Blood Pressure and Cholesterol-lowering Efficacy of a Fixed-dose Combination With Irbesartan and Atorvastatin in Patients With Hypertension and Hypercholesterolemia: A Randomized, Double-blind, Factorial, Multicenter Phase III Study

Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular disease

Fixed-dose combination (FDC) therapy, also known as polypill therapy, targets risk factors for atherosclerotic cardiovascular disease (ASCVD) and has been proposed as a strategy to reduce global ASCVD burden. Here we conducted a systematic search for relevant studies from 2016-2022 to assess the effects of FDC therapy for prevention of ASCVD. The studies selected include randomized trials evaluating FDC therapy with at least one blood pressure-lowering drug and one lipid-lowering drug. The study data were independently extracted, the quality of evidence was appraised by multiple reviewers and effect estimates were pooled using a fixed-effect meta-analysis when statistical heterogeneity was low to moderate. The main outcomes of the analysis were all-cause mortality, fatal and nonfatal ASCVD events, adverse events, systolic blood pressure, low-density lipoprotein cholesterol and adherence. Among 26 trials (n = 27,317 participants, 43.2% female and mean age range 52.9-76.0), FDC therapy was associated with lower low-density lipoprotein cholesterol and systolic blood pressure, with higher rates of adherence and adverse events in both primary and mixed secondary prevention populations. For studies with a mostly primary prevention population, FDC therapy was associated with lower risk of all-cause mortality by 11% (5.6% versus 6.3%; relative risk (risk ratio) of 0.89; 95% confidence interval 0.78 to 1.00; I2 = 0%; four trials and 16,278 participants) and risk of fatal and nonfatal ASCVD events by 29% (6.1% versus 8.4%; relative risk (risk ratio) of 0.71; 95% confidence interval 0.63 to 0.79; I2 = 0%; five trials and 15,503 participants). One adequately powered trial in an exclusively secondary prevention population showed that FDC therapy reduced the risk of major adverse cardiovascular events by 24%. These findings support adoption and implementation of polypills to lower risk for all-cause mortality and ASCVD.

Efficacy and safety of combination therapy with telmisartan, rosuvastatin, and ezetimibe in patients with dyslipidemia and hypertension: A randomized, double-blind, multicenter, therapeutic confirmatory, phase III clinical trial

This study aimed to compare and evaluate the efficacy of the blood pressure (BP) control and cholesterol-lowering effects and safety of combination therapy with telmisartan, rosuvastatin, and ezetimibe versus rosuvastatin and ezetimibe double therapy or telmisartan single therapy in dyslipidemia patients with hypertension. After a wash-out/therapeutic lifestyle change period of ≥4 weeks, a total of 100 eligible patients were randomized and received one of three treatments for 8 weeks: (1) telmisartan 80 mg/rosuvastatin 20 mg/ezetimibe 10 mg (TRE), (2) rosuvastatin 20 mg/ezetimibe 10 mg (RE), or (3) telmisartan 80 mg (T). The primary endpoint was the efficacy evaluation of TRE by comparing changes in mean sitting systolic blood pressure (msSBP) and mean percentage change in low-density lipoprotein-C (LDL-C) from baseline after 8 weeks of treatment. The least square (LS) mean (SE) changes in msSBP at 8 weeks compared with baseline were -23.02 (3.04) versus -7.18 (3.09) mmHg in the TRE and RE groups, respectively (p < .0001), and -25.80 (2.74) versus -14.92 (2.65) mmHg in the TRE and T groups, respectively (p = .0005). The percentage changes in the mean (SD) LDL-C at 8 weeks compared with baseline were -54.97% (3.49%) versus -0.17% (3.23%) in the TRE and T groups, respectively (p < .0001). No serious adverse events occurred, and no statistically significant differences in the incidence of overall AEs and adverse drug reactions occurred among the three groups. TRE therapy significantly decreased msSBP and LDL-C compared to RE or T therapy with comparable safety and tolerability profiles.

The Impact of Polypill on Adherence and Cardiovascular Outcomes: A Comprehensive Systematic Review with Meta-Analysis

BACKGROUND

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide. Polypills, containing various combinations of medications for primary and secondary CVD prevention, have been developed to enhance medication adherence and reduce the healthcare burden of CVD. However, their effectiveness compared to usual care remains uncertain.

OBJECTIVE

This meta-analysis aimed to evaluate the effects of polypills on cardiovascular risk factors, major adverse cardiovascular events (MACE), and medication adherence.

