HJAR Nov/Dec 2023

HEALTHCARE JOURNAL OF ARKANSAS I  NOV / DEC 2023 25 placement in stable cardiovascular disease. So, depending on which cardiologist a patient sees or which health system delivers their care, these stents continue to be placed along with their attendant risk of harm and lack of benefit. Optimal medical therapy in cardiovascular disease What is optimal medical therapy? In the last two articles published in this journal, we dis- cussed the optimal treatment of high blood pressure and diabetes mellitus. Ultra-forward- thinking health systems — like HealthPartners in Minnesota, described in detail in the last issue — were able to show definitively that when care is redesigned using a team-based approach while aligning care delivery with per- formance measures that foster accountability for outcomes, disease-related complications are prevented, lives are saved, and health- related medical expenditures are drastically reduced. Remarkable results were achieved through business model reinvention that lever- aged the economics of their own health plan to make care more affordable, not by ration- ing or denying care, but rather by improving it. Successfully achieving 90%+ rates of blood pressure control and 90%+ rates of blood sugar control, along with achieving equally high rates of smoking cessation and aggressively lowering cholesterol are the real keys to preventing heart attacks and improving cardiovascular care. As it relates to abnormalities with cholesterol, just like with high blood pressure and diabetes or even cigarette smoking, it is very important to understand that both magnitude and dura- tion of exposure are of paramount importance. For example, very high blood pressures (like 180/120) can be quite harmful even over a short period of time. The same goes for very high blood sugar elevations. It also makes sense that someone smoking two to three packs of cigarettes per day will experience harm- ful repercussions much sooner than someone smoking only a few cigarettes per day. In these cases, the magnitude of elevation or exposure matters a great deal. But duration is equally important. Even mildly elevated blood pres- sures or blood sugars over a period of many years can be very harmful. And we know that no amount of tobacco exposure is safe over time. The same principles hold true for cholesterol. Even modest elevations of cholesterol over many years can significantly increase the risk of developing the atherosclerotic plaques of coronary artery disease, which can later rupture and cause an acute heart attack or stroke. And when cholesterol is extremely elevated, those patients develop vascular disease much sooner. Abnormal or high cholesterol is also known as dyslipidemia or hyperlipidemia. When present, aggressive therapy with medications is essen- tial, especially with statins. Examples of these drugs include atorvastatin (Lipitor) and rosuvas- tatin (Crestor), which are the two most powerful members of the statin family. Depending on the dose, these drugs have the potential to lower low density lipoprotein (LDL) cholesterol — the so-called “bad” cholesterol — by 30-50%. For every 40% reduction in LDL, we lower ma- jor cardiovascular events by 20-30%. And yet, statins have received lots of unwarranted bad publicity. In my own patients, I don’t tend to see the same level of fear regarding anti-hyperten- sive or anti-diabetic medications as I encounter with statins. Physicians who are well versed in the medical literature know that statins are one of the most powerful and useful medications in our arsenal. Their mortality lowering benefit in patients with coronary artery disease is undeni- able. And yet, many patients are afraid of them. One of the reasons cited as a fear of statins is the myopathy or muscle aches that can oc- cur in a very small number of patients who take “As the forward-thinking healthcare systems transition away from being a traditional health system and toward a system that delivers health, they find themselves on a path that conflicts with deriving their profitability solely from volume-driven, transaction-based economic models and instead toward new business models that are value-driven and outcomes-based.”