Transcript: Lipid Management Case Study Lab Interpretation for Nurse Practitioners

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Transcript

Liz Rohr:

Today's topic is one of the most requested I've gotten so far, and that is lipid and cholesterol management. So if you're new here, I'm Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, my weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

So I'm going to be using a case study of a patient that we've seen before, if you've been following along. I'm going to do a deep dive on his cholesterol panel and management, how to treat it, how to go forward, all the main questions that you had. Important note here is that the vast majority of patients in primary care are going to fall into this pattern in this category. However, there are some caveats to think about. And so there's no way I could cover all of it in one video here. So if you want to learn more about that, head on over to realworldnp.com/labs and join us for the lab interpretation crash course for new nurse practitioners. You still have time to join. It's open until Thursday, January 30th at 10:00 PM Eastern time. It not only covers more caveats about lipid management, but CBCs, CMPs, urinalysis, TSH, all that stuff, all the main things in primary care. So I'd love to have you. Clearly I'm very excited about it because I can't stop talking about it. But without further ado, I'm going to share my screen with you.

So this is the hyperlipidemia case study. So this is Raul. So if you watched this last week, I'm going to have a timestamp on the top right corner, if you want to fast forward through the recap of this case. So you can forward ahead. But if not, this is Raul. He's 58 years old. He's here for follow-up of diabetes. And again, this is not his real name or his photo. So he had requested a refill the month prior for medications, but he hadn't been in the office for about 18 months. Had been asking for refills, so I gave him a month's worth of medication and then had him schedule a follow-up appointment because I'd never met him before. I'm a new PCP for him at my new clinic. And so he was asymptomatic that day. Just really wanted some refills. Was a little annoyed with me.

The A1C at that time for the point of care test right in the room was a 10.8. And he was taking Humalog mix, which I'm not super familiar with. It's Lispro protamine and Lispro insulin 30 units once a day, instead of twice a day, as prescribed. And that's an intermediate acting with a shorter acting one. And I actually can't remember if it's a short-acting or a rapid-acting one, but I believe it's short-acting for the second one. And he was also not taking metformin 1,000 milligrams twice a day. Neither was he taking lisinopril five milligrams or simvastatin 10, as we had asked him to in the past. So his past medical history had hypertension, obesity, diabetes, and hyperlipidemia. He hadn't had any surgeries before, but his brother had diabetes. Luckily, he's a non-smoker. No alcohol or drugs.

And his blood pressure was great at this visit, 135 over 81. Heart rate of 67, oxygen of 96. His BMI was rather high though at 45. He had a normal physical exam. Overall, aside from obesity, he had normal heart and lung sounds, cardiovascular respiratory, an extremity exam. So plan, I'm really going to be focusing today on lipids, but I'll talk about the other components of his care at the end. And so I checked some labs for him. I checked a CBC, a CMP, a lipid panel, and then urine microalbumin. So overall, aside from some hyperglycemia, his BMP was normal. His LFTs and his CBC were also normal. The urine microalbumin was not normal, but that is the subject of last week's case study, if you want to go back and watch that, if you haven't seen that already. So this is his cholesterol panel, and these are all in the US kind of standard units, if you're watching from Canada or outside the country, outside of the States rather.

So total cholesterol here is 230. Everything is abnormal, but the total cholesterol is 230. The LDL is 150, which is high. HDL 30, which is low. And triglycerides, which are high at 160. And luckily, these are actually not that high compared to how high his blood sugar was, and typically that tends to go together. So pausing with Raul for a second, when we're talking about hyperlipidemia, we're talking about assessing ASCVD risk, atherosclerotic cardiovascular disease risk, because it's very different from other labs that we're talking about. Whereas potassium, you're much more worried about what's going on in this moment and bringing it down, you're not really titrating the labs as much in this case study. So just stick with me for a second. So the number one thing I want you to think about when it comes to the lipids is, what is their risk of ASCVD?

Because it doesn't really matter... An LDL of a certain number or a HDL of a certain number doesn't necessarily matter if their risk factors are not also there. So step back for a second. So clinical ASCVD, so signs somebody has atherosclerotic disease are heart attack and stroke are the most common ones we think about. But I just want to remind you that peripheral arterial disease, some causes of renal artery stenosis, not all of them. Some of them are from other reasons. But mesenteric ischemia, very uncommon diagnosis, but those are all signs of atherosclerosis, and those patients are treated differently. And so that's what we're talking about. What is their risk of developing those things? And thinking about, what is their baseline risk? And then would it improve with treatment? Because you can have, and I think that makes a lot of new grads and students uncomfortable, because they look at labs and they're like, "Well, you're not treating them. And they're just there."

