The cardiometabolic syndrome is a concept recently developed by the American Heart Association to denote the totality of risk in a patient with risk factors that may lead to or worsen chronic kidney disease or cardiovascular events. A new validated scoring system has been endorsed by AHA to better assess the short and long-term risk for these in the general population. We will discuss this scoring system in this podcast.
The GameChanger
A new validated scoring system has incorporated factors to better determine the 10 and 30 year risk of CVD and CKD in a general population.
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Mathew Boyd, PharmD
Clinical Pharmacist
Unity Point
Reference
Guidelines: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001191
Calculator: https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the concept of the Cardiovascular-Kidney-Metabolic syndrome.
2. Discuss how the PREVENT scoring system is applied to patients.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-075-H01-P
Initial release date: 3/4/2024
Expiration date: 3/4/2025
Additional CPE details can be found here.
The cardiometabolic syndrome is a concept recently developed by the American Heart Association to denote the totality of risk in a patient with risk factors that may lead to or worsen chronic kidney disease or cardiovascular events. A new validated scoring system has been endorsed by AHA to better assess the short and long-term risk for these in the general population. We will discuss this scoring system in this podcast.
The GameChanger
A new validated scoring system has incorporated factors to better determine the 10 and 30 year risk of CVD and CKD in a general population.
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Mathew Boyd, PharmD
Clinical Pharmacist
Unity Point
Reference
Guidelines: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001191
Calculator: https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the concept of the Cardiovascular-Kidney-Metabolic syndrome.
2. Discuss how the PREVENT scoring system is applied to patients.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-075-H01-P
Initial release date: 3/4/2024
Expiration date: 3/4/2025
Additional CPE details can be found here.
Hey CE plan members from CE Impact. This is Game Changers. I'm Jen Moulton and this week we have with us two guests. One, Dr Jeff Wall, a clinical pharmacist with Methodist Medical Center in Des Moines, Iowa, and you all know and love Jeff. So welcome today, Jeff.
Speaker 2:Thank you.
Speaker 1:We also have with us Matthew Boyd, who is a cardiology pharmacist at Methodist, and I'll let him tell you a little bit about his practice. Welcome, matthew.
Speaker 3:Hi, thanks. Yeah, so I'm one of the cardiology pharmacists here at Methodist and I work with our cardiovascular team on the floor and the ER and then ICU, so I see quite an array of all of our cardiovascular patients here.
Speaker 1:Yeah, that's awesome. Thank you for being with us today. I know Jeff pulled you in as sort of the expert in this area, and so I'm anxious for the conversation kind of between the two of you today. We're talking about a new cardiometabolic sporing system prevent, so I will I'll let you two take it away from here.
Speaker 2:All right, thanks, jeff. Again, welcome to Matthew. Dr Boyd, I is definitely an expert here and I'm glad he was. You know I appreciate the time he's taking because it's always good to have an expert's opinion of what's going on here. Of course, for those of you, if we decide to do this on video, you're seeing our faces, as I was telling Jen. Yes, I definitely have a face made for radio, but that's okay.
Speaker 2:So anyway, today we are going to be talking about the prevent scoring system. You may have seen this has actually had quite a bit of laminated coverage and it's basically a statement from the American Heart Association talking about a new scoring system to that. Basically, I think the design is basically to incorporate a couple of extra factors that older scoring systems did not incorporate, and the one in particular that it really tries to incorporate is the degree of chronic kidney disease, and we've known for a long time that chronic kidney disease is a huge respect for cardiovascular events, and so I think that's one of the reasons why they've tried to kind of incorporate that. So again, dr Boyd here will help kind of.
Speaker 2:You know his take on the paper itself. And again, since we have a lot of practitioners listening to us, you know, after we kind of discuss. You know, gee, this is why it's better or worse, or here's what I'd use it in. You know maybe talking about a few scenarios where you're going to utilize this information. So, rather than just saying to somebody, oh well, you know, you have a 10% chance of having a heart attack in the next 10 years, you know how can you actually use this information to improve outcomes? And I think if you read the paper from the American Heart Association, they do say that this is not supposed to be some static thing that you kind of say well, you know, I guess that's the way things are, you know.
Speaker 2:I mean that you can do things to help with that, and so I think that's the point of this is not just to give people a number, though that's important, but I think it's also a jumping off point to consider therapies for people who you may not consider therapies for right out of the gate, right. So the name of the scoring system is the prevent scoring system, that it stands for AHA, predicting risk of cardiovascular disease events. I don't know how they go with that either, but that's where it comes from. And if you talk, if you look at the paper, one of the things that they talk about is okay, first up, why do we need a new scoring system? And you know I'm holding up to remember when the old Frammy scoring system was like the thing right.
