Shared Decision Making in High CV Risk Patients - My Method

Understanding the Meaning of High and Very High Ten-Year CV Risk

A ten-year CV risk score of 20% is high and 30% and over greater is very high - it means that the likelihood of that person having a heart attack, a stroke or suffering a sudden death event is at least 1 in 5 for the 20% risk to 1 in 3.3 in the 30% risk. (Put that in proper perspective, one’s lifetime risk, not ten-year risk, of dying from a car accident in 1 in 606. If it were a ten-year risk of dying from a car accident instead, it could be 1 in 3,000 to 1 in 5,000.) This is the risk for “ hard events” only. If we include “soft events” which also includes the development of angina or TIA, need for stenting or bypass, then ten-year gets even worse. Every year 250,000 Americans die from a heart attack without reaching the hospital. 

Could this happen to me

This is the patient side of the issue. This scenario is very different from the patient and the physician/nurse practitioner trying to decide if an antibiotic or a chest X ray is needed for a cough that started three days before.  

The physician/medical practitioner side is that you have the knowledge to share with the patient and make the patient understand his/her risk, what atherosclerosis is, what plaque rupture is, how statins stop the natural progression of atherosclerosis and in some cases even induce regression, what happens without optimal medical therapy, etc. For a patient who is at high or very high risk, the physician’s decision to offer optimal medical therapy and the patient’s decision to accept the treatment is among the most impactful health decision they will make together.

Understanding the Treatment Goal - Stop Disease Progression, Even Induce Disease Regression

I practiced traditional non-invasive cardiology for the first 20 years and then added preventive cardiology and clinical lipidology for the last 15 years - 35 years of accumulated clinical experience. Combining those three components for each patient visit is time-consuming and difficult to do well. I had to develop my own numerically goal-oriented clinical management system and e-tools. They have served me and my patients well.

Here I am explaining to my patient about where LDL cholesterol comes from - he was concerned that his LDLc level at 45 mg/dL might be too low. Sometimes, patients bring up misinformation generated in the Internet or from the media or their friends. I find these mentoring slides indispensable anytime I have to explain something important. It allows me to help my patients understand their high risk for heart attack and stroke, what plaque rupture is, how medications work, the goals of treatment, what happens without optimal medical therapy, etc. Over time, trust, respect and partnership develop.

Being Self-Employed and an Established Cardiologist Helps

Patients come to see me for cardiac evaluation and management, for treatment of complex dyslipidemia - including heterozygous FH and statin intolerance, advanced cardiovascular risk assessment, need to continue statin therapy, etc. I publicly supported the Million Hearts Initiative since 2012 and challenged hospital administrators to build a coalition for a heart attack and stroke-free community. 

When a new patient comes to my office for the first time, the door signage tells them at a glance what services I will provide them.

Patient education starts while they are sitting in my waiting room using posters I developed myself and a self-looping four-minute powerpoint video. There are no educational/promotional materials from pharmaceutical companies in my office.  

Having Published Performance Data Helps Too

I also have a mini-poster copy of my poster presentation in 2006 at the national meeting of the SGIM about the care innovations I developed to close the treatment gap in my practice.

New patients have a good idea of what I bring to the table to help them stay healthier before we actually meet.

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