Setting the Stage in the Cath Lab for Ongoing Lipid Management

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The cardiac catheterization laboratory plays a critical role in the management of patients with acute coronary syndrome (ACS). This uniquely positions interventional cardiologists and the cath lab–based care team to capture the attention of patients and begin conversations about ongoing monitoring of lipid levels and lipid-lowering therapy. Approaching patients while they are keenly aware of an acute cardiovascular (CV) event provides a key opportunity to engage them in shared decision-making around lipid-lowering therapy and develop a plan of care for lipid management after discharge.

Lipid measurement in the first 24 to 48 hours after an ACS hospitalization provides important baseline information needed for care team members to begin educating the patient on secondary prevention strategies, including risk reduction through lifestyle management and pharmacologic regimens. Interventional care team members may use that information to help develop an individualized plan of care, including lipids. Employing a multidisciplinary approach to lipid management during the hospital stay supports a more comprehensive approach to successfully improving lipid levels after discharge—with lifestyle management and high-intensity statins alone or in combination with other nonstatin therapies.

To provide high-quality care for patients with ACS, CV clinical team members benefit from decision-making tools that support collaboration with other members of the clinical team, along with broader system-level interventions, which are some of the key findings from TRANSFORM: ACS.

TRANSFORM: ACS is part of the multiproject TRANSFORM series developed by the American College of Cardiology (ACC) to turn ACC clinical algorithms and standards into actionable results for patients while lowering administrative barriers for clinicians and patients.¹ The goal of TRANSFORM: ACS is to improve secondary prevention for post-ACS patients through the intensification of relevant lipid therapies. The project hypothesizes that rapid cholesterol testing after an event (in the hospital and within 75 days postdischarge) will drive subsequent initiation of lipid-lowering treatment within the first year post-ACS.¹ A secondary hypothesis is that testing after an event will increase adherence more effectively than current practice. This quality improvement project focuses on approaches to address early lipid testing after an ACS event that may drive guideline-based low-density lipoprotein cholesterol (LDL-C) management within the first year post-ACS.¹ Best practices from this initiative have been collected from participating sites, published literature on the topic, and the MedAxiom knowledge base and are now being disseminated through a new CV business white paper. This article applies some of these best practices through the lens of the interventional cardiology care team.

SET THE STAGE WITH EARLY INTERVENTION

Lipid levels measured at the beginning of an ACS hospitalization are a reliable foundation for treatment decisions, despite older misconceptions surrounding changes in the lipid profile when assessed immediately after a myocardial infarction. The LUNAR study assessed lipid changes 1 to 4 days after onset of ACS, before initiation of study treatment. Mean lipid levels had relatively little variation in the 4 days after ACS, thus allowing lipid measurement early in the patient’s hospitalization to guide the selection of lipid-lowering medication, according to the authors of the new CV business white paper.^2,3

All patients presenting with ACS should have an evaluation of lipid levels while in the hospital. This early assessment directs initial treatment and provides the context needed to monitor response to therapy in the ambulatory setting.

THE GUIDELINES GUIDE CARE

Clinicians need evidence-based decision-making tools that provide standard approaches to care. This is particularly important in the fast-paced environment of the acute care setting. These tools can be found in the guidelines but can sometimes be difficult to find or apply to clinical practice. Organizational approaches that make the guidelines actionable are one method for standardizing care within a single facility or across an entire health system.

A system-level approach can decrease the time between the guideline release and guideline updates and clinical implementation.⁴ As stated in the CV business white paper, “Systematic evaluation of the efficacy of lipid-lowering therapy initiated post-ACS should be performed early, with a > 50% reduction target for LDL-C from baseline.”³ Creating easily applied treatment algorithms and decision trees based on the guidelines can support clinicians in developing treatment plans for lipid-lowering therapy after discharge to the ambulatory setting.