And it's like, well, the guidelines, we don't have to treat them because it's not about titrating numbers and getting them perfectly aligned. It's about, what is their risk of having one of those clinical ASCVD events? And what is their baseline risk compared to if it would improve with treatment? And the biggest concern here is actually LDL. And so there's a lot of numbers. There's total cholesterol, HDL, triglycerides, all that stuff. Triglycerides have their own caveats, which I'm not going to talk about in this video. But the biggest concern here is LDL, because what we know is based on the data, based on the research. We're talking about long-term risk of ASCVD. And so what we know is that high LDL increases risk for that. And when you lower it, it reduces the risk. Whereas the same thing is not necessarily true with all of the other labs, which is why we kind of quote don't care about them.

We still care about them, but we're not going to chase them down with medications, which you'll see in a second. And again, this presentation is specifically talking about the scenario of primary prevention. So for this patient, he has not had clinical ASCVD. He's never had a stroke or heart attack or peripheral arterial disease, things like that. So these recommendations are only for people who have not had that happen before. So it doesn't include people who have had an MI, stroke, all those other things. Or high triglycerides again have their own caveats. So who should be tested? And this is about screening because again we're talking about primary prevention. And so this is a little bit controversial. I mean, it's actually not really controversial, but it's just there are some differing thoughts on it. And so an expert level of opinion is that patients... If you treat kids, you're familiar with the AAP guidelines, the American Academy of Pediatrics, has recommendations about lipid screening in childhood.

And so the thought is is that if you're in internal medicine, because this presentation is all about adults here. I should have specified that at the beginning. But if you have somebody who's 18 who you don't have any pediatric records for, probably you can get a one-time screening and kind of assess what their risk is, but definitely check those guidelines if you're taking care of kids. So risk factors for, again, clinical ASCVD, heart attack, stroke, et cetera. The risk increases, and these risk factors are important, so the risk increases with age, men more than women, smoking, diabetes, hypertension, sedentary lifestyle, obesity, and then family history of coronary artery disease, especially in first degree relatives of men under the age of 55 and then women under the age of 65, so their mother or father, things like that. And then the USPSTF is not the only screening guideline organization.

But it's a pretty solid one to follow. And their recommendation is that men over the age of 35 and women over the age of 45 should be screened. However, anybody under those ages above the age of 20 could be screened if they have those risk factors, that laundry list that I just mentioned, like if they smoke, if they have diabetes, obesity, hypertension, et cetera, et cetera, or family history. So treatment, I'm going to jump into this first before I talk about assessing risk and deciding if they need treatment, because I'm going to reference it a bunch. So it makes more sense to talk about it now. So number one is lifestyle modification. You know that. You learned that in school. However, one thing I really want to highlight here, what we're talking about is saturated fat. And cholesterol patients talk about like, "Oh, should I stop eating eggs? What has cholesterol in it?"

Quite honestly, without getting too much into it, and I get more into this into the lab course if you're interested, but what we're talking about here is that lipids, LDL specifically, hold on to all of those fats and turns it into atherosclerosis. And so we're talking about saturated fats, which come from meat products. And people talk about red meat, but chicken and fish almost have as much saturated fat. So typically what I recommend to patients, you don't necessarily have to go for a plant-based diet, it's actually worth considering if you have severe clinical ASCVD, but that's another story for another day. But reducing portion sizes, talking about portion size is a deck of cards for meat, plate method, meatless Mondays. How can we think about this and be thoughtful about it? And if they're not willing to reduce it, at the very least monitoring it. That's kind of what I recommend in terms of that motivational interviewing thing.

And then exercises, especially in patients who are obese, have been shown to lower the LDL and raise the HDL. So definitely worth recommending, and the standard recommendation is 30 minutes, five days a week, that kind of thing, of low intensity exercise. And then medication is statins. I'm sure you've learned about the ATP III guidelines about all the different medications in pharmacology, which I think is also really overwhelming for new nurse practitioners and for students as well. But quite honestly, the vast majority of the data... Again, this is not about titrating numbers. This is about reducing risks over time. The best data for actual morbidity and mortality protection over time, preventing that heart attack, stroke and death, is statins. And again, it's not necessarily about... I mean, it's tied to lowering the LDL, but it isn't necessarily just about that. Because I think that in terms of the other studies we have of other medications that may also help with that don't necessarily confer that same benefit. Again, not just about lowering numbers.

