Improving outcomes for people at risk of heart attack and stroke: initiating Inclisiran for people living with high cholesterol

Inclisiran is a new treatment for people with cardiovascular disease whose cholesterol is still too high despite other treatments. It’s given by injection six months and is a “gene silencing” drug that works by silencing the PCSK9 gene which boosts the liver’s ability to remove LDL cholesterol. Reducing cholesterol is very effective at preventing heart attacks and strokes.

Cardiovascular disease is a major cause of death in England accounting for 27% deaths; furthermore CVD is strongly associated with health inequalities. Data also shows that premature CVD mortality is four times higher in the most deprived communities and that people from a black, Asian or minority ethnic background are more likely to be affected by CVD. 

However, it is largely preventable through changes to lifestyle and though treatment of major risk factors like cholesterol. Lowering cholesterol levels especially in those who are highest risk would prevent large numbers of heart attacks and strokes.

This case study illustrates how Central Camden Primary Care Network utilised a centralized hub to deliver Inclisiran in addition to existing oral therapies or as an alternative to statins where these medications are contraindicated.

Challenge/problem identified

In Camden, men have greater inequality in life expectancy than women across the social gradient (11.3 vs. 9.4 fewer years) for living in the most deprived areas than those living in the least deprived areas in 2015-17. Men and women from the most deprived areas die 11 years or 9 years younger respectively than in the least deprived areas.

In some neighborhoods in Camden, the levels of deprivation are within the top 10% to 20% in the UK and over 34% of Camden’s residents are from Black, Asian and other ethnic backgrounds.

The COVID pandemic highlighted the disproportionate impact of Covid on these same groups meaning delivery of the Covid vaccine back in 2021 was an absolute priority for Central Camden PCN.  This community-hub based approach was extended to tackle high cholesterol.

Dr Ammara Hughes, GP, The Bloombsury Surgery, Camden and Clinical Director Central Camden PCN: “High cholesterol is a major risk factor, but it can be corrected. But some of our patients remain at high risk of heart attack and stroke because existing treatments do not lower cholesterol sufficiently. Inclisiran is an important new treatment that we can offer to these patients – it is very effective at lowering cholesterol and very convenient for patients with just one injection every six months”

[Inclisiran] is very effective at lowering cholesterol and very convenient for patients with just one injection every six months”

Dr Ammara Hughes

Overview of innovation

During the COVID pandemic, Central Camden PCN developed a centralised COVID vaccination service. This was the first time the practices had started to collaborate in response to the urgency of rolling out the COVID vaccine. This has since been adapted for the administration of Inclisiran offered in addition to existing available therapies for high cholesterol. 

Actions taken/progress to date

Data sharing agreements were implemented so that centrally, the PCN could access the health records of every practice.  Patients were identified and contacted for the COVID vaccine accordingly.

Central Camden PCN used the UCLP Proactive Care Framework search tool to identify patients eligible for Inclisiran; 200 patients were initially identified through these searches.

Care Coordinators contact eligible patients and schedule appropriately within pharmacist-led clinics; either in a local purpose built “Living Centre” in the heart of Kings Cross or within the extended access clinics in the various practices that make up the PCN.

The PCN also developed an EMIS-based referral mechanism so that when a practice identifies a patient that is eligible, they can refer them into the central hub.

Once the Inclisiran is administered, it is recorded into the patient record, enabling the practice to be able to view this information as well as the individual via the NHS app; enabling a single patient view.

Outcome/impact

To date 30-40 patients have received at least one dose of Inclisiran.  For patients that have received their second dose, there has been a substantial drop in their LDL cholesterol levels, with decreases as high as 88%.

Case example: A 52 year old man with history of acute MI in 2022, previous MI earlier in the year. The patient’s main concern was to not have second episode.

Existing Lipid treatment: Atorvastatin 80mg
Cholesterol on statin alone:
Total Cholesterol 4.5 mmol/l
LDL cholesterol 2.6 mmol/l

3 months after first dose of Inclisiran:
Total Cholesterol 2.59 mmol/l
LDL Cholesterol 0.31 mmol/l

Benefits

The injectable nature of Inclisiran has made it much easier to ensure medication adherence. In the past, the “fire-and-forget” nature of prescribing statins made it more difficult to ensure that patients are taking their medication correctly and on time. Patients also reported a higher sense of engagement in the process which translated into more acceptability in terms of taking statins.

There have been positive impacts on the wider workforce. Clinical colleagues reported feeling more comfortable and confident with new treatment pathways.