively
and sustainably is critical to reducing
the risk of car cardiovascular disease,
and how do we distinguish between a
high risk and a very high risk patient.
And could you speak to how the guidelines
(03:24):
differ between the two types of patients?
Colleen (03:28):
Yes.
So generally in the healthy population,
we like to see an LDLC of less than a
hundred, but for those people who are
at high risk, including people who might
have diabetes or clinical atherosclerotic
cardiovascular disease without actually
having had an event or a procedure.
For patients who are at higher, a 10 year
(03:48):
risk of greater than 20%, or have had a
calcium artery coronary, a artery calcium
score greater than a hundred, these
patients are considered at high risk.
And then the goal for these patients
should be an LDLC of less than 70.
But we know that looking at patients
who are at higher risk, patients who
have had major events such as an acute
(04:11):
coronary syndrome in the past 12 months,
or a history of an MI or ischemic stroke,
patients with symptomatic peripheral
artery disease, those patients who
also have high risk conditions such as
diabetes, familial hypercholesterolemia,
hypertension, chronic kidney disease.
Who are smoking and who might
(04:32):
have a history of heart failure.
These patients are considered very high
risk, and the goal for these patients
should be an LDLC of less than 55, which
is really shocking considering for all
the years we've been measuring L DLCs.
This lower number is
going to be surprising.
So for some clinicians and
(04:52):
certainly for our patients.
Sophia (04:54):
Absolutely, and I wanna
get into the labs in just a second.
I wanna ask you about risk scoring,
because I think a lot of people wait,
everybody knows about the calcium risk
score, but there are also other risk
scoring tools that people can use.
The 10 year A-S-C-V-D risk
score and things like that.
Could you just speak to that for a second?
Colleen (05:13):
Sure.
I think it's really important, and
I think patients really like to
be able to see this in writing.
When I do my patient's risk scores
on the calculator, on the computer,
and then I'm able to show them
how all of these things add up.
They don't think that their high
blood pressure is such a bad thing.
Everybody has high blood pressure
maybe, but you add in there
(05:33):
smoking and you add in that.
They're getting higher blood
sugars and getting close to
being considered diabetic.
All of these things contribute
to putting them at higher risk.
And for these patients specifically,
we need to be much more aggressive.
It's LDLC is a primary factor in
cardiovascular disease, and I think that.
(05:56):
Maybe because we didn't have
as many options as we used to.
Now we're gonna talk about
that a little bit later.
Some of the medications that we have
now to get to these lower numbers, or
maybe it's just that as clinicians,
when we first started measuring
cholesterol, I remember if you had
cardiovascular disease, the goal was
to get your LDL less than a hundred.
Mm-hmm.
But I think a lot of people
(06:16):
are still have that as a goal.
Or then when we got to 70 people still
thinking, gee, I only have to be at 70
and maybe I'm 72, but I'm close enough.
I think it's really imperative
that we start to, to explain to our
patients that the goal line has moved.
We wanna be lower and we
wanna be lower longer.
(06:37):
That's what the guidance that came
out in June from the National Lipid
Association said is longer, is better.
So I think instead of waiting until
somebody has that first event.
We have to be really proactive,
prescriptive when it comes
to explaining to patients.
Yes, proactive about explaining to
patients that the goal lines have
changed and we need to be more
(06:57):
aggressive and more aggressive sooner.
Absolutely
Sophia (07:01):
and explain to our clinical
colleagues as well because the
guidelines do change and we have lots
of people in primary care and other
specialties that may not realize.
And I think about the patients.
Our patients all have patient portals
now and they can log on and see their lab
results themselves, and maybe their lab
results are green on that patient portal,
but their provider will still recommend.
(07:23):
Being more aggressive when
managing their lipids.
And so how do we explain to patients the
discrepancy between their lab results
and then what their healthcare provider
recommends based on the risk factors?
Colleen (07:36):
I think that's, that's where
we excel as NP is that education
piece, explaining to patients that
although, yes, for a typical patient
who doesn't have all these risk
factors, the goal would be this number.
But here you are sitting in front
of me with all of these risk factors
and in order to prevent you from
getting cardiovascular disease
(07:57):
or having an event that could.
Alter your life.
We really wanna be aggressive
in treating you now rather than
waiting until something happens.
I think primary prevention is, it
overlooks a lot and now is the time
to really get aggressive with that.
Sophia (08:13):
Yeah.
And so I was gonna ask you about how we
as healthcare providers can do a better
job of communicating the importance
of treating early and urgently.
But you've answered my question.
Colleen (08:22):
I really do
think that preventing.
An event in a patient is so important
and we ha we can definitely do that.
If we can get them to get their
cholesterol levels lower longer,
we can possibly prevent a life
altering event from happening.
Sophia (08:41):
Yeah, absolutely.
So let's talk about the provider's
role in testing, especially
regarding the CAC scores.
How have things changed when it comes
to testing and testing guidelines,
and what else should we think about
when it comes to the risk assessment?
