Optimal implementation of the 2019 ESC/EAS dyslipidaemia guidelines in patients with and without atherosclerotic cardiovascular disease across Europe: a simulation based on the DA VINCI study

Treatment pathways of lipid-lowering therapies in Germany 2016-2022

BACKGROUND

Despite the availability of effective LDL cholesterol (LDL-C)-lowering drugs, only a minority of patients achieves the guideline-recommended treatment targets. This analysis describes treatment pathways of lipid-lowering therapy (LLT) in Germany.

METHODS

Health claims data were used to identify patients at high or very-high cardiovascular risk who received a LLT prescription 2016-2022. Treatment pathways and the time to switch or discontinue LLT were analysed for statins, ezetimibe, bempedoic acid (BA), and PCSK9 inhibitors (PCSK9i).

RESULTS

Out of 3,487,827 insured persons, 247,529 met the inclusion criteria. The most frequent first-line LLT were statins in 96.3%. Ezetimibe, BA, and PCSK9i were first-line LLT in only 0.9%, 0.061%, and 0.046%, respectively. Only few patients experienced a change in their treatment regimen following LLT initiation. Prescriptions of BA and PCSK9i were mainly second-, third-, or fourth-line add-on treatment. Termination of treatment with BA and PCSK9i was less frequent compared to statins and ezetimibe. The median time to treatment discontinuation was 1.45, 1.04, 0.60, and 2.45 years for statins, ezetimibe, BA, and PCSK9i, respectively, and the median time to switch therapy was 4.81 and 4.87 years for ezetimibe and PCSK9i, respectively (median not reached for statins and BA).

CONCLUSIONS

Changes in LLT were only observed in a minority of patients. BA and PCSK9i were switched more frequently than statins and ezetimibe. BA was discontinued earlier, and PCSK9i later than the other agents. Continued efforts to maintain long-term adherence and overcome therapeutic inertia are needed to realise the potential of available LLT with proven cardiovascular benefit.

Optimization of Cardiovascular Care: Beyond the Guidelines

Scientific cardiac and vascular societies provide essential guidelines tailored to broad patient populations [...].

Risk-factor control and secondary prevention in ischemic heart disease in primary care: real-world insights from QregPV

AIMS

With current, stricter lipid and blood pressure targets in patients with ischemic heart disease (IHD), secondary prevention may be insufficient and vary between patient groups and primary health care centres (PHCCs). We assessed the heterogeneity of risk-factor control and secondary prevention using contemporary Swedish primary-care data.

METHODS

Cross-sectional study of IHD patients in September 2023 from QregPV, a Swedish regional primary-care register. We evaluated the proportions attaining risk-factor control (blood pressure <140/90 mmHg, LDL-cholesterol [LDL-C] <1.4 mmol/L, and non-smoking) and the use of lipid-lowering therapy (LLT) and antithrombotic therapy (ATT) by age and sex using logistic regression models. Heterogeneity among PHCCs was estimated using multilevel models and summarised as adjusted median odds ratios (aMOR).

RESULTS

45 771 patients (34.5% women) were included. Combined risk-factor control was low, 15.5% (95% CI 15.0-16.0), mainly due to low LDL-C attainment, 20.7% (20.3-21.1). Combined risk-factor control decreased with higher age (p<0.001) and was lower in women than in men, age-adjusted odds ratio (aOR) 0.60 (0.55-0.66). LLT and ATT were used by 77.2% (76.8-77.6) and 85.6% (85.2-85.9), with lower usage in women, aOR 0.52 (0.50-0.54) and aOR 0.58 (0.54-0.62). Substantial heterogeneity among PHCCs was observed, with combined risk-factor control aMOR 1.39 (1.32-1.48).

CONCLUSION

Combined risk-factor control was low, largely due to low LDL-C control, despite high LLT usage. Risk-factor control and the use of LLT and ATT varied between PHCCs and were lower in women than men. Concrete clinical strategies for attaining risk-factor goals in both sexes and for reducing PHCC variation are warranted.

Obicetrapib exhibits favorable physiochemical and pharmacokinetic properties compared to previous cholesteryl ester transfer protein inhibitors: An integrated summary of results from non-human primate studies and clinical trials

Anacetrapib, a cholesteryl ester transfer protein (CETP) inhibitor previously under development, exhibited an usually extended terminal half-life and large food effect and accumulated in adipose tissue. Other CETP inhibitors have not shown such effects. Obicetrapib, a potent selective CETP inhibitor, is undergoing Phase III clinical development. Dedicated assessments were conducted in pre-clinical and Phase I and II clinical studies of obicetrapib to examine the pharmacokinetic issues observed with anacetrapib. After 9 months of dosing up to 50 mg/kg/day in cynomolgus monkeys, obicetrapib was completely eliminated from systemic circulation and not detected in adipose tissue after a 13-week recovery period. In healthy humans receiving 1-25 mg of obicetrapib, the mean terminal half-life of obicetrapib was 148, 131, and 121 h at 5, 10, and 25 mg, respectively, and food increased plasma levels by ~1.6-fold with a 10 mg dose. At the end of treatment in Phase II trials, mean plasma levels of obicetrapib ranged from 194.5 ng/mL with 2.5 mg to 506.3 ng/mL with 10 mg. Plasma levels of obicetrapib decreased by 92.2% and 98.5% at four and 15 weeks post-treatment, respectively. Obicetrapib shows no clinically relevant accumulation, is minimally affected by food, and has a mean terminal half-life of 131 h for the 10 mg dose. These data support once daily, chronic dosing of obicetrapib in Phase III trials for dyslipidemia management.

