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Landmesser U, Koenig W, Leiter LA, Raal FJ, Ray KK, Wright RS, Han J, Conde LG, Schwartz GG. Inclisiran in patients with prior myocardial infarction: A post hoc pooled analysis of the ORION-10 and ORION-11 Phase 3 randomised trials. Atherosclerosis 2023; 386:117354. [PMID: 38016401 DOI: 10.1016/j.atherosclerosis.2023.117354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/22/2023] [Accepted: 10/17/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND AIMS Among patients with prior myocardial infarction (MI), the risk of future ischaemic cardiovascular events is increased, and intensive lipid-lowering therapy (LLT) is indicated to achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals. Here, the efficacy and safety of inclisiran, a small interfering ribonucleic acid, were evaluated in patients with or without prior MI from the pooled ORION-10 and ORION-11 Phase 3 trials. METHODS Patients (n = 2636) were randomised 1:1 to receive 284 mg inclisiran (300 mg inclisiran sodium) or placebo on Day 1, Day 90, and 6-monthly thereafter over 18 months, along with background oral LLT, including statins. Of these, 1643 (62.3%) patients had an MI prior to randomisation, stratified as recent (>3 months to <1 year) or remote (≥1 year), and 993 (37.7%) patients were without a prior MI. The percentage change in LDL-C from baseline and safety were assessed. RESULTS Baseline characteristics were well balanced across the treatment arms and MI strata. The mean (95% confidence interval) placebo-corrected LDL-C reductions from baseline to Day 510 with inclisiran were 52.6% (40.1, 65.1), 50.4% (47.0, 53.8), and 51.6% (47.4, 55.9) for recent, remote, and no prior MI, respectively. Corresponding time-adjusted LDL-C reductions were 50.0% (41.4, 58.7), 52.2% (49.8, 54.7), and 51.2% (48.1, 54.2). In each MI stratum, treatment-emergent adverse events (TEAEs) at the injection site (all mild to moderate) were observed more in inclisiran-treated patients than placebo, without an excess of other TEAEs. CONCLUSIONS Inclisiran provided effective and consistent LDL-C lowering, irrespective of MI status.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité; Charité Universitätsmedizin Berlin, Berlin Institute of Health (BIH), DZHK, Partner Site Berlin, Berlin, Germany.
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, and German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany; Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Frederick J Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College, London, UK
| | - R Scott Wright
- Division of Preventive Cardiology and Department of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Jackie Han
- Novartis Pharmaceuticals Corp, East Hanover, NJ, USA
| | | | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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Wambua PM, Khan Z, Kariuki CM, Ogola EN. A Retrospective Study on the Adoption of Lipid Management Guidelines in Post-Myocardial Infarction Patients in a Tertiary Care Centre. Cureus 2023; 15:e41402. [PMID: 37546064 PMCID: PMC10402653 DOI: 10.7759/cureus.41402] [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] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Lipid management after acute myocardial infarction (AMI) is one of the important aspects of secondary prevention in the high cardiovascular (CV) risk group, and targeted reduction of low-density lipoprotein cholesterol (LDL-C) remains the primary target for lipid therapy after myocardial infarction (MI). STUDY OBJECTIVE To conduct a retrospective study of the adequacy of lipid management in post-MI patients admitted to a tertiary care centre as compared to the 2019 European Society of Cardiology (ESC) guidelines for the management of dyslipidaemia. METHODOLOGY The study was a retrospective review of medical records of patients admitted with MI under the Ubora Heart Service, Nairobi Hospital, from January 2020 to June 2022. RESULTS The study population included 79 patients, with a mean age of 59.3 (SD ±12), predominantly male (61 patients, 77.2%), and of African descent (60 patients, 75.9%). The majority of the study population presented with an ST-segment elevation myocardial infarction (STEMI) (62%), and the six most prevalent cardiovascular risk factors recorded amongst the patients were: systemic arterial hypertension in 50 (63.3%) patients; dyslipidaemia in 34 (43.0%); type II diabetes mellitus (T2DM) in 25 (31.6); history of smoking in 12 (15.2%); obesity or being overweight in 12 (15.1%); and family history of premature coronary artery disease or sudden cardiac death in four (5.1%) patients. Moreover, 88.6% of the patients had their lipid profile assessment done within 48 hours of admission, with a mean LDL-C level of 3.18 mmol/L (SD ±.18). All the patients recruited in the study were started on high-intensity statins with either 40 mg or 80 mg of atorvastatin or 20 mg or 40 mg of rosuvastatin. Thirty-nine (44%) patients recruited had repeat lipid profiles on follow-up, with a median lipid analysis time of five months (interquartile range (IQR): 2.0-10.0). Of those, only six (17.1%) achieved the LDL-C goal of <1.4 mmo/L while only 16 (45.7%) achieved a greater than 50% reduction from their baseline LDL-C level, with three (8.6%) patients having an increased LDL-C level from baseline. Overall, 14.7% of the patients studied achieved the guideline-recommended LDL-C goal of an LDL-C target of <1.4 mmo/L and a ≥ 50% reduction from baseline LDL-C. After five months of follow-up, 75 (94.9%) patients were on statin monotherapy, with 4 (5.1%) on high-intensity statin and ezetimibe combination therapy. CONCLUSION This retrospective study highlights the need for early sensitisation and the adoption of secondary prevention strategies in acute coronary syndrome (ACS), as recommended by the 2019 ESC guidelines.
