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, we cover a wide range of important clinical findings. We discuss the feasibility of digital cognitive assessments for Alzheimer screening in primary care, patient preferences for atopic dermatitis treatments, and the impact of social determinants of health on hormonal therapy use among midlife women. Additionally, we explore the FDA's Breakthrough Device designation for a multi-cancer detection test and new findings linking the quality of low-carb and low-fat diets to coronary heart disease prevention. Tune in for these key insights that are shaping clinical practice.

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Discover essential clinical insights on Alzheimer disease screening in primary care, eczema treatments, and the latest in cancer detection and diet impacts on CHD risk.

The Weekly Dose: Clinical Updates on Cancer Detection, Cognitive Screening, CVD Prevention, Atopic Dermatitis Treatment

, obesity medicine specialist Alina Elperin, MD, discusses preventive cardiology and obesity, including 2 cardiovascular disease risk factors to screen patients with obesity for, the top 3 cardiovascular complications seen in patients with obesity, the importance of checking a patients' current medication list, and how clinicians can start a conversation around nutrition plans with their patients. 

Dr Elperin is an internist and a Clinical Assistant Professor at the University of Chicago Pritzker School of Medicine. 

 podcast features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today. 

 to subscribe on your favorite streaming service.

Listen to our latest podcast episode for details on top CVD risk factors to screen patients with obesity for, medications to help prevent CVD, and more.

Navigating Cardiovascular Complications of Obesity: Expert Insights for Primary Care

The following transcript has been edited for clarity and length.

, a website for primary care physicians. Today I'm speaking with Dr. Patrick Moriarty about cardiovascular risk and risk assessment. More specifically, we're going to talk about the evidence for the role of lipoprotein A, which I will call Lp(a) here on, as an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and as a target for therapy. Dr Moriarty is a professor in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City, where he is also the Director of Clinical Pharmacology and the Atherosclerosis/Lipoprotein-Apheresis Center. He'll be speaking on this topic that we're talking about today, next week at the 2020 virtual Cardiometabolic Health Congress. Welcome Dr. Moriarty. 

 Thank you Grace for inviting me. Good afternoon to you.

 Thank you. So, you're involved in the most current research on the role of Lp(a) in the development of ASCVD and also in some promising research on a potential treatment to reduce levels in patients at high risk. Could you just give us a little bit of background on how Lp(a) became identified as one of the more important markers of residual cardiovascular risk?

 Sure. It goes back all the way to 1963. A Dr. Berg from Norway - he was a physician but also a researcher - was trying to investigate if there were new blood types. In his investigation, he immunized rabbits with a human beta lipoprotein from a single donor. The antibodies that he found that developed from this procedure, were found in one-third of the population. And eventually he found out that these patients that had this protein, had an increased risk of cardiovascular disease and he called it lipoprotein A, and that's where it originated from. So, we're going all the way back there, and it's progressing and progressing up until now. If you want, I can give you a quick overview of what this lipoprotein is.

 It contains an LDL-like moiety 100 in size, like a typical LDL. It has this apolipoprotein A bound to it and this apolipoprotein A looks somewhat like plasminogen, except it doesn't have an active protease domain. The protease domain of plasminogen is what causes clots to break up because our blood is constantly clotting or unclotting, daily, if not we would bleed to death or we'd clot to death. So, this plasminogen goes to where a clot is and breaks it up. Well, Lp(a) goes where it is, binds to it, but does not increase the fibrinolytic cascade. The clot sustains a longer duration, which in places like cardiac and brain, could be very detrimental. Third, it’s a major carrier of inflammatory molecules, including, more importantly, oxidized phospholipids. About 80% of our oxidized phospholipids in the blood are carried on this lipoprotein. And oxidized phospholipids are major players in the plaque foam cell deposition and degradation of plaque causing rupture, which is a major etiology of a cardiovascular event is a ruptured plaque. So, it's a triple whammy because it has LDL too. It's LDL, inflammation, and coagulation. About a third—20% to 30%—of the world’s population have this lipoprotein, and you're born with it. It's an autosomal dominant gene that dictates it. So, if you have it, 50% chance your children might have it. And you can't change it by lifestyle, diet, exercise has no effect on it. Actually, statins might raise it a certain percentage. Well, the good thing about that, even though statins do raise it, the statins still give clinical benefit. There was a study called JUPITER where they used rosuvastatin—if you remember that—and it was a primary prevention study and they showed a reduction in cardiovascular events and reduction of LDLs quite dramatically, but then they looked back and said "okay, what about the patients in that trial that had a high Lp(a)?" Well, they showed that they still got benefit with the statin, but it was attenuated. It was weakened by the high Lp(a), so you never stop a statin therapy in a patient based on their Lp(a) level.

