Guía ESC/EAS 2016 sobre el tratamiento de las dislipemias

Low-density lipoprotein cholesterol goal attainment in patients with clinical evidence of familial hypercholesterolemia and elevated Lp(a)

BACKGROUND

Although potent lipid-lowering therapies are available, patients commonly fall short of recommended low-density lipoprotein cholesterol (LDL-C) levels. The aim of this study was to examine the relationship between familial hypercholesterolemia (FH) and elevated lipoprotein(a) [Lp(a)] and LDL-C goal attainment, as well as the prevalence and severity of coronary artery disease (CAD). Moreover, we characterized patients failing to meet recommended LDL-C goals.

METHODS

We performed a cross-sectional analysis in a cohort of patients undergoing cardiac catheterization. Clinical FH was determined by the Dutch Clinical Lipid Network Score, and Lp(a) ≥ 50 mg/dL (≈ 107 nmol/L) was considered elevated.

RESULTS

A total of 838 participants were included. Overall, the prevalence of CAD was 72%, and 62% received lipid-lowering treatment. The prevalence of clinical FH (probable and definite FH) was 4%, and 19% had elevated Lp(a) levels. With 35%, LDL-C goal attainment was generally poor. Among the participants with clinical FH, none reached their LDL-C target. Among patients with elevated Lp(a), LDL-C target achievement was only 28%. The prevalence and severity of CAD were higher in participants with clinical FH (86% prevalence) and elevated Lp(a) (80% prevalence).

CONCLUSION

Most participants failed to meet their individual LDL-C goals according to the ESC 2016 and 2019 guidelines. In particular, high-risk patients with clinical FH or elevated Lp(a) rarely met their target for LDL-C. The identification of these patients and more intense treatment approaches are crucial for the improvement of CAD primary and secondary prevention.

Vitamin D-Related Single Nucleotide Polymorphisms as Risk Biomarker of Cardiovascular Disease

Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels. In addition to environmental risk factors, genetic predisposition increases the risk; this includes alterations in the vitamin D receptor gene (VDR). These alterations play a key role in modifying vitamin D uptake, being able to modify its function and increasing susceptibility to cardiovascular disorders. The aim of this study was to evaluate the association of polymorphisms in the VDR gene and risk of CVD in a Caucasian population. A retrospective case-control study was conducted comprising 246 CVD patients and 246 controls of Caucasian origin from Southern Spain. The genetic polymorphisms BsmI (rs1544410), TaqI (rs731236), ApaI (rs7975232), FokI (rs2228570) and Cdx2 (rs11568820) were determined by means of real-time polymerase chain reaction (PCR) for allelic discrimination using TaqMan® probes. The logistic regression analysis adjusted for body mass index and diabetes revealed that the TT genotype was associated with a higher risk of CVD in both the genotypic model (p = 0.0430; OR = 2.30; 95% CI = 1.06–5.37; TT vs. CC) and the recessive model (p = 0.0099; OR = 2.71; 95% CI = 1.31–6.07; TT vs. C). Haplotype analysis revealed that the haplotype GAC (p = 0.047; OR = 0.34; 95% CI = 0.12–0.98) was associated with increased risk of CVD. The VDR polymorphisms FokI (rs2228570) was significantly associated with the development of CVD. No influence was observed of the VDR polymorphisms BsmI (rs1544410), TaqI (rs731236), ApaI (rs7975232) and Cdx2 (rs11568820) on the risk of developing CVD in the patients studied.

The Regular Consumption of Nuts Is Associated with a Lower Prevalence of Abdominal Obesity and Metabolic Syndrome in Older People from the North of Spain

Background: The aim of this study was to relate the adherence to nut consumption (30 g) three or more days per week to the prevalence of abdominal obesity and metabolic syndrome (MetS) in an elderly population from the north of Spain. Methods: The study consists of an observational, descriptive, cross-sectional, and correlational study conducted in 556 non-institutionalised individuals between 65 and 79 years of age. To define the consumption recommendation of nuts the indication of the questionnaire MEDAS-14 was followed. The diagnosis of MetS was conducted using the International Diabetes Federation (IDF) criteria. Results: In 264 subjects aged 71.9 (SD: ±4.2) years old, 39% of whom were men, the adherence to nut consumption recommendations was 40.2%. Of these individuals, 79.5% had abdominal obesity. The prevalence of MetS was 40.2%, being 47.6% in men and 35.4% in women (p < 0.05). A nut consumption lower than recommended was associated with a 19% higher prevalence of abdominal obesity (Prevalence Ratio: 1.19; 95% CI: 1.03−1.37; p < 0.05) and a 61% higher prevalence of MetS (Prevalence Ratio: 1.61; 95% CI: 1.16−2.25; p = 0.005) compared to a consumption of ≥3 servings per week. Conclusion: An inverse relationship was established between nut consumption and the prevalence of abdominal obesity and metabolic syndrome.