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Affiliation(s)
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
- Cardiology, Barts Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
| | - Charles M Kariuki
- Cardiology, Ubora Heart Service, Nairobi, KEN
- Cardiology, The Nairobi Hospital, Nairobi, KEN
| | - Elijah N Ogola
- Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, KEN
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Salem AM, Harris D, Bray JJH, Obaid DR, Stephens JW, Halcox J. Achievement of the ESC recommendations for secondary prevention of cardiovascular risk factors in high-risk patients with type 2 diabetes: A real-world national cohort analysis. Int J Cardiol 2023; 377:104-111. [PMID: 36764610 DOI: 10.1016/j.ijcard.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
AIM To assess compliance with European Society of Cardiology (ESC) secondary prevention recommendations in a nationwide contemporary population with diabetes mellitus (DM) and coronary artery disease. METHOD We conducted a retrospective observational study using linked health data in patients across Wales with DM undergoing percutaneous coronary intervention (2012-2017). The follow-up was for one year. We analysed the clinical characteristics, medications, target levels for HbA1c, low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C) and blood pressure against the ESC prevention guidelines. RESULTS Overall, 3478 patients with diabetes had available data at 1-year post-PCI. Only 43% had HbA1c levels <53 mmol/L, but 81% had blood pressure < 140/80 (current ESC targets). Prescribing frequency of the newer hypoglycaemic agents (glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors) was suboptimal, with a higher rate in patients with HbA1c ≥53 mmol/mol. Only 51% & 27% of the patients had LDL-C levels <1.8 &1.4 mmol/L (2016 & 2019 guidelines recommendations respectively), and 55% & 34% had non-HDL-C levels <2.6 & 2.2 mmol/L (2016 & 2019 guidelines respectively). Of the uncontrolled LDL-C patients, 42% (2016 target) and 35% (2019 target) were prescribed high-intensity statins. Females were more likely to have LDL-C targets above the recommended level. CONCLUSION Achievement of ESC treatment goals in this very-high risk cohort for DM and hyperlipidaemia was far from optimal, with a low prescription rate of the guidelines-recommended therapy. Target goals for hypertension were met more frequently. An up-to-date analysis reflecting the current practice against the most recent guidelines is warranted.
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Affiliation(s)
- Ahmed M Salem
- Cardiology Department, Swansea Bay University Health Board, United Kingdom; Institute of Life Sciences-2, Swansea University Medical School, United Kingdom.
