Clinician-Patient Risk Discussion for Atherosclerotic Cardiovascular Disease Prevention

Abstract

Successful implementation of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines hinges on a clear understanding of the clinician-patient risk discussion (CPRD). This is a dialogue between the clinician and patient about potential for atherosclerotic cardiovascular disease risk reduction benefits, adverse effects, drug-drug interactions, and patient preferences. Designed especially for primary prevention patients, this process of shared decision making establishes the appropriateness of a statin for a specific patient. CPRD respects the autonomy of an individual striving to make an informed choice aligned with personal values and preferences. Dedicating sufficient time to high-quality CPRD offers an opportunity to strengthen clinician-patient relationships, patient engagement, and medication adherence. We review the guideline-recommended CPRD, the general concept of shared decision making and decision aids, the American College of Cardiology/American Heart Association Risk Estimator application as an implementation tool, and address potential barriers to implementation.

Temporal shifts in clinical presentation and underlying mechanisms of atherosclerotic disease

“…The 2013 guideline of the ACC/AHA recommends statin use for all individuals with a risk of >7.5% suffering from a MI or stroke in 10 years 14 . This evidence-based guideline aimed to allocate statins to high-risk patients who harbor a greater burden of atherosclerosis and followed a process of shared decision making between patient and clinician 15 . The application of this guideline might prevent as many as 450,000 atherosclerotic cardiovascular disease events over 10 years 16 .…”

Statin Eligibility, Coronary Artery Calcium, and Subsequent Cardiovascular Events According to the 2016 United States Preventive Services Task Force (USPSTF) Statin Guidelines: MESA (Multi‐Ethnic Study of Atherosclerosis)

“…These guidelines recommended that individuals aged 40 to 75 years with 1 or more major ASCVD risk factors (hypertension, tobacco use, diabetes mellitus, or dyslipidemia) and a 10‐year ASCVD risk ≥10% initiate statin therapy. Similar to the USPSTF guidelines, the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the treatment of blood cholesterol recommended a risk‐based approach to allocation of statin therapy in primary prevention,2 with an important focus on a clinician–patient risk discussion before initiation of statin therapy 3. The ACC/AHA guidelines identified a lower threshold for initiating statin therapy compared with the USPSTF guidelines, recommending statins for individuals with a 10‐year ASCVD risk ≥7.5%.…”

Preventing Atherosclerotic Cardiovascular Disease Using American College of Cardiology and American Heart Association Prevention Guidelines: Some Good News, But Caveats Remain

“…This description addresses control of other ASCVD risk factors and the need for optimal lifestyle, the potential for benefit of statin therapy versus the potential for adverse effects and drug–drug interactions, and the inclusion of informed patient preference in final decision making. Further papers described techniques for making the CPRD truly effective 10, 11…”