Colleen (08:54):
The LDLC is still one of the
foundational measures that we use, and we
do have LP little A, and we do have non
HDLs and we do have our CAC score, but.
Anybody and everybody can order an LDLC.
And I think regardless of what practice
you're in, even family practice, we
have FNPs like yourself or patients,
(09:15):
even pediatric nps out there.
The guidelines are pretty evident that
we wanna start screening younger too,
children, as at between nine and 11.
Then again between 17 and 21.
Then after that, as adults, pretty much
every five years, we wanna get an LDLC
to assess risk and to assess if things
have changed that now warrant some type
(09:36):
of education regarding diet and exercise.
While we can still have that be
really effective before starting
pharmacology agents, I think the fact
that we need to be cognizant of the
risk factors that patients bring with
them when they come into the office.
But it's really all
hands on deck nowadays.
Like it's not just the cardiovascular
(09:58):
clinic clinicians or the endo clinicians.
We can't wait till the
patients walked into our office
after they've had an event.
We need to be really proactive and be
screening everybody and then we can
talk about guidelines as far as after
they've been on medications for a while,
myself included, was leaning towards the
fact that once we start a patient on a
(10:18):
medication, it's once you get them to, to.
To where you want them to be to goal,
then you can loosen up measuring.
But one of the things I found out is
that even though I do a really good
medication reconciliation with my
patients, and they've been on their
statin for years and they're doing
well, and everything's been fine.
Every once in a while I'll find a
(10:39):
patient who will say to me that they're
taking their statin, but then when I
actually check their cholesterol, their
LDLC, and all of a sudden it's gone
up significantly since the last visit.
And then you had that conversation
with them and it is like they fess
up that maybe they had stopped
it or they thought they were
controlled, so they weren't really
convinced that they still needed it.
(10:59):
I think.
Once patients are even at goal, we still
need to monitor them occasionally, three
months, six months, or 12 months, just
to make sure that they are continuously
compliant with the medications that we ask
them to take or suggest that they take.
And sometimes things change and they
need to have an add-on medication.
Sophia (11:17):
Absolutely.
And it's just like with diabetics,
we're still monitoring their A1C.
Even if they're at goal, we still
want to make sure that there's
nothing else we need to do.
Things haven't changed.
Absolutely.
Or they decided to not
take their medication.
And yeah, there are so many other
components to the lipid panel and
there are elevated triglycerides.
And what do you do about that?
(11:38):
Let's talk about the
provider a little bit more.
What resources do you
want everyone to utilize?
When you are seeing patients, this,
as you said, is an all hands on deck
approach and they should work with a
variety of providers, not necessarily
just one provider, but what do you, what
resources do you want people to use?
Colleen (11:58):
So we do have the calculators,
we have the prevent calculator, we
have the PCE calculator, I think.
We have CAC scores.
When we have those patients who are on
the fence about whether they really,
truly wanna start a medication or not,
sometimes they need that little extra
convincing to be done to show them that
they actually do have some plaque buildup.
(12:18):
Let me interrupt you.
So CAC score stands for what?
Sophia (12:22):
For coronary artery calcium score.
Okay.
And so that's the, the calcium score.
And then the others are calculators
that we can use in the office.
Yes.
Based on the number of
factors they have, they're,
Colleen (12:35):
yes.
And I think also honestly, just
knowing that the targets just know
without having to spend a lot of
extra time in the office, knowing
that the, the goal is lower is better.
We know that.
Even as low as 30 or 40 is perfectly
acceptable, so not being afraid of
adding on medication to get the patient
(12:57):
to goal and not being concerned.
When their LDL drops significantly
and they're down to 30 or 40, there's
no such thing as being too low.
We're born with cholesterol levels
of 30, so getting down to 30 is fine.
Sophia (13:11):
That's great.
And so let's talk about some medications.
We know that some patients have side
effects when they take statins and
others have heard misleading information
about statins over social media.
I've certainly seen a
lot of that right now.
What can you say to challenge some of
those preconceptions that patients may
have had, and what are some alternatives
for patients who are concerned about side
(13:32):
effects or who can't take the medication?
Colleen (13:37):
Okay.
To start with the first piece?
Yeah.
Okay.
Statins got a bad name when they
came out, or they've been around for.
20 something years now.
Yeah, they're fir, they're still first
line therapy regardless of anything else.
Statins are still first line therapy.
We know that they reduce the risk
of coronary vascular disease.
We know that they improve outcomes,
so they're still very effective.
(13:59):
They did get a bad rap.
I always joke that everybody
knows somebody whose dog sitter
had a reaction, but it's.
Reactions to statins and true
statin intolerance is less than 10%.
It's about five to 10% of people
have true statin intolerance, which
actually sometimes improves when we do
either switching them to a different
statin, a lower dose of statins.
(14:22):
We can do intermittent dosing
where we, the patient takes
a statin every other day, so.
There's still lots of tricks in the bag to
get them on statins, even if it's a lower
statin, then you need to get them to goal.
