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Revankar S, Park JK, Satish P, Agarwala A. Is there a role for earlier use of combination therapy? Am J Prev Cardiol 2024; 17:100639. [PMID: 38419948 PMCID: PMC10900258 DOI: 10.1016/j.ajpc.2024.100639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
As the global population ages and cardiovascular risk factors rise, we can expect a continued increase in atherosclerotic disease. Low-density lipoprotein cholesterol (LDL-C) reduction is a cornerstone of cardiovascular risk reduction with strong, causal evidence indicating that the greatest benefit is derived from early and large decreases in LDL-C. Despite the adoption of statins as the backbone of lipid-therapy regimens, numerous studies and registry analyses reveal our collective inability to achieve LDL-C goals in high-risk patients. Combination therapy with ezetimibe has been shown to result in statistically significant decreases in LDL-C level, atheroma volume, and cardiovascular adverse event rates. A major barrier to implementing an upfront combination therapy approach is the perceived side effects from therapeutic agents although multiple studies show that a therapeutic patient-physician relationship could overcome this issue. Novel agents such as PCSK-9 inhibitors, bempedoic acid, and inclisiran have the potential to achieve similar outcomes although additional research is needed regarding the cost effectiveness of these approaches. Despite these hurdles, there is a role for the newer agents early in the disease course of high-risk patients such as those with markedly elevated LDL-C >190 mg/dL and FH. The implementation of upfront combination therapy, especially in high-risk patients, will decrease clinical inertia while allowing for earlier consideration of newer, effective agents to decrease cardiovascular burden.
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Affiliation(s)
- Shruti Revankar
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jong Kun Park
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA
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Boeckling F, Stähli BE, Rudolph T, Lutz M, Schatz AS, Vogelmann T, Stueve M, West NEJ, Boone E, Erbay A, Leistner DM. Fractional flow reserve measurements and long-term mortality-results from the FLORIDA study. Front Cardiovasc Med 2024; 11:1337941. [PMID: 38404721 PMCID: PMC10885355 DOI: 10.3389/fcvm.2024.1337941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
Background Randomized evidence suggested improved outcomes in fractional flow reserve (FFR) guidance of coronary revascularization compared to medical therapy in well-defined patient cohorts. However, the impact of FFR-guided revascularization on long-term outcomes of unselected patients with chronic or acute coronary syndromes (ACS) is unknown. Aims The FLORIDA (Fractional FLOw Reserve In cardiovascular DiseAses) study sought to investigate outcomes of FFR-guided vs. angiography-guided treatment strategies in a large, real-world cohort. Methods This study included patients enrolled into the German InGef Research Database. Patients undergoing coronary angiography between January 2014 and December 2015 were included in the analysis. Eligible patients had at least one inpatient coronary angiogram for suspected coronary artery disease between January 2014 and December 2015. Patients were stratified into FFR arm if a coronary angiography with adjunctive FFR measurement was performed, otherwise into the angiography-only arm. Matching was applied to ensure a balanced distribution of baseline characteristics in the study cohort. Patients were followed for 3 years after index date and primary endpoint was all-cause mortality. Results In the matched population, mortality at 3 years was 9.6% in the FFR-assessed group and 12.6% in the angiography-only group (p = 0.002), corresponding to a 24% relative risk reduction with use of FFR. This effect was most pronounced in patients in whom revascularization was deferred based on FFR (8.7% vs. 12.3%, p = 0.04) and in high-risk subgroups including patients aged ≥75 years (14.9% vs. 20.1%, p < 0.01) and those presenting with ACS (10.2% vs. 14.0%, p = 0.04). Conclusions FFR-based revascularization strategy was associated with reduced mortality at 3 years. These findings further support the use of FFR in everyday clinical practice.
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Affiliation(s)
- Felicitas Boeckling
- Department of Medicine, Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Barbara E. Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Tanja Rudolph
- Department for General and Interventional Cardiology/Angiology, Heart- und Diabetes Center NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Matthias Lutz
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne-Sophie Schatz
- Department of Cardiology, Charité—University Medicine Berlin, Berlin, Germany
| | | | | | | | - Els Boone
- Abbott Vascular, Santa Clara, CA, United States
| | - Aslihan Erbay
- Department of Medicine, Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - David M. Leistner
- Department of Medicine, Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Relation of Cardiovascular Events and Deaths to Low-Density Lipoprotein Cholesterol Level Among Statin-Treated Patients With Atherosclerotic Cardiovascular Disease. Am J Cardiol 2019; 123:1739-1744. [PMID: 30948001 DOI: 10.1016/j.amjcard.2019.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023]
Abstract
This study describes subsequent cardiovascular events and deaths by low-density lipoprotein cholesterol (LDL-C) level in patients with atherosclerotic cardiovascular disease (ASCVD) receiving moderate- to high-intensity statins. Olmsted County, Minnesota residents with index ASCVD (myocardial infarction, unstable angina, coronary revascularization, ischemic stroke or transient ischemic attack) occurring between 2005 and 2012 were identified, and those with a prescription for a moderate- or high-intensity statin and an LDL-C measurement in the 90 days after index were included. Cox regression models were used to examine associations between LDL-C, modeled as a time-dependent variable, and a composite outcome of subsequent cardiovascular events or all-cause death. Among 1,854 patients with ASCVD (mean [SD] age 66.0 [13.3] years, 63.6% male), a total of 1,241 events were observed from index ASCVD through follow-up (median of 5.9 years). The rate (95% confidence interval) per 100 person-years was 11.26 (10.64 to 11.91). Starting follow-up 90 days after index ASCVD event, the rates per 100 person-years were 10.51 (9.57 to 11.52), 9.57 (8.66 to 10.55), and 11.40 (9.96 to 12.98) for LDL-C <70, 70-<100 and ≥100 mg/dl, respectively. After adjustment for age, sex, and previous diagnoses of ASCVD, diabetes, hypertension, heart failure, and chronic kidney disease, the hazard ratio for cardiovascular event and/or death was significantly higher for patients with LDL-C ≥100 mg/dl than those with LDL-C <70 mg/dl (1.31 [1.08 to 1.59]). In conclusion, in patients with ASCVD, subsequent cardiovascular events occur at a high rate and the rates are highest in patients with LDL-C ≥100 mg/dl suggesting unmet treatment needs even in patients receiving moderate- to high-intensity statins.
