Lipoprotein(a), PCSK9 Inhibition and cardiovascular risk: Insights from the Fourier trial

Lipid Optimization in Lower Extremity Peripheral Arterial Disease

AIMS

This review aims to explore the current guidance and issues surrounding lipid optimisation of patients with peripheral arterial disease (PAD).

METHODS

A narrative review of the global PAD guidance, specifically focusing on low density lipoprotein cholesterol (LDL-C) reduction methods including; 'treating to target', 'fire and forget' and LDL-C percentage reduction. Advanced literature searches were carried out in Pubmed and Google Scholar databases comparing most recent PAD lipid guidance.

RESULTS

PAD lipid guidance could be improved internationally to help clinicians implement the best lipid-reduction strategies for their patients and challenge the arbitrary 1.4 mmol/L LDL-C target in line with novel proprotein convertase subtilisin/kexin type 9 inhibitors trials. By educating primary and secondary care staff on the benefits of maximal lipid-reduction therapies, we can reduce major adverse cardiovascular events and major adverse limb events. Championing PAD community clinics may lead to earlier prevention. Research comparing lipid-reduction strategies in practice is needed to improve outcomes internationally, and ongoing practice audited to understand the extent of under-prescribing in PAD.

CONCLUSIONS

This review highlights the current PAD lipid-reduction treatments and the clarity issues of global guidance. Further research is needed to tackle ongoing mortality and morbidity rates in PAD patients against their better off cardiovascular disease (CVD) peers. MESH KEY TERMS: "Cholesterol", "Hydroxymethylglutaryl-CoA Reductase Inhibitors", "Ezetimibe", "Evolocumab", "Alirocumab", "Peripheral Arterial Disease", "Vascular Disease", "Atherosclerosis", "Secondary Prevention", "Lipoprotein, LDL".

Treatment and prevention of lipoprotein(a)-mediated cardiovascular disease: the emerging potential of RNA interference therapeutics

Lipid- and lipoprotein-modifying therapies have expanded substantially in the last 25 years, resulting in reduction in the incidence of major adverse cardiovascular events. However, no specific lipoprotein(a) [Lp(a)]-targeting therapy has yet been shown to reduce cardiovascular disease risk. Many epidemiological and genetic studies have demonstrated that Lp(a) is an important genetically determined causal risk factor for coronary heart disease, aortic valve disease, stroke, heart failure, and peripheral vascular disease. Accordingly, the need for specific Lp(a)-lowering therapy has become a major public health priority. Approximately 20% of the global population (1.4 billion people) have elevated levels of Lp(a) associated with higher cardiovascular risk, though the threshold for determining ‘high risk’ is debated. Traditional lifestyle approaches to cardiovascular risk reduction are ineffective at lowering Lp(a). To address a lifelong risk factor unmodifiable by non-pharmacological means, Lp(a)-lowering therapy needs to be safe, highly effective, and tolerable for a patient population who will likely require several decades of treatment. N-acetylgalactosamine-conjugated gene silencing therapeutics, such as small interfering RNA (siRNA) and antisense oligonucleotide targeting LPA, are ideally suited for this application, offering a highly tissue- and target transcript-specific approach with the potential for safe and durable Lp(a) lowering with as few as three or four doses per year. In this review, we evaluate the causal role of Lp(a) across the cardiovascular disease spectrum, examine the role of established lipid-modifying therapies in lowering Lp(a), and focus on the anticipated role for siRNA therapeutics in treating and preventing Lp(a)-related disease.