Treatment gaps in the implementation of LDL cholesterol control among high- and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study

Safety and Efficacy of Obicetrapib in Patients at High Cardiovascular Risk

BACKGROUND

Obicetrapib is a highly selective cholesteryl ester transfer protein inhibitor that reduces low-density lipoprotein (LDL) cholesterol levels. The efficacy and safety of obicetrapib have not been fully characterized among patients at high risk for cardiovascular events.

METHODS

We conducted a multinational, randomized, placebo-controlled trial involving patients with heterozygous familial hypercholesterolemia or a history of atherosclerotic cardiovascular disease who were receiving maximum tolerated doses of lipid-lowering therapy. Patients with an LDL cholesterol level of 100 mg per deciliter or higher or a non-high-density lipoprotein (HDL) cholesterol level of 130 mg per deciliter or higher, as well as those with an LDL cholesterol level of 55 to 100 mg per deciliter or a non-HDL cholesterol level of 85 to 130 mg per deciliter and at least one additional cardiovascular risk factor, were eligible for inclusion. The patients were randomly assigned in a 2:1 ratio to receive either 10 mg of obicetrapib once daily or matching placebo for 365 days. The primary end point was the percent change in the LDL cholesterol level from baseline to day 84.

RESULTS

A total of 2530 patients underwent randomization; 1686 patients were assigned to receive obicetrapib and 844 to receive placebo. The mean age of the patients was 65 years, 34% were women, and the mean baseline LDL cholesterol level was 98 mg per deciliter. The least-squares mean percent change from baseline to day 84 in the LDL cholesterol level was -29.9% (95% confidence interval [CI], -32.1 to -27.8) in the obicetrapib group, as compared with 2.7% (95% CI, -0.4 to 5.8) in the placebo group, for a between-group difference of -32.6 percentage points (95% CI, -35.8 to -29.5; P<0.001). The incidence of adverse events appeared to be similar in the two groups.

CONCLUSIONS

Among patients with atherosclerotic cardiovascular disease or heterozygous familial hypercholesterolemia who were receiving maximum tolerated doses of lipid-lowering therapy and were at high risk for cardiovascular events, obicetrapib reduced LDL cholesterol levels by 29.9%. (Funded by NewAmsterdam Pharma; BROADWAY ClinicalTrials.gov number, NCT05142722.).

Patterns and predictors of statin therapy after ischemic stroke and TIA: insights from the LIPYDS multicenter study

BACKGROUND

Patients with ischemic stroke (IS) or TIA face an elevated cardiovascular risk, warranting intensive lipid-lowering therapy. Despite recommendations, adherence to guidelines is suboptimal, leading to frequent undertreatment. This study aims to evaluate the statin use after IS and TIA.

METHODS

LIPYDS is a multicenter, observational, retrospective study including ≥ 18-year-old patients discharged after IS/TIA from 19 Italian centers in 2021. Multivariable logistic regression analysis was used to determine (1) the association between statin prescription (Any-statin versus No-statin), type (High-Intensity-statin versus Other-statin [Moderate/Low-Intensity]) with stroke etiology (TOAST), (2) clinical variables independently associated with statin prescription in the entire cohort and within TOAST categories.

RESULTS

We included 3,740 patients (median age 75 [IQR 64-82]; median LDL-C 104 [IQR 79-131]). At discharge, 1,971 (52.7%) received a High-intensity-statin, 800 (21.4%) Other-statin, 969 (25.9%) No-statin therapy. Among patients not on statin therapy before the event (N = 2686 [71.8%]), 50.1% initiated High-intensity-statin (78.2% of those with Large-Artery-Atherosclerosis, 60.8% Small-Vessel-Disease, 34.7% Cardioembolic, 47.4% Undetermined etiology); in 33% the decision to abstain from initiating statin therapy persisted. Large-Artery-Atherosclerosis showed the strongest association with Any-statin (aOR 3.07 [95%CI 2.39-3.95], p < 0.001) and High-intensity-statin (aOR 4.51 [95%CI 3.39-6.00], p < 0.001), while Cardioembolic stroke showed an inverse association (respectively, aOR 0.36 [95%CI 0.31-0.43], p < 0.001 and aOR 0.52 [95%CI 0.44-0.62], p < 0.001). Stepwise regression highlighted LDL-C and previous statin therapy as consistent predictors of statin at discharge. Older patients and women were less likely to be on a high-intensity formulation.

CONCLUSION

Statins, especially at high-intensity, are under-prescribed after IS and TIA, with older patients, women and those with non-atherosclerotic strokes being the most affected.

Therapeutic inertia in lipid management among Polish adults with type 1 diabetes - results from the cross-sectional PARADISE T1DM study

BACKGROUND AND AIMS

Adults with Type 1 diabetes (T1DM) have increased cardiovascular risk. Most of the Polish general population fails to meet lipid goals. Recent data on the effectiveness of dyslipidemia treatment in T1DM population is lacking. We aimed to investigate which part of adults with T1DM met the dyslipidemia treatment goals according to the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) 2016 and 2019 guidelines.

METHODS AND RESULTS

We recruited adult people with T1DM, for whom a cross-sectional assessment of disease progression was performed. Anthropometric measurements and a basic panel of laboratory tests were conducted for each person. We assessed cardiovascular risk and lipid goals according to the ESC/EAS dyslipidemia guidelines from 2016 to 2019. Among the n = 233 participants, only 34.3 % met the lipid goal according to the 2016 guidelines, while for the 2019 guidelines, merely 13.3 %. Only 12.8 % of individuals with very high cardiovascular risk met the LDL cholesterol goals according to ESC/AES 2016, and 4.9 % when ESC/EAS 2019 guidelines were considered. The median difference between the LDL cholesterol value and the target value was 18.0 (-16.0 to 49.0) mg/dl [20.4 % (-19.8 %-41.2 %)], when considering the 2016 ESC/EAS guidelines, whereas for the 2019 guidelines, it was 36.0 (11.0-60.0) mg/dl [36.3 % (13.9 %-48.0 %)].

CONCLUSION

Therapeutic inertia results in the failure to meet the lipid goals according to the ESC/EAS guidelines for 2016 and 2019 in most Polish adults with T1DM. Many adults with T1DM may require intensification of lipid-lowering interventions.

Oral PCSK9 Inhibitors: Will They Work?

PURPOSE OF REVIEW

Lowering low-density lipoprotein cholesterol (LDL-C) is a crucial step in reducing the risk of atherosclerotic cardiovascular disease. Inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9), an important regulator of circulating LDL-C levels, represent a modern approach for the treatment of hypercholesterolaemia. Approved approaches targeting PCSK9 to date include injectable biologics. Here, we provide an overview of the current state of research on the development of oral PCSK9 inhibitors.

RECENT FINDINGS

Several small molecules have been developed in recent years. Enlicitide decanoate (formerly known as MK-0616) has been shown to significantly reduce LDL-C levels by a maximum of 66% from baseline with a good safety and tolerability profile. Its formulation with sodium caprate enabled a higher bioavailability. Several clinical trials are currently underway to evaluate the efficacy and safety of this drug, including an outcome trial. AZD0780 is another oral small molecule that lowers LDL-C levels by 52% and can be administered on top of a statin. Several other small molecules with the potential to inhibit PCSK9 have been identified, some of which have stopped the development. Oral PCSK9 inhibitors are showing promising results in early studies. If the results of the outcome studies will be positive, we will have a safe, effective and easy-to-use oral therapy. Oral PCSK9 inhibitors could provide a convenient alternative to injectable PCSK9 inhibitors and result in a greater number of patients receiving an effective LDL-C-lowering therapy.

Consumption and expenditure of drugs used for the treatment of hypercholesterolemia: a governance analysis

BACKGROUND

Elevated cholesterol levels are a significant contributor to cardiovascular disease risk. While statins have long been the cornerstone for lowering LDL cholesterol, their associated side effects have prompted the exploration of alternative treatments, including ezetimibe, bempedoic acid, PCSK9 inhibitors and inclisiran.f.

RESEARCH DESIGN AND METHODS

This research seeks to analyze the usage patterns and financial implications during 2023 and 2024. The goal is to assess the economic impact of emerging therapies in hypercholesterolemia.

RESULTS

Findings indicate a decline in the exclusive use of traditional statins and a rise in the adoption of newer and combination therapies. Statin monotherapy usage decreased markedly from 42% in 2023 to 30% in 2024. Combination treatments, such as statins paired with ezetimibe, remained steady at 17% across both time frames. The utilization of novel treatments, notably PCSK9 inhibitors, increased from 33% to 40% between the two periods, whereas bempedoic acid, whether used alone or with ezetimibe, stayed below 2%.

CONCLUSION

The landscape of hypercholesterolemia treatment has expanded with several new therapeutic options. Bempedoic acid may mitigate adverse effects and enhance treatment efficacy, potentially delaying the need for costlier injectable medications like evolocumab, alirocumab, and inclisiran.