METHODS

We conducted a comprehensive search for large-scale randomized controlled trials and observational studies comparing the effects of polypills versus usual care on CVD risk factors and events. Outcomes included changes in systolic and diastolic blood pressure (SBP, DBP), lipid profiles, occurrence of MACE, and medication adherence.

RESULTS

The use of polypills led to a statistically significant yet clinically modest reduction in SBP (mean difference -1.47 mmHg, 95% CI: -2.50 to -0.44, p<0.01) and DBP (mean difference- 1.10 mmHg, 95% CI: -1.68 to -0.51, p< 0.01) compared to usual care. Polypills also showed a significant reduction in the risk of MACE (RR: 0.86, 95% CI: 0.77 -0.95, p<0.01). There was a non-significant reduction in LDL and HDL levels. Adherence to medication improved by up to 17% in polypill users compared to those on usual care (p < 0.01). A multivariable metaregression analysis suggested that adherence may be the underlying factor responsible for the observed effect of the polypills on blood pressure.

CONCLUSION

Polypills were found to significantly reduce SBP, DBP and MACE. An improvement in medication adherence was also observed among polypill users, which might be responsible for the significant reduction in SBP observed users. Future research might benefit from exploring a more personalized approach to the composition of polypills, which could reveal a more clinically significant impact of increased adherence on CVD outcomes.

Polypill Therapy in Cardiovascular Disease: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

The effectiveness of polypill therapy in the prevention and treatment of cardiovascular disorders is still unclear. This meta-analysis aimed to assess the efficacy of polypill therapy in reducing cardiovascular risk factors.

METHODS

We conducted a systematic search of PubMed, Cochrane CENTRAL, SCOPUS, and Google Scholar for randomized controlled trials (RCTs) that evaluated polypill therapy for cardiovascular diseases, hypertension, or dyslipidemia. We included 18 RCTs with a total of 20,463 participants in our analysis. Pooled effect estimates were reported as Odds ratios (ORs) with a 95% confidence interval (CI) using a random-effects model.

RESULTS

Polypill therapy was associated with a statistically significant reduction in systolic blood pressure (SBP) [OR: -0.33, 95% CI (-0.64, -0.03); P-value= 0.03], diastolic blood pressure (DBP) [OR: -0.70, 95% CI (-1.20, -0.21); P-value= 0.005], and total cholesterol level [OR: -1.25, 95% CI (-1.82, -0.68); P-value < 0.0001]. Polypill therapy also showed improved adherence [OR 2.18, 95% CI (1.47, 3.24); P-value= 0.0001]. However, there was no statistically significant benefit in the reduction of all-cause mortality, major cardiovascular events, and LDL-c levels.

CONCLUSIONS

The use of polypill therapy is associated with a statistically significant reduction in SBP, DBP, and total cholesterol levels, as well as improved adherence. Further research is needed to determine its impact on hard clinical outcomes such as mortality and major cardiovascular events.

Virtual Screening of Novel 24-Dehydroxysterol Reductase (DHCR24) Inhibitors and the Biological Evaluation of Irbesartan in Cholesterol-Lowering Effect

Hyperlipidemia is a risk factor for the development of fatty liver and cardiovascular diseases such as atherosclerosis and coronary heart disease, and hence, cholesterol-lowering drugs are considered important and effective in preventing cardiovascular diseases. Thus, researchers in the field of new drug development are endeavoring to identify new types of cholesterol-lowering drugs. 3β-hydroxysterol-Δ(24)-reductase (DHCR24) catalyzes the conversion of desmosterol to cholesterol, which is the last step in the cholesterol biosynthesis pathway. We speculated that blocking the catalytic activity of DHCR24 could be a novel therapeutic strategy for treating hyperlipidemia. In the present study, by virtually screening the DrugBank database and performing molecular dynamics simulation analysis, we selected four potential DHCR24 inhibitor candidates: irbesartan, risperidone, tolvaptan, and conivaptan. All four candidates showed significant cholesterol-lowering activity in HepG2 cells. The experimental mouse model of hyperlipidemia demonstrated that all four candidates improved high blood lipid levels and fat vacuolation in the livers of mice fed with a high-fat diet. In addition, Western blot analysis results suggested that irbesartan reduced cholesterol levels by downregulating the expression of the low-density lipoprotein receptor. Finally, the immune complex activity assay confirmed the inhibitory effect of irbesartan on the enzymatic activity of DHCR24 with its half-maximal inhibitory concentration (IC50) value of 602 nM. Thus, to the best of our knowledge, this is the first study to report that blocking the enzymatic activity of DHCR24 via competitive inhibition is a potential strategy for developing new cholesterol-lowering drugs against hyperlipidemia or multiple cancers. Furthermore, considering that irbesartan is currently used to treat hypertension combined with type 2 diabetes, we believe that irbesartan should be a suitable choice for patients with both hypertension and hyperlipidemia.

