by Misty Kevech, HHQI RN Project Coordinator
Heart disease is the leading cause of death in the U.S. for men and women (CDC, 2017). Every year, 735,000 Americans have a heart attack (CDC, 2017). Cardiovascular health is important to the well-being of people for primary and secondary preventation of atherosclerotic cardiovascular disease (ASCVD), which can lead to heart attacks and strokes. The CDC (2015) states, “People with high cholesterol have about twice the risk of heart disease as people with lower levels.” Your home health patients often have a high cholesterol diagnosis, but do they understand and have a plan to address the levels?
Patient Confusion & Non-Adherence
Patients are often confused over how to interpret their blood lipid panel results and to differentiate common myths from evidence-based facts. For example, many people think that heredity affects cholesterol levels, not lifestyle choices. The truth is that lifestyle modifications are recommended for everyone, no matter their cholesterol level. Yes, heredity does factor in for some patients, but there are important lifestyle changes everyone can make. Many Americans continue to not eat heart-healthy diets and are not getting enough exercise. The U.S. Department of Health and Human Services recently released the second edition of the Physical Activity Guidelines for Americans that reinforces the 150 minutes to 300 minutes/week recommendation, if physically able, but now adds that any amount of exercise is beneficial (HHS, 2018). Would exercising 5 to 10 minutes several times a day sound more reasonable to your patients?
Lipid-lowering medications are added to lifestyle modifications for people with higher levels of cholesterol or to reduce the level more quickly. Medication adherence for these medications (e.g., satins) is only at 55% (CDC, 2018). The 39.1 million people who are at high risk for an ASCVD event, but are not taking a statin, could reduce their risk of a heart attack or stroke by up to half if therapy was taken regularly (Million Hearts®, 2018). Consider using open-ended questions to ask your patients about how, when, or how they physically feel related to cholesterol medications. Some examples of questions are, “Tell me how/when you take the ___________ pill?” and “How does the pill make you feel?” Explain that there are other medications that can be ordered if there are side effects.
Home Health & Cholesterol Management
Where does cholesterol management fit into your home health visits? Patient education on cholesterol effects, lipid levels, diet, exercise, and medications are essential for cardiovascular (CV) health. Educating your patients on reducing CV risk factors, especially lifestyle management, often aligns with other chronic disease management interventions you are teaching your patients. You could use pictures or videos as visual education to show the effects of cholesterol on the CV system. Check out the American Heart Association’s Watch, Learn and Live: Cholesterol resources. HHQI’s My Questions about My Heart for My Doctor tool can be utilized to prep your patients to discuss CV concerns with their doctor, including what their lipid results mean.
A heart-healthy diet often aligns with other disease dietary recommendations and fits nicely into your patient’s care plan. Increasing exercise is also appropriate for most chronic diseases. Consider making a therapy referral to set up a safe home exercise program for your patients, if appropriate. Even older patients with chronic diseases can increase activity levels at home, even if chair-bound. Use the Exercise & Keep Your Seat patient education tool (a diabetes tool, but appropriate for all) for those who need to safely exercise from a chair. This tool is also available in other languages.
Medication teaching is part of the Home Health Conditions of Participation. As a clinician, you need to understand and be able to explain to patients the importance of taking cholesterol-lowering medications to decrease their risk of heart attacks and strokes. You must also educate patients on the common side effects with tips and tricks to address them or work with the practitioner to try alternative medications. Teach your patients to speak up and communicate their concerns about side effects. These interventions will assist with disease management of all chronic conditions.
It is important that home health clinicians to stay up to date with all evidence-based guidelines so you can teach patients the rational and guide them toward adherence with better outcomes.
Updated Cholesterol Clinical Practice Guidelines
In November 2018, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released the 2018 Cholesterol Clinical Practice Guidelines. The report was approved by many other leading organizations (see the report for listing). This is the first update since 2013.
The key changes include creating two classifications in the Secondary Prevention group for those patients with atherosclerotic cardiovascular disease (ASCVD) including a “very high risk” and recommendations for these groups (see below). LDL-C threshold returns to the guidelines to assist practitioners with prescribing statins and alternative therapies (see below). The ACC/AHA recommends the use of either fasting or non-fasting lipid panels for monitoring of cholesterol levels. An unusual recommendation is for insurers to consider a no co-pay for cholesterol-lowering medications that are evidence-based (A or B categories).
The report provides the Top 10 Take-Home Messages to Reduce Risk of Atherosclerotic Cardiovascular Disease Though Cholesterol Management (see pages 5-6 for more specifics for each item).
- In all individuals, emphasize a heart-healthy lifestyle across the life course.
- In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.
- In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.
- In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), begin high-intensity statin therapy without calculating 10-year ASCVD risk.
- In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk.
- In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy.
- In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
- In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy (see No. 7).
- In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.
- Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.
- Are You at Risk for Heart Attack or Stroke? patient video provides risk factors and signs/symptoms (HHQI)
- CVD: Reduction of Risk & Treatment through Diet & Lifestyle Changes course features a webinar by an expert on Therapeutic Lifestyle Changes including the DASH diet (HHQI)
- Cardiovascular Health Part 2: Cholesterol management & Smoking cessation Best Practice Intervention Package (BPIP) provides evidence-based practices and resources (HHQI)
- Cholesterol Management: The Good, the Bad and the Ugly course includes webinar by pharmacist with educational information and patient tips/tricks (HHQI)
- Home Health Cardiovascular Data Registry is an optional, powerful, and convenient quality improvement tool available to CMS-certified home health agencies. Using this tool will help target potential disparities in care and advance cardiovascular health improvement efforts, including the use of statin therapy for targeted populations. Learn more and register. (HHQI)
- Lifestyle Modifications Part 1 clinician video focuses on weight reduction, DASH eating plan, and sodium reduction (HHQI)
- Lifestyle Modifications Part 2 clinician video focuses on physical activity, alcohol moderation, and smoking cessation (HHQI)
- My Healthy Heart Workbook provides key information to patients to improve their cardiovascular health including cholesterol management and is available in many languages (HHQI)
- Statin Therapy for the Prevention & Treatment of CVH course features two pharmacists providing information on treatment guidelines and medication including mitigation of side effects and how to work with local pharmacist.
- Take Control of Your Cholesterol is a patient handout on cholesterol management and is available in Spanish (HHQI)
- Cholesterol and Statins Infographic provides a visual description of how cholesterol works in the body (FDA)
- High Cholesterol Tools and Training for Professionals website includes fact sheets, guidelines, tools and training, and journal articles (CDC)
- Preventing and Managing High Cholesterol website provides information about patient actions including medications (CDC)