Speaker 2:So in the early 2000s that was the scoring system that pretty much everybody used for assessing cardiovascular risk. It was well validated, it was relatively simple to do, but the big problem was is that it underestimated patients' risk and in fact it didn't count a lot of risk factors that people had for cardiovascular risk. And so you know it was good, but it, like all scoring systems, had some issues associated with it. So a few years after that the ASCBD score became kind of the standard score that everybody kind of used. And the beauty of the ASCBD score is that it did incorporate some extra risk factors that hadn't previously been done in the Frammy scoring and it has become kind of the standard. I mean it's been documented in study after study, in guideline after guideline.
Speaker 2:Everybody just about uses the ASCBD scoring system and there's been some evidence in recent years that it in fact may overestimate the risk of cardiovascular disease, especially in non-diabetics, in diabetes patients. The previous scoring system in the ASCBD scoring system considers diabetes basically a cardiovascular risk equivalent and in fact that may not necessarily be true that in patients who don't have any other risk factors, that it yes, it's definitely a risk factor for coronary disease, but is it the same thing? So has that type two diabetes for two years? Is that the? Is that person at the same risk as someone at a heart attack two years ago? Probably not, and so there's been some concern that that the ASCBD scoring system tended to overestimate.
Speaker 2:And so again, like, like, like you know everything else, we're trying to like, hone in on stuff that has the highest positive predictive value in patients at risk and gives them a number that they can kind of go off of. And so that's kind of the background of all that. You know, matt, what. You know what, what do you think about it? And I'm sure you've done 12 billion cardiovascular scoring calculations on people. So you know what, what do you think about all that?
Speaker 3:Yeah, honestly, I think it's good that we're kind of transitioning and trying to find like the right positives and negatives to take away from our scoring system. Because not to date you or myself, but I wasn't practicing in pharmacy, no one was I enrolled enough to use the scoring system. But as I've been through pharmacy school and during that time of like the ASCBD risk calculator, I remember doing those a plethora in school and I always thought, you know, like I felt like they were a high risk, especially when you're doing it with patients and you could have no risk factors and then diabetes on, all of a sudden your ASCBD would shoot up. So then it would kind of make you question like what was going on, what we needed to actually do in order to prevent it in these patients, and I think that's something that we see a lot in the hospital. So once you get here, we don't necessarily need to calculate the risk because you've already had your event and that's normally when we're seeing you is after your event.
Speaker 3:But I would say, as we kind of see the patients, even the ones that are in our internal med, who come in for a pneumonia and have the risk factors, those are kind of things that we need to be looking at as clinicians and practitioners to kind of figure out hey, you're here for pneumonia, but your ASCBD risk or your prevent risk is going to be elevated. So maybe we should start trying to think about all of our patients and kind of this big scope of cardiovascular disease and kidney disease and this cardio-cardiorenal syndrome that we have often in cardiology. So I would say that as we're transitioning, I think we're trying to find kind of the nice mixing pot of like what we're adding and what parts of this we're going to adding into our score, and so I think that will kind of be the big takeaway from the prevent.
Speaker 2:Absolutely, and I completely agree, and one of the things that I think we've learned a lot about in the last 15 years is that complex interplay between chronic kidney disease and cardiovascular disease or vascular disease in general. We know that patients with stage three or more chronic kidney disease are actually much more likely to die of cardiovascular disease than they are to ever progress on dialysis. That's saying something, and so I think that that statistic right there tells you that. You know it is a huge risk factor, and so figuring out some way to integrate that into a scoring system is going to be pretty crucial, because it is entirely possible that somebody has hypertension and that's it. But they've also developed, you know, some chronic kidney disease from that and we just go well, you just have one risk factor. You know you actually probably have more than one risk factor now in chronic kidney disease.
Speaker 2:So how the prevent scoring system is and we'll talk a little bit more in detail about its background again has to. One of the things that it talks about is this construct, that is the and that's what Dr Boyd was talking about the cardiovascular kidney metabolic syndrome construct. So it's a four phase or three phase construct that not only takes into account cardiovascular traditional risk factors like hypertension and dyslipidemia, but also takes a new effect again chronic kidney disease and also takes to affect the metabolic syndrome so obesity and things along those lines and tries to bring them all together. And if you get to the prevent scoring system website, we're going to have a link to that in the show notes. It incorporates all that. It asks you know, what was your last EGFR, what was your, what's your BMI? So it does include those things in the prevent scoring system and again, try to give us a little more robust take on people's risk.