Effectiveness and Safety of a Fixed-Dose Combination of Valsartan and Rosuvastatin (Rovatitan® Tablet) in Patients with Concomitant Hypertension and Hyperlipidemia: An Observational Study

Purpose

This study aimed to assess the effectiveness and safety of a fixed-dose combination of rosuvastatin and valsartan (Rovatitan^®) in Korean patients with concomitant hypertension and hyperlipidemia.

Patients and Methods

A total of 1008 eligible patients with concomitant hypertension and hyperlipidemia were enrolled and treated for 12 weeks. Both upward and downward drug dose titrations were allowed based on the investigator's discretion. This study evaluated the effectiveness of the study drug, defined by the percentage of patients achieving the blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) treatment targets. Additionally, regression analyses were conducted to evaluate the factors associated with the effectiveness and safety of the study drug. Of the 1008 patients enrolled in the study, 911 were analyzed for clinical effectiveness.

Results

At 12 weeks, 84.6% and 75.9% of patients treated with the study drug achieved their BP and LDL-C targets, respectively, and 64.8% of patients achieved both targets simultaneously. Furthermore, the percentage of patients who achieved their BP and LDL-C treatment targets demonstrated a trend across the respective risk groups; the higher the risk group, the lower the success of attaining the respective target. This trend was also observed regardless of the prior antihypertensive and/or lipid-lowering treatments. According to regression analysis, poor metabolic profiles, including a higher body mass index (BMI) and higher BP and LDL-C levels at baseline, were significantly associated with treatment failure for BP. Among the 1005 patients included in the safety analysis, 17 patients (1.7%) experienced serious adverse events; however, none were considered related to the study drug.

Conclusion

The study drug used for the treatment of concomitant hypertension and hyperlipidemia in a real-world setting was effective and was well tolerated. Therefore, the study drug is suggested as a good alternative to increase patient convenience and compliance, particularly in those taking multiple medications.

Comparative efficacy of fixed-dose statin and antihypertensive agent combinations: A network meta-analysis of randomized controlled trials

BACKGROUND

The concurrent administration of statins and antihypertensive agents has been associated with improved cardiovascular outcomes, although the optimal fixed-dose combination remains unclear. This meta-analysis aims to compare the blood pressure and lipid-lowering effects of various statin and antihypertensive drug combinations.

METHODS

PubMed, Scopus, Web of Science, CENTRAL and Clinicaltrials.gov were systematically searched from inception to 20 March 2021. Randomized controlled trials evaluating the effects of statin-antihypertensive agent combinations on systolic blood pressure or serum lipids were held eligible. A random-effects frequentist model was applied to provide estimates of mean difference of percentage change.

RESULTS

Overall, 18 studies were included, comprising 4450 patients. Compared to statin monotherapy no significant difference in the percentage change of low-density lipoprotein cholesterol was achieved by adding any antihypertensive agent. Compared to amlodipine monotherapy, the addition of moderate-intensity statin resulted in a significantly greater percentage reduction of systolic blood pressure (-2.22%, 95% confidence intervals: [-3.82 to -0.62]). Combined high-intensity statin and amlodipine lead to significant increase of high-density lipoprotein cholesterol (8.34%, 95% confidence intervals: [0.73 to 15.95]), while effective triglyceride reduction was achieved by adding amlodipine and telmisartan to high-intensity statin (-14.68%, 95% confidence intervals: [-28.48 to -0.89]). No significant difference of adverse effects was observed.

CONCLUSION

The present network meta-analysis suggests that the administration of fixed-dose combinations of statins and antihypertensive agents is safe and effective in reducing blood pressure and serum lipids. The optimal dosing strategy to prevent cardiovascular events remains to be determined.