 This new molecule, I believe it's an antisense oligonucleotide, is what you were looking at in your research that was published in the beginning of the year. What is it? And how does it work?

 We published a paper in January of this year in the 

. It was a phase 2 trial where we had different levels of this drug dosing in patients, about 85% got some dose and 15% got placebo; and it's an antisense oligonucleotide, as you mentioned. Present day monoclonal antibodies, such as the PCSK9 inhibitors, inhibit the protein as produced in the blood to prevent it from being active, with whatever its mechanism of action is. For antisense, this drug causes a missense reading of the messenger RNA to prevent the protein from being read out and made. It inhibits the protein being made itself and the drug has a special addition to it, which makes it liver specific, so it goes directly to the liver only because it can't go out other tissues. So, this is a new version, we had one that didn't have that. This one is 100-times more potent, so the dose is much lower. And we found that the drug could lower LDL, Lp(a) by about 80%.

 The results were quite remarkable, if you just look at raw numbers.

 Incredibly powerful. And now we're moving into so-called phase 3 trial, which hard endpoint is looking at reduction of cardiovascular events, and dose is going to be 80 mL once a month, compared to placebo. It'd be 50/50. We're talking about thousands of patients worldwide, it started already late last year, and COVID-19 has slowed down the process of it, as you would expect, but it's moving ahead. We're one of the sites and it looks in 5 years, hopefully, we'll be able to show that this drug not only lowers Lp(a), which we know it does, but lowers cardiovascular events on top of that. We have a paper coming out in 

JACC (Journal of the American College of Cardiology)

, giving an overview of the drug—its initiation, its progression—because we were working on this drug for a very long time. So, it gives you kind of an overview of the Lp(a) and of this drug itself. Now there's another drug that just finished its phase 1 trial and this is similar in the sense of inhibiting the messenger, but it's an RNA interference. This one has similar powerful effects, like the other one we just mentioned, but they're just initiating a phase 2 trial, so they're a little bit behind the competition.

: Well, at least there's competition, that's always good to know.

 It helps, your right. It speeds up the process and lowers hopefully the price.

 In general, in the world of preventive cardiology, is the idea of lowering Lp(a) well received? I know that the ACC/AHA and European counterpart both recommend using Lp(a) as a risk enhancer when looking at cardiovascular risk. Thirty percent of the population sounds like a big number, but does that mean we should be looking at Lp(a) in everyone, or just in these very specific patients?

 Well, I'm biased. I've been in this field for a long time but let me give you an idea. The American guidelines, as you said, recommends you measuring it as a risk enhancer only in patients who have cardiovascular disease, or very severe family history, because it doesn't change levels throughout your lifetime. The European guidelines came out last year and said, "We recommend universal testing for every adult at least once," which I think is the appropriate thing to do. Because it's not an expensive test, and there is ICD coding for it. So, it's a 1-time test and if it's normal, then for the rest of that person's life, they don't have to worry about it. But if it's elevated, then you have that risk enhancer, as you mentioned, on your medical history that should be identified.

: Again, I'm biased and I always say everyone should be and I think as time goes on, everyone will be. I don't know if you remember that TV show called The Biggest Loser. It was about an athletic guy who trained people who were overweight. A few years ago, he had a heart attack at age 50 and his heart attack was directly related to Lp(a). He had a massive MI in the gym. Luckily, there were 2 doctors in the gym that did CPR and he was in a coma for 2 days and woke up and found out his Lp(a) was high.

What's interesting—and I'll tell you this as a personal story—is that for strokes in children, unlike adults where 90% of strokes is related to thrombosis and atherosclerotic plaque, <2% of the strokes, thrombotic strokes in children, you find atherosclerosis at the source. And 40% of people <50 [years] when they have their stroke, thrombotic stroke not hemorrhagic, 40% is idiopathic. We just don't know why. We do know now that high Lp(a) in children increases their risk of a stroke. If they have a stroke with a high Lp(a) in the highest 90 percentile, they have a 10-fold risk of another stroke after their first one. I say that personally because I was sent a child from the children's hospital here in Kansas City, who had a stroke at age 11—thrombotic stroke, hemorrhagic, and obviously neurological deficits. They saw the thrombus and they brought him to KU to do, the invasive radiology team did a thrombectomy at the basilar artery. They removed the thrombus, but he still persisted with the symptoms. So, they consult, they did full bloodwork, hypercoagulable state. Nothing was there. His LDL was 60 milligrams per deciliter, but his Lp(a) was 160 where normal is <30. They consulted me and at that time I said the only thing we have at this point are my machines: the lipid apheresis machine, which is approved for treating Lp(a) now. We treated him and lowered his LDL and Lp(a) by 80%. He has been on this treatment now for 5 years, every 2 weeks, and he hasn't had an event. His neurological symptoms have greatly improved. Now, stroke in young children is very uncommon. The etiology is even more uncommon and that's where Lp(a) could be a major informative measure to do to see what's going on with these patients. And it's just a blood test, nothing complex.

conducted with Dr Moriarty, please go to 

Expert Update on Lp(a): Dr Patrick Moriarty Explains the Next CVD Target

Patrick Moriarty, MD, from the University of Kansas Medical Center, discusses the role of Lp(a) as a risk factor for cardiovascular disease and the phase 3 trials of a potential treatment.