Speaker 2:The other interesting thing about the this scoring system is that it's not a moment in time. They actually say okay. Well, rather than saying okay, age 65, this is your risk, or age 75, this is your risk, it literally, from one point in time forward, says this is your 10 and 30 year risk. So, as you might imagine that that last number is always pretty high because you know, when we get older we tend to die of coronary disease. That's just kind of the way humans are. But but I think it does give you kind of more of a short term and a long term horizon.
Speaker 2:It kind of take a look at stuff, and the other thing that they mentioned in the, in the text, the guidelines, is that it shouldn't be a static calculation. If someone loses 75 pounds because they're on a GOP one drug, if somebody's blood pressure gets under really good control, if they're able to halt the progression of their chronic kidney disease, you should redo this calculation to get a new risk factor score. So I think I think that's some of the interesting pieces about that, and so to do this and again, you don't have to physically calculate any of this they have the scoring system. That's online and I played around with it a little bit, dr Boyd, as you play around with it and and you know basically what it does is is it assesses all these three things right.
Speaker 2:So again, it looks at traditional cardiovascular risk, it asks for your EGFR and it asks for your, for your BMI, and kind of brings that all into a scoring system. Then, once that happens, what are you going to do about it? And I think that's that's some of the things that that that we can certainly talk about. You know, dr Boyd, what did you think, I mean, when you played around with it again, like I said, I just, like you know, punched in a couple of like fake patients, and so what did you? I mean? Do you think the ease of use was okay? You know, etc. What else did you think about?
Speaker 3:it.
Speaker 3:Yeah, I can really say that using it was really simple when I did it and it actually recommends or like, at least gives you like even the the labs that it wants to see if you want the most specific way or the most accurate percentage that you can have.
Speaker 3:One of the coolest things that I thought about when we're going through and having the final percent, or the percentages that are given, is the 10 and 30 year because, as I was kind of looking at it, like, for most patients, especially if you're under the age of 50, if you get a 10 year risk stratifier to essentially figure out if you're going to have some kind of pornier disease in the next 10 years, for most patients it's not going to be like some absorbent number or you're going to have like something that flags you. And so that's where I kind of feel like the ASPD risk calculator kind of I don't know, maybe disilluded people and made them not really believe it, because the percentage you know when you think about it in 10 years, if it's a 10% risk, even though that was high, people could see look at it and be like, oh well, that's 1% per year. So I'm probably okay, we're here when it looks at it your 30 per year, your 30 year kind of outlook.
Speaker 3:It's a little more daunting, like I even did it for myself today and I was like, oh, that's higher than I probably wanted it to be for a 30 year outlook.
Speaker 3:But if you think about it, that's kind of where we are as a society, like, as you can see when you're looking at the prevent score just in general, there's this stage one, this CKD that they have, or the CKM the first port or the stage zero is people having risk factors. So it kind of goes back to when we last talked about like the eighth of guidelines to and kind of how cardiac diseases are now working on preventing the disease from even happening. Because we have, especially in the society we live in now, like we have job security, because there's so much cardiovascular disease and there's so much chronic disease that goes on that we manage in the hospital. That if we got a better grasp on it right from the beginning of time whether you're 20, 25, 30, and you started thinking about these things before it happened then hopefully we can eventually prevent these things from happening, which then we have a healthier patient population and we're truly being able to take care of, like the sickest of the sick and we're not just chronically managing things in the hospital.
Speaker 2:Right, and that's that. I completely agree with that, and in fact one of the things they know in the text of the guidelines is that this is designed for younger people. This isn't designed for the 75 year old all-timer patient who comes into your office. It's like this is a great time to do your prevent score so we can see what your cardiovascular risk is when you're 105. I mean, I think this is really targeted for.