Atorvastatin Treatment Modulates the Gut Microbiota of the Hypercholesterolemic Patients

Hypercholesterolemia is one of the most important risk factors for development of cardiovascular diseases. The composition of gut microbiota (total microbes residing in the gut) impacts on cholesterol and lipid metabolism. On the contrary, alterations in gut microbiota in response to hypercholesterolemia or drug treatment with atorvastatin (a cholesterol-lowering agent) are rarely investigated. We performed 16S rDNA amplicon sequencing to evaluate the gut bacterial community of 15 untreated hypercholesterolemic patients (HP) and 27 atorvastatin-treated hypercholesterolemic patients (At-HP) and compared with 19 healthy subjects (HS). In total, 18 different phyla were identified in the study groups. An increase in relative abundance of Proteobacteria was observed in the HP group compared with At-HP and HS groups. The atherosclerosis-associated genus Collinsella was found at relatively higher abundance in the HP group. The anti-inflammation-associated bacteria (Faecalibacterium prausnitzii, Akkermansia muciniphila, and genus Oscillospira) were found in greater abundance, and proinflammatory species Desulfovibrio sp. was observed at decreased abundance in the drug-treated HP group compared with the untreated HP group. Relative abundances of the Bilophila wadsworthia and Bifidobacterium bifidum (bile acid-associated species) were decreased in the At-HP group. The At-HP and HS clustered separately from HP in the principal coordinate analysis. Decreased bacterial diversity was observed in the atorvastatin-treated group. In conclusion, these data suggest that atorvastatin treatment of patients with hypercholesterolemia may selectively restore the relative abundance of several dominant and functionally important taxa that were disrupted in the HP. Further studies are required to investigate the putative modifying effects of hypocholesterolemic drugs on functionality of gut microbiota, and the potential downstream effects on human health.

Efficacy of a fixed dose combination of irbesartan and atorvastatin (Rovelito®) in Korean adults with hypertension and hypercholesterolemia

Purpose

Coexistence of hypertension (HTN) and hypercholesterolemia is a major synergistic and modifiable risk factor for cardiovascular disease (CVD). Thus, a fixed-dose combination (FDC) of anti-HTN drugs and statins may be useful for treating CVD. This study evaluated the efficacy of an FDC of irbesartan and atorvastatin (Rovelito^®) in Korean patients.

Patients and methods

Patients with HTN and hypercholesterolemia were screened for this prospective, observational, descriptive, multi-center, phase IV study. Eligible patients were administered with Rovelito for 3 months. Dose adjustment was allowed based on the physician’s discretion. Blood pressure (BP) goal was <140/90 mmHg, and blood lipid goal was based on Adult Treatment Panel III. Compliance with therapeutic lifestyle modification and safety of the study drugs were evaluated.

Results

Of the 2,777 patients enrolled in this study, 931 were analyzed for clinical efficacy. BP and low-density lipoprotein cholesterol (LDL-C) goals were achieved in 801 (86.04%) and 797 (85.61%) patients, respectively. For the BP goal, higher baseline BP and higher body mass index were risk factors for treatment failure. For LDL-C goal, baseline LDL-C level, number of concomitant drugs, smoking status, and alcohol consumption were risk factors for treatment failure. Of the 931 participants, 694 (74.54%) achieved the treatment goals for both BP and LDL-C. Smoking status, alcohol consumption, number of concomitant drugs, and higher baseline LDL-C and BP levels were risk factors for treatment failure in both BP and LDL-C goals. Adherence with Rovelito was 97.90%±5.79%, and incidence of adverse events was 4.19% (116).

Conclusion

FDC of irbesartan and atorvastatin (Rovelito) could be extremely helpful in treating patients with both HTN and hypercholesterolemia. Poor metabolic profiles were risk factors for poor treatment response and the reason for choosing Rovelito. Therapeutic lifestyle modification should still be underscored despite the 75% treatment success rate with Rovelito for both conditions.

Evaluating the Efficacy of Atorvastatin on Patients with Carotid Plaque by an Innovative Ultrasonography

BACKGROUND

The present study aimed to explore the efficacy of atorvastatin on patients with carotid plaque, applying superb microvascular imaging (SMI), and contrast-enhanced ultrasound (CEUS) for evaluating carotid intraplaque neovascularization.

METHODS

A total of 82 patients (82 carotid plaques) who were randomized into treatment group and control group underwent conventional ultrasound, CEUS, and SMI examinations. Patients in treatment group received a dose of 20 mg atorvastatin per day for 6 months while those in control group received placebo instead. Lipid parameters were assessed and intraplaque neovascularization were evaluated by CEUS and SMI before and 6 months after atorvastatin treatment.