Planning of lipid-lowering treatment in atherosclerotic vascular disease. Consensus SEC/SEA/SEEN/SEMFYC/SEMERGEN/SEMG/SEN/SEACV/S.E.N

In recent years we have been experiencing an advance in lipid-lowering therapies, with the appearance of new drugs that act on the different metabolic pathways, reducing both the levels of cholesterol associated with low-density lipoproteins (LDL-C) containing apoproteinB (ApoB), and vascular risk. However, the results in achieving goals are still scarce, as well as the use of the different therapies that help us to achieve them. Among the reasons that justify this situation are: the inadequate identification of vascular risk, the underuse of therapies, poor adherence to the recommended treatment, the lack of organization in terms of the assignment of roles and algorithms of action in the follow-up of patients and the need for improved education and psychosocial interventions that influence both adherence and consolidation of Healthy lifestyle habits. This consensus document aims to improve the approach and follow-up of dyslipidemia in a comprehensive way, defining the planning of lipid-lowering therapies as a control strategy (SEC/SEA/SEEN/SEMFYC/SEMERGEN/SEMG/SEN/SEACV/S.E.N.).

Modern therapy of patients with lupus erythematosus must include appropriate management of their heightened rates of atherosclerotic cardiovascular events: a literature update

Atherosclerotic cardiovascular disease (ASCVD) remains the biggest killer of patients with lupus erythematosus (LE) and the general non-autoimmune population. In this literature update on LE and ASCVD, we focused on published work since our earlier review article, meaning from 2021 to the present, with an emphasis on cutaneous LE. Several themes emerged. First, new work shows that patients with lupus still exhibit a high burden of conventional risk factors for ASCVD events. Second, recent studies continue to implicate possible effects of lupus disease activity to worsen rates of ASCVD events beyond predictions from conventional risk factors. Third, new work on estimating the risk of future ASCVD events in patients with lupus supports arterial-wall imaging, inclusion of lupus-specific factors, estimators of ASCVD event risk that take lupus status into account and considering lupus as a diabetes equivalent or even as a diabetes-plus-smoking equivalent in this context. Technologies for arterial-wall imaging continue to improve and will likely play an increasing role in ASCVD assessment and management. Fourth, purported cardiovascular benefits from certain disease-modifying antirheumatic drugs such as antimalarials have become less clear. Fifth, earlier treatment of atherosclerosis, which is a lifelong disease, can be accomplished with diet, exercise, smoking cessation and new classes of safe and effective medications for lipid-lowering and blood pressure control. Benefits on subclinical arterial disease by imaging and on ASCVD events have been reported, supporting the concept that ASCVD is eminently manageable in this autoimmune condition. Sixth, despite the heightened risk for ASCVD events in patients with lupus, available therapeutic approaches remain unused or underused and, accordingly, event rates remain high.Raising awareness among patients and healthcare providers about ASCVD assessment and management in patients with LE is essential. Greater vigilance is needed to prevent ASCVD events in patients with lupus by addressing dyslipidaemias, hypertension, smoking, obesity and physical inactivity.

Distribution of lipoprotein (a) levels in patients with lower extremity artery disease and their impact on amputation and survival: a retrospective study

BACKGROUND

Elevated lipoprotein (a) (Lp(a)) is an independent risk factor for lower extremity artery disease (LEAD) with equivocal effect on amputation and mortality. Results regarding aggressive lipid-lowering therapies (LLT) are missing. We examined LEAD patients with Lp(a) measurement and the impact of intensive LLT on amputation and survival.

METHODS

Baseline characteristics of 263 LEAD patients with Lp(a) measurement treated in a tertiary hospital from 01/2017 until 01/2022 were recorded. Patients were categorized into three groups according to their Lp(a) values (< 30 mg/dL, 30-90 mg/dL and > 90 mg/dL). Lipid values and LLT were recorded at baseline and during follow-up (median 750 days). Peripheral endovascular revascularizations (EVR), amputations and death during follow-up were analysed.

RESULTS

Of 263 patients, 75% were male, mean age was 67 ± 10 years. Elevated Lp(a) values ≥ 30 mg/dL were found in 32%, 16% had values > 90 mg/dL. Baseline low-density lipoprotein cholesterol (LDL-C) was 89 ± 38 mg/dL, decreasing to 61 ± 30 mg/dL at follow-up, with no difference between Lp(a) groups (63 ± 32 mg/dL vs. 52 ± 23 mg/dL vs. 60 ± 25 mg/dL, p = 0.273). Statin dose was intensified more frequently in those with elevated Lp(a) (16% vs. 35% vs. 33%, p = 0.005), who also received significantly more often ezetimibe (50% vs. 58% vs. 73%, p = 0.028) and proprotein convertase subtilisin/kexin type 9 inhibitors (2% vs. 3% vs. 8%, p = 0.043). No difference was seen regarding EVR (91% vs. 95% vs. 90%, p = 0.729), amputations (4% vs. 7% vs. 0%, p = 0.245) and death (8% vs. 5% vs. 3%, p = 0.436).

CONCLUSIONS

Aggressive LLT in high-risk LEAD patients with elevated Lp(a) levels enabled LDL-C target achievement in a majority by combination of established lipid-lowering agents. An increase in EVR, amputation or death could not be observed in patients with high Lp(a) levels.

Assessing LDL-C Levels and Lipid-Modifying Therapies in a Real-World Cohort of Patients with Atherosclerotic Cardiovascular Disease: The REALITY Study

Background and Objectives: Patients with atherosclerotic cardiovascular disease (ASCVD) remain at high risk of recurrent events. REALITY aims to analyse the actual levels of low-density lipoprotein cholesterol (LDL-C), the modalities of lipid-lowering therapies (LLT) used, and ASCVD patient outcomes in a real-world setting in Spain. Methods: REALITY is a retrospective observational study conducted using a healthcare database of 1.8 million patients representative of the Spanish population. The study included 26,976 patients with new or recurrent ASCVD events recruited from 2017 to 2019 and followed up for two years. Results: Management of ASCVD involved the utilisation of high-intensity (53%) or very high-intensity (36%) LLT. After two years, a decrease in total cholesterol (from 228.7 to 176.7 mg/dL), LDL-C (from 126.4 to 99.0 mg/dL), and triglycerides (from 216.7 to 163.7 mg/dL), accompanied by a moderate increase in HDL-C levels was observed. However, LDL-C goals of ESC/EAS guidelines were only reached by a minority of patients. Less than 15% of ASCVD patients achieved their LDL-C goals of <70, as stated in contemporary guidelines (3% if the present <55 mg/dL threshold in the ESC/EAS guidelines is considered). During the follow-up period, 9% of ASCVD patients died and 25% experienced a new ASCVD event. Conclusions: In the REALITY study, most patients did not achieve their target LDL-C goals despite receiving high- or very high-intensity LLT. Increasing the utilisation of extreme LLT is crucial to reducing recurrent ASCVD events and mitigating these patients' high morbidity and mortality risk.

Cardiovascular Risk Assessment and Lipid-Lowering Therapy Recommendations in Primary Prevention

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, underscoring the importance of effective primary prevention strategies. Current total cardiovascular disease (CVD) risk assessment tools, such as the Systematic Coronary Risk Evaluation 2 (SCORE2) in Europe and the Pooled cohort equations (PCEs) and Predicting Risk of CVD EVENTs (PREVENT) in the USA, aim to identify individuals at high CVD risk and guide clinical decision-making in the primary prevention setting. Statin therapy reduces cardiovascular events and is recommended as the first step for individuals with estimated CVD risk above specific thresholds. Moreover, the presence of risk modifiers, as well as the detection of asymptomatic atherosclerosis, reclassifies low-moderate CVD risk individuals into higher risk categories, contributing to tailored therapeutic decisions in primary prevention. However, differences in the performance of the available CVD risk assessment tools, the recommended thresholds for intervention, and the treatment targets by scientific societies introduce considerable inconsistency to the statin therapy practices. In addition, physicians' inertia and poor patients' adherence contribute to inadequate dyslipidemia control rates. This narrative review examines the available evidence on the current most used CVD risk assessment tools and the respective lipid-lowering recommendations, and highlights the role of targeted screening for asymptomatic atherosclerosis in terms of individualized therapy for primary prevention.

[Practical approach to the patient with hypercholesterolemia in Spain. SEMERGEN position statement]

Hypercholesterolemia, specifically the increase in the set of lipoproteins containing apolipoproteinB and, in particular, low-density lipoprotein cholesterol (LDL-C), together with the decrease in high-density lipoprotein cholesterol (HDL-C) constitute the etiopathogenic basis of atherosclerotic vascular disease. Multiple clinical trials have shown that lowering LDL-C by lipid-lowering therapy is associated with a significant decrease in the risk of vascular complications. Thus, LDL-C is the main therapeutic target in patients with dyslipidemia. Unfortunately, current LDL-C control figures are still very low, partly due to insufficient intensification of lipid-lowering therapy, but also due to the need for new tools to achieve these goals. This paper reviews the different lipid-lowering treatment options, including the latest available therapies, and provides a practical approach to achieving LDL-C control goals in patients with hypercholesterolemia, as well as in different patient subgroups.

