Focus on K2P Faculty: Dr. Neil Stone
Dr. Neil Stone serves as faculty for K2P’s LEGENDS series, where he has provided a talk on the prevention of cardiovascular disease through lipid management.
Dr. Stone is the Robert Bonow Professor of Medicine in Preventive Cardiology at the Feinberg School of Medicine of Northwestern University. He has a practice in cardiovascular diseases and a special clinic for the diagnosis and management of lipid-related disorders at the Northwestern Medical Faculty Foundation. He is currently the Suzanne and Milton Davidson Distinguished Physician at Northwestern Memorial where he serves as the Medical Director of the Vascular Center for the Bluhm Cardiovascular Institute.
Dr. Stone was a member of the first and third National Cholesterol Education Program Adult Treatment Panels. (ATP I, III) and is past Chairman of the AHA Nutrition Committee and Clinical Affairs Committee. He served on the AHA Expert Panel on Population and Prevention Science and has participated in multiple writing groups producing clinical practice guidelines in primary and secondary prevention and cholesterol management. He was the chair of the 2013 ACC/AHA Cholesterol Guidelines and vice-chair of the 2018 AHA/ACC/Multisociety Cholesterol Guidelines. Most recently, he was on the writing group for the 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients with Persistent Hypertriglyceridemia. He has chaired and/or participated annually in educational sessions on lipids and preventive cardiology at national meetings for over 30 years.
We were able to sit down with Dr. Stone and ask a few questions we thought physicians would be interested to hear.
What would you like learners to take from your Legends talk on prevention?
I’m hoping learners realize from the talk, not just how valuable the randomized control trials are for showing that cholesterol-lowering drugs are efficacious, but realize also that they’re the best way to see the risk-benefit relationship. Too often, we hear studies that show drugs are very beneficial or a little beneficial, and there’s a big argument about which studies show which effect. The beauty of the randomized controlled trial is that it looks at specific groups of people and it asks a very important question: is there a benefit, and what are the negative aspects or risks. In other words, there’s a common phrase, “Is the juice worth the squeeze?”
And we get that from randomized controlled trials. Sometimes—because these clinical trials are unbiased and placebo-controlled—we learn, when they are negative, that the benefits of what we thought was valued therapy may not be worth the risks. Recent examples include the failed randomized controlled trials with niacin. On the other hand, we’ve learned that certain medications like statins, ezetimibe, and PCSK9 monoclonal antibodies—have stood the test of randomized controlled trials and can be used safely and effectively when intensive lipid-lowering therapy is needed. The randomized trials are especially valuable in pointing out which subgroups benefit the most. One additional point is that meta-analyses of randomized controlled trials are also valuable. However, a per person meta-analysis, not a per study meta-analysis, should be the kind of meta-analysis that clinicians study to understand these valuable drugs in greater detail.
Where do you think we’re going to be in preventive cardiology and risk factor management in 10 years?
I think the field of prevention is going to move forward briskly for two reasons. One, I think we’re going to be able to use various forms of imaging to allow us to tease out those people at the highest risk earlier in their lives who may benefit from more aggressive or intensive therapy. That’s really helpful because one of the reasons that a lot of medications don’t look as good in primary prevention versus when they’re used in secondary prevention is that probably a lot of people get the medication in those primary prevention trials who will never need it. If we can tease out the ones who benefit the most, that’ll be a big deal.
The second big area of improvement is going be in lifestyle. I think we’re going to learn how to take care of ourselves better. Despite the many negatives of the COVID pandemic, it forced a lot of people to stay home and to think about how to stay fit, even if they can’t get to the club. And those who failed learned that they need the club. For those who persevered and stayed fit despite the club, maybe they’ve learned ways to continue to stay in good shape.
Do you have any best practices for the assessment of a patient at risk for heart disease?
In the 2013 ACC-AHA cholesterol guidelines, the pooled equation was a big advance because it included a separate risk equation for African Americans. It was validated for adults 40-75 years in a natural history study, but shown to overpredict in healthier populations such as those chosen for clinical trials. However, the biggest advance came with the proposed use of the coronary artery calcium (CAC) scoring when risk decisions were uncertain. In the 2018 AHA-ACC-MultiSociety guidelines, there was an emphasis on a CAC score=0 in lower-risk primary prevention that could, when there’s the uncertainty of benefit, allow doctors to defer statin therapy. Exceptions were higher-risk patients with LDL-C ≥ 190 mg/dL, those with diabetes, or active cigarette smokers in whom the long-term risk of atherosclerotic events made deferral of statin therapy undesirable. I think it’s important to be neither pro-statin or anti-statin but to advocate statins for those shown to benefit most.
What was the greatest advice you were given by a mentor that still holds true today?
My father famously said to myself and my brothers, “Some of the best things I ever said, I didn’t say. And some of the best things I ever did, I didn’t do.” From this, I learned to hold back and think first.
The other sage advice I received came from reading about Oliver Wendell Holmes, Sr. He advised his students, “Number one, don’t guess when you can know. Number two, don’t speak with authority when you can have more facts. And number three, don’t treat with a physic someone just because they have an illness.” And of course, by physic, it means don’t treat with medication just because somebody is sick. Look first and see if the medication has been shown to make a difference. We like to treat with medication in situations where it has been shown that the benefits greatly outweigh the risks of the therapy and the randomized controlled trial is the best way to establish the value of treatment in a specific patient group.
What career would you have chosen if you hadn’t chosen to become a physician?
It was never a question. At age six. I realized my family was devastated by coronary artery disease. I never met my grandmother, she had a fatal heart attack at age 48. Her 3 brothers died of heart attacks in their 40s. When I was 6, I found out my uncle was dying from his second heart attack. So, given that it was so rampant in my family, everyone who knew me as I grew up knew that I was going to be a cardiologist.
By the way, having said that, I was always struck by people who say that only total mortality counts with randomized trials. I saw the devastation in families of an early heart attack. It made major differences in how the family functioned. And so, when I see the ability to cut down early heart attack or early stroke, even if they don’t live a day longer, it results in a better life for the patient and their family.
What is an interesting fact about you?
I do magic tricks for my grandchildren and, at times, I do them for my patients. When I was an intern, we had a very sad patient and I recalled one of the magic tricks I had learned from a close family friend. So, it made her laugh and made her feel better about the therapies that she had to undergo. Periodically, I will do an interesting trick that gets them bright and smiling and feeling that their life is better.
What has been the greatest advance in the field over the last five years?
I think the greatest advance in the field of prevention has been the recognition of how valuable imaging is and new modalities of imaging that allow us to understand the whole process of atherosclerosis. I think the ability for imaging to better inform preventive efforts has been striking, and, in my view, we’re really just beginning to understand how to use these tools