And then the recommendations are when they talk about it, it's actually low, moderate, and high-intensity statins. And for the vast majority of patients, they're going to recommend a moderate. Based on the guidelines, they're going to recommend a moderate-intensity versus a high-intensity is for certain populations. And that just has to do with what medication we're talking about and then what dose we're talking about. Higher doses in certain medications are considered high-intensity. So, okay, that's the treatment. We know what it's tested for. We know kind of why we care about it. So how do we evaluate and manage people? And again, we're assessing their baseline risk and deciding if the treatment is actually going to help them with those outcomes. Not the numbers. So, we're looking at the ACC/AHA guidelines. So ASCVD risk calculator, if you have not seen this before, is a thing of beauty and you need to use it because that is the most up-to-date guidelines in managing lipids.

It's not about guessing. It's not about looking at numbers. It's literally you take this tool, you plug in some stuff, and then it tells you what to do. It's beautiful. You still have to use your brain. You still have to think. But what it does is assesses the next 10-year risk of having those clinical ASCVD events. If you want to sound really smart, you can say clinical ASCVD. Actually no, maybe that sounds kind of dumb. But I feel like when I read about it and I learn about it, people always talk about that. Anyway, heart attack and stroke, and then their lifetime risk. So this is problematic because it assesses risk for white patients and black patients well or fairly, but it doesn't necessarily account for other races and ethnicities. And it also doesn't take into account family history because this is based on very large studies of patients and outcomes.

And that's where they developed the tool. It was made in 2013, and there was an update in 2018, I believe. And they talked about "risk enhancers", and I'm going to link to the resources below. I don't have the rights to kind of use the images, but I'll link to the website to kind of give you more information. But thinking about their risk enhancers, this is where you kind of have to use your brain, where you have to think about not just the score it's given you and the direction that it's told you, but thinking about, does this fully capture their risk? So, way to make it super easy in primary prevention, again people who have not had a heart attack or stroke, there's four high risk categories. One, patients who have an LDL over 190, perfect. You don't even have to do the risk calculator.

They just get a moderate-intensity statin, moderate to high. You could plug it in and it can kind of give you those directions actually. But typically, those patients need a satin. I don't remember off the top of my head. Diabetes, patients with diabetes with ages 40 to 75, you basically don't have to do the calculation either because most patients qualify for moderate-intensity statin. They are recommended to take that. However, you may consider entering the data because it may point you into the direction of a higher-intensity statin. And off the top of my head, it's atorvastatin and rosuvastatin are the high intensity ones at the higher doses. And then moderate-intensity statins include a lot more types of medications. Patients who have an ASCVD risk greater than 20, recommend medication treatment. And then ASCVD risk rate of seven and a half to 20% are considered intermediate risk.

So those are not necessarily one-offs right, but those are kind of easier. So treatment, if it's less than five, they recommend lifestyle modification. They don't need medication. Intermediate, seven and a half to 20, we always want to talk about lifestyle. However, it's a discussion of treatment because we're looking at, again, those risk enhancers, family history, menopausal status, things like that. However, this is a caveat down here because there is some expert level of evidence opinion that anybody greater than 10% really should have both lifestyle and medication. And then patients who have less than 10%, if their LDL is greater than 160, they probably should have medication too. So that's, again, expert level of opinion. So that's a lot of information that I've thrown at you, but literally you pull up this risk calculator, you plug it in. If it recommends a statin, awesome.

And then if it doesn't, you want to think about, are they greater than 5%? Are they greater than 7.5%? Then think about, what are the risk factors that could push them into statin category? So four steps, so recapping. Number one, making sure this is primary prevention versus secondary. Because I'm not talking about secondary. They have their own recommendations. So number two, what is their ASCVD risk? Plug it in. It's a beautiful tool. Number three is lifestyle plus or minus medications, depending on their score. And then what's the follow-up? I'm actually going to take a pause right here, and I'm going to share my screen with you for that tool. And I plugged it in for this gentleman. Oops, spoiler alert, there's his ASCVD risk there. I wanted to make sure it was all filled out for you.

So basically what you do is you fill in, again it has that note here, only primary prevention. His age is 58. He's a man. He's Latino. So it doesn't count. Well, it's not as fair. So, definitely something to think about. And so blood pressure, systolic, diastolic, total cholesterol, HDL, LDL. Do they have diabetes? Do they smoke? Do they have hypertension treatment? Are they on a statin? Also, are they on aspirin therapy? Which is lovely because I feel a little bit conflicted about recommending aspirin sometimes, and it gives you a nice recommendation. And then they can refine current risk based on their previous data, if you want to do that. And it literally tells you what to do. So you view the advice, and he has a pretty high risk. And so he actually definitely qualifies for, spoiler alert, qualifies for moderate-intensity statin versus possible high-intensity statin. So going back to here though. So those are the four steps.