Development and validation of a novel nomogram to predict overall survival of patients with moderate to severe chronic kidney disease

Introduction

The risk of death significantly increased from stage 3 chronic kidney disease (CKD) onward. We aimed to construct a novel nomogram to predict the overall survival (OS) of patients afflicted with CKD from stage 3–5.

Methods

A total of 882 patients with stage 3–5 CKD were enrolled from the NHANES 2001–2004 survey. Data sets from the 2003–2004 survey population were used to develop a nomogram that would predict the risk of OS. The 2001–2002 survey population was used to validate the nomogram. Least absolute shrinkage and selection operator (Lasso) regression was conducted to screen the significant predictors relative to all-cause death. The multivariate Cox regression based on the screened factors was applied to effectively construct the nomogram. The performance of the nomogram was evaluated according to the C-index, the area under the receiver operating characteristic curve (AUC), and the calibration curve with 1000 bootstraps resample. Kaplan–Meier’s curves were used for testing the discrimination of the prediction model.

Results

Five variables (age, urinary albumin-to-creatinine ratio (UACR), potassium, cystatin C (Cys C), and homocysteine) were screened by the Lasso regression. The nomogram was constructed using these factors, as well as the CKD stage. The included factors (age, CKD stage, UACR, potassium, Cys C, and homocysteine) were all significantly related to the death of CKD patients, according to the multivariate Cox regression analysis. The internal validation showed that this nomogram demonstrates good discrimination and calibration (adjusted C-index: 0.70; AUC of 3-, 5-, and 10-year OS were 0.75, 0.78, and 0.77, respectively). External validation also demonstrated exceedingly similar results (C-index: 0.72, 95% CI: 0.69–0.76; AUC of 3-, 5-, and 10-year OS were 0.76, 0.79, and 0.80, respectively).

Conclusions

This study effectively constructed a novel nomogram that incorporates CKD stage, age, UACR, potassium, Cys C, and homocysteine, which can be conveniently used to facilitate the individualized prediction of survival probability in patients with stage 3–5 CKD. It displays valuable potential for clinical application.

First national registry on the effectiveness and safety of evolocumab in clinical practice in patients attended in cardiology in Spain. The RETOSS-CARDIO study

OBJECTIVE

To present the first registry used to analyse the clinical profile of patients treated with evolocumab in Spain, including the effectiveness on the lipid profile and safety in the «real world» setting.

METHODS

Multicentre, retrospective, and observational study of patients starting treatment with evolocumab from February 2016 to May 2017 in clinical practice in Spanish cardiology units.

RESULTS

A total of 186 patients (mean age 60.3 ± 9.8 years were included, 35.5% with familial hypercholesterolaemia, and 94.1% with a previous cardiovascular event) from 31 cardiology units. Baseline lipid profile: Total cholesterol 219.4 ± 52.2 mg/dL, LDL-cholesterol 144.0 ± 49.0mg/dL, HDL-cholesterol 47.7 ± 13.0mg/dL, and triglycerides 151.0 ± 76.2mg/dL. At the time of initiating evolocumab, 53.8% of patients were taking statins (50% had partial or total intolerance to statins), and 51.1% ezetimibe. In all cases, the dose of evolocumab used was 140 mg, mainly every 2 weeks (97.3%). Evolocumab compliance was high (92.3%). Treatment with evolocumab was interrupted in 6 patients (3.2%), with only 1 (0.5%) due to a probable side effect. Evolocumab significantly reduced total cholesterol (30.9% at week 2, and 39.3% at week 12; P<.001), LDL cholesterol (44.4% and 57.6%, respectively; P<.001), and triglycerides (14.8% and 5.2%, respectively; P<001), with no significant changes in HDL-cholesterol (6.7% and 2.0%; P=.14).

CONCLUSIONS

In clinical practice, evolocumab is associated with reductions in LDL cholesterol, with nearly 60% after 12 weeks of treatment, and with low rates of interruptions due to side effects and high medication compliance. These results are consistent with those reported in randomised clinical trials.

