Paradigm Shifts in Lipid Lowering - Episode 2

Risk Factors for Developing Hyperlipidemia

March 22, 2021
Linda Hemphill, MD

Massachusetts General Hospital

Dean Karalis, MD

Thomas Jefferson University Hospital

Norman Lepor, MD, FACC, FAHA, FSCAI

Cedars-Sinai Medical Center

Manesh Patel, MD

Duke University School of Medicine

Keith C. Ferdinand, MD

Tulane University School of Medicine

Expert panel of cardiologists provide their perspective on the specific population that may be at a risk of developing hyperlipidemia.

Keith C. Ferdinand, MD: It's important to recognize that it's not just adult disease, that it is in fact childhood adolescence where these happen, and that tight stenosis that you intervene on has probably been there for decades before you have the thrombosis superimposed on the plaque, is that correct?

Manesh Patel, MD: That's right. I think the couple things we most worry about that is happening in the United States. I know you are in New Orleans; I'm here in Durham, North Carolina, and so unfortunately the Southeast United States is the hypertension belt, the obesity belt, the diabetes belt. In addition to it being lifelong, unfortunately the childhood obesity and diabetes rates are going up higher and higher, and we know that that eventually leads to this plaque that has been in people's arteries for many years.

And then whether it is tight or whether or not it's sort of tight and then ruptures leads to whether or not they come in with symptoms that are chronic, or whether they come in with an acute heart attack. And unfortunately, our ability to predict what is going to happen with our patients is very poor and that's why we need systemic therapies. I say as an interventional cardiologist I am often in the vessel trying to treat the pothole on the highway, but I need something to fix the whole highway; I can't just fix that one little pothole. And so I often talk to my patients about I've done something to help this problem, but you have miles of road that need to be treated all the time.

Keith C. Ferdinand, MD: I like that concept. In fact, if you look at various populations, for instance, African Americans have a high risk of premature disease and death, high incidence of heart failure, high incidence of stroke, peripheral vascular disease, limb loss, amputations. But if you then look in the MESA or NHANES, the LDL levels are about the same as everyone else. In fact, the HDL may be a little higher and the triglycerides, despite obesity especially in black females, may be a little lower. But then hypertension comes into play, diabetes comes into play, and of course issues of access and the social determinants of health, not having a primary care provider or usual source of care. Not getting appropriate adherence because you cannot afford the medications.

There's a hodge-podge of factors that come in to play then, then just the build-up of plaque. Would you agree with that?

Manesh Patel, MD: Absolutely. We often say in our area that unfortunately there's a mixture between your genetic code and your zip code that's determining what your health is, and it's the space between, as we just said for our children that are born with a certain genetic code and the environmental influences that lead to that, unfortunately the United States zip code where you're growing up and having different access and potentially social determinants of care, which lead to both obesity, food/nutritional insufficiency, a variety of things that you've highlighted. I think our global mission in trying to get to health equity and improved cardiovascular health is going to be focused on taking these concepts that start with the plaque and the biology and say what can we do across a population to lead to better health.

Keith C. Ferdinand, MD: Now I am going to say something but I am not trying to insult Duke, because I think it's the same for Tulane and I'm pretty sure it's the same for UCLA and Cedars Sinai. Some of the worst outcomes are in zip codes that are within walking or a long bike ride of major academic centers. People can live in areas in major cities with the best academic centers in the world and still have poor outcomes.

Manesh Patel, MD: Oh, no, you are not upsetting me. It is one of the reasons I am doing what I'm doing. I think our focus must be -- Peter Smith, one of my colleagues in CT surgery says you cannot be the best in the world if you are not the best in your back yard. If we do not have people healthier in Durham, we are not going to be telling people how you could be healthier at worldwide. So, I fully agree with what you are saying.

I think unfortunately it starts not just with access, but what is the blood pressure of our population, what are we doing for activity, how are we getting this information out. And we are going to talk a little bit later in the program about disruptive therapies. But one could take the analogy of how well we are doing with COVID vaccines for our population. We have things that work, why cannot we get it to the people that need it the most.

Keith C. Ferdinand, MD: If you enjoyed watching this HCPLive® Peer Exchange, if you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchanges and other great content right in your inbox.

Thank you very much for listening to this program.

Transcript Edited for Clarity