Physician Resources
Last Updated : December 07, 2023
Let’s Talk Cholesterol: A Physician Conversation Guide was collaboratively designed by family physicians, specialists, and patient partners as a tool to help you effectively discuss cholesterol management with your patients with dyslipidemia and/or statin indicated conditions.
This guide has been separated into three phases of shared decision-making:
- Phase 1: The Importance of Cholesterol Management
- Phase 2: Understanding Cholesterol Management
- Phase 3: Medication Discussions
Also included in this guide are additional resources to assist with cholesterol management decision-making for your patients.
Key Discussion Principles
The following principles will help you talk about cholesterol with your patients throughout all phases of their cholesterol management journey:
- Use open-ended questions and practice reflective listening
- Provide education that resonates with patients
- Provide recurring reminders
- Encourage positive affirmations for change
Based on previous work (Butalia et. al.), the management of dyslipidemia has the following barriers:
• Dyslipidemia is asymptomatic
• Ambivalence regarding treatment with statins
• Patients do not perceive it to be important, as often it is not their primary reason for visiting a physician’s office.
These barriers align when motivational interviewing techniques are most effective (Bischof et. al.). The motivational interviewing principles were derived from the OARS (open questions, affirmation, reflective listening, and summary reflections) and LEAP (listen, empathize, agree, partner) mnemonic frameworks for motivation interviewing [insert reference].
Sources:
Butalia S, et al. (2020). Barriers and Facilitators to Using Statins: A Qualitative Study With Patients and Family Physicians. CJC Open https://doi.org/10.1016/j.cjco.2020.07.002.
Bischof G, Bischof A, Rumpf HJ. Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice. Dtsch Arztebl Int. 2021 Feb 19;118(7):109-115. doi: 10.3238/arztebl.m2021.0014.
Importance of Cholesterol Management
How to discuss risk and relevance from a patient perspective?
“I feel fine, I don’t feel anything.”
Do you know anyone who has had a sudden heart attack or stroke? What has been the impact on their personal life?
Patients can reflect on the effects of such an event; it can also lead to conversations around how these events could be prevented.
What do you know about cholesterol and its impact on your health?
This question is a good starting point for assessing a patient’s level of understanding about cholesterol; it can also bring about an educational opportunity.
During this phase, education should centre around what cholesterol is, how it can affect a patient’s health and why preventive measures are key (i.e., high cholesterol is preventable, not reversable). The information you provide should be relevant to each individual patient.
Examples:
“You will not feel any symptoms when you have high cholesterol. No one can tell what their cholesterol levels are by how they feel.”
“Over time, high cholesterol leads to a buildup of plaque in your artery walls. This buildup is called atherosclerosis. Even though you don’t feel symptoms of high cholesterol, over time, it can lead to heart attack, stroke and peripheral arterial disease.”
“Think of high cholesterol, and the buildup of plaque in your artery walls, as a blocked drain. Water was flowing fine until the build-up of plaque caused a blockage or an overflow.”
Cholesterol management is not a one-time discussion; getting patients engaged in their cholesterol management can take multiple appointments.
Important: Providing recurring reminders, without putting pressure on the patient, is key.
- “You are not alone in this journey, and I am here to support you every step of the way.”
- “I can see that you’re concerned about your health. Taking steps to manage your cholesterol levels can be a great way to improve your overall well-being.”
- Men ≥ 40 years of age
- Women ≥ 40 years of age (or postmenopausal)
Consider earlier in ethnic groups at increased risk such as South Asian or Indigenous individuals.
All patients with any of the following conditions, regardless of age:
- Clinical evidence of atherosclerosis
- Abdominal aortic aneurysm
- Diabetes mellitus
- Arterial hypertension
- Current cigarette smoking
- Stigmata of dyslipidemia (corneal arcus, xanthelasma, xanthoma)
- Family history of premature CVD*
- Family history of dyslipidemia
- CKD (eGFR ≤ 60 mL/min/1.73 m2 or ACR ≥ 3 mg/mmol)
- Obesity (BMI ≥ 30)
- Inflammatory diseases (RA, SLE, PsA, AS, IBD)
- HIV infection
- Erectile dysfunction
- COPD
- History of hypertensive disorder of pregnancy
*Men younger than 55 years of age and women younger than 65 years of
age in first-degree relatives.
ACR, albumin-to-creatinine ratio; AS, ankylosing spondylitis; BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; IBD, inflammatory bowel disease; PsA, psoriatic arthritis; RA, rheumatoid arthritis; SLE, systemic lupus erythematous.
Recommended resource for quick reference: Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
Understanding Cholesterol Management
How do I discuss different management options with my patients?
Use the Heart Health Calculator to calculate risk and come to management options
During this phase, patients should have a better understanding of what cholesterol is and the importance of cholesterol management. Some patients, however, might still be hesitant to make a change. These patients will benefit from open conversations and positive affirmations.
What concerns you most about your cholesterol levels?
This will help you identify a patient’s specific concerns, which can help you guide the conversation and address the patient’s needs.