And so what I want to talk about... So let's go back to Raul. So what's next? So spoiler alert, he automatically gets treatment because he's in a high-risk group. But again, I always complete the ASCVD risk score, even if they have diabetes, just because I want to see if they qualify for high-intensity treatment. And sometimes I think I know what the risk is going to be, and then I plug it in and then it's less than 1%. And then other times, it's 25%, and I don't know. Anyway, that's what I recommend. So I recommend also lifestyle modification and weight loss for him because his BMI is 45. And so management, just two quick other notes to talk about when you're talking about statin therapy. It's recommended expert opinion level of evidence to check a baseline LFTs and a baseline CK is "helpful", but there are no guidelines.

I have to be honest, I've never checked a baseline CK. I have checked baseline LFTs. However, there are recommendations do not routinely check these for monitoring. You really want to go based on symptoms. And then a thing to watch out for you, you want to watch out for signs of rhabdomyolysis. This is very uncommon, but you can have statin-associated myalgias. So for statin-related myalgias, they're typically symmetrical, meaning both sides, and then they're proximal more than distal, so it's your bilateral thighs versus your upper extremities. It typically happens sooner than later, like in the first two weeks or so. And then for rhabdomyolysis, you have some other concerning signs, so red/brown urine, elevated muscle enzymes. So the CK is typically above five times the upper limit of normal.

They may also have fever, malaise, tachycardia, GI symptoms. So definitely things to watch out for. Very uncommon, but the myalgias can be common. And that's kind of a whole topic in and of itself, how to kind of manage that, which I talk about in the lab course of how do you adjust statins, and what if patients have side effects, and what do you do next? Things like that. That's a whole conversation. So I'm not going to get into that, but you try your best to keep them on statins because, again, they have the best evidence. So follow up, I always get this question. So when do you recheck lipid? When do you recheck the lipid panel? The moral of the story here, which I think will make you feel a lot better, and you might be a little bit resistant to, but the data tells us that just the fact that they're on a moderate-intensity statin especially is really protective for them.

And so the recommendations of rechecking lipids are typically two to three months after starting. And that's really to kind of assess adherence more than anything else, because you're expecting to see a 30 to 50% drop in the LDL. And if you don't and they are adherent, you want to think about some other things and maybe considering sending to cardiology. It's kind of a lot to get into. But anyway, after that though, you really want to check it annually for primary prevention. Patients, we're not talking about secondary, we're not talking about people who've had a heart attack. And then you want to assess their risk factors in clinical ASCVD. Do they need to increase the intensity of the statin? Majority of the time, they really don't necessarily need the high intensity. It doesn't necessarily improve their outcomes that much more. So a moderate intensity is usually adequate.

And then do they have any signs of clinical ASCVD? Because again, that changes your management altogether. But most likely if they've had those events, they're kind of in the care of a specialist, which is nice. But anyway, so that's it for lipids. So this is Raul again, just recap. So we called with the results by phone, both the lipids and the urine microalbumin. Again, you can go back and watch that if you haven't already. He wasn't that concerned, surprise. I advised him to come back in about a month for diabetes. He said no, but he said he would come back in three months. And I feel like that's harm reduction. I'm much happier because he hadn't been there in 18 months. And he said he's going to restart checking the blood sugars. A note also is that I recommended that he kind of go back and start taking what he took before.

And he did agree to restart the Metformin and consider going back to the 30 twice a day of the insulin. I am not a big fan of the mixed insulins with the long-acting or the longer-acting, intermediate-acting and the short-acting. They're not my favorite to adjust. But it tends to come down to insurance and what they're used to and all that stuff. But I can definitely get into uncontrolled diabetes in another video for sure. I definitely have that in the plans. But I'm kind of just working with what I got for right now. And lifestyle modification is amazing when patients can commit to it and lose weight. And anyway, I could go on and on. But anyway, so that's what he's going to do. And then he was due for a physical exam, but again, harm reduction here. I'm really just focusing on, "Please don't leave again. Please come back. Let me help you with your A1C," getting his buy-in, getting his consistency, things like that. But that's it.

Did you like this video? If so, hit like and subscribe, and share with your NP friends so together we can reach as many new nurse practitioners as possible to help make their first years a little bit easier. And if you want to join us for the Lab Interpretation Crash Course for New Nurse Practitioners, I'm obsessed with how it came out. It's so good. I'd love to have you. There's still time, but there's a hard stop January 30th at 10:00 PM Eastern time. The next time it's coming back is not until the summertime. So if you feel like you're ready to work on some lab interpretation, feel really awesome about it finally, head on over to realworldnp.com/labs. Thank you so much again for watching. Hang in there, and I'll see you soon.