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.

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.

Intensive early and sustained lowering of non-high-density lipoprotein cholesterol after myocardial infarction and prognosis: the SWEDEHEART registry

BACKGROUND AND AIMS

Non-HDL-C provides an estimate of lipid-associated risk and is a secondary treatment target after myocardial infarction (MI). The aim was to study the relationship between non-HDL-C levels after MI and risk of adverse outcomes.

METHODS

From the SWEDEHEART registry, 56 262 patients with MI were included. Outcomes were major adverse cardiovascular event (MACE: death, MI, and ischaemic stroke), death, and non-fatal MI. Non-HDL-C was assessed at admission, 2 months, and 1 year. Target achievement (<2.2 mmol/L) of non-HDL-C, timing thereof, and outcomes were assessed.

RESULTS

During median follow-up of 5.4 years, 9549 had MACE, 5427 died, and 3946 had MI. Long-term hazard ratio (HR) for MACE in the lowest vs. the highest quartile of achieved non-HDL-C at 1 year was 0.76 [95% confidence interval (CI) 0.71-0.81]. Short-term results were consistent also when assessing non-HDL-C levels at 2 months, including early events up to 1 year (HR 0.80, 95% CI 0.68-0.92). Similar results were observed for all outcomes. Patients achieving both early and sustained targets had lowest risk of outcomes (HR 0.80, 95% CI 0.74-0.86) vs. patients achieving target early or late (HR for both 0.86, 95% CI 0.79-0.93).

CONCLUSIONS

The lowest achieved levels both at 2 months and at 1 year of non-HDL-C were associated with better outcome. The lowest risk was observed when target was achieved within 2 months of MI and sustained thereafter. These findings challenge the current stepwise approach for cholesterol lowering after MI, which inevitably results in delaying goal attainment and possible harm.

Expanding therapeutic options: overview of novel pharmacotherapies for dyslipidemia

INTRODUCTION

Dyslipidemia plays a crucial role in the development of atherosclerotic cardiovascular diseases.

AREAS COVERED

This article explores the emerging therapeutic targets for the treatment of dyslipidemia and provides novel insights into this field. Thus, it aims to contribute to the understanding and advancement of therapeutic options for managing dyslipidemia.

EXPERT OPINION

Optimizing the use of available first- and second-line lipid-lowering drugs allows us to adequately control low-density lipoprotein cholesterol (LDL-C) levels, even in statin-intolerant individuals and in patients at high and very high risk of developing cardiovascular diseases who must reach more aggressive LDL-C targets. The drugs under development will further improve our ability to manage the overall lipid-related cardiovascular disease risk and target other dyslipidemia biomarkers.

Achievement of LDL-Cholesterol Goals in Patients Receiving LLT in Primary Care: TERESA-AP Study: LDL-Cholesterol Goals in Primary Care

Background and Aim: Since 2019, LDL-cholesterol (LDL-C) is the risk factor with the strictest goals and the most difficult to reach, due to its role in the development of atherosclerotic plaque and, therefore, cardiovascular risk. The objective of the TERESA-AP study is to analyze the degree of LDL-C control in patients followed up in primary care with lipid-lowering drug treatment (LLT). Methods: Observational, multicenter, cross-sectional, nationwide study was conducted, in which 50 PC physicians recruited 929 patients who were receiving LLT during at least the preceding 6 months. The variables required to estimate the patients' cardiovascular risk and LDL control were recorded. Results: Nearly half of sample was women (50.5%), and the mean age was 67.8 (10.4) years. High blood pressure (65.3%) and sedentary lifestyle (59.7%) were the most frequent risk factors. Recommended goals were reached in 26.0% (95% CI: 23.3%-29.0%) of patients, with a slightly higher percentage in patients with cardiovascular disease (CVD) (26.7%), diabetes mellitus (DM) (35.5%), and a lower one in patients with chronic kidney disease (CKD) (12.1%). The most frequent drug treatments were statin monotherapy (69.0%) and statin with ezetimibe combination (27.6%), with moderate-intensity statins being the most commonly used in both groups. Conclusions: On average, only a quarter of the patients followed up in PC and who receive drug treatment reach their therapeutic targets. This percentage is slightly higher if the patients have CVD and DM and lower if they have CKD. The most commonly used therapeutic strategy is moderate-intensity statins, both in monotherapy and in combination with ezetimibe.