Impact of a personalized, strike early and strong lipid-lowering approach on low-density lipoprotein-cholesterol levels and cardiovascular outcome in patients with acute myocardial infarction

AIMS

Considering the lack of evidence, we evaluated the impact on cardiovascular outcome of the systematic introduction in our institution of a personalized strike early and strong (SES) approach for lipid-lowering therapy (LLT) in patients admitted for acute myocardial infarction (MI).

METHODS AND RESULTS

We retrospectively analysed data from 500 consecutive patients hospitalized across three periods: Period A (N = 198, January-June 2019), when the low-density lipoprotein cholesterol (LDL-C) goal was <70 mg/dL and a stepwise LLT approach was recommended; Period B (N = 180, January-June 2021), when the LDL-C goal was <55 mg/dL and a stepwise approach was recommended; Period C (N = 122, January-June 2023), when the LDL-C goal was <55 mg/dL and our SES protocol was implemented. Primary endpoints were achievement of the LDL-C goal during follow-up and 1-year incidence of major adverse cardiovascular events (MACE). Compared to the other periods, in Period C, there was a higher use of potent statins, alone or in combination with ezetimibe, and of proprotein convertase subtilisin/kexin type 9 inhibitor inhibitors at discharge. This translated into higher achievement of the LDL-C goal (83% vs. 55% in Period A and 43% in Period B; P < 0.001) and reduced incidence of MACE (3% vs. 12% and 11%; P = 0.026). MACE rates were lowest in patients with early and sustained LDL-C <55 mg/dL and in those achieving both LDL-C <55 mg/dL and ≥50% LDL-C reduction.

CONCLUSION

The systematic introduction of a personalized, SES strategy for LLT in patients with acute MI led to greater achievement of LDL-C goal and lower risk of MACE at 1 year vs. the stepwise approach.

Plasma proteomics improves prediction of coronary plaque progression

AIMS

Coronary computed tomography angiography (CCTA) offers detailed imaging of plaque burden and composition, with plaque progression being a key determinant of future cardiovascular events. As repeated CCTA scans are burdensome and costly, there is a need for non-invasive identification of plaque progression. This study evaluated whether combining proteomics with traditional risk factors can detect patients at risk for accelerated plaque progression.

METHODS AND RESULTS

This long-term follow-up study included 97 participants who underwent two CCTA scans and plasma proteomics analysis using the Olink platform. Accelerated plaque progression was defined as rates above the median for percent atheroma volume (PAV), percent non-calcified plaque volume (NCPV), and percent calcified plaque volume (CPV). High-risk plaque (HRP) was identified by positive remodelling or low-density plaque at baseline and/or follow-up. Significant proteins associated with PAV, NCPV, CPV, and HRP development were incorporated into predictive models. The mean baseline age was 58.0 ± 7.4 years, with 63 (65%) male, and a median follow-up of 8.5 ± 0.6 years. The area under the curve (AUC) for accelerated PAV progression increased from 0.830 with traditional risk factors and baseline plaque volume to 0.909 with the protein panel (P = 0.023). For NCPV progression, AUC improved from 0.685 to 0.825 (P = 0.008), while no improvement was observed for CPV progression. For HRP development, AUC increased from 0.791 to 0.860 with the protein panel (P = 0.036).

CONCLUSION

Integrating proteomics with traditional risk factors enhances the prediction of accelerated plaque progression and high-risk plaque development, potentially improving risk stratification and treatment decisions without the need for repeated CCTAs.

Low-density lipoprotein cholesterol goal attainment and mortality in ischaemic heart disease: a two-year observational study

INTRODUCTION

Achieving low-density lipoprotein cholesterol (LDL-C) levels is key to preventing atherosclerotic cardiovascular events. However, many high-risk cardiovascular patients still experience poor LDL-C goal attainment and receive suboptimal lipid-lowering therapy (LLT) prescriptions. Herein, we evaluated LLT prescription patterns, LDL-C goal attainment and cardiovascular mortality among this population group in Singapore.

METHODS

This prospective observational cohort study included 555 patients with ischaemic heart disease (IHD) admitted to the hospital in 2020. The LLT prescriptions, corresponding LDL-C levels and cardiovascular outcomes were assessed over a 24-month period.

RESULTS

Most participants were male (82.3%), with 48.5% identified as Chinese. High-intensity statin prescriptions increased from 45.4% at hospital admission to 87.1% at discharge and remained stable at approximately 80% at 6, 12, and 24 months post-discharge. Combination LLT prescriptions increased from 12.3% at discharge to 33.8% by 24 months. Ezetimibe was the most commonly prescribed second-line LLT (40.8%), followed by inclisiran (1.09%) and anti-proprotein convertase subtilisin/kexin type 9 monoclonal antibody therapies (0.87%). Over 24 months, LDL-C goal attainment rates were 22.1% for LDL-C < 1.4 mmol/L and 47.2% for LDL-C < 1.8 mmol/L. Multivariable Cox proportional hazards regression indicated that achieving LDL-C < 1.8 mmol/L goal was associated with a reduction in all-cause mortality at 24 months (hazard ratio 0.53, 95% confidence interval 0.30-0.94, P = 0.030).

CONCLUSION

Treatment gaps in lipid management persist in 80% of the study population, indicating that statin monotherapy alone is insufficient to achieve LDL-C goals. Greater efforts to improve LDL-C goal attainment rates in high-risk cardiovascular patients are imperative.

"Inclisiran: Early LDL-C target achievement in a real-life population"

Background and objectives

Elevated low-density lipoprotein cholesterol (LDL-C) levels are associated with atherosclerotic cardiovascular diseases. Inclisiran, a small interfering RNA, has been observed to effectively and sustainably reduce LDL-C in large randomized controlled trials (RCTs); however, real-world data on its short-term efficacy and use are limited. This study aims to assess the efficacy and safety of inclisiran in a real-life population within one month from the first administration.

Methods

This observational, single-center, retrospective cohort study included patients affected by dyslipidemia who could not achieve their LDL-C target despite a maximum tolerated oral lipid-lowering therapy (LLT). 284 mg Inclisiran was subcutaneously administered. Blood samples were collected before the inclisiran administration and at week and one month afterward with the aim toevaluate achievement of LDL-C targets at these time intervals (primary endpoint) and reduction in LDL-C levels (secondary endpoint).

Results

From September 2022 to December 2023, inclisiran was administered to 33 patients at Mater Salutis Hospital. After exclusion of two patients due to statin therapy modification or discontinuation during follow-up, a final number of 31 patients were included. At a median follow-up of 32 (IQ1-3 30-37) days, 21 (67.7 %) patients reached their LDL-C target (primary endpoint). At 7 days, LDL-C mean value decreased from 123.6 ± 42.1 mg/dl to 97.9 ± 53.6 mg/dl, (p < 0.001), with a 29.9 ± 20.6 % reduction. At 32 days, LDL-C mean value declined to 58.5 ± 42.8 mg/dl (p < 0.001), with a 56.9 ± 20.9 % reduction.

Conclusion

In a real-life single center population, inclisiran safely led to LDL-C target achievement within one month. Significantly reduction of LDL-C levels were already present in the early days after the first administration.

New Approaches to Lipoproteins for the Prevention of Cardiovascular Events

Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of mortality, and recent research has underscored the critical role of lipoproteins in modulating cardiovascular (CV) risk. Elevated low-density lipoprotein cholesterol (LDL-C) levels have been linked to increased CV events, and while numerous trials have confirmed the efficacy of lipid-lowering therapies (LLT), significant gaps remain between recommended LDL-C targets and real-world clinical practice. This review addresses care gaps in LLT, emphasizing the necessity for innovative approaches that extend beyond LDL-C management. It explores combination therapy approaches such as statins combined with ezetimibe or PCSK9 inhibitors, which have shown promise in enhancing LDL-C reduction and improving outcomes in high-risk patients. Additionally, this review discusses new approaches in lipid modification strategies, including bempedoic acid, inclisiran, and drugs that lower Lp(a), highlighting their potential for CV risk reduction. Furthermore, it emphasizes the potential of polygenic risk scores to guide LLT and lifestyle changes despite challenges in implementation and genetic testing ethics. This article discusses the current guidelines and proposes innovative approaches for optimizing lipoprotein management, ultimately contributing to improved patient outcomes in ASCVD prevention.