We can then add on treatments, things like
ezetimibe, which is very well tolerated.
(14:43):
We can add on PCSK nine inhibitors.
We have bmp aoic acid now,
so we have lots of treatment
options now, and I have to say.
These medications are not as
difficult to get as they used to be.
So I think that's a key factor is
sometimes clinicians are afraid
of the amount of time that it's
(15:03):
going to take to get these approved
by their insurance companies.
But I think that things have changed
just in the last few years, and if you're
able to document that the patient is
statin intolerant, or they haven't gotten
to goal, it's a lot easier to justify
getting these medications approved.
Sophia (15:21):
Oh, that's good news.
And we've seen a lot of welcome
changes regarding the variety of and
availability of these medications.
For low end cholesterol, is there
one in particular or some of the
better ones that you've seen?
Colleen (15:35):
I really think it comes down to
having that discussion with your patients.
As I work for the va, I have a lot
of patients who are older, maybe an
injectable, a PCSK nine inhibitor is
going to be diff more difficult for
them than something like bmp, ioic acid.
Certainly Ezetimibe is of.
The one I would go to before I try
anything else because it is, it's
generic, it's extremely well tolerated.
(15:57):
Very few patients have adverse effects.
And adding on ezetimibe to a
statin can be just what you need
to get that patient to goal.
So I think, again, it's about having
that patient conversation when seeing
what their insurance company will
approve and what they're willing to do.
'cause at the end of the day, if
they're not willing to do it, it
doesn't matter what we prescribe.
Sophia (16:18):
Exactly, and it's important to
realize that there are other options
out there other than the statins.
I think many people don't know that.
Certainly patients don't know that,
and there's been so many changes
over the last few years in the world
of lipids, so that's very exciting.
Finally, I wanna ask you, what are
some of the important takeaways
(16:39):
that you want listeners to
remember from this conversation?
We've talked about the risk calculators,
and I would assume you would tell
everyone who's listening to find a
risk calculator on the internet and
use that and check out their own score.
Colleen (16:54):
Oh, that'd be great if
we could just affect everybody
listening to this podcast.
That alone would be worthwhile.
Yeah.
The risk calculators are great for
figuring out where you need to be.
Definitely knowing that the target
LDL for you and your patients is key
to getting yourself and your patients
and your loved ones is the goal.
I think knowing that there
are other options out there.
(17:16):
If you know beyond statins and ezetimibe,
we have the PCSK nine inhibitors.
We have, we have bemed acid, we have
Lyran also, which is newer to the markets.
If you can't get the patient to goal
yourself, then find a lipid specialist
who can potentially, you know.
Again, we wanna prevent these
patients, if at all possible,
from having adverse effects, from
(17:37):
having long-term effects of high
cholesterol, and the targets have moved.
They're lower than ever.
So I think people need
to be aware of that.
Sophia (17:46):
Okay.
And the targets for all of the lipids,
or specifically just for the LDLC?
Colleen (17:54):
For the LDLC really has changed.
That's the one we're still using as the
primary measurement for cholesterol.
We know that lowering LDLC has a
significant change in your risk of
cardiovascular disease, so that's the one
that we're looking currently looking at.
Sophia (18:11):
Okay, and so a
couple more takeaways for me.
Colleen (18:15):
So I think, I think
having that conversation with
patients, really that's key.
I think it's hard for people to
understand that they're walking
around and that they could be
actually at risk for heart disease.
Absolutely.
I think nobody wants to believe that.
So having that conversation,
understanding that they might push
(18:35):
back, especially when it comes to
starting a statin or increasing a
statin, having that conversation
with them and then making sure that.
You're following up with patients,
but you can't just start somebody
on a statin and then say, okay,
return to office in six months.
We really need to be aggressive
once we have them there and we know
that their LDL is elevated and we
(18:56):
need to get that lowered, we need
to be aggressive in doing that.
And that means either getting them to
get their labs and you calling them or
having them come back to the office to
have that conversation, but getting them
to go increasing our statins, we have.
Multiple statins on the market.
We have the matter intensity
and the high intensity dosages.
So I think it's really important to,
(19:18):
to make sure that we get, that the
patients to understand that this is
significant, that this is important
to improve their health overall.
Also, I think that a misconception
I see a lot with statins is that all
statins need to be taken at night.
So initially when our first statins came
out on the market, it was recommended
(19:40):
that they be taken at night because we
know that our body makes manufacturers
most of the cholesterol when we sleep.
So the thought was by.
Prescribing statins at night, we can
get a little bit more bang for our buck.
But since then, atorvastatin and
Rosuvastatin both have 24 hour
half-lifes, which is different than
(20:00):
our original statins that came out that
only had 12 hour half-lifes, I think.
One of the things I found with patients
is that if they're on medications
that they take every morning and then
they think they have to take their
atorvastatin or their Rosuvastatin
at night, doses get skipped.
Mm-hmm.
So, because they just forget that one
pill that they're only taking at night.