Clinical impact of genetic testing for lipid disorders

PURPOSE OF REVIEW

Genetic testing is increasingly becoming a common consideration in the clinical approach of dyslipidemia patients. Advances in research in last decade and increased recognition of genetics in biological pathways modulating blood lipid levels created a gap between theoretical knowledge and its applicability in clinical practice. Therefore, it is very important to define the clinical justification of genetic testing in dyslipidemia patients.

RECENT FINDINGS

Clinical indications for genetic testing for most dyslipidemias are not precisely defined and there are no clearly established guideline recommendations. In patients with severe low-density lipoprotein cholesterol (LDL-C) levels, the genetic analysis can be used to guide diagnostic and therapeutic approach, while in severe hypertriglyceridemia (HTG), clinicians can rely on triglyceride level rather than a genotype along the treatment pathway. Genetic testing increases diagnostic accuracy and risk stratification, access and adherence to specialty therapies, and cost-effectiveness of cascade testing. A shared decision-making model between the provider and the patient is essential as patient values, preferences and clinical characteristics play a very strong role.

SUMMARY

Genetic testing for lipid disorders is currently underutilized in clinical practice. However, it should be selectively used, according to the type of dyslipidemia and when the benefits overcome costs.

Validation of the Novel Web-Based Application HUMTELEMED for a Comprehensive Assessment of Cardiovascular Risk Based on the 2021 European Society of Cardiology Guidelines

Background and aims: SCORE2/SCORE2-OP cardiovascular risk (CVR) charts and online calculators do not apply to patients with comorbidities, target organ damage, or atherosclerotic cardiovascular disease, for whom the assessment relies on the conventional consultation of the 2021 ESC guidelines (qualitative approach). To simplify the CVR evaluation, we developed an integrated multi-language and free-to-use web application. This study assessed the agreement between the conventional method versus our web app. Methods: A cross-sectional study was carried out on 1306 consecutive patients aged 40+ years referred to our center for the diagnosis and management of hypertension and dyslipidemia. Two double-blind operators performed the CVR assessment and classified each patient into low-moderate-, high-, and very-high-risk categories by using the conventional method (SCORE2/SCORE2-OP charts and consultation of the 2021 ESC guidelines) and the web app. The Kappa statistics were used to compare the two methods. Results: The mean age was 60.3 ± 11.9 years, with male prevalence (51.4%). Patients in primary prevention were 77.0%. According to the SCORE2/SCORE2-OP charts and 2021 ESC guideline consultation, the CVR was low-moderate in 18.6% (n° 243), high in 36.8% (n° 480), and very high in 44.6% (n° 583). According to the web app, individual CVR was low-moderate in 19.5% (n° 255), high in 35.4% (n° 462), and very high in 45.1% (n° 589). The two methods strongly agreed (Kappa = 0.960, p < 0.001), with a 97.5% concordance. Conclusions: our application has excellent reliability in a broad "real life" population and may help non-expert users and busy clinicians to assess individual CVR appropriately, representing a free-to-use, simple, time-sparing and widely available alternative to the conventional CVR evaluation using SCORE2/SCORE2-OP and 2021 ESC guideline charts.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients

Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.

Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol in type 1 diabetes and type 2 diabetes: Lipid goal attainment in a large German-Austrian diabetes registry

AIM

To assess the implementation of the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guideline recommendations for lipid-lowering therapies among more than 30 000 patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) in a German and Austrian registry from 2020 to 2022.

MATERIALS AND METHODS

Registry data from 2020 and 2021 of 32 170 adult patients (8314 patients with T1D and 23 856 with T2D) were stratified according to the 2019 ESC/EAS risk categories, and guideline-based low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goal attainment was analysed.

RESULTS

In patients with T1D (median age 38.35 [20.51-57.13] years), overall statin use was 19.3%, ezetimibe use was 2.2% and the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors or fibrates was less than 1%. In patients with T2D (median age 68.76 [58.86-78.39] years), 45.7% received statins, 3.4% received ezetimibe, and fibrates and PCSK9 inhibitors were used by 1% and 0.1%, respectively. Among patients with T1D, 6.16% reached their risk-based recommended LDL-C goal of less than 55 mg/dL (very high risk), 10.97% of less than 70 mg/dL (high risk), and 69.50% of less than 100 mg/dL (moderate risk), respectively. In patients with T2D, 11.81% reached their risk-based goal of LDL-C less than 55 mg/dL, 16.25% of less than 70 mg/dL, and 51.33% of less than 100 mg/dL. Non-HDL-C goals were reached more often, with 15.3%, 25.52% and 91.61% in patients with T1D and 18.56%, 17.96% and 82.30% in patients with T2D for very high, high and moderate risk, respectively.

CONCLUSION

Approximately 2 years after publication of the guidelines, LDL-C and non-HDL-C goal attainment was rarely achieved in patients with T1D and T2D with a high or very high cardiovascular risk.