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Abstract

Background While secondary prevention treatment options for atherosclerotic cardiovascular disease (ASCVD) have increased substantially over the years, significant implementation gaps remain. As a result we implemented a novel model of care, a nurse practitioner (NP) run cardiometabolic clinic, supervised by cardiologists. This was developed based on the hypothesis that a secondary prevention clinic can achieve treatment of ASCVD risk factors in a timely and integrated manner, in collaboration with primary care and specialists. Methods/Results In Hamilton, Ontario from November 2022 to October 2023, 274 patients were seen (median age 62 years [IQR 56-70 years], 72% male). The NP saw patients in person or virtually to provide timely, comprehensive patient-centered care. ASCVD education included verbal instructions, handouts, videos and demonstrations to enhance disease knowledge and management strategies. The NP referred to allied health for additional support, as needed. 85% of patients were referred for coronary artery disease (CAD), followed by cerebrovascular disease or peripheral artery disease. At first visit, uncontrolled risk factors were, dyslipidemia (57% [157/274] LDL-C >1.8 mmol/L), obesity (50% [136/274] BMI >30kg/m2), hypertension (46% [125/274] blood-pressure >130/80), type II diabetes (39% [107/274] HbA1c >6.5%), current smokers (20% [54/274]), chronic kidney disease (16% [43/274] eGFR <60 mL/min/1.73m2, albumin-creatinine ratio >3mg/mmol) and depression (6% [15/274] PHQ-2 > 3). We noted that 35% (95/274) of patients had a family history of premature CAD and 75% (206/274) had >2 uncontrolled risk factors. At initial consultation, 56% (154/274) of patients had pharmacologic intervention, most commonly for dyslipidemia (45% [124/274]), followed by diabetes (10% [28/274]), hypertension (9% [25/274]) and smoking cessation (5% [15/274]). Common pharmacological interventions were change in statin dose (40% [49/124]), ezetimibe (31% [38/124]), icosapent-ethyl (20% [25/124]), PCSK9i (36% [45/124]), GLP1-agonist (50% [14/28]), SGLT2i (25% [7/28]), varenicline (53% [8/15]), and nicotine- replacement-therapy (53% [8/15]). Among patients with LDL-C > 1.8 mmol/L, average LDL-C at visit one was 3.10 mmol/L, 2.39 mmol/L at visit two, 2.12 mmol/L at visit three, 1.85 mmol/L at visit four and 1.69 mmol/L at visit five. As of March 8th 2024, 1417 patient visits were conducted and 599 new consultations were completed in the cardiometabolic clinic. Conclusion Uncontrolled risk factors are common in ASCVD. An NP run clinic (supervised by cardiologists) dedicated to risk factor modification can improve secondary prevention through use of evidence-based treatments in a stepwise, integrated approach. The NP model reduces care silos, addresses multiple risk factors, and bridges gaps arising from current models of specialty and primary care.

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