Primary Care Can Lead in CVD Prevention

There has never been a better and more important time for primary care providers to help move the needle on reducing risk for cardiovascular disease and mortality, says lipidologist and preventive cardiologist Seth Baum, MD. There are many agents newly approved for cardioprotection in patients with type 2 diabetes and add-on agents approved for patients in whom maximum statin therapy is not enough. PCPs have the touch points with patients that specialists, including endocrinologists and cardiologists, simply don’t. And with every clinician doing the very best he or she can in the space of an office visit, the idea of territory or turf does not pertain.

The following transcript has been edited for clarity and length.

Patient Care: I am curious about how primary care utilizes the add-on therapies after statins. What about ezetimibe and the PCSK9 inhibitors? I know for the latter there was and probably still is an insurance barrier. But, are primary care physicians paying attention to next steps?

Seth Baum, MD: That's a great question. I would say so often primary care practitioners/physicians do see the issue and do, frankly want to start a PCSK9 inhibitor—and they tend to defer to cardiology. And maybe cardiology doesn't do it as much as we should. So, what my suggestion is to the primary care providers is that they take the bull by the horn, and they prescribe the PCSK9 inhibitor and fight the insurance companies just like cardiologists do. And they’ll win. You know, the drugs [price] fell 60% a couple years ago, so we have access to them now. We just need to prescribe.

And, you know, from a prevention standpoint, we also have drugs for diabetes, the SGLT2 inhibitors and GLP-1 receptor agonists that now have cardiovascular indications. So that's another area of prevention that primary care practitioners could be more involved in. I think to leave the prescribing of those drugs to the endocrinologist or to the cardiologist, frankly, as a mistake. I think the primary care practitioners should be the ones; they're on the front line, they're seeing these patients all the time. And they need to, to prescribe these drugs. Even if they get some pushback, frankly, from cardiology, and endo.

They need to prescribe them when they're indicated. Best of all possible worlds, of course, is to work in a you know, collaborative, collegial fashion, and to speak to the cardiologists and speak to the endocrinologist. But sometimes it's hard to connect to these people, to other practitioners. And the patient needs to come first. So, I think that the PCPs, if they could address that, if they could prescribe the SGLT2s, the GLP-1s, if they could prescribe the PCSK9 inhibitors and ezetimibe, I think it would make an enormous change in in prevention.

I'd like to emphasize one other thing, though, and that's therapeutic lifestyle changes. You know, these are the things that are tending to fall apart now, with COVID. You know, the exercise the diet, stress reduction. So, that, too, can be emphasized from a PCP standpoint. I know it sounds like I'm putting a whole burden on the PCPs but you know, they are the front lines. You guys are the front lines. And it would be really helpful if you did this, even if you got to push back and then we in cardiology should be doing, our part, too. So, we all need to we all need to work together to improve this. We have the tools now we need to take advantage of them.