Evaluation of internal medicine physicians' attitudes toward the treatment of dyslipidemia

Objectives: Dyslipidemia is one of the risk factors for atherosclerotic cardiovascular disease. Cardiovascular events decrease with decreasing LDL-C levels and all guidelines emphasize the importance of LDL-C lowering. However, implementation in real life is suboptimal. This study aimed to evaluate the treatment approaches to the dyslipidemia of physicians. Methods: This study was conducted as an online survey for internal medicine specialists and residents. The survey included questions on the physicians' demographics, their attitudes toward dyslipidemia management in three different case scenarios and questions. The physicians were asked to indicate their treatment and guideline preferences in the three cases. Results: Among the 366 participants 67.5% were internal medicine specialists and 18.9% were internal medicine residents. Fourteen percent of physicians did not use guidelines in clinical practice. Five percent of specialists and 10.1% of residents doubted the necessity of dyslipidemia treatment, 30% of both specialists and residents were affected by the patient's reluctance. The specialists were more likely to state that reaching the target LDL-C should be a priority compared to the residents (p = 0.003). Most physicians (58.7%) treated the patients according to the guideline recommendations if the patients were at high risk. They were less likely to get to guideline recommendation goals if the patients were at low risk (29.8%). Conclusion: Despite overwhelming evidence, some physicians did not use guidelines and some physicians doubted the necessity of dyslipidemia treatment. A significant proportion of physicians were affected by the patient's reluctance. There is a clear need to educate physicians about the importance of guidelines.

Recommendations to improve lipid control. Consensus document of the Spanish Society of Cardiology

T***he current control of low-density lipoprotein cholesterol among patients with atherosclerotic cardiovascular disease is very low and this is associated with an increase of cardiovascular outcomes. In addition, the latter this happens, the risk will be greater. This is mainly due to an insufficient use of the lipid-lowering therapy currently available. In fact, with current treatments (statins, ezetimibe and PCSK9 inhibitors), the majority of patients in secondary prevention should achieve low-density lipoprotein cholesterol goals. For these reasons, in this manuscript promoted by the Spanish Society of Cardiology we propose three simple and feasible decision-making algorithms that include the majority of clinical scenarios among patients with ischemic heart disease, with the double aim of attaining therapeutic goals in the majority of patients as soon as possible; in secondary prevention the magnitude of the benefit is risk- and time-dependent.

[Clinical and economic consequences in patients initiating therapy with clopidogrel brand-name vs. generic: A real-life retrospective study]

OBJECTIVE

To evaluate the adherence to treatment, resource use, and costs in subjects initiating treatment with brand-name versus generic clopidogrel for acute coronary syndrome (ACS) and peripheral arterial disease (PAD).

PATIENTS AND METHODS

Observational, retrospective study based on the medical records of patients aged ≥18 years who initiated treatment with clopidogrel (brand-name vs. generic) between 4 April 2015 and 31 March 2017. Four study groups were compared, and the follow-up was one year. The main measurements were: comorbidity, treatment adherence, medication possession ratio (MPR), resource use, and costs. The results were analysed using multivariate analysis. The level of statistical significance was P<.05.

RESULTS

Four groups were compared: a) ACS: brand-name clopidogrel (N=1,067) vs. generic (N=3,504), and b) PAD: brand-name clopidogrel (N=425) vs. generic (N=994). In the ACS comparison (mean age: 69.7 years, 61.4% male), adherence (65.3% vs. 61.0%, P<.001), adjusted hazard ratio 0.85 and MPR (89.8% vs. 86.7%, P=.045) were more superior with brand-name clopidogrel than with the generic and with a lower mean cost per unit (€2,890 vs. €3,865, P=.001). In the PAD comparison, similar results were observed: persistence (64.7% vs. 58.9%, P=.039); adjusted hazard-ratio 0.86 and MPR (88.6% vs. 81.7%; P=.013) were more superior with brand-name clopidogrel than for the generic, with a lower mean cost per unit (€2,880 vs. €3,532, P=.044).

CONCLUSIONS

There was better treatment adherence in patients initiating treatment with brand-name compared with generic clopidogrel for ACS and PAD, resulting in lower health costs for the Spanish National Health System.

The prevalence and risk factors associated with dyslipidemia in type 2 diabetic patients in the autonomous Region of Cantabria

BACKGROUND AND OBJECTIVE

Dyslipidemia is one of the main risk factors in cardiovascular disease in patients with diabetes mellitus type 2 (DM2). The aim of this study is to evaluate the prevalence and risk factors associated with dyslipidemia in the population with diabetes mellitus type 2 in the region of Cantabria.

MATERIAL AND METHODS

This is a transversal study carried out at Cantabrian primary health care centres (n=680). A representative, random sample of the population with DM2, ranging from 18-85, was selected using a multistage procedure. The medical records were obtained, and by means of interviews the data of the risk factors to be studied was secured. The correlation with dyslipidemia was analysed by means of logistic regression.