The interventional cardiology care team is poised to address the various factors that lead to undertreatment. Interventional providers can start the conversations about factors that may cause patients to avoid or abandon treatment. Discussion topics may include concerns surrounding statin intolerance and other perceived risks; socioeconomic and geographic disparities; disparities in race, sex, and age; variations in protocols and practices across health systems; previous health care experiences; and cost restrictions (see Factors Impacting LDL-C Lowering to Achieve Recommended Levels Sidebar).⁴

Cardiology administrators and clinicians can also advocate best practices that support guideline adherence by developing clinical and operational workflows and deploying tools to limit practice variation, overcome clinical inertia, recognize and address side effects, ease patient financial burden, encourage medication adherence, and recognize patient-specific disparities.⁴

DELIVERING CARE THROUGH TEAMS AND SYSTEMS

Although interventional clinicians have the responsibility to begin conversations about lipid-lowering therapy and establish treatment plans and a cadence for follow-up testing after discharge, optimal ACS and lipid-lowering therapy management is the responsibility of the entire CV team and the larger hospital system. Interventional clinicians can initiate guideline-based medical therapy for patients with ACS, but other care team members must lend their support in the ambulatory setting as well.

A multidisciplinary, team-based care approach is key to providing effective care across the inpatient and ambulatory settings. Team members in the cath lab benefit from hearing concerns from the cardiac rehab specialists who coordinate ongoing patient monitoring and follow-up care. Team members in the ambulatory setting can help implement the follow-up plans created during the acute care stay. Having a variety of skill sets reduces the burden placed on clinicians, who face numerous competing demands. A multidisciplinary team approach can facilitate patient engagement and help manage patient-related barriers to care.

CV leaders are responsible for creating cultural changes that may be required to support the clinicians who support the patients. The guidelines can only be applied if care models have been effectively established to operationalize the guidelines at the point of care. All stakeholders need to be involved by sharing their unique perspective when developing care delivery strategies. Those stakeholders must also be able to represent their specific population and identify factors that will impact patient adherence.

Clinical pharmacists are also key members of the team caring for patients with ACS. Together, interventional clinicians and clinical pharmacists can create and deliver a sustainable plan for therapeutic medication reconciliation and discharge education. Insights provided by clinical pharmacists may help nurses create discussion points for patients, including expected therapeutic goals and potential side effects that may affect medication adherence. Nurses are essential to communicating and coordinating care at admission and throughout the hospital stay. They can deliver education and treatment instructions to patients and translate the care plan to the providers in the ambulatory setting who will follow through on next steps.

BEYOND THE CATH LAB: EFFECTIVE DATA MONITORING AND MANAGING CHANGE

Beyond facilitating conversations and establishing care plans, interventional clinicians can have an impact on the essential monitoring of care delivery performance and adherence to guideline-directed medical therapy. Since the interventional team is often closest to the work being performed, their feedback is essential to identifying workflows and uncovering performance gaps in effective care delivery.

Once the workflows are agreed on and implemented, cardiovascular leaders are essential for socializing and managing the change. Monitoring compliance and CV performance feedback is critical. Engaging the entire interventional care team is key to successful performance management. Staff education about the “what” and “why” of changes in clinical practice highlights the benefits of change and positively impacts staff morale. Finally, providing an opportunity for feedback on what is working well and what challenges remain facilitates the identification of remaining barriers and the opportunity to celebrate success. This approach can potentially generate satisfaction and engagement, which is important with the ongoing staffing issues in interventional cardiology because the staff set the stage for adherence to lipid-lowering therapies and better outcomes.

1. American College of Cardiology. American College of Cardiology to collaborate with Amgen, Veradigm to optimize ACS care. December 15, 2020. Accessed June 20, 2024. https://www.acc.org/about-acc/press-releases/2020/12/15/15/06/american-college-of-cardiology-to-collaborate-with-amgen-veradigm-to-optimize-acs-care

2. Pitt B, Loscalzo J, Monyak J, et. al. Comparison of lipid-modifying efficacy of rosuvastatin versus atorvastatin in patients with acute coronary syndrome (from the LUNAR study). Am J Cardiol. 2012;109:1239-1246. doi: 10.1016/j.amjcard.2011.12.015

3. American College of Cardiology, MedAxiom. TRANSFORM: ACS best practices for LDL-c management. June 3, 2024. Accessed June 20, 2024. https://hubs.li/Q02zmRNQ0

4. Claessen BE, Guedeney P, Gibson CM, et al. Lipid management in patients presenting with acute coronary syndromes: a review. J Am Heart Assoc. 2020;9:e018897. doi: 10.1161/JAHA.120.018897