more_vert
General practice is the place to provide preventive care in the detection and management of atherosclerotic cardiovascular disease risk, but GPs must do the obvious work well.
In the area of lipid management, Australian clinicians have three useful recent publications to consider as we strive to improve cardiovascular health outcomes for Australians.
They are:
- the 2019 European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk (here);
- the 2021 consensus statement Integrated guidance for enhancing the care of familial hypercholesterolaemia in Australia (here); and
- the 2023 Australian guideline for assessing and managing cardiovascular disease risk (here) — noting the Australian cardiovascular disease (CVD) risk calculator provides Australians with a tool to engage with the guideline.
Research evidence continues to build to guide best practice in managing hyperlipidaemia, but achieving ideal targets in Australia is poor. This is illustrated by a retrospective cohort study of Australian patients with acute coronary syndrome from 2009 to 2018 which found only 45%, six to 12 months after hospital discharge, had achieved ideal low-density lipoprotein cholesterol (LDL-C) or total cholesterol targets.
Clearer messages coming from the research literature are that the lower the achieved LDL-C values, the lower the risk of future atherosclerotic cardiovascular events, with no lower limit to LDL-C values or the production of other negative effects from lower limits.
A person’s atherosclerotic cardiovascular disease (ASCVD) risk is a function of the duration of their exposure to, and the absolute magnitude of, LDL-C (here).
Lipid levels should be managed within the context of a person’s risk estimate for ASCVD. Wholistic care of this nature requires long term chronic health care best provided by the patient’s general practitioner (GP) and their primary care team. However, the challenge is to devise a management plan with each person at risk, negotiate CVD risk reduction goals, including ideal lipid levels, then reviewing progress over time. Rather than seeking other magic bullets, doing these obvious management steps well is the challenge for the GP and their team, noting this is harder to do in the context of underfunded and, hence, understaffed Australian primary care.
Depending on a person’s ASCVD risk estimate, a stepwise intensification of interventions to lower LDL-C is advised. Lipid management options are evolving. However, nutrition, exercise, and weight management strategies still come first.
Most clinicians have a range of web-based resources to share with their patients. In the area of nutrition and ASCVD risk reduction, I recommend the Royal Australian College of General Practitioners (RACGP) Handbook of non-drug interventions (HANDI) for information on the Mediterranean diet and for patient resources. The Mediterranean diet has been proven to prevent subsequent cardiovascular events in people who have had myocardial infarction (here).
Statins are next added, with dose escalation to achieve targets. If targets are not met, ezetimibe is next used and, if the target is still elusive for high and very high risk patients, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are added. Bile acid sequestrants can also be considered as additives to care. This is based on the 2019 ESC/EAS guideline for the management of dyslipidaemias (here).
Intolerance of statins is managed by dose reduction or use of the other agents. For a useful approach to managing statin-attributed muscle symptoms, see page 9 of the supplementary data file to the ECS/EAS guideline.
The use of a PCSK9 inhibitor warrants involvement of a practitioner with expert lipid management skills. The local lipidologist may be a cardiologist, endocrinologist or pathologist. If no local expert exists, access to a lipidologist may require the use of remotely located services. It is also worth noting that the patient’s GP can initiate use of the PCSK9 inhibitor evolocumab in consultation with a non-GP specialist physician (here and here).
In the area of lipid management an Australian first was the 2021 development and publication of guidelines to enhance the care of those with familial hypercholesterolaemia (FH). An overall synopsis and general practice guide complimented this work. The better care of those with FH is another area where we need to do the obvious well.
Heterozygous FH (HeFH) is an autosomal dominant disorder with high phenotypic penetrance that is present in the Australian population in approximately 1:250 people and is the commonest form of FH (here). Homozygous FH (HoFH) is a much more serious condition, affecting 1:300 000 people (here). Those with HeFH and HoFH have elevated LDL-C. Risk calculators do not accurately assess these patients (here). The clue to the diagnosis of HeFH is likely to be found in a family history of premature heart disease defined as less than 55 years for men or less than 60 years of age for women.
Index cases of HeFH should be sought by screening adults with premature ASCVD. A plasma LDL-C level greater than 5.0 mmol/L can also act as a screening mechanism in primary care. The Dutch Lipid Clinic Network Score (DLCNS) criteria should be used to make a phenotypic diagnosis in adults. The Australian Atherosclerosis Society provide an online DLCNS calculator.
An Australian study led by Professor Tom Brett that I was also involved with used these principles to improve the identification and management of general practice patients with FH (here). The study found many participating GPs and practice nurses lacked prior knowledge of, or confidence in, managing FH (here). However, the intervention improved these aspects of practice (here).
In this study, enhancing the general practice detection and care of people with FH was modelled to provide substantial health benefits at modest financial costs.
When modelled to the whole Australian population, the use of the enhanced model of Australian general practice care utilised in the study was calculated to return $5.64 per dollar invested (here).
Once identified, people with HeFH provide an index case who may then lead to the identification of other family members who will benefit from screening, a process referred to as cascade testing. This may involve children, siblings and parents. Genetic testing is now available to supplement phenotypic diagnosis of HeFH. GPs in the study found this aspect of care challenging unless relatives of an index case were also patients of the same practice (here). The universal screening of children is seen as a viable solution, as care aims to decrease the length of time a person is exposed to high LDL-C levels. This type of screening is being trialled in Western Australia.
General practice is the place to provide preventive care in the detection and management of ASCVD risk. General practice’s challenge is to this work systematically and to do the obvious work well. Obvious work is to get LDL-C to target and to seek accurate family histories for premature ASCVD.
Professor Jan Radford is Professor in General Practice and Director of the Launceston Clinical School, part of the Department of Medicine at the University of Tasmania.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.