RESULTS

There were 52.1% of males, the average age was 69.8, the evolution of diabetes was 9.99 years, 84.3% had arterial hypertension, 76.6% were overweight or obese and the average HbA1c was 6.96%. The prevalence of dyslipidemia was 85.3%, and in the bivariate analysis this is associated with a history of peripheral artery disease, controlled diabetes, antihypertensive treatment, glomerular filtration, HbA1c>7%, body fat estimated as being either overweight or obese, a history of cardiovascular disease, age and HbA1c. In the multivariate analysis the independent factors were being female and a history of cardiovascular disease.

CONCLUSION

The prevalence of dyslipidemia in our study was 85.3%, and is consistent with figures found in previous published studies. The independent associated risk factors were being female and a past medical history of cardiovascular disease.

Remnant Lipoprotein Cholesterol Independently Associates With In-Stent Restenosis After Drug-Eluting Stenting for Coronary Artery Disease

This study evaluated the prognostic value of remnant lipoprotein cholesterol (RLP-C) as a predictor of in-stent restenosis (ISR) after drug-eluting stent (DES) implantation in patients with coronary artery disease (CAD). Consecutive patients with CAD (n = 612) who underwent both successful coronary DES implantation and follow-up angiography ranging from 6 to 24 months were enrolled. The independent predictors of ISR were explored by multivariate logistic regression analysis; 95 (15.52%) patients were identified to have ISR. Multivariate logistic regression analysis showed that RLP-C concentration (odds ratio [OR]: 4.245, 95% confidence interval [CI]: 2.493-7.229), age (OR: 1.026, 95% CI: 1.002-1.051), diabetes mellitus (DM; OR: 1.811, 95% CI: 1.134-2.892), and lesion length (OR: 1.013, 95% CI: 1.002-1.024) were associated with ISR. Via subgroup analysis, we found that RLP-C was independently associated with ISR in both CAD with DM (OR: 4.154, 95% CI: 1.895-9.104) and CAD without DM (OR: 4.455, 95% CI: 2.097-9.464) groups. In the analysis of the receiver operating characteristics curve, RLP-C level >0.515 mmol/L exhibited 77.9% sensitivity and 56.5% specificity (area under the curve: 0.705, 95% CI: 0.648-0.762) in predicting ISR. In conclusion, RLP-C is independently associated with the development of ISR in patients with CAD after DES implantation.

Visit-to-visit fasting plasma glucose variability is an important risk factor for long-term changes in left cardiac structure and function in patients with type 2 diabetes

BACKGROUND

To investigate the effect of visit-to-visit fasting plasma glucose (FPG) variability on the left cardiac structure and function in patients with type 2 diabetes mellitus (T2DM).

METHODS

In this prospective cohort study, 455 T2DM patients were included and follow-up for a median of 4.7 years. FPG measured on every hospital visit was collected. FPG variability was calculated by its coefficient of variation (CV-FPG). Left cardiac structure and function were assessed using echocardiography at baseline and after follow-up. Multivariable linear regression analyses were used to estimate the effect of FPG variability on the annualized changes in left cardiac structure and function. Subgroup analysis stratified by mean HbA1c levels (< 7% and ≥ 7%) were also performed.

RESULT

In multivariable regression analyses, CV-FPG was independently associated with the annualized changes in left ventricle (β = 0.137; P = 0.031), interventricular septum (β = 0.215; P = 0.001), left ventricular posterior wall thickness (β = 0.129; P = 0.048), left ventricular mass index (β = 0.227; P < 0.001), and left ventricular ejection fraction (β = - 0.132; P = 0.030). After additionally stratified by mean HbA1c levels, CV-FPG was still independently associated with the annualized changes in the above parameters in patients with HbA1c ≥ 7%, while not in patients with HbA1c < 7%.

CONCLUSIONS

Visit-to-visit variability in FPG could be a novel risk factor for the long-term adverse changes in left cardiac structure and systolic function in patients with type 2 diabetes. Trial registration ClinicalTrials.gov (NCT02587741), October 27, 2015, retrospectively registered.

