Cholesterol as a Risk Factor for CHD: Perception vs Reality

1
Cholesterol as a Risk Factor for CHD Perception
vs Reality
2
Global Burden of Disease 10 Leading Causesand
Number of Deaths Worldwide (1990)

• CHD 6,300,000
• Stroke 4,400,000
• Respiratory 4,300,000 disorders
• Diarrheal 2,900,000disease
• Perinatal 2,400,000disorders

• COPD 2,200,000
• Tuberculosis 2,000,000
• Measles 1,000,000
• Traffic accidents 990,000
• Cancer of trachea, 940,000lung, bronchus

Lancet 19973491268.
3
CHD Epidemiology Death Rates From CVDin Europe
(1997)

• CHD is the leading manifestation of CVD in both
  men and women

Men Women 44 38 45 31 38 34 37 29 32 29
40 39
Men Women 42 31 45 37 46 35 44 34 24 21
29 30
4
Primary Risk Factors for CHD
Age
Hypertension
Diabetesmellitus
Male gender
CHD
Cigarettesmoking
Family history of CHD
Dyslipidemia
Non-modifiable
Modifiable
Wood et al. Eur Heart J 1998191434?1503.
5
Impact of Multiple CHD Risk Factors
Total-C 165 mg/dL
Total-C 240 mg/dL
5-Yr probability of event
SBP 100 180 180 180 180 180 HDL-C 65 65 35 35 35 3
5 Smoking - - - Glucose
intolerance - - - - ECG-LVH - - - - -
ECG-LVH left ventricular hypertrophy confirmed
by electrocardiogram HDL-C high-density
lipoprotein cholesterolSBP systolic blood
pressure. Kannel WB. Coron Art Dis 19978565?575.
6
Rationale for Management of High Cholesterol

• Well-established relationship between elevated
  total-C and LDL-C levels and increased CHD risk
• Each 1 reduction in total-C is associated with a
  1.5 to 3 reduction in CHD risk
• Slows progression of atherosclerosis and appears
  to inhibit plaque rupture
• Extends overall survival in patients with CHD

7
CHD Guidelines

• Describe current knowledge in the treatment and
  prevention of CHD
• Define good clinical practice
• Do not provide solutions
• Summarize the most important issues in CHD
  prevention
• Set a goal for a standard of therapy

8
Second Joint Task Force Guidelines
Lipoprotein marker Goal of therapy LDL-C goal
lt3.0 mmol/L (115 mg/dL) Total-C goal lt5.0 mmol/L
(190 mg/dL)
9
Widespread Undertreatment of High Cholesterol

• Undertreatment is a major problem in the
  management of hypercholesterolemia
• Data from EUROPE and the USA consistently show
  that a large proportion of patients do not reach
  their LDL-C goal
• Problem is greatest in patients with existing CHD

10
Lack of Cholesterol Screening in CHD Patients
Patients not screened
11
High Prevalence of Modifiable Risk Factors

• EUROASPIRE
• Risk factor profile 6 months after coronary
  event

Elevated Cholesterol ?5.5 mmol/L 44 (?213
mg/dL) Blood Pressure ?140/90 mmHg 53 Current
Smokers Yes 19 Overweight BMI?30 kg/m2 25
EUROASPIRE Study Group. Eur Heart J
1997181569?1582.
12
High-Risk Patients Are Not Reaching NCEPLDL-C
Goals

• 63 of patients with ?2 risk factors and no CHD
  did not reach NCEP goals

• 82 of CHD patients did not reach NCEP goals

18
37
63
82
Data from a survey of 901 US primary care
providers. Data collected from 4888 patients
being treated for hypercholesterolemia. Pearson
TA, Kaiser AD, Laurora I. Arch Int Med 1999 In
press.
13
US Adult Population at Highest CHD Risk IsNOT
Reaching LDL-C Goals
NHANES III
L-TAP
100
82.5
82.5
80
62.8
54.6
60
Not at LDL-C Goals
40
20
0
CHD
gt2 RF/No CHD
LDL-C goal levels (mg/dL) gt2 RF lt130 CHD
lt100 National Center for Health Statistics.
National Health and Nutrition Examination Survey
(III)1994. (Data collected 1991-1994.) L-TAP
data courtesy of TA Pearson.
14
US Physicians Are More Likely to Treat and
Control Hypertension Than Lipids
80
75
Diagnosed
On medication
70
Controlled on medication
60
54
52
50
patients
40
30
22
16
20
7
10
0
Hyperlipidemia
Hypertension
Data run from NHANES III Morning Examination
Subset hypertension, June 1998 hyperlipidemia,
August 1998.
15
Summary