(20:22):
So just making it, making that
conversation around you can take this
in the morning with everything else,
can actually improve their LDL levels.
Having those conversations with them
about when and where they're taking
it, and do they have a pill box?
I'm shocked when I find out how many of
my patients don't use a pill box and then
they think they took their medications.
(20:44):
But if you ever did a pill
count, you might find out that
they have missed some doses.
So things like that, having those
conversations with patients, talking
about statin intolerance, anticipating
that they're going to have concerns.
I say to my patients, if you think you
get leg cramps while you're on this,
call me, you know, anticipating that.
(21:04):
Don't just stop it and wait till you
come back to my office in three months
to tell me that you had leg cramps.
We know that there was a, there,
there's been a, a study done a few
years ago that showed that follow
up phone calls helped increase.
The ability for patients
to stay on their statins.
So I think anticipating their questions,
anticipating their concerns, anticipating
that they've heard about all these
(21:25):
negative impacts of cholesterol
medications in general, and just going
over and over again with them, the
risk of not controlling their LDLC.
Sophia (21:37):
Absolutely we're for years
we've called Hypertension the
silent Killer, but cardiovascular
disease and high LDLC is also a
Colleen (21:45):
silent killer.
Oh, a hundred percent.
Like we said, we know that LDLC is a
huge marker for the risk of coronary
vascular disease, and I think now that
we have more medications and more tools,
we need to be more aggressive than ever.
To get our patients to go
before they have an event.
Like to get them to not just keep
(22:06):
waiting or waiting, thinking that it's
going to get better because it's not.
And while diet and exercise help,
and I certainly am willing to give
a patient a trial for a little bit
regarding diet and exercise, ultimately
making sure they understand that.
Chances are they're probably
going to need some medication
at somewhere down the line.
Having those conversations early and
(22:27):
trying to convince them it's not worth
waiting until an event happens, and then
we're chasing their cholesterol per se.
Absolutely.
And
Sophia (22:36):
I've previously talked
about familial hypercholesterolemia
and things like that there.
There are other factors at play as well.
So guide and exercise should be the
foundation of everything, no matter
what the disease disease process is.
I mean, that's our first
line recommendation for
just about everything, but.
Beyond that, we do need to look
at all these other available
(22:56):
tools that are helpful so we can
help take care of our patients.
And ultimately, you mentioned that deaths
were on the rise from heart disease.
Now we do want to turn that around
and get us back on the decline.
Colleen (23:09):
Yes, and we have the tools to do
that, especially for those patients who
are statin intolerant or those patients
for familial hypercholesterolemia.
We have medications now that can really
make a huge difference, and we have
to avoid clinical inertia, which is
another thing I like to speak about.
Sophia, I know you and I have
talked about this before, but.
About getting it in our heads that the
(23:31):
patient won't try something without
actually giving them the opportunity.
We can't let up.
We, we have to be advocates for our
patients and sometimes that's advocating
for them when they won't advocate for
themselves and we can't let you know
our busyness or thinking we know that
the patient's gonna refuse to do this.
We can't let that interfere
(23:51):
with the care we provide.
We have to be absolutely the
best we can for our patients.
Sophia (23:57):
Every patient, every time.
Colleen, thank you so much for
joining us today on NP Pulses.
As always, it was a great discussion
and I certainly learned a lot.
I appreciate you taking the time today.
Thanks, Sophia.
Thanks for having me.
I always enjoy speaking with you.
(24:17):
Thank you so much for
joining us on np Pauls.
Please subscribe to this podcast,
share it with your colleagues, and
check back regularly for new episodes.
And as always, be kind, be
safe, be effective, and be the
voice of the nurse practitioner.
From the American
Association of Nurse Practitioners,
I'm your host, Dr. Sophia Thomas,
and this is NP Paul, the voice.
Of the nurse practitioner.
Welcome to NP Pulse, a P'S
official podcast, bringing you
unique nurse practitioner voices
and expertise on issues that
matter to NPS and our patients.
(00:36):
Many of you may remember our guest
for today, Colleen Walsh Irwin,
who joined me earlier this year to
speak about the updated treatment
guidelines for hyperlipidemia.
And today we're going to be continuing
that discussion, digging a little
bit deeper into what NPS and patients
should know about testing medications.
(00:56):
And we'll also bust some
myths while we're at it.
And so before we get started, I wanna
thank you, Colleen, for joining us today.
And for our listeners who
may not know you, could you
please reintroduce yourself?
Colleen (01:08):
Sure.
Always a pleasure to
speak with you, Sophia.
So my name is Colleen Walsh.
Rowan, I have, I've been a nurse
practitioner for nearly 30 years
working for the Department of
Veterans Affairs in cardiology.
I am also running a national program
for evidence-based practice for
the Department of Veterans Affairs.
I am a very proud member of A A
(01:30):
NP and a fellow with the American
Association of Nurse Practitioners.
And I'm really excited to be here
today to talk about hyperlipidemia.
I've written some articles.