Lipid-lowering therapy and LDL target attainment in type 2 diabetes: trends from the Italian Associations of Medical Diabetologists database

BACKGROUND

Hypercholesterolemia is a major cardiovascular risk factor, particularly in individuals with type 2 diabetes (T2DM), where cardiovascular events are more prevalent. Adherence to low-density lipoprotein cholesterol (LDL-c) targets remains suboptimal globally and in Italy. This study evaluates trends in LDL-c target achievement and lipid-lowering treatment with a stratification by cardiovascular risk among Italian patients with type 2 diabetes from 2019 to 2022.

METHODS

A cross-sectional analysis was conducted using the AMD Annals database, encompassing over 700,000 patients with T2DM. Patients were categorized by cardiovascular risk levels, LDL-c ranges and therapy types (statins, ezetimibe, PCSK9 inhibitors). Linear trends across the four years were evaluated.

RESULTS

The percentage of patients achieving LDL-c targets improved across all risk levels. In very high-risk patients, LDL-c < 55 mg/dL was achieved by 16.3% in 2019, increasing to 23.6% in 2022. High-risk patients achieving LDL-c < 70 mg/dL rose from 20.3 to 26.6% over the same period. Use of PCSK9 inhibitors, particularly in combination with statins, was associated with the highest target achievement rates, reaching 62% in very high-risk patients by 2022. We observed a reduction of moderate-intensity statins use in favor of combination therapies across the four years. Despite this, nearly one-third of patients still had LDL-c levels ≥ 100 mg/dL in 2022.

CONCLUSIONS

While LDL-c management in Italian patients with T2DM has improved, significant gaps remain, particularly for very high-risk individuals. Expanding the use of advanced therapies like PCSK9 inhibitors and adhering more closely to guideline-based recommendations are critical to improve cardiovascular risk in this population.

Achieving More Optimal Lipid Control with Non-Statin Lipid Lowering Therapy

PURPOSE OF REVIEW

The use of statins has transformed approaches to the prevention of cardiovascular disease. However, many patients remain at a major risk of experiencing cardiovascular events, due to a range of factors including suboptimal control of low-density lipoprotein cholesterol (LDL-C). Accordingly, there is an ongoing need to develop additional strategies, beyond the use of statins, to achieve more effective reductions in cardiovascular risk.

RECENT FINDINGS

Genomic studies have implicated the causal role of LDL in atherosclerosis and identified that polymorphisms influencing factors involved in lipid metabolism influence both the level of LDL-C and cardiovascular risk. These findings have highlighted the potential for cardiovascular benefit from development of therapies targeting these factors and incremental benefit when used in combination with statins. Clinical trials have demonstrated that these new agents have favourable effects on both atherosclerotic plaque and cardiovascular events. Additional work has sought to improve intensification of statin therapy and adherence with lipid lowering therapy, to achieve more effective cardiovascular prevention via lipid lowering. Emerging therapies, beyond statins, have the potential to optimise lipid levels and play an effective role in the prevention of cardiovascular disease.

Clinically Accessible Liver Fibrosis Association with CT Scan Coronary Artery Disease Beyond Other Validated Risk Predictors: The ICAP Experience

Background/objectives: Cardiovascular risk (CVR) stratification in clinical settings remains limited. This study aims to evaluate clinical parameters that could improve the identification of higher-than-expected coronary artery disease (CAD) in CT scan coronarography. Methods: In a cross-sectional study of asymptomatic patients from the Integrated Cardiovascular Assessment Program (ICAP), volunteers aged 40-80 without diagnosed cardiovascular disease were assessed. CVR factors like obesity, lipid and glucose profiles, liver fibrosis risk (FIB-4 ≥ 1.3), C-reactive protein, and family history of CVD were evaluated. Patients were stratified by CVR following ESC guidelines. "CVR excess" was defined as CAD-RADS ≥ 2 in low-to-moderate-risk (LMR), CAD-RADS ≥ 3 in high-risk (HR), and CAD-RADS ≥ 4 in very-high-risk (VHR) groups. Results: Among 219 patients (mean age 57.9 ± 1.15 years, 14% female), 43.4% were classified as LMR, 49.3% as HR, and 7.3% as VHR. "CVR excess" was observed in 18% of LMR, 15% of HR, and 19% of VHR patients. LMR patients with prior statin use and HR patients with obesity were more likely to have "CVR excess" (p < 0.01 and p < 0.05, respectively). FIB-4 modified the effect of statin use and obesity on "CVR excess" prediction (p for interactions < 0.05). Models including age, sex, and both interactions showed a strong discrimination for "CVR excess" in LMR and HR groups (AUROC 0.84 (95% CI 0.73-0.95) and 0.82 (95% CI 0.70-0.93), respectively). Conclusions: Suspected liver fibrosis combined with statin use in LMR patients and obesity in HR patients is associated with CVR excess, providing potential indications for image CAD assessment in asymptomatic patients.

Considerations on the sustainability of hypercholesterolemia treatment in the context of new drugs on the market: data from Campania, Italy

Hypercholesterolemia is a major risk factor in the development of cardiovascular diseases. Statins have been the primary treatment for reducing LDL cholesterol for years; however, adverse events related to their use have led to the development of alternative therapies, such as ezetimibe, bempedoic acid, and PCSK9 inhibitors, including alirocumab, evolocumab, and inclisiran. The study is aimed at comparing the consumption and costs of lipid-lowering drugs in the first half of 2023 (21,446,011.54 DDD and 10,974,495.47 €) and 2024 (19,493,540.71 DDD and 12,260,634.95 €) to assess the economic impact of new therapies in the management of dyslipidemia and adherence to guidelines. Dispensing data, without access to patient data, were collected from private community pharmacies and hospital and district pharmacies. Drug consumption was measured using the ATC classification system and the defined daily dose (DDD). The study revealed a trend toward a reduction in the use of traditional statin monotherapy and an increase in more recent and combined therapies. Statins showed a significant reduction from 42% in the first half of 2023 to 30% in the first half of 2024. Combined therapies, such as statins with ezetimibe, showed no change in trend, maintaining a 17% share in both periods. New therapies, such as PCSK9 inhibitors, demonstrated an increase from 33% in the first half of 2023 to 40% in the first half of 2024, while bempedoic acid, either as monotherapy or in combination with ezetimibe, remained below 2%. In recent years, the treatment of dyslipidemia has seen the introduction of many therapeutic alternatives. Bempedoic acid, recently introduced and less expensive, when used as an adjunct therapy with statins and ezetimibe, could reduce side effects and improve therapeutic efficacy without immediately resorting to higher-cost injectable drugs such as evolocumab, alirocumab, and inclisiran. Monitoring prescription trends and costs is essential to maintain the sustainability of the healthcare system, enabling investments in innovation and effective therapies without waste.

Efficacy and safety of PCSK9 inhibitors in real life

OBJECTIVE

To confirm the effectiveness and safety of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in daily clinical practice.

METHODS

Retrospective observational study of patients from hospital registry of PCSK9 inhibitor treatment with a follow-up ≥ 6 months. The lipid-lowering effect and safety were evaluated.

RESULTS

Of the 193 patients included in the study, 168 (87%) had cardiovascular disease, and 54 (28%) had familial hypercholesterolemia; 85 (44%) were intolerant to statins/ezetimibe. No differences between alirocumab and evolocumab groups regarding the rate of LDL-C reduction ≥ 50% (82.8% vs. 83.1%), achievement of the therapeutic target (60.9% vs. 65.5%), or complete remission (60.2% vs. 58.5%) were found. An erythema at the injection site in one patient treated with alirocumab and urticaria in one patient treated with evolocumab were recorded. According to the logistic regression analysis, complete remission of LDL-C in subjects treated with PCSK9 inhibitors was positively associated with increased age (OR: 1.045; 95%CI: 1.0-1.092; P=.049) and active smoking (OR: 4.562; 95%CI: 1.434-14.515; P=.010), and negatively associated with female gender (OR: 0.403; 95%CI: 0.171-0.949; P=.038), baseline LDL-C levels (OR: 0.969; 95%CI: 0.957-0.981; P<.001)and statin/ezetimibe intolerance (OR: 0.403; 95%CI: 0.176-0.925; P=.041).

CONCLUSION

This real-world practice study has confirmed that PCSK9 inhibitors are effective, safe and well tolerated, with lipid-lowering effects comparable to those described in randomized controlled trials, regardless of the monoclonal antibody used.

Inclisiran, Reasons for a Novel Agent in a Crowded Therapeutic Field

PURPOSE OF THE REVIEW

A significant number of patients fail to achieve target LDL cholesterol (LDL-C) levels. This review aims to explore why inclisiran, a novel class of LLT, should be considered a valuable addition to the current treatment options.

