^Improving Risk Stratification in Severe Hypercholesterolemia: Provider Recommendations for Developing a Program to Communicate ASCVD Risk

Abstract

Study Funding

Research reported in this abstract was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number: R01HL159182.

Background/Synopsis

Genetic studies suggest that severe hypercholesterolemia (defined as LDL-C >190mg/dL) can be categorized into four subtypes: monogenic familial hypercholesterolemia (FH), polygenic hypercholesterolemia, elevated lipoprotein(a), and severe hypercholesterolemia with or without a positive family history in the absence of a genetic cause. This information has the potential to improve atherosclerotic cardiovascular disease (ASCVD) risk stratification of individuals affected with severe hypercholesterolemia. By improving understanding and management of the subtypes, health systems can reduce the burden of ASCVD morbidity and mortality in this high-risk population.

Objective/Purpose

Due to the complexity and heterogeneity of the severe hypercholesterolemia phenotype, we assessed the readiness and needs of providers who communicate ASCVD risk information to affected individuals.

Methods

Semi-structured interviews were conducted via videoconference with providers who care for patients with severe hypercholesterolemia. Interviewers described the four classification subtypes to participants and invited responses to hypothetical scenarios involving communication with a patient with each subtype. Interviewers also asked participants how they would respond to a scenario in which a risk stratification tool included genomic information. Participants were compensated after interviews were completed.

Results

Interviews were completed with 11 providers (5 primary care providers (PCPs), 3 cardiology specialists, and 3 genetic counselors) from a single integrated healthcare system. Four patterns from provider interviews emerged about managing each subtype (see Table 1). First, providers described how they would treat and talk with patients across subtypes, which revealed key differences between clinical professions. Most PCPs described a lack of knowledge about the differences among subtypes but expressed interest in understanding and following treatment recommendations for each subtype. Second, providers recommended varying communication resources they and their patients would need to effectively talk about and address the ASCVD risks of each subtype. Next, most PCPs and genetic counselors responded with positive reactions to an ASCVD risk stratification tool that incorporates genomic information, however, cardiology specialists expressed hesitancy to trust this such a tool. Finally, providers gave recommendations for how to implement a program including the genomics informed risk stratification tool to better care for patients with each subtype.

Conclusions

To design and implement a program to identify and manage severe hypercholesterolemia, health care systems should leverage the value providers place on the importance of ASCVD risk stratification to overcome the barrier of current limited knowledge related the causes of severe hypercholesterolemia.