Tackling Australia’s leading risk factor for heart attack: New report and practical tools for high cholesterol

By Kelly Donnelly, Senior Healthcare Programs Officer, Heart Foundation, Pauline Ryan, Senior Healthcare Programs Officer, Heart Foundation and Natalie Raffoul, Healthcare Programs Manager, Heart Foundation  

Source: APNA Primary Times Summer 2022-23 (Volume 22, Issue 2)

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General practices play a critical role in the fight against cardiovascular disease (CVD). Among people who attend Australian general practices with CVD (mainly heart disease or stroke), almost half are not achieving recommended cholesterol levels, even though most are prescribed cholesterol-lowering medicines.¹  

Despite the proven efficacy of cholesterol-lowering medicines and lifestyle management, too many Australians are still not receiving interventions to help achieve target cholesterol levels to prevent heart disease and strokes.2 3 4 5 

Experts from around the country met on 30 June 2022 in Canberra at Australia's National Roundtable on Cholesterol. Hosted by the Heart Foundation in collaboration with the World Heart Federation, the participants were a cross-functional representation of health-care professionals, researchers, peak medical bodies, Indigenous health groups, the pharmaceutical industry and consumers. The full report is available on the Heart Foundation website.⁶ 

 

The burden of cholesterol remains high 

High cholesterol still causes too much avoidable heart disease and stroke in Australia. This is despite clear evidence that people’s risk of heart disease and related conditions, like stroke, increases as their low-density-lipoprotein (LDL) increases.^7,8 High cholesterol is not the only risk factor for heart disease and stroke – it contributes to a person’s overall risk along with other factors, such as raised blood pressure, smoking, diabetes, and heart disease in the family. High cholesterol is, however, responsible for more than one-third of all the years of healthy life lost by Australians due to heart disease.⁹ 

‘General Practice Management Plans, intended to enable multidisciplinary care, are ideal for cholesterol management, but we need more consultation time to do a good job.’ — GP Roundtable participant 

Measuring cholesterol in the context of broader CVD risk assessment 

Strategically timed measurement and management of blood cholesterol is central to primary and secondary prevention of CVD.⁷ For those recovering from a heart attack, the evidence suggests that 12 months after a heart attack or angina admission, almost 50% of people still have higher-than-recommended cholesterol levels.^3,4  

Current expert consensus is that clinicians should request, and laboratories should measure and report, the full lipid profile^7,10: total cholesterol (including LDL cholesterol, high-density-lipoprotein [HDL] cholesterol and non-HDL cholesterol), triglycerides, and other lipid fractions where possible.7 Additionally, a patient’s cholesterol should be measured and interpreted in the context of broader CVD risk assessment and through the use of a validated risk-prediction equation in the primary prevention setting. 

 

Managing LDL cholesterol in people with high CVD risk 

Healthy lifestyle changes (diet, physical activity, smoking cessation and weight management) are recommended first-line management strategies for all individuals, regardless of medicine initiation.  

For people without CVD, cholesterol-lowering treatment is currently recommended for those with a greater than 15% probability of a cardiovascular event within the next 5 years, estimated using the Australian CVD risk calculator. New Australian guidelines for the assessment and management of CVD risk are currently in development and will be available after May 2023.  

Intensive cholesterol-lowering treatment is recommended for all patients with atherosclerotic CVD, unless clinically inappropriate.5  

Current guidelines recommend sequential addition of medicines to reach lipid targets (Fig. 1).¹¹ The Heart Foundation’s Heart Health Check Toolkit provides practical advice on managing high cholesterol. Go to the Heart Foundation website to learn more.  

 

Key findings from the Roundtable report 

Australian and international treatment guidelines set out the best combinations of lifestyle changes and medicines that have been proven to reduce the risk of heart disease and strokes.^3,12 The problem is, this prevention is not happening. Roundtable attendees examined the most significant barriers standing in the way of best practice (Fig. 2). They also proposed and debated potential strategies to overcome the most important roadblocks to optimal primary prevention, secondary prevention, and management of familial hypercholesterolaemia (Fig. 3). Attendees agreed that CVD in Australia could be significantly reduced by a national integrated program to identify and recall people for comprehensive CVD risk assessment and management, including systematic cholesterol screening.  

 

Practical application and tools for primary health care nurses 

For the primary prevention of CVD, cholesterol screening is an essential part of a Heart Health Check (MBS items 699 or 177). The Heart Foundation has developed the Heart Health Check Toolkit to help GPs, primary health care nurses and other primary care providers support patients to manage their risk of CVD. The toolkit provides resources and a range of templates to help with the implementation of Heart Health Checks in primary health care. By providing regular screening and encouraging healthy lifestyle changes, primary health care teams can make a significant contribution to the fight against CVD in Australia. 

 

 

 

 

 

  

References 

1. M Carrington, T Cao, T Haregu et al., CODE RED: Overturning Australia’s cholesterol complacency, Baker Heart and Diabetes Institute, Melbourne, 2020  

2. CM Hespe, A Campain, R Webster et al., ‘Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed’, Med J Aust, 2020, 213(7):327–328. 

3. N Alsadat, K Hyun, F Boroumand et al., ‘Achieving lipid targets within 12 months of an acute coronary syndrome: an observational analysis’, Med J Aust, 2022, 216(9):463–468.  

4. D Brieger, M D'Souza, K Hyun et al., ‘Intensive lipid-lowering therapy in the 12 months after an acute coronary syndrome in Australia: an observational analysis’, Med J Aust, 2019, 210(2):80–85.  

5. LA Simons, ‘An updated review of lipid-modifying therapy’, Med J Aust, 2019, 211(2):87–92.  

6. Heart Foundation, ‘Cholesterol roadblocks and solutions: Report from Australia’s National Roundtable on Cholesterol’, Heart Foundation website, 2022, accessed 28 October 2022. www.heartfoundation.org.au 

7. A Murphy, JP Faria-Neto, K Al-Rasadi et al., ‘World Heart Federation cholesterol roadmap’, Glob Heart, 2017, 12(3):179–197.  

8. F Mach, C Baigent, AL Catapano et al., ‘2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk’, Eur Heart J, 2020; 41(1):111–188.  

9. Australian Institute of Health and Welfare (AIHW), ‘Biomedical risk factors’, AIHW website, 7 July 2022, accessed 28 October 2022. www.aihw.gov.au 

10. Therapeutic Guidelines Limited, Therapeutic guidelines: Cardiovascular 2018, Therapeutic Guidelines Limited, Melbourne, 2021. 

11. Heart Foundation, ‘Practical guide to pharmacological lipid management’, Heart Foundation website, accessed 28 October 2022. www.heartfoundation.org.au 

12. Stroke Foundation, Clinical guidelines for stroke management, Stroke Foundation, Melbourne, 2022.