Speaker 2:Exactly what Dr Boyd said is that we should be looking at the 35 and 40 year old especially. God help us that the 35 and 40 year old who has a BMI of 35 already probably has diabetes, has probably dyslipidemia and hypertension too. We're kind of ignoring them, I mean. I mean ignoring is probably a strong word, but we certainly don't go well, boy, you're at really risk of having in the next 10 and 30 years. You're a real risk of having a cardiovascular event. We just go well, you know. I mean you're 35, you're probably going to be fine. And I've certainly seen and I suspect Matthew's probably seen where we are seeing younger and younger and younger patients have coronary events. And that's because, you know again, obesity and chronic kidney disease and all this stuff kind of gets wrapped up in these patients. And I'm not really sure you know the Framium score or the SCVD score was really ever designed to take a look at younger patients. You know. I mean, if I remember right, scvd even started at 40. And you know this. You know, basically they say if you're an adult, you're over 18, you can actually take this, this scoring system.
Speaker 2:So I mean I totally agree with with Dr Boyd that I think that that one of the advantages of the scoring system is, you know it does, it does give you a time window that should affect people. I mean, I punched my numbers in and I will give the individuals because it just embarrass the crap out of me. But my 30 year now I would be in my 80s by then, but my 30 year CBD risk in the Prevent Spore was 22%. So I have a one in five chance of having a cardiovascular event in the next 30 years, which I guess in the cosmic scheme of things isn't terrible. But I mean my eyes kind of popped because the 10 year risk was like 5%. I'm like, oh, that's pretty good. So, as Dr Boyd points out, giving you a 30 year window when you're 30 years old actually means something, and so I totally agree that that's an important piece of the Prevent Spore system. So, as we talked about, you enter all these numbers into the Prevent Spore system and then it gives you a stage right and so that stage there's a one to four stage system and again, people who have clinical cardiovascular disease are automatically gonna be stage four. You don't have to do a Prevent Spore system because they already are in stage four. Then that's not that different from our previous scoring systems.
Speaker 2:Prevent scoring systems were always really designed for primary treatment or primary prevention, I suppose. So stage zero, or people who are basically normal, have no CKM and remember not this is CAD, it's CKM. So not just cardiovascular factors like hypertension, but chronic kidney disease or metabolic factors. Stage one are patients who have excess or dysfunctional adiposity, which I suspect is most people, certainly me has some excess and or dysfunctional adiposity CKM. Stage two are patients who have actual metabolic risk factors for cardiovascular disease or clinical chronic kidney disease. Stage three are patients who have subclinical cardiovascular disease, very high risk chronic kidney disease or again a highly predicted CBD risk by the Prevent Score. And then stage four again is clinical cardiovascular disease. The guidelines that are the paper, not only guidelines, the papers that surround them, is basically say that it's really at stage two that we should start doing stuff, that we should start working on patients to again if they're smoking, help them quit. If they're obese, try to get them into a treatment plan.
Speaker 2:We were talking before the podcast started that are we literally gonna be at a point in the next 10 years where every American who can afford it's gonna be on a GOP one drug? And the answer is probably yes. So can we arrest to that point of preventing cardiovascular disease almost entirely? Can we prevent that by attacking those kind of lifestyle things that leads to the metabolic syndrome? Right? So that's some things that we'll do. If you're on the fence about treatment, this is where I think.
Speaker 2:An early assessment of things like diabetes, so getting an immunoluminated one C, seeing if they're pre-diabetic and should we try to if lifestyle modification it doesn't do it, or if they can afford a GOP one drug, is that where Metforin may play a role, something along those lines checking a urine album and the creatin ratio in those patients.
Speaker 2:Their GFR may be decent, maybe 60 to 80, but you wanna get a more fine risk score than checking a urine album and creatin ratio just to make sure that they're in the right box of the CKD algorithm. Maybe the way to give you some even more focused information, right? So one sure, stage two you should make sure that, of course, all patients are doing that and then at that point trying to assess are there other risk factors that we can attack? The other thing I thought was interesting and again, matthew, I'm interested in your thoughts on this is not only is the prevent risk factor risk score designed to look at cardiovascular disease, is on a look at heart failure, and that's completely new, right. We've never really had at least to my knowledge anyway a decent general scoring system for primary populations that look at development of heart failure. So what's your take on that?
Speaker 3:Yeah, no, I think that's really important because I feel like a lot of the times, especially in healthcare, in the healthcare setting, our main thing that we have been taught from day one of pharmacy school or medical school is to make sure that we have these risk factors for coronary artery disease kind of controlled, and I don't really feel like any other risk factor or risk stratifier has ever really incorporated the progression of heart failure.