I've been in textbooks
presented nationally.
I sit on VA and DOD guidelines
for hyperlipidemia, and I'm
just very passionate about it
and happy to be here today.
Sophia (01:51):
You are truly an expert, and I
know this and I've known you for years.
There are so many components of the
lipid panel, but today we're gonna
really be focusing on the LDLC, and
I wanna begin by discussing what
has changed since we last scope.
What do you believe is
different in the way.
Providers should approach
LDLs risk factors and testing.
Keeping in mind that I think half of all
(02:11):
Americans are affected by cardiovascular
disease and while cardiovascular
disease was previously on the decline,
it's actually an increase, right?
Colleen (02:22):
Yes, that's true.
After 40 years of it decreasing,
it's actually on the incline.
25% of deaths in the United States are
attributed to cardiovascular disease.
And sadly, not only is it increasing,
but it's increasing among younger people.
And I think it's really appropriate
that we're discussing this.
'cause September is National
(02:42):
Cholesterol Education Month.
So I think as people
listen to this podcast.
They should not only be thinking of
their patients, but thinking of their own
health and their loved one's health too,
because I think it's really, truly not
recognized enough the impact that high
cholesterol can have on our outcomes.
Sophia (03:03):
Absolutely.
And this June, the National Lipid
Association shared some new clinical
guidelines, which really concluded that
lowering the LDLC early intensively
and sustainably is critical to reducing
the risk of car cardiovascular disease,
and how do we distinguish between a
high risk and a very high risk patient.
And could you speak to how the guidelines
(03:24):
differ between the two types of patients?
Colleen (03:28):
Yes.
So generally in the healthy population,
we like to see an LDLC of less than a
hundred, but for those people who are
at high risk, including people who might
have diabetes or clinical atherosclerotic
cardiovascular disease without actually
having had an event or a procedure.
For patients who are at higher, a 10 year
(03:48):
risk of greater than 20%, or have had a
calcium artery coronary, a artery calcium
score greater than a hundred, these
patients are considered at high risk.
And then the goal for these patients
should be an LDLC of less than 70.
But we know that looking at patients
who are at higher risk, patients who
have had major events such as an acute
(04:11):
coronary syndrome in the past 12 months,
or a history of an MI or ischemic stroke,
patients with symptomatic peripheral
artery disease, those patients who
also have high risk conditions such as
diabetes, familial hypercholesterolemia,
hypertension, chronic kidney disease.
Who are smoking and who might
(04:32):
have a history of heart failure.
These patients are considered very high
risk, and the goal for these patients
should be an LDLC of less than 55, which
is really shocking considering for all
the years we've been measuring L DLCs.
This lower number is
going to be surprising.
So for some clinicians and
(04:52):
certainly for our patients.
Sophia (04:54):
Absolutely, and I wanna
get into the labs in just a second.
I wanna ask you about risk scoring,
because I think a lot of people wait,
everybody knows about the calcium risk
score, but there are also other risk
scoring tools that people can use.
The 10 year A-S-C-V-D risk
score and things like that.
Could you just speak to that for a second?
Colleen (05:13):
Sure.
I think it's really important, and
I think patients really like to
be able to see this in writing.
When I do my patient's risk scores
on the calculator, on the computer,
and then I'm able to show them
how all of these things add up.
They don't think that their high
blood pressure is such a bad thing.
Everybody has high blood pressure
maybe, but you add in there
(05:33):
smoking and you add in that.
They're getting higher blood
sugars and getting close to
being considered diabetic.
All of these things contribute
to putting them at higher risk.
And for these patients specifically,
we need to be much more aggressive.
It's LDLC is a primary factor in
cardiovascular disease, and I think that.
(05:56):
Maybe because we didn't have
as many options as we used to.
Now we're gonna talk about
that a little bit later.
Some of the medications that we have
now to get to these lower numbers, or
maybe it's just that as clinicians,
when we first started measuring
cholesterol, I remember if you had
cardiovascular disease, the goal was
to get your LDL less than a hundred.
Mm-hmm.
But I think a lot of people
(06:16):
are still have that as a goal.
Or then when we got to 70 people still
thinking, gee, I only have to be at 70
and maybe I'm 72, but I'm close enough.
I think it's really imperative
that we start to, to explain to our
patients that the goal line has moved.
We wanna be lower and we
wanna be lower longer.
(06:37):
That's what the guidance that came
out in June from the National Lipid
Association said is longer, is better.
So I think instead of waiting until
somebody has that first event.
We have to be really proactive,
prescriptive when it comes
to explaining to patients.
Yes, proactive about explaining to
patients that the goal lines have
changed and we need to be more
(06:57):
aggressive and more aggressive sooner.
Absolutely
Sophia (07:01):
and explain to our clinical
colleagues as well because the
guidelines do change and we have lots
of people in primary care and other
specialties that may not realize.
And I think about the patients.
Our patients all have patient portals
now and they can log on and see their lab
results themselves, and maybe their lab
results are green on that patient portal,
but their provider will still recommend.