RECENT FINDINGS

Inclisiran is a small interfering RNA (siRNA) that targets PCSK9 synthesis specifically in the hepatocytes. The drug remains in circulation for less than 48 h, but its effect lasts for over six months. Two subcutaneous injections per year consistently lowers LDL-C by approximately 55% with a favorable safety profile. In combination with other LLTs, it can achieve LDL-C reductions of over 80%, supporting its role in high-intensity LLT strategies. Inclisiran represents a novel class of LLT. Administered biannually, reduces baseline LDL-C levels by half. Additionally, it has a strong safety profile. Due to its pharmacokinetic properties, is likely to improve adherence to LLT and persistently maintain low LDL-C levels.

Learnings from Implementation Strategies to Improve Lipid Management

PURPOSE OF REVIEW

Lowering low-density lipoprotein (LDL)-cholesterol reduces cardiovascular risk. International lipid management guidelines recommend LDL-cholesterol goals or thresholds for initiating lipid-lowering therapy. However, contemporary real-world studies have shown that many high- and very high-risk patients are not attaining LDL-cholesterol goals and are not receiving intensive lipid-lowering therapies. In this review, recent examples of implementation strategies for optimising lipid management are discussed.

RECENT FINDINGS

Implementation studies are heterogenous in their strategies and design. At the clinician level, multidisciplinary team-based care (including multidisciplinary lipid clinics), pharmacist- or nurse-led interventions, decision-support algorithms or protocols, and educational initiatives have shown potential to improve lipid management. Various strategies to improve patient adherence to lipid-lowering therapies have demonstrated at least short-term efficacy, including education, shared decision-making, behavioural support and nudges. Electronic health records can be leveraged at low cost to identify patients requiring initiation or intensification of lipid-lowering therapies, but the optimal method of integrating automated alerts or nudges to influence decision-making requires further research. Moreover, telehealth and remote care delivery models can improve access to healthcare and facilitate lipid-lowering. Multifaceted strategies with a systematic approach to targeting clinician, patient and system related factors can be successful in improving lipid management. Future implementation research should evaluate longer-term outcomes and follow implementation science theories, models and/or frameworks at all stages. By doing so, ongoing implementation studies will help researchers better understand the impact, sustainability and scalability of strategies, and where barriers and facilitators to lipid management may exist in other contexts.

Rosuvastatin-based combination treatment with acetylsalicylic acid or ezetimibe in the management of patients at high and very high cardiovascular risk. Expert opinion paper of the Polish Lipid Association 2025

Lipid disorders are the most common risk factor for atherosclerotic cardiovascular disease (ASCVD) in Poland, where it is responsible for up to 200,000 deaths per year, with the number of myocardial infarctions and strokes reaching 80,000 annually and 25% of people dying within 3 years after a myocardial infarction. Despite the availability of effective drugs, the level of control of low-density lipoprotein cholesterol (LDL-C) is low, at only about 20% among high- and very high-risk patients, who often require combination lipid-lowering therapy (LLT) with a potent statin (e.g. rosuvastatin) and ezetimibe. Moreover, in Poland, several million patients require concomitant lipid-lowering and antiplatelet (acetylsalicylic acid) therapy based on their risks and indications. Single pill combinations (SPCs) improve adherence to treatment as well as the achievement of therapeutic goals and allow a greater reduction in cardiovascular incidents and mortality. This expert opinion paper, endorsed by the Polish Lipid Association (PoLA), provides practical recommendations for more effective treatment of patients with indications for LLT and antiplatelet therapy using available rosuvastatin-based combination therapies (with ezetimibe or acetylsalicylic acid).

Metabolic risk factor targets in relation to clinical characteristics and comorbidities among individuals with type 2 diabetes treated in primary care - The countrywide cross-sectional AUSTRO-PROFIT study

AIMS

This study assessed the achievement rates of metabolic risk factor targets and their association with clinical characteristics and comorbidities among individuals with type 2 diabetes (T2D) treated in the primary care in Austria.

MATERIALS AND METHODS

A countrywide cross-sectional study, the AUSTRO-PROFIT, was conducted in Austria from 2021 to 2023 on 635 individuals with T2D. Metabolic risk factor targets were defined as the percentage of people achieving low-density lipoprotein cholesterol (LDL-C) <70 mg/dL (or < 55 mg/dL if cardiovascular or microvascular disease was present), glycated haemoglobin (HbA1c) <7% (53 mmol/mol) and blood pressure < 140/90 mmHg.

RESULTS

The mean age of the participants was 65.7 ± 11.2 years; the median duration of T2D was 8 (4-14) years; and 58.7% of the participants were male. The percentages of participants achieving LDL-C, HbA1c, blood pressure and all targets were 44%, 53%, 57% and 13%, respectively. Older age, longer T2D duration, cardiovascular disease and microvascular complications were associated with suboptimal achievement of metabolic risk factor targets.

CONCLUSIONS

The AUSTRO-PROFIT study revealed notable variations in metabolic targets achievement with respect to clinical characteristics and comorbidities. These findings underscore the importance of establishing national diabetes registries and implementing multifactorial targeted and individualized interventions to further improve the quality of T2D care in primary care settings in Austria.

Efficacy and safety of bempedoic acid in acute coronary syndrome. Design of the clinical trial ES-BempeDACS

INTRODUCTION AND OBJECTIVES

Only about 1 out of every 3 patients with acute myocardial infarction (AMI) achieve low-density lipoprotein cholesterol (LDL-C) values <55mg/dL in the first year. The present study aims to evaluate the impact of early intensive therapy on lipid control after an AMI.

METHODS

An independent, prospective, pragmatic, controlled, randomized, open-label, evaluator-blinded clinical trial (PROBE design) will analyze the efficacy and safety of an oral lipid-lowering triple therapy: high-potency statin+bempedoic acid (BA) 180mg+ezetimibe (EZ) 10mg versus current European-based guidelines (high-potency statin±EZ 10mg), in AMI patients. LDL-C will be determined within the first 48hours. Patients with LDL-C ≥ 115mg/dL (without previous statin therapy), ≥ 100mg/dL (with previous low-potency or high-potency statin therapy at submaximal dose), or ≥ 70mg/dL (with previous high-potency statin therapy at high dose) will be randomly assigned 1:1 between 24 and 72hours post-AMI to the BA/EZ combination or to statin±EZ, without BA. The primary endpoint is the proportion of patients reaching LDL-C <55mg/dL at 8 weeks after treatment.

RESULTS

The results of this study will provide novel information for post-AMI LDL-C control by evaluating the usefulness of an early intensive lipid-lowering strategy based on triple oral therapy.

CONCLUSIONS

Early intensive lipid-lowering triple oral therapy vs the treatment recommended by current clinical practice guidelines could facilitate the achievement of optimal LDL-C levels in the first 2 months after AMI (a high-risk period).

IDENTIFICATION NUMBER

EudraCT 2021-006550-31.

Clinical profile and management of patients with acute myocardial infarction admitted to cardiac care units: The EYESHOT-2 registry

BACKGROUND

The clinical governance of patients with acute myocardial infarction (AMI) has markedly changed in the last few years. We sought to assess the contemporary in-hospital management patterns of patients with AMI at a country level.

METHODS

EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units)-2 was a nationwide, prospective registry aimed to evaluate the current management of patients admitted to intensive cardiac care units (CCUs) for an AMI in Italy.

RESULTS

Over a 4-week period (February 1st-29th, 2024), 183 CCUs enrolled 2806 consecutive patients: 52.6 % with non-ST elevation myocardial infarction (NSTEMI) and 47.4 % with ST-elevation myocardial infarction (STEMI). The median time from hospital admission to angiography in NSTEMI was 22.3 h (IQR 10.9-46.1), while for STEMI was 1.1 h (IQR 0.5-2.2) with significant difference between hospitals with and without catheterization laboratories. In both NSTEMI and STEMI patients, percutaneous coronary intervention (PCI) was the preferred management strategy (73.3 % and 94.2 %, respectively). An optimal secondary prevention therapy, including dual antiplatelet therapy, inhibition of the renin-angiotensin system, a beta-blocker and a high-intensity statin was prescribed at discharge in more than 75 % of patients with AMI. In-hospital major bleedings occurred in 2.0 % and 2.3 % (p = 0.58), while death in 1.8 % and 2.8 % (p = 0.09) of NSTEMI and STEMI patients, respectively.

CONCLUSIONS

The EYESHOT-2 registry shows the current management strategies and outcome of AMI patients admitted to Italian CCUs and provides insights to improve the clinical care of such patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT06316128.

How to achieve LDL cholesterol goals with the funding criteria for new lipid-lowering drugs?