Speaker 3:And I think that's important because we're starting to see again the younger and younger patients presenting with symptoms of heart failure and maybe that won't be like your classic systolic heart failure, so your ischemic cardiomyopathy, reduced EF. It's the ones that have had long-term hypertension or long-term uncontrolled diabetes, where you have this microvascular disease or you have this left ventricular hypertrophy and you really just have this diastolic feeling problem and then you have heart failure symptoms on top of everything else that you're trying to manage as a somewhat obese 40-year-old patient with diabetes, hypertension, and now you have to take chronic medications for your heart failure symptoms as well. So I think one as a pharmacist just being the role of wanting to avoid polypharmacy. I think that's something that, as we try to prevent this earlier, it'll kind of hopefully wean down the number of medications that our patients are on when they get to the, you know, 60, 70, 80 years old.
Speaker 3:But yeah, I would say having the heart failure calculation, or at least the risk for developing heart failure symptoms, is really important, especially because I don't think it was ever something that we thought of as, like this, preventable disease. I think we've always thought of heart failure as something that just occurs chronically over time because you know it's a muscle. As you age, your muscle is going to get a little weaker, which is totally okay, but again we're starting to see these patients who are in their 30s, 40s and 50s who classically would not have had heart failure symptoms probably 40 or 50 years ago, or at least it wasn't diagnosed. We're now we're starting to see that more providently and I think this is something that we're gonna have to be more cautious of and more prevalent or aware of.
Speaker 2:As you know, time goes on Right, and I understand that there's a study and I don't know, probably the prevent score has nothing to do with it, but as I remember reading a couple of months ago that one of the four or five companies that makes STL2 drugs they're looking, they're doing a study right now looking at early type 2 diabetes and prevention of heart failure. So early initiation of STL2 drugs to see if you can prevent heart failure in patients and these patients at high risk. So I mean, again, this would be the perfect scoring system to say, okay, well, your hemoglobin a1c is 8% and right now your EF is stellar, you know, and so you know, I normally would just put you on that form because you don't have, you know, other than diabetes, you're not at high risk for cardiovascular disease. But now that we have this data, it's like maybe we should just put all early type 2 diabetics who are candidates on STL2 drugs. So you know, if that study I mean if that study is ongoing but if that study were to come back positive, you know that, you know, and we had the possibility of preventing the development of heart failure, I mean, I mean not only has that got huge implications for patients but it's got huge implications for economics and the health system. We spend billions on those patients. So that would be very interesting to see.
Speaker 2:So let's, let's wrap up talking a little bit about you know, just your, and again you know this is, we're kind of in, you know, kind of in a, you know, I would say, an evidence-free zone but and maybe an evidence-to-be-determined zone. I mean, there's going to be a lot of art of medicine stuff up here. But so let me, let me give you a couple of hypotheticals and just you know what your take on, what you think you would do. So let's say you had somebody who had stage 2, you know the prevent stage 2 of CKM, right. And let's say it was a patient who was obese but happened to have a slightly high creatinine and a albumic-crannoracial, say, 60. So they've got microalbuminuria and they've got some degree of chronic disease. Their doctor says, okay, yeah, you need to be, you need to be on an ACE and then burn ARBs. So they started ARB, for example.
Speaker 2:And you know, now they check their other cardiometabolic risk factors and they find that, let's say, their LDL isn't in the we're going to start a statin immediately range, but it's in that kind of mid-late. So how would you approach that patient? Would you just say, okay, look, in my opinion, the benefit of that way is the risk to start a statin. Is there a tiebreaker lab you would use, like LB Lillet? Or would you? Or would you say, let's just wait and see how all this stuff plays out? Well, what would be your gestalt there?
Speaker 3:Yeah, I would say honestly, from this point of view, I am a firm believer that statins should probably just be in the water anyway.
Speaker 2:Me too.
Speaker 3:And so I would probably, depending on the patient's age, I would probably have that conversation with them that you know your LDL or your cholesterol is at really where the point where we would start a cholesterol medication.
Speaker 3:But there are other benefits to being on a statin medication, especially for patients who have these risk factors for coronary artery disease or for just cardiovascular disease in general. Just the description of this patient in general makes me want to start an SGLT2 on them. And because they have these risk factors for their CBD and they now have like this progression of their CKD, which we all know as pharmacists and clinicians, that these ACE and ARBs were kind of the go-to medication for slowing the progression of, you know, your coronary or your CKD originally. And now SGLT2 has kind of jumped on that to bandwagon as well and honestly they might even be better than our ACEs and ARBs when we think about it, especially with the slowing of CKD progression.