(07:23):
Being more aggressive when
managing their lipids.
And so how do we explain to patients the
discrepancy between their lab results
and then what their healthcare provider
recommends based on the risk factors?
Colleen (07:36):
I think that's, that's where
we excel as NP is that education
piece, explaining to patients that
although, yes, for a typical patient
who doesn't have all these risk
factors, the goal would be this number.
But here you are sitting in front
of me with all of these risk factors
and in order to prevent you from
getting cardiovascular disease
(07:57):
or having an event that could.
Alter your life.
We really wanna be aggressive
in treating you now rather than
waiting until something happens.
I think primary prevention is, it
overlooks a lot and now is the time
to really get aggressive with that.
Sophia (08:13):
Yeah.
And so I was gonna ask you about how we
as healthcare providers can do a better
job of communicating the importance
of treating early and urgently.
But you've answered my question.
Colleen (08:22):
I really do
think that preventing.
An event in a patient is so important
and we ha we can definitely do that.
If we can get them to get their
cholesterol levels lower longer,
we can possibly prevent a life
altering event from happening.
Sophia (08:41):
Yeah, absolutely.
So let's talk about the provider's
role in testing, especially
regarding the CAC scores.
How have things changed when it comes
to testing and testing guidelines,
and what else should we think about
when it comes to the risk assessment?
Colleen (08:54):
The LDLC is still one of the
foundational measures that we use, and we
do have LP little A, and we do have non
HDLs and we do have our CAC score, but.
Anybody and everybody can order an LDLC.
And I think regardless of what practice
you're in, even family practice, we
have FNPs like yourself or patients,
(09:15):
even pediatric nps out there.
The guidelines are pretty evident that
we wanna start screening younger too,
children, as at between nine and 11.
Then again between 17 and 21.
Then after that, as adults, pretty much
every five years, we wanna get an LDLC
to assess risk and to assess if things
have changed that now warrant some type
(09:36):
of education regarding diet and exercise.
While we can still have that be
really effective before starting
pharmacology agents, I think the fact
that we need to be cognizant of the
risk factors that patients bring with
them when they come into the office.
But it's really all
hands on deck nowadays.
Like it's not just the cardiovascular
(09:58):
clinic clinicians or the endo clinicians.
We can't wait till the
patients walked into our office
after they've had an event.
We need to be really proactive and be
screening everybody and then we can
talk about guidelines as far as after
they've been on medications for a while,
myself included, was leaning towards the
fact that once we start a patient on a
(10:18):
medication, it's once you get them to, to.
To where you want them to be to goal,
then you can loosen up measuring.
But one of the things I found out is
that even though I do a really good
medication reconciliation with my
patients, and they've been on their
statin for years and they're doing
well, and everything's been fine.
Every once in a while I'll find a
(10:39):
patient who will say to me that they're
taking their statin, but then when I
actually check their cholesterol, their
LDLC, and all of a sudden it's gone
up significantly since the last visit.
And then you had that conversation
with them and it is like they fess
up that maybe they had stopped
it or they thought they were
controlled, so they weren't really
convinced that they still needed it.
(10:59):
I think.
Once patients are even at goal, we still
need to monitor them occasionally, three
months, six months, or 12 months, just
to make sure that they are continuously
compliant with the medications that we ask
them to take or suggest that they take.
And sometimes things change and they
need to have an add-on medication.
Sophia (11:17):
Absolutely.
And it's just like with diabetics,
we're still monitoring their A1C.
Even if they're at goal, we still
want to make sure that there's
nothing else we need to do.
Things haven't changed.
Absolutely.
Or they decided to not
take their medication.
And yeah, there are so many other
components to the lipid panel and
there are elevated triglycerides.
And what do you do about that?
(11:38):
Let's talk about the
provider a little bit more.
What resources do you
want everyone to utilize?
When you are seeing patients, this,
as you said, is an all hands on deck
approach and they should work with a
variety of providers, not necessarily
just one provider, but what do you, what
resources do you want people to use?
Colleen (11:58):
So we do have the calculators,
we have the prevent calculator, we
have the PCE calculator, I think.
We have CAC scores.
When we have those patients who are on
the fence about whether they really,
truly wanna start a medication or not,
sometimes they need that little extra
convincing to be done to show them that
they actually do have some plaque buildup.
(12:18):
Let me interrupt you.
So CAC score stands for what?
Sophia (12:22):
For coronary artery calcium score.
Okay.
And so that's the, the calcium score.
And then the others are calculators
that we can use in the office.
Yes.
Based on the number of
factors they have, they're,
Colleen (12:35):
yes.
And I think also honestly, just
knowing that the targets just know
without having to spend a lot of
extra time in the office, knowing
that the, the goal is lower is better.
We know that.
Even as low as 30 or 40 is perfectly
acceptable, so not being afraid of
adding on medication to get the patient
(12:57):
to goal and not being concerned.
When their LDL drops significantly
and they're down to 30 or 40, there's
no such thing as being too low.
