Whether you’re a healthy 40-something with a family history of premature cardiac events, a 50-year-old mother who experienced a complicated pregnancy decades ago, or a 65-year-old man whose statin treatment has failed to lower high cholesterol levels, take heart in the growing arsenal of tests and therapies aimed at preventing disease. A long-time advocate for proactive, preventive cardiac care, Dara Lee Lewis, MD, a cardiologist at Boston’s Lown Cardiology Group and Assistant Professor at Harvard Medical School, shares insightful updates in the Q&A below.
Q: What do you see as some of the most promising recent developments in preventive heart care?
A: As a cardiologist, I’m trained to help patients live well with chronic conditions like coronary atherosclerosis, heart failure and atrial fibrillation. But let’s face it – by the time patients are referred to me, their cardiac disease is already established. Wouldn’t it be better to prevent these diseases from developing in the first place? While we can do an excellent job minimizing symptoms and stabilizing disease, I’m just treating the tip of the iceberg. We know that atherosclerosis, or hardening of the arteries, takes decades to develop. The time for intervention is in the iceberg itself, before that first heart attack, when someone may feel fine but under the surface, disease is brewing. That’s where risk factors such as inflammation, pre-diabetes, high cholesterol levels, and unhealthy behaviors are putting the patient at risk. We have the opportunity to make a huge impact by working with our primary care colleagues to identify high-risk patients at the earliest stages and reduce the chance of having a cardiovascular event in the first place.
Q: In addition to the well-documented factors that can signal a person at high risk for heart disease – unhealthy cholesterol levels, hypertension, diabetes, metabolic syndrome, smoking, lack of physical activity, age, family history – have others been identified?
A: Yes, we’re beginning to better understand the key role inflammation plays in the development of coronary artery disease, and now consider chronic inflammatory conditions such as gingivitis, rheumatoid arthritis and certain autoimmune disorders to be risk factors. Women who experienced a complicated pregnancy history, premature menopause or certain cancer treatments are also at a higher risk of heart disease and require close monitoring and screening throughout their lifetime. Most notably, elevated levels of lipoprotein (a), known as Lp(a) (a subtype of LDL cholesterol), have been identified as an independent risk factor.
Q: Why is Lp(a) so significant?
A: An elevated Lp(a), greater than 30-50 mg/dl, is often present in otherwise healthy people. It is a genetically determined risk factor for heart disease, peripheral artery disease, and ischemic stroke. What makes this challenging is that traditional strategies for lowering cholesterol such as statins or exercise and diet modifications have little to no effect on Lp(a); however, PCSK9 inhibitors (non-statin therapy for lowering cholesterol), hormone replacement therapy and Tamoxifen can work for certain individuals. There are also some promising newer medications currently being studied.
Q: Sometimes statins (e.g. Lipitor, Crestor) don’t work to lower LDL or ‘bad’ cholesterol either…are other options available?
A: A number of non-statin therapies can be prescribed, including:
- Ezetimibe (Zetia), a relatively inexpensive pill that can be used alone or given with statins to reduce cholesterol absorption.
- PCSK9 inhibitors (e.g. Praluent, Repatha), monoclonal antibodies given as a shot every two to four weeks. These inactivate the protein PCSK9 to promote more LDL receptors and help clear LDL from the bloodstream.
- Bempedoic acid (Nexletol), a daily pill that causes the liver to make less cholesterol, but with fewer of the muscle aches experienced by some who take statins.
- Inclirisan (Leqvio), given as a shot twice yearly, blocks production of PCSK9.
- Evinacumab (Evkeeza), a monthly infusion approved only for people with a family history of hypercholesterolemia.
Q: Are there any new tools for calculating an individual’s risk of heart disease?
A: I’ve found the American Heart Association’s new PREVENT calculator to be a convenient resource to assess an individual’s risk of heart attack, stroke or heart failure over the next 10 and 30 years. It’s more comprehensive than earlier versions, as it includes measures of kidney function and metabolic health and can be used to predict risk in patients as young as age 30, which is extremely valuable in terms of early detection.