Primary Viewpoints Episode 4: Lp(a): The Next CVD Target?

Hello and welcome to Primary Viewpoints from 

, a monthly podcast that features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

My name is Sydney Jennings and I am the Associate Editor at 

 and in our third episode Grace Halsey, senior editor of 

, talks with Naomi Deirdre Fisher, MD, director of the Hypertension Service and Hypertension Specialty Clinic at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, about the challenges of hypertension management at the level of primary care.

It's been about 3 years since the American Heart Association/American College of Cardiology published its revised guideline on blood pressure management in adults that included the change in the cutoff for stage 1 hypertension going from 140/90 to 130/80. There was a good deal of discussion around that topic and I'm wondering if there still is controversy over the actual target? Or if clinicians are much more focused on simply getting their patients under control?

 I think discussion is putting it mildly. You're right, when the guidelines were published in late 2017, they were met with a firestorm of challenges. They had been a long time in coming. For decades, hypertension was simply >140/90 and that's the way we all learned it and we all practiced it. Many doctors, and primary care physicians in particular, were really reluctant to look at this new goal of 130/80 and to accept it; both for diagnosis of hypertension and for treatment goal. But in the time that has passed, I do sense a general acceptance. I think there's been a widening understanding that there is increased cardiovascular risk along a continuum and that nothing magically happens at that cutoff point of 140/90.

I've read over the years, too, that some of the thought behind lowering the cut point was that, as you said, the disease happens along the continuum, and there are already changes happening at lower levels of elevated blood pressure. There was also, I believe, concern that this might lead to hundreds of thousands of Americans being put on blood pressure medicine. Also, one of the authors of the guidelines said, 

No, we really hope it will be a yellow light, and that people - physicians, patients - will start to take lifestyle changes a little bit more seriously.

 For the vast majority of patients who fall into the newly created category of stage 1 hypertension - that is a systolic pressure between 130-140 - we're going to be recommending lifestyle changes and not medications.

From your vantage point, how are primary care physicians doing overall in 2020 with managing hypertension? I know some things have gotten better over time, but where are the areas that specialists see sticking points or areas for improvement?

: Improvement has come in the area of increased awareness. For a long time, hypertension kind of sat in the background as a chronic disease and we kind of skipped over it and we got to the reason that a patient was in your office that day, which could be fever, chest pain, or something much more exciting. There is definitely a widening understanding and a widening awareness that it has to be brought to the forefront. The areas that need improvement are really to go further. There is a long, long history of what we call "therapeutic inertia" on the part of us; we doctors not taking care of hypertension with enough of a focus. And there's also of course, great resistance on the part of patients. Patients don't take medications for all sorts of reasons. They can be expensive, there can be side effects that are real or perceived. They just don't understand why they need to take medication for high blood pressure, it doesn't cause any symptoms. I think our job would be so much easier if hypertension caused pain. Of course, the therapy really starts with lifestyle modifications and those are so very, very hard. We do know that now there's an ASCVD risk calculator built into the treatment and primary care doctors have been really good and quick to pick that up because they have experienced in the statin prescribing world to do that. But there's a lot of challenges. In fact, most times I would say we have to treat patients with more than one antihypertensive medication to get them under control. So there are just a lot of pieces, a lot of stumbling blocks to get over.

And I think if a patient is diagnosed with hypertension, it is highly likely that is not the only thing metabolically going on.

: When we add our hypertension pills, we're adding it to a long list of pills they are already taking.

 I was interested in the American Heart Association, American Medical Association, 

 program to help practices improve their blood pressure control rates. There is a lot of focus on the very basic core competency of accurate blood pressure measurement, whether that's in the office or having patients do it at home. Is there really a real problem with accurate blood pressure measurement?

 Yes, without accurate, proper blood pressure measurement, we can't possibly provide good care for our patients. For better or worse, the blood pressure reading is the outcome that we're measuring and that we’re guiding all of our therapy by. So, I think the issue of measurement has a lot of facets. We understand pretty well “why”—why we have to measure. Let’s talk about where we have to measure it. And then I'd like to talk about "how" and then I'd like to talk about "when."

In episode 3 of Primary Viewpoints, Brigham and Women's hypertension expert Naomi Deirdre Fisher, MD, discusses the challenges of hypertension management in primary care. 

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