We're born with cholesterol levels
of 30, so getting down to 30 is fine.
Sophia (13:11):
That's great.
And so let's talk about some medications.
We know that some patients have side
effects when they take statins and
others have heard misleading information
about statins over social media.
I've certainly seen a
lot of that right now.
What can you say to challenge some of
those preconceptions that patients may
have had, and what are some alternatives
for patients who are concerned about side
(13:32):
effects or who can't take the medication?
Colleen (13:37):
Okay.
To start with the first piece?
Yeah.
Okay.
Statins got a bad name when they
came out, or they've been around for.
20 something years now.
Yeah, they're fir, they're still first
line therapy regardless of anything else.
Statins are still first line therapy.
We know that they reduce the risk
of coronary vascular disease.
We know that they improve outcomes,
so they're still very effective.
(13:59):
They did get a bad rap.
I always joke that everybody
knows somebody whose dog sitter
had a reaction, but it's.
Reactions to statins and true
statin intolerance is less than 10%.
It's about five to 10% of people
have true statin intolerance, which
actually sometimes improves when we do
either switching them to a different
statin, a lower dose of statins.
(14:22):
We can do intermittent dosing
where we, the patient takes
a statin every other day, so.
There's still lots of tricks in the bag to
get them on statins, even if it's a lower
statin, then you need to get them to goal.
We can then add on treatments, things like
ezetimibe, which is very well tolerated.
(14:43):
We can add on PCSK nine inhibitors.
We have bmp aoic acid now,
so we have lots of treatment
options now, and I have to say.
These medications are not as
difficult to get as they used to be.
So I think that's a key factor is
sometimes clinicians are afraid
of the amount of time that it's
(15:03):
going to take to get these approved
by their insurance companies.
But I think that things have changed
just in the last few years, and if you're
able to document that the patient is
statin intolerant, or they haven't gotten
to goal, it's a lot easier to justify
getting these medications approved.
Sophia (15:21):
Oh, that's good news.
And we've seen a lot of welcome
changes regarding the variety of and
availability of these medications.
For low end cholesterol, is there
one in particular or some of the
better ones that you've seen?
Colleen (15:35):
I really think it comes down to
having that discussion with your patients.
As I work for the va, I have a lot
of patients who are older, maybe an
injectable, a PCSK nine inhibitor is
going to be diff more difficult for
them than something like bmp, ioic acid.
Certainly Ezetimibe is of.
The one I would go to before I try
anything else because it is, it's
generic, it's extremely well tolerated.
(15:57):
Very few patients have adverse effects.
And adding on ezetimibe to a
statin can be just what you need
to get that patient to goal.
So I think, again, it's about having
that patient conversation when seeing
what their insurance company will
approve and what they're willing to do.
'cause at the end of the day, if
they're not willing to do it, it
doesn't matter what we prescribe.
Sophia (16:18):
Exactly, and it's important to
realize that there are other options
out there other than the statins.
I think many people don't know that.
Certainly patients don't know that,
and there's been so many changes
over the last few years in the world
of lipids, so that's very exciting.
Finally, I wanna ask you, what are
some of the important takeaways
(16:39):
that you want listeners to
remember from this conversation?
We've talked about the risk calculators,
and I would assume you would tell
everyone who's listening to find a
risk calculator on the internet and
use that and check out their own score.
Colleen (16:54):
Oh, that'd be great if
we could just affect everybody
listening to this podcast.
That alone would be worthwhile.
Yeah.
The risk calculators are great for
figuring out where you need to be.
Definitely knowing that the target
LDL for you and your patients is key
to getting yourself and your patients
and your loved ones is the goal.
I think knowing that there
are other options out there.
(17:16):
If you know beyond statins and ezetimibe,
we have the PCSK nine inhibitors.
We have, we have bemed acid, we have
Lyran also, which is newer to the markets.
If you can't get the patient to goal
yourself, then find a lipid specialist
who can potentially, you know.
Again, we wanna prevent these
patients, if at all possible,
from having adverse effects, from
(17:37):
having long-term effects of high
cholesterol, and the targets have moved.
They're lower than ever.
So I think people need
to be aware of that.
Sophia (17:46):
Okay.
And the targets for all of the lipids,
or specifically just for the LDLC?
Colleen (17:54):
For the LDLC really has changed.
That's the one we're still using as the
primary measurement for cholesterol.
We know that lowering LDLC has a
significant change in your risk of
cardiovascular disease, so that's the one
that we're looking currently looking at.
Sophia (18:11):
Okay, and so a
couple more takeaways for me.
Colleen (18:15):
So I think, I think
having that conversation with
patients, really that's key.
I think it's hard for people to
understand that they're walking
around and that they could be
actually at risk for heart disease.
Absolutely.
I think nobody wants to believe that.
So having that conversation,
understanding that they might push
(18:35):
back, especially when it comes to
starting a statin or increasing a
statin, having that conversation
with them and then making sure that.