Speaker 3:And I think sometimes you forget that SGLT2 is also we're studied kind of as weight loss drugs originally too. So you're not getting like a net neutral weight loss with an SGLT2. You are still having some of that benefit. So if the patient is, you know, at somewhat overweight, they have these risk factors for CKD. Putting them on an SGLT2 wasn't necessarily a bad thing, you know, as long as they can afford it. I think that's the right transition to go to. So we have a little bit of weight loss. You know, that might be motivating for the patient to kind of get it on. You know, start doing things on their own as well.
Speaker 3:And then it helps them with their you know chronic CKD and potentially CBD.
Speaker 2:Right. And again, maybe the prevent score can be a motivator, shall we say, because you know you, you know you sit the patient down and say well, let's just punch all your data in and then say well, guess what? You've got a 40% chance of having a heart attack in the next 30 years. You know, will that be enough for someone to go Wow, okay, maybe I will take that cholesterol. Mad hell.
Speaker 2:So, yeah, I agree with you. I think that and I would probably lean toward that. Since we're on the subject and the guidelines, going into some discussion about the, I've always been kind of an healthy little A-nealist, but what's your take?
Speaker 3:I honestly feel like we use it sometimes in patients who have kind of that borderline cholesterol. But I don't necessarily see that we use it that often, especially with us. We're a little spoiled. We don't have to do a lot of risk stratifying when we're in the hospital because most of our patients have, the risk has already happened.
Speaker 3:So, whether you've had your 40% risk stratification, the events already happened, we're already here, and so that's normally when we see the patients and that's when we're already on a stand. So I don't think we necessarily have that, but there is a place for it, I think, and they do talk about it a little bit, just in the paper in general, which I don't necessarily think it would be something that we want to monitor all the time, but it is a good at baseline.
Speaker 3:Say you go in for your physical, you're 25 years old and your provider's like, hey, let's do this, prevent risk, just so we can kind of figure out where we're going from here. Say you are a little overweight but everything else checks out Getting these labs, whether it be your A1C, your LipOA, your urine studies I think that would overall, just be beneficial for you to know. In general. It's not necessarily something that we need to have done, but it does just kind of give you that peace of mind that you don't have anything brewing in the back that you are kind of aware of.
Speaker 2:Right and also to help you a little bit, is a marker of basically genetic dyslipidemia. I mean, you could argue it's an expensive lab, but you could argue that patients at risk, especially if they have a non-family history of coronary disease, that might be the no go of starting a stand earlier than later. So yeah, so I think that's a good point, all right. Second and last hypothetical 40 years. So 55 year old guy, obese, but no other as these states accept hypertension.
Speaker 2:So you look at his CKM risk. I mean, let's say for kicks and gills, let's say he's pre-diabetic I'm always a little hazy on what exactly that means. But let's say his A1C is I don't know, 5.8% or something like that. And he comes to you and says I'm on the fence about starting an aspirin today. Now, primary prevention for aspirins really kind of got in the toilet in the last five or six years and I think in general that's probably a good idea. But what would be your take on this particular person? Or would there be another test you might want to do to help break the tie?
Speaker 3:basically, yeah, I would honestly say for them. I'm not a huge advocate for aspirin for primary prevention, especially kind of the way our data has driven the last five years or so For those advanced age patients who you know their respect is for bleeding are gonna outweigh their primary prevention for having some sort of coronary event or some cardiovascular disease. So I would say for him it'd be one of those conversations too of whether or not he would want to take it, because you know that is just a medication that could or could not be doing him any harm or good. It could just be, you know, taking it for fun, essentially if you're not really doing anything for your coronary or your cardiovascular disease. But then also kind of outlying like hey, like this could cause stomach upset or no potential bleeding in the long term, especially if you're not eating with it or things like that.
Speaker 3:So this is kind of one of those conversations and then also kind of looking at whether he has like any family history of any coronary artery disease or cardiovascular disease can kind of be a play in that point too. And I think from the patient you've described would be kind of one of those patients where you know the old guidelines would say like, hey, we should do like lifestyle modifications, and so I think that's kind of where you should start. But again, we live in a world where patients don't always want to do like the long term, where we're doing like, oh, let's eat a salad three times a week and you'll see five pounds fall off in a matter of, you know, a year.
Speaker 3:We kind of live in a society where none of us are that patient and we kind of want to see results tomorrow when we wake up.
Speaker 3:So I don't necessarily. He's a pre-diabetic and you know everyone's kind of on that GLP one kick anyway. So if he was at this moderate low risk and he kind of wants to have something that gets him over the hump to with his weight loss journey, that could be something that could help or help to kind of give him that motivation that he needs. But that kind of all goes down that dark spiral that we talked about before we got online today with the potential and how long that really is going to be good for a patient.