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Janković SM, Tešić D, Anđelković J, Kostić M. Profile of evolocumab and its cost-effectiveness in patients with high cardiovascular risk: literature review. Expert Rev Pharmacoecon Outcomes Res 2018; 18:461-474. [PMID: 30014724 DOI: 10.1080/14737167.2018.1501679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Evolocumab is fully human monoclonal antibody which binds to proprotein convertase subtilisin/kexin type 9 (PCSK9), and prevents its blocking effect on recycling of liver low-density lipoprotein (LDL) receptors. Areas covered: The aim of this review is to assess efficacy, safety, and cost-effectiveness of evolocumab in adult patients with high cardiovascular risk. Major research databases MEDLINE, EBSCO, and CENTRAL were systematically searched for relevant study reports. Expert commentary: Even when given in full doses, statins augmented with ezetimibe and cholesterol-binding resins could not reduce cholesterol baseline level for more than 66%, while evolocumab reduces cholesterol level for 75% or even more. Up to now, evolocumab showed good safety profile, and patents tolerate it very well. The abovementioned advantages of evolocumab made it almost ideal drug for hypercholesterolemia, and probably in the future the best drug for secondary prevention of major cardiovascular events. Evolocumab is borderline cost-effective for the treatment of patients with high cardiovascular risk in European countries, while in the U.S.A. it is under debate where the underlying assumption (risk of cardiovascular disease events) determine the true value.
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Affiliation(s)
- Slobodan M Janković
- a Faculty of Medical Sciences, Department of Pharmacology and Toxicology , University of Kragujevac , Kragujevac , Serbia
| | - Danka Tešić
- b Sector for Clinical Trial , Medicines and Medical Devices Agency of Serbia , Belgrade , Serbia
| | - Jelena Anđelković
- c Veterinary Medicines , Medicines and Medical Devices Agency of Serbia , Belgrade , Serbia
| | - Marina Kostić
- a Faculty of Medical Sciences, Department of Pharmacology and Toxicology , University of Kragujevac , Kragujevac , Serbia
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Cherepanov D, Bentley TGK, Hsiao W, Xiang P, O'Neill F, Qian Y, Yurgin N, Beenhouwer D. Real-world cardiovascular disease burden in patients with atherosclerotic cardiovascular disease: a comprehensive systematic literature review. Curr Med Res Opin 2018; 34:459-473. [PMID: 29105492 DOI: 10.1080/03007995.2017.1401529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Based on randomized controlled trials (RCTs), non-fatal myocardial infarction (MI) rates range between 9 and 15 events per 1000 person-years, ischemic stroke between 4 and 6 per 1000 person-years, CHD death rates between 5 and 7 events per 1000 person-years, and any major vascular event between 28 and 53 per 1000 person-years in patients with atherosclerotic cardiovascular disease (ASCVD). We reviewed global literature on the topic to determine whether the real-world burden of secondary major adverse cardiovascular events (MACEs) is higher among ASCVD patients. METHODS We searched PubMed and Embase using MeSH/keywords including cardiovascular disease, secondary prevention and observational studies. Studies published in the last 5 years, in English, with ≥50 subjects with elevated low-density lipoprotein cholesterol (LDL-C) or on statins, and reporting secondary MACEs were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of each included study. RESULTS Of 4663 identified articles, 14 studies that reported MACE incidence rates per 1000 person-years were included in the review (NOS grades ranged from 8 to 9; 2 were prospective and 12 were retrospective studies). Reported incidence rates per 1000 person-years had a range (median) of 12.01-39.9 (26.8) for MI, 13.8-57.2 (41.5) for ischemic stroke, 1.0-94.5 (21.1) for CV-related mortality and 9.7-486 (52.6) for all-cause mortality. Rates were 25.8-211 (81.1) for composite of MACEs. Multiple event rates had a range (median) of 60-391 (183) events per 1000 person-years. CONCLUSIONS Our review indicates that MACE rates observed in real-world studies are substantially higher than those reported in RCTs, suggesting that the secondary MACE burden and potential benefits of effective CVD management in ASCVD patients may be underestimated if real-world data are not taken into consideration.
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Affiliation(s)
- Dasha Cherepanov
- a Partnership for Health Analytic Research LLC , Beverly Hills , CA , USA
| | - Tanya G K Bentley
- a Partnership for Health Analytic Research LLC , Beverly Hills , CA , USA
| | - Wendy Hsiao
- b Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Pin Xiang
- c Amgen Inc. , Thousand Oaks , CA , USA
| | | | - Yi Qian
- c Amgen Inc. , Thousand Oaks , CA , USA
| | | | - David Beenhouwer
- a Partnership for Health Analytic Research LLC , Beverly Hills , CA , USA
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Toth PP, Stevens W, Chou JW. Why published studies of the cost-effectiveness of PCSK-9 inhibitors yielded such markedly different results. J Med Econ 2017; 20:749-751. [PMID: 28471246 DOI: 10.1080/13696998.2017.1327440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Peter P Toth
- a CGH Medical Center , Sterling , IL , USA
- b Ciccarone Center for the Prevention of Heart Disease, John Hopkins University School of Medicine , Lutherville , MD , USA
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