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Primary care physicians are the frontline warriors in the battle against cardiovascular disease — a killer that takes the life of someone in the United States every 33 seconds.

“Most patients have more regular contact with their primary care doctor than with any specialist,” said Lt. Col. Zaid Fadul, MD, the founder and CEO of Bespoke Concierge MD in Scottsdale, Arizona. That “means we are often the first to spot early warning signs of heart trouble, even before a patient ever realizes anything is wrong.”

“Our ongoing relationships allow us to track changes in health overtime, manage chronic conditions like high blood pressure, diabetes, and cholesterol and provide personalized education and support,” Fadul said.

Here are some tips for you — the primary care physician — to help your patients stave-off cardiovascular disease or manage their condition more effectively.

#1: Be Aggressive

“The primary caregiver’s job is to make sure that their patients never need a cardiologist because this disease is preventable,” said Louis Malinow, MD, an internist in Baltimore and director of Education and Clinical Excellence for MDVIP, a nationwide network of doctors that has more than 1300 affiliated physicians.

The keys are to identify at-risk patients early and provide them with comprehensive and aggressive care.

“I think it’s important for docs to know that you can’t determine who’s at risk by just doing a yearly cholesterol profile,” Malinow said. “That’s 20th century medicine.”

In the old days, high high-density lipoprotein or “good” cholesterol was believed to protect the heart and blood vessels even if low-density lipoprotein (LDL) or “bad” plaque-forming cholesterol was elevated, he explained. “We know that is simply untrue now,” said Malinow.

Instead, triglycerides and LDL cholesterol particles are key determinants of cardiovascular health, according to Malinow.

The LDL cholesterol in the blood sits in particles called Apolipoprotein B (ApoB). Often, a patient might have a healthy LDL cholesterol number but a high ApoB, which is a concept called discordance, explained Malinow.

The only way to get a clear picture is to order a lipid profile with an ApoB blood test for your patients. The higher the ApoB number, the greater the risk. “Countless studies show that heart attack risk always tracks with the (ApoB) particle number, not the cholesterol,” Malinow said.

Strongly consider cholesterol-lowering drugs for patients with high ApoB, even if LDL cholesterol looks healthy, Malinow advised.

Lifestyle changes like drinking less alcohol, quitting smoking, eating less carbs and sugar, and exercising can help lower triglycerides and other risk factors.

#2: Check for Genetic Risks

“You can’t start a fire without firewood,” Malinow said. “Well, the firewood is the cholesterol particles. The more that firewood gets packed into the wall of coronary arteries, the more likely a fire will break out.”

Genetic factors can add fuel to that fire. Lipoprotein(a), or Lp(a), is another plaque-forming particle that makes blood clot easier and makes clots harder to break down. Lp(a) levels can be picked up by genetic tests.

Malinow said everyone should have the Lp(a) test at least once as 20% of people have this abnormal cholesterol particle. “It is the single biggest determinant of early cardiovascular risk and the biggest single driver of aortic valve stenosis,” he said. Patients with elevated Lp(a) levels should be followed even more closely.

#3: Calm Inflammation and More

Cholesterol and inflammation both play significant roles in cardiovascular disease. All primary care doctors should order a high-sensitivity C-reactive protein test to check for that marker of inflammation, said Malinow. If it’s elevated, the gout drug colchicine can lower cardiac risk.

One of the best ways to lower inflammation is losing weight, Malinow added. If patients are having trouble shedding pounds through diet and exercise, a glucagon-like peptide 1 medication can help them drop weight and “miraculously” decrease inflammation.

Endothelial dysfunction: The endothelium acts like a fence in artery walls that keep cholesterol particles flowing free in the bloodstream. If that fence is broken, those particles can pile up in artery walls. Certain tests run once a year can check for signs of endothelial dysfunction:

• Urine microalbumin
• Homocysteine blood test
• Uric acid test

Insulin resistance: In addition to fasting glucose and A1c, Malinow also runs a fasting insulin test. “Insulin levels go up 10 years before we see the sugar budge,” Malinow said. “So that’s a window into the future. If you see someone with perfect sugar, but it’s taking way too much insulin to keep it normal, they’re in trouble.”

The prescription in cases like that is usually lifestyle changes first before opting for medication, Malinow noted.

#4: Flag Common Mistakes and Misconceptions

It’s important for patients to know that a stent does not prevent heart attacks in people with stable heart disease, according to Fadul. Stents mainly help relieve symptoms but do not prolong life.

Many people believe crushing chest pain signals heart trouble. It’s the doctor’s role to warn that subtle symptoms — including dizziness, unexplained worsening of shortness of breath, and pain in the jaw — are just as dangerous, Fadul explained.

It’s also critical not to overlook the risk for heart disease in both women and younger patients, which can lead to missed or delayed diagnosis, he said.

Malinow also noted that doctors shouldn’t solely rely on the 10-year calculated risk to decide whether to start cholesterol-lowering medications, as that algorithm is largely based on a population of people with that number. To obtain your patient’s personal risk, get an imaging test, like a coronary calcium score. “Any score that’s not zero means that the patient is at increased risk and needs to be managed more aggressively,” Malinow said.

#5: When to Refer to a Cardiologist

“I refer patients to a heart specialist when they have significant heart disease, like heart failure, a previous heart attack, or irregular heart rhythms,” said Fadul. Women with pregnancy-related complications that increase heart risk get referred, as well.

Both Fadul and Malinow would also call in a specialist if there are any symptoms of heart trouble, whether obvious or subtle. Malinow would also refer if there are signs of heart failure, like swollen ankles or a new ECG change.

Final Thoughts

“If there is one thing I have learned, it is that successful cardiovascular care depends on vigilance, communication, and empowering patients,” Fadul said. “I have seen patients’ lives changed by catching subtle symptoms early or by helping them make lasting lifestyle changes.”

Malinow agrees that early cardiovascular prevention is the name of the game. “We know this is a lifetime disease that starts in childhood,” he said. “We just don’t start seeing heart attacks in most people who don’t have severe problems until their 40s, 50s, or 60s, etc.”

Hopefully, with aggressive, early action, patients in the later part of life will never experience cardiovascular disease.