Speaker 2:So, yeah, you know, yeah, we had a whole. You know, and I'm sure there's already been sociology dissertations on this that have been published about you know, we've literally entered a world, in the first world, where we make so much food we have to put everybody on medication so they don't eat all the food. You know, it's just, it's pretty amazing, which I guess it's better than the opposite. It's better than people starving to death. So, yeah, I would agree with that. You know, like you have kind of become a primary prevention nihilist. It's like it doesn't really seem to do a lot and it just harms people.
Speaker 2:I know some cardiologists are kind of gung ho on the calcium sporing as kind of a tiebreaker and again, I've been a bit of a nihilist on that. I know there's some data suggesting that it helps if the score is zero, but if it's anything else it's useless. So I'm really able to do that. So the other piece that it's worth mentioning, and we won't go into something into detail about this, because I think if Dr Boyd and I had the answer to this we would be kings of the world is.
Speaker 2:It does go into some detail about the fact that social determinants of health play a huge role in all this. And you know, we can try and fix the little pieces of this right. We can try and make sure that they're on the appropriate medication, that they're getting good followup, that they are getting monitored et cetera et cetera.
Speaker 2:But you know the impact that social determinants of health are gonna have on a lot of these patients is just enormous and there's no easy fix, as we all know. And so you know I think there are programs which we can do and we can participate in that help, but in the end, without massive societal change that helps give people who need the help the help they need, you know we can, at the patient level, do good stuff At the population level. Sometimes it feels like we're trying to rearrange deck chairs on the Titanic, and so you know, I'm hopeful that at some point somebody will come up with some way to improve that. But I think that's. The paper goes into some detail, talking about how we should do our best to address social determinants of health and try and help things, and I think at the individual level we can.
Speaker 2:I think pharmacists play a big role in this. There's at least two studies that show that, for example, in African-American neighborhoods, that pharmacists go into the barber shops that a lot of African-American males use as kind of a social gathering space, they can actually detect and treat hypertension way better than if those patients actually went in to see doctors, right? So I mean, if we go to where patients are. I think that can help as well. So, anyway, that's it for this episode of Game Changers. Again, thank you, dr Boyd, for your expertise.
Speaker 2:It's always a hell of a lot of fun to have you here, and you know, get your take on this, because this you know, cardi Baster disease is still the number one killer of Americans where we've got some room to go yet. So again, I really appreciate you being here and hopefully you'll join us again. Thank you.
Speaker 1:Yeah, actually I've got a couple questions. So I mean for me this, I mean this is a real game changer. I mean I think for sure, you know you talked about GLP-1s and because of that, you know, when people you know, knowledge is power, and so when people have this information and you're looking ahead, it's like okay, now I want to make an impact. You know, I want to be healthier. I had bone density screening done recently and I've been lifting weights like my life, to kind of put.
Speaker 1:So, you see that risk score and you're like I don't want to be a little old frail lady falling. And so I think you know, jeff, you made a really good point Like there's. You know, social determinants of health as well and all of us are different and motivated by different things. But you know, we have health coaching and you know and we can have an impact here and I think maybe even little things help. So I'm curious, matthew, like what do you think? Do you think pharmacists can encourage patients to do this risk scoring on their own? Is this something that like even in the community, where we can say you know, you should be putting your numbers into this? I mean, so much of us have that patient data available and you know, follow my health portals and you know all the things that we have, so that information is available to us. Can we plug it in? Should we be doing this on our own?
Speaker 3:Yeah, I definitely think that the better to have like, the more awareness the better.
Speaker 3:So, whether it be you know the pharmacist and the community setting having that conversation, or you know the nurses even at discharge from a hospital, or you know anyone really in the healthcare field that has you know patient to patient or patient to a clinician interaction, I think that's really where we can make the difference, you know. So, whether that be someone finding out about this, whether in the community pharmacy, and then going back to their provider and saying like, hey, I'm getting to that age, I'm in my 40s, I know I'm a little overweight and I take an anti-apertensive, but like, can we get my other labs done that are in this, you know, prevent scoring tools?
Speaker 2:So you know whether it's your urine analysis with your so A1C and then the A1C and then the Alton-Cranin ratio?