Given the apparent inconsistency of having potent lipid-lowering drugs and the unacceptable rate of achievement of therapeutic goals in LDL cholesterol, it is imperative to define new strategies. In this regard, it is appropriate to detail the key points in planning to start lipid-lowering therapy, emphasizing relevant clinical aspects such as the considerable individual variability in the response to statin therapy, positioning in relation to high-potency statins versus statin+ezetimibe combination therapy, and the order of choice of lipid-lowering drugs in the therapeutic strategy. An algorithm is then proposed that ensures a personalized approach to lipid-lowering drug treatment in patients with cardiovascular disease and/or familial hypercholesterolemia with the aim of achieving the therapeutic goal in the shortest possible time, taking into account the patient's previous treatment, the funding criteria for new drugs, and the individualized goal of LDL cholesterol reduction.

Prescriptive Appropriateness and Efficacy of Cholesterol-Lowering Drugs in a Secondary Prevention Setting-A Retrospective Analysis from Two Italian Cardiac Rehabilitation Centers

Background: Treatment of CV risk factors, such as cholesterol level, represents one of the main goals to reduce atherosclerotic burden. The aim of this study was to investigate the prescriptive appropriateness of cholesterol-lowering drugs among patients who experienced an atherosclerotic CV disease (ASCVD). Methods: We investigated 155 patients who underwent cardiac rehabilitation in 2020. The European Society of Cardiology (ESC) 2021 guidelines on CV disease prevention and 2019 ESC Guidelines on dyslipidemias were followed to detect the appropriateness of prescription. SCORE2 and SCORE2-OP risk estimations were used to detect patients' CV risk profiles. Patients were divided into three groups: 1 (n = 118) patients admitted for their first CV event, 2A (n = 18) patients who experienced a previous CV event years before, and 2B (n = 19) patients admitted for a new event with a previous CV event 2 years before. Low-density lipoprotein (LDL) cholesterol level was detected at the time of admission to the hospital, during cardiac rehabilitation, and at the first visit after rehabilitation. Results: The statistics for our study participants, with a mean age of 66.1 years, were: 72.4% overweight/obese, 63.9% diabetic, 72.5% smokers, 93.0% hypertensives, and 91.7% had dyslipidemias. In group 1, only 5.1% had a low/moderate risk, 44.1% presented a high risk, and 50.8% a very high risk according to calculators. The average LDL levels were 115.8 mg/dL (2.99 mol/L) upon admission to the hospital, 66.4 mg/dL (1.72 mmol/L) at the time of cardiac rehabilitation, and 64.8 mg/dL (1.67 mmol/L) at the subsequent medical visit. In the overall group, only 36.0% had LDL < 55 mg/dL (1.42 mmol/L). In group 1, 79.4% were treated with high-intensity statin alone or plus ezetimibe; in group 2A, the percentage increased up to 87.5%, while group 2B 33.4% was treated with high-intensity statin plus ezetimibe and 33.3% were treated with PCSK9 inhibitors. Conclusions: This retrospective study confirms the importance of properly calculating CV risk profiles. The main limitations for the efficacy of lipid-lowering drugs were: patient's compliance, drugs side effects, lifestyle habits, and collaboration with a general practitioner.

Efficacy and safety of lipid-lowering therapies in combination with or without statin to reduce the cardiovascular risk: A systematic review of randomised controlled trials

Background and aims

Cardiovascular diseases (CVD) pose a significant global health burden. Lowering low-density lipoprotein-cholesterol is the primary therapeutic aim for preventing primary and secondary CVD events. While statins are the standard treatments, their limitations, such as side effects and intolerance in certain patient groups, necessitate exploration of alternative lipid-lowering therapies (LLTs). We systematically reviewed randomised controlled trials (RCTs) evaluating cardiovascular outcomes associated with non-statin LLTs (bempedoic acid, alirocumab, evolocumab, ezetimibe, and inclisiran) in adults with CVD or high cardiovascular risk.

Methods

EMBASE, Medline, Cochrane Library, and clinical trial registries were systematically searched for eligible studies, from inception until February 08, 2023. Two reviewers independently screened the studies, with discrepancies resolved by a third reviewer. Data extraction and validation were conducted, and the risk of bias was assessed using the Cochrane Risk-of-Bias tool-2 for RCTs.

Results

The search strategy yielded 2104 citations. Post screening for eligibility, nine unique trials/studies (84 publications) were identified. Among these, one trial each was identified for bempedoic acid and alirocumab, three for evolocumab, and four for ezetimibe. No published literature documenting the cardiovascular outcomes of inclisiran was identified. Only one trial (CLEAR Outcomes) included statin-intolerant patients at baseline. Most studies evaluated a 3-component, 4-component, or 5-component major adverse cardiovascular events composite as an outcome along with individual components. The quality of the included trials was found to be fair-to-good.

Conclusions

The systematic review findings emphasise the significance of considering non-statin LLTs as viable treatment options for individuals with CVD or high cardiovascular risk who cannot tolerate or achieve optimal lipid control with statin therapy alone.

Benefits of intensive lipid-lowering therapies in patients with acute coronary syndrome: a systematic review and meta-analysis

BACKGROUND

Previous meta-analyses have investigated the efficacy of lipid-lowering therapies for atherosclerotic cardiovascular disease; however, few have focused on patients with acute coronary syndrome (ACS). This meta-analysis aimed to compare the benefits of intensive lipid-lowering therapy with those of background statin therapy in patients with ACS.

METHODS

Searches were performed on PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for articles published until April 13, 2023. Randomized controlled trials that compared intensive lipid-lowering therapies and background statin therapies in patients with prior ACS and recorded the outcome of three-point major cardiovascular events (MACE) were included. The risk ratio (RR) with 95% confidence interval (CI) was used as a measure of primary and secondary outcomes.

RESULTS

Nine trials involving 38,640 patients with ACS were identified. Pooled results suggested that intensive lipid-lowering therapies are associated with a reduction in the risk of three-point MACE (RR, 0.88; 95% CI, 0.83-0.94; p < 0.001), recurrent ACS (RR, 0.82; 95% CI, 0.71-0.96; p = 0.013), nonfatal myocardial infarction (MI) (RR, 0.87; 95% CI, 0.81-0.93; p < 0.001), stroke (RR, 0.83; 95% CI, 0.73-0.94; p = 0.003), and unstable angina-related hospitalization (RR, 0.57; 95% CI, 0.33-0.99; p = 0.046), but not all-cause mortality (RR, 0.94; 95% CI, 0.82-1.07; p = 0.329), cardiovascular disease-related mortality (RR, 0.96; 95% CI, 0.88-1.06; p = 0.457) or coronary revascularization (RR, 0.89; 95% CI, 0.79-1.00; p = 0.057).

CONCLUSIONS

Intensive lipid-lowering therapies may reduce the risk of three-point MACE, recurrent ACS, nonfatal MI, stroke, and hospitalization for unstable angina in patients with ACS undergoing background statin therapy. These results may assist in clinical decision-making for the secondary prevention of cardiovascular events to initiate intensive lipid-lowering therapies immediately after ACS.

From clinical development to real-world outcomes with inclisiran

PURPOSE OF REVIEW

Inclisiran is a small interfering RNA that blocks hepatocyte production of the PCSK9 (proprotein convertase subtilisin/kexin type 9) protein by specifically targeting PCKS9 mRNA in the cytoplasm. This results in reduced degradation of LDL receptors and thus lowers LDL cholesterol by around 50% in addition to other lipid-lowering therapies. beyond 6 years of therapy. This review covers the latest published data and outlines future studies currently in process.

RECENT FINDINGS

To date, half a million doses have been given worldwide with no untoward adverse events thus far. The twice-yearly injections make it potentially very user-friendly. The large phase 3a trials saw no diminution of effect with time up to nearly 7 years. Very large phase 3b randomized controlled trials are underway and may produce significant reductions in major adverse cardiovascular events.

SUMMARY

Inclisiran has been evaluated in numerous trials, primarily the ORION 9 26 , ORION 10 27 and ORION 11 28 studies, which demonstrated that in patients already on maximally tolerated statin therapy, biannual inclisiran injections reduced LDL cholesterol by up to 52% compared to placebo with a good safety profile. The only observed side effects were mild and transient at the injection site. As mentioned in the accompanying video, this adds to our armamentarium of lipid treatments.

2024 Recommendations on the Optimal Use of Lipid-Lowering Therapy in Established Atherosclerotic Cardiovascular Disease and Following Acute Coronary Syndromes: A Position Paper of the International Lipid Expert Panel (ILEP)

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Fortunately, as much as two thirds of this disease's burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that, with respect to low-density lipoprotein cholesterol (LDL-C), "lower is better for longer", and recent data have strongly emphasised the need for also "the earlier the better". In addition to statins, which have been available for several decades, ezetimibe, bempedoic acid (also as fixed dose combinations), and modulators of proprotein convertase subtilisin/kexin type 9 (PCSK9 inhibitors and inclisiran) are additionally very effective approaches to LLT, especially for those at very high and extremely high cardiovascular risk. In real life, however, clinical practice goals are still not met in a substantial proportion of patients (even in 70%). However, with the options we have available, we should render lipid disorders a rare disease. In April 2021, the International Lipid Expert Panel (ILEP) published its first position paper on the optimal use of LLT in post-ACS patients, which complemented the existing guidelines on the management of lipids in patients following ACS, which defined a group of "extremely high-risk" individuals and outlined scenarios where upfront combination therapy should be considered to improve access and adherence to LLT and, consequently, the therapy's effectiveness. These updated recommendations build on the previous work, considering developments in the evidential underpinning of combination LLT, ongoing education on the role of lipid disorder therapy, and changes in the availability of lipid-lowering drugs. Our aim is to provide a guide to address this unmet clinical need, to provide clear practical advice, whilst acknowledging the need for patient-centred care, and accounting for often large differences in the availability of LLTs between countries.