You're following up with patients,
but you can't just start somebody
on a statin and then say, okay,
return to office in six months.
We really need to be aggressive
once we have them there and we know
that their LDL is elevated and we
(18:56):
need to get that lowered, we need
to be aggressive in doing that.
And that means either getting them to
get their labs and you calling them or
having them come back to the office to
have that conversation, but getting them
to go increasing our statins, we have.
Multiple statins on the market.
We have the matter intensity
and the high intensity dosages.
So I think it's really important to,
(19:18):
to make sure that we get, that the
patients to understand that this is
significant, that this is important
to improve their health overall.
Also, I think that a misconception
I see a lot with statins is that all
statins need to be taken at night.
So initially when our first statins came
out on the market, it was recommended
(19:40):
that they be taken at night because we
know that our body makes manufacturers
most of the cholesterol when we sleep.
So the thought was by.
Prescribing statins at night, we can
get a little bit more bang for our buck.
But since then, atorvastatin and
Rosuvastatin both have 24 hour
half-lifes, which is different than
(20:00):
our original statins that came out that
only had 12 hour half-lifes, I think.
One of the things I found with patients
is that if they're on medications
that they take every morning and then
they think they have to take their
atorvastatin or their Rosuvastatin
at night, doses get skipped.
Mm-hmm.
So, because they just forget that one
pill that they're only taking at night.
(20:22):
So just making it, making that
conversation around you can take this
in the morning with everything else,
can actually improve their LDL levels.
Having those conversations with them
about when and where they're taking
it, and do they have a pill box?
I'm shocked when I find out how many of
my patients don't use a pill box and then
they think they took their medications.
(20:44):
But if you ever did a pill
count, you might find out that
they have missed some doses.
So things like that, having those
conversations with patients, talking
about statin intolerance, anticipating
that they're going to have concerns.
I say to my patients, if you think you
get leg cramps while you're on this,
call me, you know, anticipating that.
(21:04):
Don't just stop it and wait till you
come back to my office in three months
to tell me that you had leg cramps.
We know that there was a, there,
there's been a, a study done a few
years ago that showed that follow
up phone calls helped increase.
The ability for patients
to stay on their statins.
So I think anticipating their questions,
anticipating their concerns, anticipating
that they've heard about all these
(21:25):
negative impacts of cholesterol
medications in general, and just going
over and over again with them, the
risk of not controlling their LDLC.
Sophia (21:37):
Absolutely we're for years
we've called Hypertension the
silent Killer, but cardiovascular
disease and high LDLC is also a
Colleen (21:45):
silent killer.
Oh, a hundred percent.
Like we said, we know that LDLC is a
huge marker for the risk of coronary
vascular disease, and I think now that
we have more medications and more tools,
we need to be more aggressive than ever.
To get our patients to go
before they have an event.
Like to get them to not just keep
(22:06):
waiting or waiting, thinking that it's
going to get better because it's not.
And while diet and exercise help,
and I certainly am willing to give
a patient a trial for a little bit
regarding diet and exercise, ultimately
making sure they understand that.
Chances are they're probably
going to need some medication
at somewhere down the line.
Having those conversations early and
(22:27):
trying to convince them it's not worth
waiting until an event happens, and then
we're chasing their cholesterol per se.
Absolutely.
And
Sophia (22:36):
I've previously talked
about familial hypercholesterolemia
and things like that there.
There are other factors at play as well.
So guide and exercise should be the
foundation of everything, no matter
what the disease disease process is.
I mean, that's our first
line recommendation for
just about everything, but.
Beyond that, we do need to look
at all these other available
(22:56):
tools that are helpful so we can
help take care of our patients.
And ultimately, you mentioned that deaths
were on the rise from heart disease.
Now we do want to turn that around
and get us back on the decline.
Colleen (23:09):
Yes, and we have the tools to do
that, especially for those patients who
are statin intolerant or those patients
for familial hypercholesterolemia.
We have medications now that can really
make a huge difference, and we have
to avoid clinical inertia, which is
another thing I like to speak about.
Sophia, I know you and I have
talked about this before, but.
About getting it in our heads that the
(23:31):
patient won't try something without
actually giving them the opportunity.
We can't let up.
We, we have to be advocates for our
patients and sometimes that's advocating
for them when they won't advocate for
themselves and we can't let you know
our busyness or thinking we know that
the patient's gonna refuse to do this.
We can't let that interfere
(23:51):
with the care we provide.
We have to be absolutely the
best we can for our patients.
Sophia (23:57):
Every patient, every time.
Colleen, thank you so much for
joining us today on NP Pulses.
As always, it was a great discussion
and I certainly learned a lot.
I appreciate you taking the time today.
Thanks, Sophia.
Thanks for having me.
I always enjoy speaking with you.
(24:17):
Thank you so much for
joining us on np Pauls.
Please subscribe to this podcast,
share it with your colleagues, and
check back regularly for new episodes.
And as always, be kind, be
safe, be effective, and be the
voice of the nurse practitioner.
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