Speaker 3:Yeah, so getting those with your provider and even doing, like you know, just more close follow-up. I think that kind of gives the general population like a better idea of what's going on with themselves in order to help themselves. Because you know we all go to work Physicals, hopefully at least once a year, but like besides that if you don't have any other chronic conditions, you don't see someone at least for 365 days. So a lot can happen in a year and so a lot of things can kind of develop and people have stressors and things that change. So I think that's something that everyone should always be aware of and something that you know providers can help to facilitate, but also pharmacists just being in the community setting or you know anywhere.
Speaker 2:You know if you're just walking down an aisle at a store or something you know and you see someone with that looks confused about something, you know, yeah, I mean, I think, I agree, I think I think that you know, knowledge is power and if you know, I would assume you know, at some large clinics they're probably just going to embed this calculation in their you know like. So basically you see your primary care doc and all this data gets dumped into the calculator and automatically just spits out these numbers for you. If the physician doesn't have the time and they often don't to discuss this stuff. Yes, I mean, when they go get their satin field and they're like yeah, I got a lot of questions about this 25% chance in the next 30 years and be dropping dead from a heart attack makes me a little bit nervous. You know, I think having pharmacists know that information can really really help.
Speaker 1:Yeah, yeah, and from a pharmacoeconomic standpoint, it'll be super interesting to see how insurance companies could use this data. You know, when you talk about STL ones and or GLP two and yeah, whether they're going to pay for that. You know whether insurance is paying for that in a preventative standpoint. You know, I mean you said there's, you know all kinds of studies that are happening. So we're just going to continue to get more and more data with those. But you know, if you have a risk score of this, then you know that gets paid for because the risk to benefit ratio and some of that cost factors. So I think that's going to be fascinating to watch all that play out when we have more information on the front side. They've been so reluctant to pay for. So, you know, for prevention and I think something like this would be a game changer.
Speaker 2:You know, I mean you know the name of the game for insurance companies, of course, is to delay, thing that you know, not to insult any insurance people listening to us. I mean, basically one of their articles of faith is you're not going to be on my insurance plan long term. So basically, you know, I just have to keep you alive with the minimum cost to me until I can dump my problems on you or on someone else or the federal government when you turn 65 or 67. Right, then it's not my problem anymore. So there really hasn't been much of an impetus, I don't think, for insurance companies to do preventative stuff and I think that has to change. Obviously, right, because you're right. By the time they, you know, have, you know, clinically ebony and cardiovascular disease. It's too late. You know, we could have put you on a GOB one 10 years ago or 15 years ago and you would have had this stuff. But unfortunately the insurance company A who was on you were being covered by a lot of times. Just don't have that, doesn't have the impetus to cover it. Yeah, but at some point I think you do reach a reach a critical mass where they have no choice.
Speaker 2:Right, where I mean when study after study after study shows that even in the short term GOP one drugs decrease health use consumption. Then you know, at that point they made the call. I know a lot of my docs, my internists, you know they're having that. You know the, the, the P, the PBMs are having them go through this. Well, you know, before they get a GOP one drug for weight loss, they have to fail other drugs for weight loss and I mean I guess that's fine, except that the other drugs for weight loss either are really expensive or have terrible side effects too. So I'm not really sure. It's like it's like insurance companies wouldn't pay for dole acts until they failed war for it. I'm like what the hell is fail war for me? They had a bleed or they had a stroke. I mean I, you know it's not. That seems like kind of a pretty severe failure to me.
Speaker 1:Yeah, yeah. Well, it'll be fascinating to watch, you know? I mean, would CMS require, you know, insurance companies to do that, because they're the ultimate payer in the end? You know just so many things to play out.
Speaker 2:So I hope it isn't used as a bludgeon for community pharmacists for yet another you know metric that they're going to have found Now, did you check their prevents score? You know we're not going to pay you if you don't pay your prevents Right. I mean, you know we should be doing it, but but I think I think PBMs shouldn't be using that as a bludgeon on on community pharmacies, especially independent pharmacies. You know, as yet another metric that they have to try and try and report.
Speaker 1:So yeah, yeah, well, if they pay him to actually do that, that would be nice.
Speaker 2:That's a whole different whole thing.
Speaker 1:We're not here to solve that problem.
Speaker 2:We could, we like again, we'd be kings of the world. Yeah, wouldn't we? Yeah, that'd be great.
Speaker 1:Well, thanks again to you both. This was a great topic. I really appreciate both of you being here to discuss it today. And remember, if you're a C plan member, be sure to claim your C credit for this episode. And, as always, have a great week and keep learning. Thanks, we'll talk soon.