• Current management of dyslipidemia, a strong risk
  factor for CAD, does not reflect current knowledge

16
REACT
Reassessing European Attitudes about
Cardiovascular Treatment
17
Objectives

• General Public (aged 40 to 70)To assess
  attitudes and behaviors about cholesterol as a
  CHD risk factor
• General PractitionersTo assess acceptance and/or
  implementation of treatment guidelines for high
  cholesterol and CHD

18
Survey Overview

• Countries
• France
• Germany
• Great Britain
• Italy
• Sweden
• Sample size
• GPs 754 (min. 150/country)
• General public 5104 (min. 1000/country)

19
Survey Overview

• Methodology
• GPs Structured telephone interviews
• General public structured face-to-face in-home
  interviews
• Fieldwork dates
• July/Aug 1999
• Margin of sampling error (total sample)
• 4 at 95 confidence level

20
Cholesterol and CHD Awareness
21
Public Unaware of 1 Cause of Death CHD

• CHD is primary cause of death in middle-aged
  adults and the elderly throughout Europe
• BUT
• Only 45 of public surveyed correctly identified
  CHD as leading cause of death in their country

Correctly identified CHD
Incorrectly identified CHD
45
55
Base All 40- to 70-year-olds (n5104)
22
Public Underestimates CHD Risk

• Half believe they run little or no risk of
  eventually developing CHD

High risk
Average risk
Low risk
No risk
None of these
Dont know
Base All 40- to 70-year-olds who have not been
diagnosed with angina and/or CHD and/or MI
(n4597)
23
Public Unaware of Cholesterol as CHD Risk Factor

• Physicians believe their patients know
  cholesterol is associated with CVD

• Only half the public is aware (after prompting)
  that high cholesterol increases CHD risk

70
Smoking
High blood pressure
65
Obesity/being overweight
62
58
Stress
High cholesterol
Yes
51
No
Drinking alcohol
40
Dont know
Base All GPs (n754)
Base All 40- to 70-year-olds (n5140)
24
Public Unaware of Good and Bad Cholesterol

• Three in four 40-to 70-year-olds do not know
  about LDL or HDL cholesterol

23
25
75
77
Aware
LDL
HDL
Unaware
Base All 40- to 70-year-olds (n5104)
25
Awareness of Goal Cholesterol vs Blood Pressure
Levels

• Members of the general public are twice as likely
  to be aware of their ideal blood pressure than of
  their goal cholesterol level

33
31
67
69
Know level
Goal cholesterol awareness
Ideal blood pressureawareness
Dont know level
Base All 40- to 70-year-olds (n5104)
26
Cholesterol Guideline Implementation

• Perception vs Reality

27
Physicians Embrace Cholesterol Guidelines

• Physicians agree with content of cholesterol
  management guidelines

Agree
4
1
Disagree
5
Neither/nor
Dont know
90
Base All GPs (n754)
28
Physicians Believe Cholesterol is Well Managed

• The majority of physicians believe cholesterol is
  well managed in at-risk and existing CHD patients

2
2
18
30
68
80
Well managed
Existing CHD patients
At-risk patients
Badly managed
Dont know
Base All GPs (n754)
29
Hypercholesterolemia in CHD Patients
Finland 40
Germany 38
UK 75
Czech Republic 44
Holland 45
Hungary 46
France 49
Slovenia 49
Spain 36
Italy 58
EUROASPIRE. Eur Heart J 1997181569?1582.Bowker
et al. Heart 199675(4)334?342.
30
Doctor/Patient Communication Gap
31
Doctor/Patient Communication Gap
Most doctors report discussing goal cholesterol
levels with patients
Less than half of 40- to 70-year-olds have
discussed cholesterol levels with their doctors
Yes
Yes
No
No
3
Dont know
6
94
47
50
GPs (n754)
40- to 70-year-olds (n5104)
Base All respondents
32
Low Awareness of Goal Cholesterol Levels