Asia-Pacific Real-World Evolocumab Use, LDL-C Reduction, Physician Goals, and Patient Perceptions: HALES Observational Study

INTRODUCTION

Real-world data are needed to understand the effectiveness of new therapeutic options for low-density lipoprotein cholesterol (LDL-C) reduction in Asia-Pacific clinical practice. Description of evolocumab use among adults with establisHed Atherosclerotic cardiovascuLar diseasE or hypercholesterolemia in ASia-Pacific region (HALES) was performed to better understand characteristics of and clinical decision-making for adults with established atherosclerotic cardiovascular disease/hypercholesterolemia after local evolocumab approval.

METHODS

The HALES observational study, conducted at 33 sites (Hong Kong, Thailand, South Korea, Singapore, Taiwan, and Australia) comprised (1) chart review of patients who received evolocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i), and (2) physician/patient survey and one-time data collection of patients with high cardiovascular risk initiating evolocumab or initiating/continuing non-PCSK9i lipid-lowering therapy. Patients could only enroll in (1) or (2).

RESULTS

Chart review included 724 very high-risk patients initiating evolocumab from regulatory approval to 2021. From median baseline LDL-C of 3.2 mmol/L (123.7 mg/dL), patients had a median percent change in LDL-C of - 60.8% at 1-6 months. Goal achievement increased from 7.9% to 69.8% for < 1.8 mmol/L (< 70 mg/dL) and 4.4% to 57.8% for < 1.4 mmol/L (< 55 mg/dL) from baseline to 12 months. In the one-time data collection, more patients had ≥ 1.8 mmol/L (≥ 70 mg/dL) baseline LDL-C in the evolocumab vs non-PCSK9i group (95.2% and 48.5%, respectively). Surveys found that physicians applied guideline-recommended treatment targets, and patients demonstrated gaps in understanding cardiovascular risk.

CONCLUSION

Real-world, Asia-Pacific data showed that LDL-C reduction after initiating evolocumab was consistent with that observed in other clinical trials and patient populations. Graphical abstract available for this article.·.

Five-Year Trends in Low-Density Lipoprotein Cholesterol Management in a Primary Healthcare Centre in Kaunas

Background and Objectives: Low-density lipoprotein cholesterol (LDL-C) is a marker of cardiovascular risk and its management. This study evaluated LDL-C control trends in patients treated at a primary healthcare center in Lithuania. Materials and Methods: Five-year (2019-2023) data on patients aged 40 years or older diagnosed with dyslipidemia were extracted from a real-world data and analytics platform, TriNetX. Patients were grouped into three groups: patients with dyslipidemia only (control group), patients with dyslipidemia and diabetes, and patients with dyslipidemia and cardiovascular disease (CVD). The following LDL-C goals were used for analysis: <1.4 mmol/L (a goal for very-high-risk patients in primary or secondary prevention), <1.8 mmol/L (a goal for high-risk patients), and <3.0 mmol/L (a goal for low-risk patients). Results: There were 18,646 patients with dyslipidemia. Of them, 8.9% of patients had diabetes, and 3.1% of patients had CVD. The median LDL-C concentration was significantly lower in patients with diabetes (2.82 mmol/L, p < 0.05) and in patients with CVD (2.45 mmol/L, p < 0.05) than in the control group (3.35 mmol/L). A trend of decreasing median LDL-C over the years was observed in all groups, with the lowest median values in 2023. The proportion of patients with LDL-C levels < 3 mmol/L increased from 32.0% in 2019 to 41.5% in 2023. The proportion of diabetic patients achieving LDL-C < 1.8 mmol/L increased from 7.4% to 25.9%, and those achieving LDL-C < 1.4 mmol/L increased from 3.1% to 10.6%. The proportion of patients with CVD achieving LDL-C < 1.8 mmol/L increased from 14.2% to 36.6%, and those achieving LDL-C < 1.4 mmol/L increased from 3.0% to 14.0%. Conclusions: Trends in the control of LDL-C levels are positive over 5 years, but a significant proportion of patients still did not reach the recommended target levels.

Ezetimibe: Integrating Established Use with New Evidence - A Comprehensive Review

PURPOSE OF REVIEW

To consolidate key information on the efficacy and safety of ezetimibe, with a focus on the latest evidence.

RECENT FINDINGS

While ezetimibe has long been used alongside statins to help achieve lipid goals when statins are insufficient or in statin-intolerant patients, recent studies confirm and extend its benefits. Ezetimibe, when added to statins, is now recognized as an effective option for high-risk cardiovascular patients. Additionally, for those intolerant to statins, it can be combined with bempedoic acid, offering significant LDL cholesterol reduction. Ezetimibe's favourable tolerability, with fewer side effects than statins, along with the availability of fixed-dose combinations, enhances both treatment efficacy and patient adherence. Overall, this review underscores ezetimibe's evolving role in lipid management, providing valuable guidance for optimizing cardiovascular risk reduction strategies.

L-shaped association of plasma low-density lipoprotein cholesterol with atrial fibrillation recurrence after catheter ablation: a prospective cohort study

The association between plasma low-density lipoprotein cholesterol (LDL-C) and atrial fibrillation (AF) recurrence after catheter ablation remains unclear. We aimed to assess the relationship between preprocedural LDL-C and the AF recurrence in patients undergoing catheter ablation. The cohort study consecutively included AF patients who underwent de novo catheter ablation between April 2021 and January 2023 in the Second Affiliated Hospital of Nanchang University in Jiangxi Province, China. Patients were divided into quartiles based on their baseline fasting LDL-C level (Q1-Q4). Multivariable Cox proportional hazards models were used to evaluate the relationship between LDL-C and AF recurrence. Our analysis included the use of a generalized additive model and smooth curve fitting (penalized spline method), and two-piecewise Cox proportional hazards models, to address the nonlinearity between preprocedural LDL-C and AF recurrence. A total of 482 AF patients with de novo catheter ablation were enrolled, with a median follow-up period of 15.00 months, AF recurrence occurred in 96 (19.92%) patients. The relationship between preprocedural LDL-C and AF recurrence after ablation presented as an L-shape, and the inflection point for the curve was found at the LDL-C level of 3.20 mmol/L (Log likelihood ratio P = 0.031). The hazard ratios (HR) [(95% confidence intervals (CI)] for AF recurrence were 0.50 (0.33-0.74) and 2.11 (0.76-5.89) to the left and right of the inflection point, respectively. Lower LDL-C level is associated with increased AF recurrence risk after catheter ablation were consistent across all subgroups.

In-silico trial emulation to predict the cardiovascular protection of new lipid-lowering drugs: an illustration through the design of the SIRIUS programme

INTRODUCTION

Inclisiran, an siRNA targeting hepatic PCSK9 mRNA, administered twice-yearly (after initial and 3-month doses), substantially and sustainably reduced LDL-cholesterol (LDL-C) in Phase III trials. Whether lowering LDL-C with inclisiran translates into a reduced risk of major adverse cardiovascular events (MACE) is not yet established. In-silico trials applying a disease computational model to virtual patients receiving new treatments allow to emulate large scale long-term clinical trials. The SIRIUS in-silico trial programme aims to predict the efficacy of inclisiran on CV events in individuals with established atherosclerotic cardiovascular disease (ASCVD).

METHODS AND RESULTS

A knowledge-based mechanistic model of ASCVD was built, calibrated, and validated to conduct the SIRIUS programme (NCT05974345) aiming to predict the effect of inclisiran on CV outcomes. The SIRIUS Virtual Population included patients with established ASCVD (previous myocardial infarction (MI), previous ischemic stroke (IS), previous symptomatic lower limb peripheral arterial disease (PAD) defined as either intermittent claudication with ankle-brachial index <0.85, prior peripheral arterial revascularization procedure, or vascular amputation) and fasting LDL-C ≥ 70 mg/dL, despite stable (≥4 weeks) well-tolerated lipid-lowering therapies.SIRIUS is an in-silico multi-arm trial programme. It follows an idealized crossover design where each virtual patient is its own control, comparing inclisiran to (i) placebo as adjunct to high-intensity statin therapy with or without ezetimibe, (ii) ezetimibe as adjunct to high-intensity statin therapy, (iii) evolocumab as adjunct to high-intensity statin therapy and ezetimibe.The co-primary efficacy outcomes are based on the time to the first occurrence of any component of 3P-MACE (composite of CV death, nonfatal MI, or nonfatal IS) and time to occurrence of CV death over 5 years.

