Comprehensive risk factor management through a dedicated secondary prevention clinic: experience from hamilton, Ontario
Authors: Sardana V , Frketich C , Khetan A , Lonn E , Morad M H , Alibhai S , Bhatt D , Alhemeiri M , Coppens D 
Published: October 2024

Abstract

Introduction and Background
Atherosclerotic cardiovascular diseases (ASCVD) remain a major source of morbidity and mortality. Modifiable ASCVD risk factors can be effectively treated, however, there is a lack of systematic implementation of secondary prevention therapies in ASCVD patients. We established a comprehensive secondary prevention program for patients with ASCVD to provide care for all modifiable risk factors in an integrated manner.

Methods
Patients with established coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral vascular disease (PVD) who had one or more uncontrolled risk factors, were referred to the center(s). Patients were assessed between November 2022 and October 2023. Uncontrolled risk factors were defined as dyslipidemia (LDL &gt; 70 mg/dL [1.8 mmol/L]), hypertension (defined as BP &gt;130/80 mmHg), diabetes (HbA1c &gt;6.5%), chronic kidney disease (eGFR &lt;60 ml/min/1.73m2) obesity (BMI &gt;30 kg/m2) and current tobacco use. Data was collected at the initial visit and subsequent follow-up visits.

Results
A total of 274 patients were seen, with 85% were referred for CAD. Median age was 62 years,72% were men. The most common uncontrolled modifiable risk factor was hypertension (62% of patients), followed by dyslipidemia (60%) and obesity (50%). 39% of patients had diabetes, with 57% on a SGLT2i, 16% on a GLP-1 agonist and with 23% with HbA1c &gt;8%. Blood pressure was above 140/90 mm Hg in 41% of patients, 20% were current smokers and 75% of patients had two or more uncontrolled risk factors.
At the first visit, 56% of patients had a pharmacological intervention. The most common was for management of dyslipidemia, followed by diabetes and then hypertension. 17.8%(n=49) patients had a change in statin,13.8% (n= 38) patients were started on Ezetmibe, 9.1%(n=25) on Icosapent Ethyl, and 16.4% (n= 45) on a PCSK9i inhibitor (monoclonal antibody or Inclisiran). Among patients with diabetes, 5.1%(n=14) patients were started on a GLP-1 agonist and 2.5%(n=7) were started on a SGLT2i. 2.9%(n=8) patients were started on Varenicline and 2.9%(n=8) were started on NRT.
Mean LDL (with LDL &gt;1.8 at baseline) at visit 1 was at 3.03 ± 1.1 (n=157) mmol/dl, which reduced to 2.05 ± 0.9 (n=77) mmol/dl by 2nd visit and to 1.90 ± 1.3 (n=32) mmol/dl by visit 3.
Average SBP (SBP &gt;130 at baseline) at visit 1 was 143.3 ± 13.4 (n=114) mm Hg, this was subsequently reduced to 126.4 ± 14.0 (n=58) mm Hg at visit 2 and further reduced to 123.2 ± 14.7 (n=31) mm Hg by visit 3.
Discussion and Impact: In our tertiary Cardiac Care center there are a significant number of patients with established ASCVD that remain on inadequate treatment for secondary prevention. Addressing these risk factors in a timely and integrated fashion in one clinic improves the implementation of guideline directed therapies for management of secondary risk factors in ASCVD and is expected to result in improved outcomes.