RESULTS

No significant differences were found between the 2 groups at the study entry. Patients with atorvastatin treatment received marked improvement in total cholesterol, triglyceride, and LDL-cholesterol compared with those in control group (P < .001). In treatment group, SMI-detected intraplaque neovascularization reduced from 69.23% to 48.72% while CEUS-detected ones reduced from 76.92% to 69.23%. By contrast, the percentage of intraplaque neovascularization in control group did not change too much either by SMI (65.12%, 67.44%) or CEUS (74.41%, 74.41%). The consistency between CEUS and SMI was above .75 at all assessments (P < .001).

CONCLUSIONS

Atorvastatin treatment works for patients with carotid plaque by reducing LDL-cholesterol and improving plaque regression. Second, the consistency between SMI and CEUS in visualizing intraplaque neovascularization is good. That indicates a high possibility to identify carotid plaque instability by a safer and cheaper ultrasonography without contrast agent.

In vivo evaluation of hypolipidemic and antioxidative effect of 'Ajwa' (Phoenix dactylifera L.) date seed-extract in high-fat diet-induced hyperlipidemic rat model

In the present study, we investigated the hypolipidemic and hepatoprotective potential of the commercially available crushed Ajwa date seed-extract on the toxicity caused by the atorvastatin in high-fat diet (HFD)-induced hyperlipidemic rats. Male albino rats were divided into two main groups, Group I (normal control) and Group II (HFD); Group II was further divided into four subgroups: Group IIa (HFD control), Group IIb (Atorvastatin: A10)-6 rats were administered with 10 mg/kg atorvastatin daily for 30 days, Group IIc (Ajwa seed extract: AJ)-6 rats were given 1000 mg/kg Ajwa seed extract daily for 30 days, Group IId (AJ + A10)-6 rats were given Ajwa seed extract 1000 mg/kg and Atorvastatin 10 mg/kg daily for 30 days. The data obtained suggested that Ajwa seed extract lowered the serum cholesterol level in HFD rats and demonstrated the hepatoprotective effect in combination with atorvastatin by reducing the levels of ALT and AST. In conclusion, it protected the tissues from the detrimental effects of hyperglycemia and enhanced antioxidant activity. Furthermore, the dose-limiting toxicity of atorvastatin may be reduced if the Ajwa seed extract is incorporated in the current treatment regimens to treat hyperlipidemia in hypercholesteremic individuals.

Comparative Effectiveness of Combination Therapy with Statins and Angiotensin-Converting Enzyme Inhibitors versus Angiotensin II Receptor Blockers in Patients with Coronary Heart Disease: A Nationwide Population-Based Cohort Study in Korea

STUDY OBJECTIVE

Patients with coronary heart disease (CHD) frequently use the combination of a statin and renin-angiotensin-aldosterone system (RAAS) blocker, an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), to control lipid levels and blood pressure, respectively, and the use of ARBs is increasing in Korean patients. Few studies are available, however, that have compared combination therapy with statin-ACEIs versus statin-ARBs. The objective of this study was to evaluate whether ARBs are associated with a reduced risk of major adverse cardiovascular and cerebrovascular events (MACCEs) compared with ACEIs when used in combination with statins in patients with established CHD.

DESIGN

Population-based retrospective cohort study.

DATA SOURCE

Korean National Health Insurance Service-National Sample Cohort database.

PATIENTS

A total of 6577 adults who started statin-RAAS blocker combination therapy (1870 in the statin-ACEI cohort and 4707 in the statin-ARB cohort) after being diagnosed with CHD between January 2003 and December 2013 were included. Of these, 3676 propensity score-matched patients (1838 in the statin-ACEI cohort and 1838 in the statin-ARB cohort) were included in the final analyses.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was MACCE (major adverse cardiovascular and cerebrovascular events), a composite of cardiovascular mortality, nonfatal myocardial infarction (MI), ischemic stroke, and revascularization. Incidences and incidence rates of MACCE were calculated to estimate the differences between the two cohorts. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by using a Cox proportional hazard model. The incidence of MACCE was 19.9% and 14.7%, and incidence rates were 11.7 and 8.1 per 100 person-years in the statin-ACEI and statin-ARB cohorts, respectively. The risk of MACCE was significantly lower in the statin-ARB cohort (adjusted HR 0.69, 95% CI 0.59-0.81).

CONCLUSION

A MACCE was less likely to occur in patients who received a statin-ARB than in those who received a statin-ACEI. Similar trends were seen in cardiovascular mortality and the occurrence of recurrent MI but not stroke. The availability of statin-ARB fixed-dose combinations may have contributed to the improved outcomes in the statin-ARB cohort by reducing pill burden and improving medication adherence. Further research is warranted to validate our findings and to address whether a particular statin-ARB combination is more effective than other combinations.