How do you feel about making changes to your diet or lifestyle to improve your cholesterol levels?
This will help you gauge a patient’s readiness for change; it might also motivate them to take action. Asking this question can also give you insight into potential barriers to change.
What are your thoughts about taking a medication to lower your cholesterol?
This can help you assess a patient’s attitude towards medication and their willingness to take a medication if needed. It can also help address any concerns a patient may have about medication.
Important: Encourage patients to share their beliefs and try to determine whether there are other people who or what might be influencing their decision-making. E.g., “My husband doesn’t want me to go on any medications,” “My daughter says it’s dangerous.”, “I read up on Google …” In situations like this, you may find it beneficial to invite family members or friends in, as a patient might need permission from another .
During this phase, patients are more open to lifestyle changes. It is important to have an open conversation with patients about what these changes might be and how they plan to reach their goals. Pharmacological interventions should be considered in combination with health behaviour changes and are necessary for those with statin indicated conditions.
Important: Health behaviour modification remains a cornerstone to chronic disease prevention. Health behaviour changes are not easy to achieve. Real efforts should be made to identify the potential benefits of these changes, and honest and clear expectations should be discussed with the patient.
Examples:
Healthy Eating: Recommendation is a Mediterranean diet (e.g., heart healthy diet)
Activity: Recommendation is 150 minutes of moderate to vigorous intensity aerobic physical activity per week, in quick bouts of 10 minutes.
Important: Discuss with your patients that short activities and small, incremental steps are ok. E.g., walk to the grocery store, park farther away, walk to the mailbox, take the stairs.
Smoking Cessation: Discuss with your patients that do smoke, steps to stop smoking to reduce their CVD risk.
Resources:
Oftentimes, patients will opt to make health behaviour changes over taking a medication. Be prepared to make compromises with your patients, even if you believe they should be on a statin.
Allow your patients to pursue other options, such as lifestyle and diet changes; however, be sure to schedule follow-up appointments and bloodwork. It is important to help your patients set definitive goals and timelines so that you have an opportunity to follow-up.
Example:
“We can try diet changes first; however, this might not be enough to lower your cholesterol levels. Let’s follow-up in ~8 weeks and see whether your number is below X. If we don’t meet that number, we can discuss other options. What do you think?”
- “I understand that managing your cholesterol levels can feel overwhelming, but making continuous, small changes can have a big impact on your overall health.”
- “Having high cholesterol is not your fault. 1 in 3 adult Canadians have high .”
- “It takes determination to change your lifestyle and diet, and I commend you for taking the first steps towards managing your cholesterol.”
*Calculate risk using the Framingham Risk Score (FRS) – refer to www.ccs.ca/calculators-and-forms/
**Screening should be repeated every 5 years for men and women aged 40 to 75 years using the modified FRS or CLEM to guide therapy to reduce major CV events. A risk assessment might also be completed whenever a patient’s expected risk status changes.
Recommended resource for quick reference: Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
- The FRS/Heart Health Calculator does not apply to statin indicated conditions (for example history of a heart attack, diabetes, chronic renal failure, low-density lipoprotein > 5 mmol/L, and others)
- The FRS/Heart Health Calculator applies to people between ages 40 to 75 years of age
*Screening should be repeated every 5 years for men and women aged 40 to 75 years using the modified FRS (Framingham Risk Score) or CLEM to guide therapy to reduce major CV events.
A risk assessment might also be completed whenever a patient’s expected risk status changes.
†Calculate risk using the FRS
†‡Refer to page 19 for low-risk individuals who may benefit from statin therapy.
Recommended resource for quick reference:
Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
Medication discussion
How do I discuss statins with my patients?
What do you think the most challenging part of sticking to your new medication will be?
This will help you identify potential obstacles so that you can support your patients.
Can you tell me more about the symptoms you’ve been experiencing since starting your new medication? How have these symptoms affected your daily life? Have you noticed any patterns or triggers that seem to make them better or worse?
Patients can reflect on their symptoms and provide more detailed information about their experiences. Patients can also think critically about their symptoms; a patient might identify other contributing factors that don’t involve their new medication.
Side effects:
Memory: Research suggests that that statins may lower your chance of getting dementia (i.e. memory issues). A common form of dementia is vascular dementia, and vascular dementia is caused by atherosclerosis. Using a statin lowers your cholesterol, and the atherosclerosis or plaques, in your vessels.
Muscle Aches: Most people taking a statin, that is 95 of 100, do not experience any muscle aches. Among, those that do, they are usually mild and go away once their statin medication is stopped.
There are strategies to try if a person develops muscle aches on a statin including trying a lower potency statin, a lower dose, or taking a statin on alternate days.
Cost:
The most common statin medications cost about $10 to $12 a month plus any pharmacy fees in Alberta.
Statins are covered by medical benefits insurance providers. Should a patient not have private health insurance coverage, there are ways Albertans can access prescription drugs through a number of programs.
Duration of statin:
Ensure the patient is aware that statin is a lifelong drug.
