Closing the Wide Treatment Gap

Why cholesterol plaque treatment is the foundation of heart attack prevention.

LDL-c LDL-p Reduction is the Cornerstone of CVD Prevention

This data is from STENO-2 showing the relative risk reduction associated with lipid (cholesterol) therapy, diabetic control and blood pressure management. Clearly all are important for maximum prevention but LDL-cholesterol treatment is the cornerstone.

Early Onset of Benefit of Statin Therapy

ASCOT trial showed that the onset of benefit from statin therapy starts almost immediately - within a few weeks. And the longer the duration of treatment, the greater the heart attack (and other events) reduction. Like most of the placebo-controlled statin trials, ASCOT has terminated prematurely after a 36% event reduction was reached. Because of the clear benefit of taking statin, it is not ethically justifiable to continue to administer placebo to the control group.

Even Lower is Even Better

This is a composite slide with several placebo-controlled clinical trials showing that the greater the LDL-cholesterol reduction, the lower the cardiovascular risk. A high risk patient with many plaques in the coronary arteries and baseline LDL-cholesterol of 155 mg/dL - lowering LDL-cholesterol to 50 mg/dL is better than just to 90 mg/dL. Remember, LDL-cholesterol level at birth is between 30 to 40 mg/dL. It is safe to have low LDL-cholesterol.

The wide treatment gap uncovered and why closing the gap is a challenge.

My personal and professional journey to aggressive heart attack prevention which started in 2001 was motivated by this L-TAP study published in 2000. 

The Wide Treatment Gap in L-TAP Study

After practicing traditional cardiology - diagnosing and treating heart disease (prevention was not part of it), during which I had treated many hundreds of acute heart attacks, was involved in many cardiac resuscitations, sent many for stents and heart bypass, I decided to find a way to prevent them - to stop a heart attack before it happens. One of the reasons why so many are having heart attacks is the wide treatment gap uncovered by the L-TAP study. Only 18% of established CHD patients were treated to an LDL-cholesterol goal of less than 100 mg/dL (now the goal is less than 70 mg/dL); 82% were treated inadequately or not treated at all.

It sounded easy to solve but it wasn’t as shown by these two studies.

This attempt using PDA involving 113 faculty and resident physicians and 2,884 patients over an 18 months was a failure. 

Here is another study using specialized lipid clinics was also a failure.

Creating disruptive care innovations is the key - PaKS approach and ACCEPT clinical management system.

I started to create a solution which each of the problems or barriers identified in the L-TAP study which slowly evolved over time. We collected our data and in 2006, published our first performance data. 

First Publication 2006
Closing The Treatment Gap 2006

85% reached LDL-cholesterol goal of less than 100 mg/dL. 32% were less than 70 mg/dL. By then, I already saw a decline in cardiovascular events. And the decline continued year after year. 

Second Publication 2016
From Closing the Treatment Gap to Turning Off the Faucet 2016

Unlike the clinical trials like ASCOT and JUPITER which were stopped prematurely because significant event reductions were reached, in clinical practice, treatment does not stop. The magnitude of event reductions in clinical practice far exceeds those reported in clinical trials.

Reducing LDL-choleterol levels to less than 70 mg/dL (most patients even less than 55 mg/dL) causes plaque stabilization, prevents plaque rupture and even reverses atherosclerosis by inducing plaque regression. My practice heart attack rate has dropped to zero to one case most years.

It is time to turn off the faucet instead of mopping the floor.

When one sees the enormous economic burden, the lost of human lives and the amount of suffering it causes as shown in the home page, it is hard not apply solutions when they are available. Even worse, blocking the implementation of these solutions for financial gain.

My practice have successfully created a strong barrier between the left side and the right side for over 10 years now.

The savings for the federal government (Medicare and Medicaid) are thousands of $$$ per Medicare patient. Saving lives and saving healthcare dollars also mean loss of income for Player 3.

But Player 1, Player 2 and Player 4 can all be winners. How do we create Player 4?

Another five years of doing nothing costs a lot.

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