Lipoprotein(a) [Lp(a)] is an independent, genetic, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). Elevated Lp(a) levels increase a person's risk for myocardial infarction, coronary artery disease, ischemic stroke, and aortic stenosis. Guidelines generally recommend testing for Lp(a) in high-risk patients, with some recent guidelines recommending testing once in all adults. It is estimated that >20% of the population carry Lp(a) levels high enough to increase risk, however due to undertesting, many of these patients have not been identified.
To understand the attitudes and barriers to testing for Lp(a) across relevant clinical settings and specialties at the University of Pennsylvania Health Systems (UPHS).
A brief IRB-approved survey in REDCap was distributed via email to select groups of UPHS providers in Cardiology, Neurology, Primary Care, and Vascular Surgery.
The survey was sent to approximately 525 providers in December 2023. Of these, 116 providers completed the survey (54% Internal Medicine/Family Practice, 31% Cardiology, 10% Neurology, 4% Vascular Surgery). Approximately 31.0% (n=36) of all providers routinely tested for Lp(a) in their practice, but this varied by specialty (44% of Cardiologists versus 22% of Internal Medicine/Family Practice providers). For these providers, the most common reasons for testing included a familial history of ASCVD, a history of ASCVD in the patient, and high cholesterol (Table 1). A total of 80 providers (69%) responded that they do not regularly test for Lp(a). The most common reasons for not testing included lack of familiarity with Lp(a), insurance/billing concerns, lack of clinical trial outcomes data, and lack of available pharmaceutical interventions (Table 2).
While there is likely selection bias in the providers who chose to complete the survey, a surprisingly high number of responders (69%) described not regularly testing for Lp(a) in their practice. While results from ongoing clinical trial investigations of novel Lp(a)-lowering treatments may address provider hesitation toward utility of Lp(a)-testing, there is still a large gap to fill in Lp(a) awareness. Increasing provider knowledge of Lp(a) and incorporation into broader clinical guidelines are needed.
This CME activity was supported by an educational grant from Regeneron Pharmaceuticals, Inc.
Despite the clear benefit of early treatment of homozygous familial hypercholesterolemia (HoFH) in reducing the risk of progressive atherosclerotic cardiovascular disease (ASCVD), many patients remain undiagnosed until advanced ASCVD is present. Diagnostic delays may relate to low screening rates found among at-risk children <9 years old.
To study the impact of an online CME program to enhance health care providers' (HCPs') competence in diagnosing and managing HoFH and to overcome barriers to screening for at-risk children.
A 60-minute CME activity was launched live online on 8/2/23 and is available on-demand for 1 year. Knowledge, attitude, and practice-pattern questions were administered before and immediately after the activity (pre vs post). Chi-square tests compared paired responses (P<0.05; pre/post).
As of 1/2/24, 260 HCPs engaged in the program (30% cardiologists, 6% endocrinologists, 29% PCPs; 17% specialize in lipid management or are lipidologists). Nearly 60% of HCPs reported managing patients with very high lipid levels (>400 mg/dL) and the average number of patients with very high lipid levels managed by these participants is 17 per year (approximately 5 of whom are <9 years of age). HCPs' knowledge of the diagnostic criteria for HoFH (30% vs 58%), mechanism of action of ANGPTL3 inhibitors (22% vs 43%), and treatment intensification strategies (48% vs 62%) increased significantly during the CME activity.
Before the activity, approximately 20% of respondents did not measure lipid levels in children <9 years old, 20% only measured in children with a parent diagnosed with familial hypercholesterolemia (FH) or with a family history of CVD, and 24% only measured in children with HoFH symptoms. After the activity, HCPs estimated that 60% of their patients with very high lipid levels (>400 mg/dL) may have undiagnosed HoFH. The proportion of HCPs who strongly agreed with the American Academy of Pediatrics' recommendation for lipid screening for children with a genetic risk of FH or ASCVD as early as age 2 years increased from 14% to 37%.
CME can break down barriers to lipid screening in children at risk for HoFH by enhancing HCPs' knowledge of HoFH diagnosis and risk factors. While the activity enhanced knowledge about the evolving treatment landscape, future education on guidelines and treatment intensification can address remaining gaps in the adoption of best practices and novel agents for HoFH.
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