How does statin work:
Cholesterol builds up in the blood vessels as “plaques” and eventually this can lead to blockages. “Statins” are a class of medications that are used to lower cholesterol levels, and thus reduce plaques from being formed. While some cholesterol comes from foods, most cholesterol is made by the liver. Statins works by reducing the amount of cholesterol made by the liver, but also helps to remove cholesterol that is already in the blood. Together, this leads to an overall decrease in cholesterol your blood stream.
Statin medications have also been found to have extra benefits that stabilize already build up plaques in the arteries. It does this by reducing inflammation within the blood vessels. This stabilizes the plaques making them less prone to break and reducing the risk of blood clot formation and blocking blood flow.
Patients have indicated that receiving reminders after starting a new care plan is helpful. In addition, studies have shown a positive effect in adherence.
Important: Consider setting up a reminder system or use the hearth health reminder via email.
Example:
“You take daily vitamins and have done everything you can to reduce your cholesterol; however, oftentimes, lifestyle factors alone aren’t enough.”
| Low-intensity | Moderate-intensity | High-intensity |
|
|
|
Recommended resource for quick reference:
Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
‡Statin indicated conditions consists of all documented ASCVD conditions, as well as other high-risk primary prevention conditions in the absence of ACSVD, such as most patients with diabetes, those
with chronic kidney disease and those with a LDL-C ≥5.0 mmol/L.
†Calculate risk using the Framingham Risk Score (FRS) – refer to the iCCS available on the App Store or on Google Play
*Screening should be repeated every 5 years for men and women aged 40 to 75 years using the modified FRS or CLEM to guide therapy to reduce major CV events. A risk assessment might also be completed
whenever a patient’s expected risk status changes.
¶ studies have evaluated the efficacy of BAS for the prevention of ASCVD, but results have been inconclusive.
FRS = Framingham risk score; LDL-C = low-density lipoprotein cholesterol; HDL-C = high-density lipoprotein cholesterol; ApoB = apolipoprotein B; IFG = impaired fasting glucose; HTN = hypertension;
hsCRP = high-sensitivity C-reactive protein; CAC = coronary artery calcium; AU – Agatston unit; Rx = prescription; BAS = bile acid sequestrant
Recommended resource for quick reference:
Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
Recommended resource for quick reference:
Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
Recommended resource for quick reference:
Dyslipidemia pocket guide 2021: https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
General Resources and References
Dyslipidemia Pocket Guide 2021:
https://ccs.ca/app/uploads/2022/07/2022-Lipids-Gui-PG-EN.pdf
Framingham Risk Score (FRS) Estimation of 10-year Cardiovascular Disease (CVD) Risk:
https://ccs.ca/app/uploads/2020/12/FRS_eng_2017_fnl1.pdf
ACTT CVD Risk Summary (Alberta)
Peer Simplified Guidelines: Prevention and Management of Cardiovascular Disease Risk in Primary Care Clinical Practice Guideline (February 2015)
https://actt.albertadoctors.org/media/b21chzfk/cvd-risk-cpg.pdf
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trails
https://www.sciencedirect.com/science/article/pii/S0140673610613505
Bischof G, Bischof A, Rumpf HJ. Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice. Dtsch Arztebl Int. 2021 Feb 19;118(7):109-115. doi: 10.3238/arztebl.m2021.0014. PMID: 33835006; PMCID: PMC8200683.
Abughosh SM, Vadhariya A, Johnson ML, Essien EJ, Esse TW, Serna O, Gallardo E, Boklage SH, Choi J, Holstad MM, Fleming ML. Enhancing Statin Adherence Using a Motivational Interviewing Intervention and Past Adherence Trajectories in Patients with Suboptimal Adherence. J Manag Care Spec Pharm. 2019 Oct;25(10):1053-1062. doi: 10.18553/jmcp.2019.25.10.1053. PMID: 31556824.
Sparrow RT, Khan AM, Ferreira-Legere LE, Ko DT, Jackevicius CA, Goodman SG, Anderson TJ, Stacey D, Tiszovszky I, Farkouh ME, Tu JV, Udell JA. Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials. JAMA Cardiol. 2019 Nov 1;4(11):1160-1169. doi: 10.1001/jamacardio.2019.3066. PMID: 31461127.
Peiris D, Usherwood T, Panaretto K, Harris M, Hunt J, Redfern J, Zwar N, Colagiuri S, Hayman N, Lo S, Patel B, Lyford M, MacMahon S, Neal B, Sullivan D, Cass A, Jackson R, Patel A. Effect of a computer-guided, quality improvement program for cardiovascular disease risk management in primary health care: the treatment of cardiovascular risk using electronic decision support cluster-randomized trial. Circ Cardiovasc Qual Outcomes. 2015 Jan;8(1):87-95. doi: 10.1161/CIRCOUTCOMES.114.001235. Epub 2015 Jan 13. Erratum in: Circ Cardiovasc Qual Outcomes. 2018 Sep;11(9):e000049. PMID: 25587090.