PERSPECTIVES/CONCLUSION

The SIRIUS in-silico trial programme will provide early insights regarding potential effect of inclisiran on MACE in ASCVD patients, several years before the availability of the results from ongoing CV outcomes trials (ORION-4 and VICTORION-2-P).

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05974345.

Use of combination therapy is associated with improved LDL cholesterol management: 1-year follow-up results from the European observational SANTORINI study

AIMS

To assess whether implementation of the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidaemia guidelines observed between 2020 and 2021 improved between 2021 and 2022 in the SANTORINI study.

METHODS AND RESULTS

Patients with high or very high cardiovascular (CV) risk were recruited across 14 European countries from March 2020 to February 2021, with 1-year prospective follow-up until May 2022. Lipid-lowering therapy (LLT) and 2019 ESC/EAS risk-based low-density lipoprotein (LDL) cholesterol (LDL-C) goal attainment (defined as <1.4 mmol/L for patients at very high CV risk and <1.8 mmol/L for patients at high CV risk) at 1-year follow-up were compared with baseline. Of 9559 patients enrolled, 9136 (2626 high risk and 6504 very high risk) had any available follow-up data, and 7210 (2033 high risk and 5173 very high risk) had baseline and follow-up LDL-C data. Lipid-lowering therapy was escalated in one-third of patients and unchanged in two-thirds. Monotherapy and combination therapy usage rose from 53.6 and 25.6% to 57.1 and 37.9%, respectively. Mean LDL-C levels decreased from 2.4 to 2.0 mmol/L. Goal attainment improved from 21.2 to 30.9%, largely driven by LLT use among those not on LLT at baseline. Goal attainment was greater with combination therapy compared with monotherapy at follow-up (39.4 vs. 25.5%).

CONCLUSION

Lipid-lowering therapy use and achievement of risk-based lipid goals increased over 1-year follow-up particularly when combination LLT was used. Nonetheless, most patients remained above goal; hence, strategies are needed to improve the implementation of combination LLT.

Trends in atherosclerotic cardiovascular disease and lipid management: a population-level observational cohort study in Wales

AIMS

European clinical guidelines recommend that patients with atherosclerotic cardiovascular disease (ASCVD), including ischaemic heart disease (IHD), stroke, and peripheral arterial disease (PAD), are prescribed lipid lowering treatment (LLT) and treated to target low-density lipoprotein cholesterol (LDL-C) levels. This study aimed to document trends in ASCVD, including treatment, monitoring, and achievement of target LDL-C.

METHODS AND RESULTS

A retrospective observational population study was performed using linked healthcare data (2010-22). Over the study period, the number of patients with ASCVD increased from 181 153 to 207 747 (8882 to 9398 per 100 000). The proportion of patients prescribed LLT decreased from 75.3% in 2010 to 67.1% in 2022; high-intensity statin therapy increased from 9.4 to 25.2%, while non-high-intensity statin therapy decreased from 59.6 to 38.2%. The prescription of high-intensity statin therapy was consistently higher amongst patients with IHD (10.9% in 2010 increasing to 28.0% in 2022) than in patients with stroke (4.7-21.6%) or PAD (3.9-10.6%).The proportion of cases with documented LDL-C decreased from 58.0% in 2010 to 49.3% in 2022. Of those with documented LDL-C in 2022, 44.0% achieved LDL-C < 1.8 mmol/L, including 45.2% of those with IHD, 42.0% of those with stroke, and only 32.8% of those with PAD.

CONCLUSION

Prescription of LLT, including high-intensity statin therapy, documentation of LDL-C, and achievement of target LDL-C levels was relatively low, especially in PAD patients. Although target achievement in 'tested patients' increased over time, the proportion of patients undergoing lipid testing declined. More rigorous lipid management requires prioritisation, especially for PAD and stroke patients.

Drug interactions in cardiology: focus on statins and their combination with other lipid-lowering drugs

INTRODUCTION

Statins are the primary therapeutic approach for treating hypercholesterolemia in hyperlipidemic high cardiovascular-risk patients, as stated by the recent European and American guidelines. However, in some patients, statin treatment is not sufficient to achieve the recommended plasma LDL-C levels, and the addition of a second hypolipidemic drug becomes mandatory. Concomitant administration of multiple medications may increase the risk of adverse events, potentially leading to statin-associated muscle or liver symptoms and non-adherence or discontinuation of statin therapy, such as in women. The addition of a second hypolipidemic drug (such as ezetimibe, anti-PCSK9 monoclonal antibodies, bempedoic acid, and inclisiran) may lead to drug-drug interactions (DDIs). The evaluation of the different pharmacokinetic profiles may improve and personalize the treatment.

AREAS COVERED

We aimed to give an update on the potential DDIs between statins and other hypolipidemic drugs currently used to treat high-risk hyperlipidemic patients.

EXPERT OPINION

It is fundamental to understand the risk associated with DDIs to manage better the addition of a concomitant hyperlipidemic drug to a statin-treated patient. Many health agencies have published specific guidelines for assessing DDIs, but these mainly apply to in vitro studies. New predictive approaches are being proposed and may help evaluate and manage DDIs.

Clinical Considerations for Healthcare Provider-Administered Lipid-Lowering Medications

Atherosclerotic cardiovascular disease (ASCVD), a leading cause of mortality and morbidity, is associated with a substantial healthcare and economic burden. Reduction of low-density lipoprotein cholesterol (LDL-C) to guideline-recommended goals is crucial in the prevention or management of ASCVD, particularly in those at high risk. Despite the availability of several effective lipid-lowering therapies (LLTs), up to 80% of patients with ASCVD do not reach evidence-based LDL-C goals. This nonattainment may be due to poor adherence to, and lack of timely utilization of, LLTs driven by a range of variables, including polypharmacy, side effects, clinical inertia, costs, and access issues. Inclisiran was approved by the US Food and Drug Administration in 2021 as a novel, twice-yearly, healthcare provider (HCP)-administered LLT. In-office administration allows HCPs more control of drug acquisition, administration, and reimbursement, and may allow for more timely care and increased patient monitoring. In the USA, in-office administered drugs are considered a Medical Benefit and can be acquired and reimbursed using the "buy-and-bill" process. Buy-and-bill is a standard system for medication administration already established in multiple therapeutic areas, including oncology, vaccines, and allergy/immunology. Initiating in-office administration will involve new considerations for clinicians in the cardiovascular specialty, such as the implementation of new infrastructure and processes; however, it could ultimately increase treatment adherence and improve cardiovascular outcomes for patients with ASCVD. This article discusses the potential implications of buy-and-bill for the cardiology specialty and provides a practical guide to implementing HCP-administered specialty drugs in US clinical practice.

A Nation-Wide Evaluation of Suboptimal Lipid-Lowering Treatment Patterns Among Patients Undergoing Intervention for Acute Coronary Syndrome in Hungary

Background/Objectives: A significant gap exists between guideline recommendations and everyday practice. Stringent treatment is needed for vulnerable patients with acute coronary syndrome (ACS). Methods: Data on the lipid-lowering therapy (LLT), including the adherence, persistence, and mortality of patients undergoing percutaneous coronary intervention or bypass surgery in Hungary in 2018 were followed up and analyzed based on the National Health Insurance Fund database until the end of 2020. Results: A total of 12,997 patients underwent revascularization for ACS in 2018, whose discharge therapy included any LLT, a high- or moderate-intensity statin, or ezetimibe at a proportion of 91%, 75%, 12%, and 4%, respectively. By the end of the observation period, the frequency of ezetimibe administration increased to 11%. Persistence decreased, reaching 50% for all therapeutic regimens by month 16. Patients on moderate statin doses had a significantly higher mortality rate at the end of follow-up than those receiving high-intensity statin with (20% vs. 9%, p < 0.0001) or without (20% vs. 14%, p = 0.00029) ezetimibe. Those taking less potent statin doses had higher rates of comorbidities; for example, a minimum of three comorbidities were present in 39% of patients taking medium statin doses and 23% among those on high-intensity statin therapy (p < 0.0001). Conclusions: LLT persistence decreased during follow-up. The administration of a higher-intensity lipid-lowering regimen was associated with better persistence and adherence, along with more favorable mortality rates. Multimorbidity was associated with the use of lower statin doses. The results suggest that more attention is needed in terms of lipid control of females, elderly people, and individuals with several comorbidities, and emphasis should be placed on improving persistence and increasing the frequency of combined LLT prescriptions.