UNC Health Talk

Choosing a Strategy to Help Patients at Risk for Heart Disease

Heart patients get the best care when primary care providers and cardiologists work together, sooner.

There is a trend toward earlier collaboration between general physicians and heart specialists, according to Thelsa Weickert, MD, a cardiologist with UNC Heart & Vascular.

“Gone are the days when we would see people after their third or fourth heart attack,” Dr. Weickert says. “We want to prevent that first heart attack from ever happening. The goal is prevention.”

For primary care physicians who want to know how they can work together with a heart specialist to provide the best patient care, we’ve answered some common questions.

When should I refer a patient to a cardiologist?

Patients who are having symptoms suggestive of heart disease, such as chest pain with exertion or a change in their functional status, should be referred to a cardiologist.

Other patients who are at high risk of developing heart disease (more than 20 percent on the ASCVD risk assessment) should also be referred to a cardiologist. In some cases, referring patients to a specialist can motivate them to take their health more seriously. A specialist will explain the benefits of being proactive and treating high blood pressure and cholesterol.

Once I refer my patient to a specialist, how will we work together?

Cardiologists with UNC Health Care work closely with primary care physicians to provide the best care for patients. “We work in collaboration with primary care doctors,” Dr. Weickert says. “We never take over the care, but instead complement the care offered by the referring physicians.”

The process generally goes as follows: You believe your patient may have a heart problem or is at risk of one, so you send him to a cardiologist. After seeing your patient, the cardiologist will translate his notes into a formal letter to send to you, giving details about the patient’s assessment and laying out a plan for managing the patient.

The patient will then come back to you, the primary care provider, for follow-up. Most patients with ongoing heart concerns will need to be seen only once a year by a specialist. The primary physician will carry out the majority of the treatment plan.

The cardiologist is available by email or an electronic medical record message if questions arise.

What heart disease prevention options are available to my patient?

Patients are classified into two broad categories when it comes to prevention: primary and secondary.

Primary Prevention

Primary prevention is used in patients who have not been diagnosed with heart disease but who are at risk of developing it.

There are three primary prevention groups:

  • People with LDL ≥190 mg/dL
  • People with type 2 diabetes who are 40 to 75 years old
  • People with an estimated 10-year ASCVD risk of 7.5 percent or higher who are 40 to 75 years old

Secondary Prevention

Secondary prevention is for patients who have documented heart or vascular disease, including people with:

  • Atherosclerosis-related cardiovascular disease (history of myocardial infarction, stable or unstable angina)
  • History of coronary revascularization
  • Stroke or transient ischemic attack presumed to be of atherosclerotic origin
  • Peripheral arterial disease or revascularization

Primary and Secondary Prevention

For both primary and secondary prevention patients, cardiologists seek change on two fronts:

  • Lifestyle modifications, including diet (such as the Mediterranean diet) and an exercise regimen consisting of moderate aerobic exercise for at least 45 minutes a day
  • Drug therapies, such as statins

When is it appropriate for me to talk with my patient about changing his or her diet and lifestyle?

All patients should be counseled regarding diet and lifestyle regardless of their age or risk factors.

As far as more aggressive prevention measures, it is important to identify whether the patient is a candidate for primary or secondary prevention.

For patients who do not have heart disease but have high blood pressure, are diabetic, or used to or still smoke, primary care physicians should assess them using a simple online test for risk calculation. The American College of Cardiology site also provides guidelines on how to treat these patients.

It’s important to note that these online tools for risk calculation have been criticized for resulting in inflated scores, indicating a falsely elevated risk.

“But still,” Dr. Weickert says, “this could be a good first step as an indication that a conversation may be in order.

Telling your patient that they have a higher risk than patients without certain risk factors can get the ball rolling on prevention.”

Which prevention groups are appropriate for statin therapy?

At this time, statins remain the cornerstone therapy for cholesterol reduction and are recommended for patients in all prevention groups identified above.

The American Heart Association/American College of Cardiology guidelines recommend that instead of focusing on a patient’s cholesterol number, doctors should think about his or her risk of developing cardiovascular disease. That appears to be a better guide to whether a patient should be on a statin.

Of course, there is some controversy around statins, especially in relation to their side effects and their efficacy in older adults. Serious or fatal statin adverse events are rare, but side effects are not. The incidence of muscle aches and weakness in statin trials is highly variable, and real-world experiences may differ from clinical trial reports.

Statins have also been associated with increases in blood sugar, which in some cases lead to a diagnosis of diabetes. Some reports have linked statin use to memory issues, but the evidence is unclear.

However, statins have been studied in the highest number of clinical trials of any medicine, and their efficacy is well known.

In the end, it’s a matter of balancing the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke and death. Dr. Weickert encourages primary care physicians to have open conversations with their patients and to consider their individual benefits and risks.

It’s important to note that statins are also anti-inflammatory medications. More and more research is showing that inflammatory conditions often drive heart disease. This is why, for instance, patients with rheumatoid arthritis are considered to be at higher risk of heart disease. Among the other pleiotropic effects of statins is their role in plaque stabilization, which is crucial in managing acute coronary syndromes.

Which patients will benefit most from anti-platelet medication?

Generally speaking, patients who have established heart disease or are at high risk of heart disease will benefit from an anti-platelet medication such as a daily baby aspirin (81 mg). For primary prevention, providers can use clinical tools such as the Aspirin Guide app to determine if the benefit of aspirin therapy would outweigh the risk. For secondary prevention, such as in those patients with established heart disease or those with a history of stroke, aspirin should probably be continued indefinitely. In addition, if these patients have undergone a stent placement or revascularization such as bypass surgery, an additional anti-platelet agent may be indicated for six to 12 months.

If you’re interested in making a referral to our heart and vascular teams at UNC Medical Center or UNC REX Healthcare, please call 984-974-2509.