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Why Prevention-Focused Strategies Are Key

Five ways stakeholders can promote screening and treatment for elevated Lp(a) in the future to improve overall cardiac disease mortality

The importance of preventative healthcare has been brought to the forefront recently due to advances in screening and diagnostic technologies, the recognition that it is usually less expensive to prevent a disease than it is to treat it, and delays in preventative care during Covid-19. Preventive care reduces the risk for diseases, disabilities, and death, yet utilization of preventive care services, such as disease screening, is underutilized. 

Nowhere is this more evident than in the prevention of cardiovascular disease, the leading cause of death in the U.S. and around the world. For example, the CDC found that nearly two in five adults in the U.S. have high cholesterol (total blood cholesterol ≥ 200 mg/dL), which, if left unchecked, can lead to a heart attack or stroke. Even considering these grim statistics, patients who are younger or do not have existing cardiovascular disease or diabetes may not be getting appropriate screening. This is particularly true regarding cholesterol screening. 

And, with the advent of new heart disease medications potentially coming to market, this problem may become even more pronounced.  

Prevention of cardiac disease was revolutionized with the introduction of statins, a group of medicines that can help lower the level of low-density lipoprotein (LDL) cholesterol, often referred to as “bad cholesterol,” in the blood. However, there remains a subset of the population who either do not respond to statins, do not reach LDL goals, or do not tolerate them. 

Some patients who develop cardiovascular disease despite statin use have an elevated Lp(a), a lesser-known type of lipid disease that affects about 20% of the population. Elevated Lp(a) may be a key to lowering the death rate. It is genetic in origin, unrelated to lifestyle choices, and associated with several cardiac conditions. Multiple studies have shown that elevated Lp(a) has been associated with not only coronary artery disease but also ischemic stroke, aortic stenosis, and heart failure. In addition, higher Lp(a) levels have been associated with more heart failure hospitalizations. 

Unfortunately, there are no FDA-approved medications for elevated Lp(a). Because of this, management consists of lifestyle changes for modifiable cardiovascular disease risk factors and statin therapy. Luckily, promising medications to lower Lp(a) are in clinical trials. 

Currently, testing for Lp(a) is not widespread and is only done for further risk stratification in patients, particularly in patients with a history of ischemic stroke, a family history of premature atherosclerotic cardiovascular disease (ASCVD), or a family history of elevated Lp(a). 

In preparation for new drugs potentially coming to market, testing for Lp(a) may need to be expanded. It will be necessary for the healthcare system to identify appropriate candidates for treatment, which will require planning and preparation from all healthcare stakeholders, including healthcare providers, payers, patients, and pharmaceutical companies.

The potential of drugs to treat elevated Lp(a) and have an impact on overall mortality from cardiac disease is high. Waiting for patients to have a cardiac event before testing for Lp(a) may be a missed opportunity, especially if these medications are shown to prevent cardiac disease. Currently, screening for elevated Lp(a) is not indicated, and disease state education for healthcare providers and the public is limited. Stakeholders must come together to address these needs to maximize the potential positive impact of Lp(a)-lowering medications.

Here are five ways stakeholders can promote screening and treatment for elevated Lp(a) in the future to improve overall cardiac disease mortality.

  1. Guidelines: Shifting the disease treatment paradigm can be slow, and guidelines may be helpful in accelerating change.  Payers and healthcare providers follow guidelines when deciding on coverage and treatment of disease. Guidelines for Lp(a) testing and screening must be updated and highlighted. Guidelines can help determine the age for screening, testing frequency, and treatment candidates.
  2. Healthcare provider education: The healthcare provider workload has not slowed and keeping up with recent developments in healthcare can be onerous. Uptake of new treatments can depend on provider knowledge and demand.  Healthcare providers will need easily accessible scientific education around testing, screening, and treatment guidelines since medications for Lp(a) will be new, and healthcare providers will need to get comfortable with testing for Lp(a).  In addition, activation of key opinion leaders in cardiology will be critical in driving demand for new treatments.  
  3. The Electronic Health Record (EHR): Leveraging EHRs to identify patients who may qualify for Lp(a) testing and treatment can help lower the risk of cardiac disease.
  4. Patient education: Disease awareness is an important factor in driving screening and treatment rates.  Patient education around genetic factors, like Lp(a), that cause cardiac disease, may support adherence and persistence to future treatments as patients begin to understand the impact of Lp(a) on their risk of developing cardiac events.
  5. Patient support resources: Cost can be a barrier to treatment.  Patient support resources can assist with patient education, prior authorization, and financial assistance to further support medication adherence and persistence.

A potential evolution in lipid management and cardiovascular disease reduction is coming, and stakeholders must prepare. Key opinion leaders, health systems, EHR vendors, payers, and pharmaceutical companies will be integral in driving the appropriate utilization of new drugs for elevated Lp(a) levels that may have a significant impact on the development of and mortality from cardiovascular disease. 

Importantly, what can be achieved with greater focus on disease awareness and screening in the cardiovascular health arena is but one example of the merits of disease prevention overall.

Promoting preventive care services is an effective strategy to reduce the need for medical services and expenditures. This is where healthcare providers can make the biggest difference in shifting the focus back to prevention. Beyond typical care, a key element of the doctor-patient relationship is based on education and sharing information that helps their patients become more active in their care and in taking steps that prevent disease. 

Educating individuals and empowering them to take greater control of their health, can create a ripple effect that impacts the full healthcare ecosystem, including lower levels of healthcare utilization for patients, decreased burden on already-strapped providers, decreased healthcare spending and, most importantly, better outcomes for patients.

Photo: Flickr user Neeta Lind

Cynthia Miller brings over 15 years of experience in the healthcare field. She is trained as an internist with a Master’s in Public Health. She has extensive experience in patient care delivery in the outpatient setting, and experience in inpatient care, palliative care, and telemedicine. Before joining Precision AQ, Cynthia served as the Senior Medical Director of Pharmacy for WellCare Health Plans and later as Vice President Medical Director in Pharmacy at Centene. Currently, she is Vice President Medical Director in the Access Experience Team at Precision AQ, where she assists clients in developing and implementing payer strategies for pharmaceutical products across the lifecycle.

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