• Only 33 of the general public surveyed know
  their goal cholesterol level

33
Know level
67
Dont know level
Base All 40- to 70-year-olds (n5104)
33
Closing the Communication Gap
34
Improving Cholesterol Management

• GPs reported that providing better patient
  education and increasing the time spent on it
  will improve cholesterol management

49
20
18
15
14
13
11
Base All GPs (n754)
35
More Cholesterol Discussion Means More Screenings

• The majority of those who have discussed their
  cholesterol level with their doctor have also had
  a cholesterol test

Yes
3
2
No
Dont know
95
Base All 40- to 70-year-olds who have discussed
their cholesterol level with their GP/doctor
(n2192)
36
Improving CHD Guideline Implementation

• GPs acknowledged that better physician and
  patient education are needed to improve guideline
  implementation

Better physician education
29
Better patient education
25
Promotion of guidelines
23
17
Simplify guidelines
12
Clarify guidelines
Base All GPs (n754)
37
Conclusions

• Despite widespread agreement with the content of
  cholesterol guidelines, they are not being
  adequately implemented
• Awareness of cholesterol as a CHD risk factor
  needs to increase within the medical community so
  that its importance can be effectively conveyed
  to patients

38
Conclusions

• People aged 40 to 70 show an alarming apathy
  where cholesterol is concerned and, as a result,
  could be placing themselves at greater risk of
  CHD and possible death
• The communication gap between patients and
  doctors needs to close to reduce apathy and the
  health risks it carries
• Improving both physician and patient education
  will help close this gap
• Doctors also need sufficient time and resources
  to put cholesterol guidelines into practice

39
Conclusions

• Doctors are overestimating their patients
  knowledge of cholesterol and its associated risk
  of CHD
• Doctors need to instill in their patients a clear
  idea of the importance of cholesterol as a risk
  factor
• Communication and knowledge will help improve
  cholesterol management via greater testing and
  treatment, when appropriate

40
Conclusions

• People in the 40 to 70 age group want, and need,
  more information about cholesterol and its
  associated risks
• Greater effort must be made to educate people
  about cholesterol
• Emphasis should be placed on informing people of
  their cholesterol goal and ways they can reduce
  cholesterol levels
• Doctors and patients should regard every office
  visit as an opportunity to discuss cholesterol
  and other CHD risk factors

41
Factors That May Influence Undertreatment of CHD
Risk
42
Doctor and Patient Factors That May Influence
Undertreatment

• Patient factors
• Patients underestimate the risk of high
  cholesterol
• AND this is made worse by doctors overestimating
  patient understanding
• High cholesterol levels are often asymptomatic
• Need for lifelong treatment
• Physician factors
• Physicians overestimate how successful they are
• Uncertainties over diagnostic thresholds
• Can cholesterol goals be reached?
• Does increase in treatment worsen quality of
  life?
• Who should be prioritized for therapy?

43
Have Variations in Guideline Recommendations
Confused Physicians?
44
Upper Limit of Normal Cholesterol
1950s 300 mg/dL 7.8 mmol/L 1970s 250 mg/dL 6.5
mmol/L 1990s 190 mg/dL 5.0 mmol/L Future? 150
mg/dL 3.9 mmol/L
45
Physicians Need Clear Priorities for Lipid
Lowering

• Whatever the preferred guideline is, use it
• Concentrate on
• Secondary prevention
• Patients with type 2 diabetes mellitus
• Patients with genetic dyslipidemia
• Patients with multiple risk factors

46
Public Health Initiatives Can Work

• Immunisation programs
• Cancer screening
• Cervical cytology programs
• Breast mammography
• Targeting the message to the public
• AIDS awareness
• US public policies on smoking
• AHA awareness program on hypertension
• AHA increasing emphasis on cholesterol
• awareness of CHD
• awareness of multiple risk factors
• awareness of treatment goals

47
Relevance of REACT and Physician Practice Data

• Management of high cholesterol
• Current underdiagnosis and undertreatment
• Patient compliance is crucial
• Statins once daily, low side effects
• Special groups need special care
• Diabetics, post CHD event (20 prevention)
• Physician and patient perceptions influence
  underuse
• Mismatch with patients understanding
• Physician knowledge