Consensus document of the Spanish Society of Arteriosclerosis (SEA) for the prevention and treatment of cardiovascular disease in type 2 diabetes mellitus

A consensus document of the Diabetes working group of the Spanish Society of Arteriosclerosis (SEA) is presented, based on the latest studies and conceptual changes that have appeared. It presents the cardiovascular risk in type 2 diabetes mellitus (T2DM) and the action guidelines for the prevention and treatment of cardiovascular disease (CVD) associated with T2DM. The importance of lipid control, based on the objective of LDL-C and non-HDL-C when there is hypertriglyceridemia, and the blood pressure control in the prevention and treatment of CVD is evaluated. The new hypoglycemic drugs and their effects on CVD are reviewed, as well as the treatment and control guidelines of hyperglycemia. Likewise, the use of antiplatelet agents is considered. Emphasis is placed on the importance of global and simultaneous action on all risk factors to achieve a significant reduction in cardiovascular events. This supplement is sponsored by Laboratorios Esteve, S.A.

Treatment persistence and adherence and their consequences on patient outcomes of generic versus brand-name statins routinely used to treat high cholesterol levels in Spain: a retrospective cost-consequences analysis

Background

High blood lipoprotein concentrations are one of the major risk factors for cardiovascular diseases. Drug therapy is the base of treatment; statins in particular. Both brand-name and generic presentations are available for statin therapy of high cholesterol levels. Factors that may influence their use in routine medical practice include, among others, patient persistence and adherence to treatment as prescribed by physicians. The aim of this retrospective analysis was to provide real-world evidence of treatment persistence and adherence and their consequences on economic and patient outcomes of generic versus brand-name statins routinely used to treat high cholesterol levels in Spain.

Methods

Existing real-world electronic medical records abstracted from a database of two regions in Spain were analyzed. The analysis compared generic versus brand-name statins data from subjects’ who started treatment between July 1, 2010 and June 30, 2012. Treatment persistence, adherence expressed as medication possession ratio (MPR), healthcare resource utilization and their costs were analyzed together with patient’s at-goal rates of low-density-lipoprotein-cholesterol (LDL-c), incidence of any major cardiovascular event (CVE) and all-cause mortality during a 5-year follow-up period. Multivariate analyses were applied.

Results

A total of 13,244 records were included. Persistence was lower with generics; adjusted hazard ratio -HR- [95% confidence interval]: 0.86 [0.82–0.91], p < 0.001) and MPR was also lower: 61.5% vs. 65.1% (p < 0.001). Less patients with generics reached their LDL-c goal: 39.2% [38.3–40.2%] vs. 42.0% [40.2–43.7%]; adjusted odds ratio; 0.87 [0.80–0.95], p = 0.003. Compared to brand-name statins, the observed probability of occurrence of a CVE; HR: 1.31 [1.15–1.50], p < 0.001, and also all-cause deaths; HR: 1.36 [1.15–1.62], was significantly higher with generics; p < 0.001 in both cases. Adjusted mean total healthcare cost per patient was also higher with generic than with brand-name statins: €9118 (9059–9176) vs. €7980 (7853–8808) [adjusted difference: €1137 (997–1277), p < 0.001].

Conclusion

This retrospective cost-consequences analysis found poorer treatment persistence and adherence in patients who first started therapy with generic instead of brand-name statins in routine medical practice in Spain. Also, patients receiving generics were more unlikely to reach LDL-c goals, showed increased probability of having CVE and all-cause mortality at a higher cost to payers.

Electronic supplementary material

The online version of this article (10.1186/s12944-018-0918-y) contains supplementary material, which is available to authorized users.

Population and methodology of the SIMETAP study: Prevalence of cardiovascular risk factors, cardiovascular diseases, and related metabolic diseases

The prevention of cardiovascular disease is based on the detection and control of cardiovascular risk factors (CVRF). In Spain there are important geographical differences both in the prevalence and in the level of control of the CVRF. In the last decade there has been an improvement in the control of hypertension and dyslipidaemia, but a worsening of cardio-metabolic risk factors related to obesity and diabetes. The SIMETAP study is a cross-sectional descriptive, observational study being conducted in 64 Primary Care Centres located at the Community of Madrid. The main objective is to determine the prevalence rates of CVRF, cardiovascular diseases, and metabolic diseases related to cardiovascular risk. A report is presented on the baseline characteristics of the population, the study methodology, and the definitions of the parameters and diseases under study. A total of 6,631 study subjects were selected using a population-based random sample. The anthropometric variables, lifestyles, blood pressure, biochemical parameters, and pharmacological treatments were determined. The highest crude prevalences were detected in smoking, physical inactivity, obesity, prediabetes, diabetes, hypertension, dyslipidaemias, and metabolic syndrome. A detailed analysis needs to be performed on the prevalence rates, stratified by age groups, and prevalence rates adjusted for age and sex to assess the true epidemiological dimension of these CVRF and diseases.