| | - Daniel Harris
- Cardiology Department, Swansea Bay University Health Board, United Kingdom; Institute of Life Sciences-2, Swansea University Medical School, United Kingdom
| | - Jonathan J H Bray
- Institute of Life Sciences-2, Swansea University Medical School, United Kingdom
| | - Daniel R Obaid
- Cardiology Department, Swansea Bay University Health Board, United Kingdom; Institute of Life Sciences-2, Swansea University Medical School, United Kingdom
| | - Jeffrey W Stephens
- Institute of Life Sciences-2, Swansea University Medical School, United Kingdom; Department of Diabetes and Endocrinology, Swansea Bay University Health Board, United Kingdom
| | - Julian Halcox
- Cardiology Department, Swansea Bay University Health Board, United Kingdom; Institute of Life Sciences-2, Swansea University Medical School, United Kingdom
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Hiremath J, Mohan JC, Hazra P, Sawhney JS, Mehta A, Shetty S, Oomman A, Shah MK, Bantwal G, Agarwal R, Karnik R, Jain P, Ray S, Das S, Jadhao V, Suryawanshi S, Barkate H. Bempedoic Acid for Lipid Management in the Indian Population: An Expert Opinion. Cureus 2023; 15:e35395. [PMID: 36987470 PMCID: PMC10040092 DOI: 10.7759/cureus.35395] [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] [Accepted: 02/24/2023] [Indexed: 03/30/2023] Open
Abstract
Lipid-lowering is a central theme in the management of patients with atherosclerotic cardiovascular disease (ASCVD) and heterozygous familial hypercholesterolemia (HeFH), with statins being currently used as the first-line lipid-lowering agent (LLAs). Bempedoic acid (BA) has been recently approved for lipid management in ASCVD/HeFH patients. This expert opinion paper brings out the essential concept to assess the current place of BA in the Indian population. Here we highlight that the majority of the patients with clinical ASCVD may not be receiving the optimal dose of statin, thereby failing to achieve their lipid targets. The addition of BA to statin results in a significant reduction in low-density lipoprotein cholesterol (LDL-C) along with substantial reductions in non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), and high-sensitivity C-reactive protein (hsCRP) levels. For patients who do not achieve LDL-C targets, BA can be an effective add-on alternative to choose among non-statin LLAs. BA is a good choice for statin-intolerant cases, especially in combination with ezetimibe. Given the lack of effect of worsening hyperglycemia or any increase in the occurrence of new-onset diabetes, BA can be used without hesitation in patients with diabetes. The small risk of hyperuricemia could be mitigated with appropriate patient selection and monitoring of serum uric acid levels in patients at high risk of hyperuricemia. We believe BA is an excellent non-statin therapy that is efficacious, well-tolerated, and cost-effective for lipid management in ASCVD, HeFH, and statin-intolerant patients in India.
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Affiliation(s)
| | - J C Mohan
- Cardiology, Jaipur Golden Hospital, Jaipur, IND
| | - Prakash Hazra
- Cardiology, Apollo Clinic Hospitals, Ballygunge, Kolkata, IND
| | - Jp S Sawhney
- Cardiology, Sir Ganga Ram Hospital, New Delhi, IND
| | | | - Sadanand Shetty
- Cardiology, Sadanand Healthy Living Center (P) Ltd. Sion (East), Mumbai, IND
| | | | - Mahesh K Shah
- Cardiology, MK's Heart Care, Vile Parle, Mumbai, IND
| | - Ganapathi Bantwal
- Endocrinology, Diabetes and Metabolism, St. John's Medical College and Hospital, Bengaluru, IND
| | | | - Rajiv Karnik
- Cardiology, Dr. Karnik's Cardiac Clinic, Mulund West, Mumbai, IND
| | - Peeyush Jain
- Cardiology, Fortis-Escorts Heart Institute and Research Centre, Delhi, IND
| | - Saumitra Ray
- Cardiology, Woodlands Multispeciality Hospital, Kolkata, IND
| | - Sambit Das
- Endocrinology, HiTech Medical College and Hospitals, Bhubaneshwar, IND
| | - Vibhuti Jadhao
- Global Medical Affairs, Glenmark Pharmaceuticals Limited, Mumbai, IND
| | | | - Hanmant Barkate
- Global Medical Affairs, Glenmark Pharmaceuticals Limited, Mumbai, IND
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Mazhar F, Hjemdahl P, Clase CM, Johnell K, Jernberg T, Carrero JJ. Lipid-lowering treatment intensity, persistence, adherence and goal attainment in patients with coronary heart disease. Am Heart J 2022; 251:78-90. [PMID: 35654163 DOI: 10.1016/j.ahj.2022.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND To examine patterns of lipid-lowering therapy (LLT) use, and persistence and adherence among patients with coronary heart disease and their associations with lipoprotein cholesterol (LDL-C) goal attainment. METHODS Observational study among 26,768 patients who had suffered a myocardial infarction or had been revascularized in Stockholm during 2012 to 2018, and followed up through 2019. Outcomes included initiation of LLT, discontinuation, re-initiation, adherence to treatment and LDL-C goal attainment according to the European dyslipidaemia guidelines from 2011 and 2016 (mainly LDL-C <1.8 mmol/L). RESULTS 82% of patients commenced or continued LLT within 90 days after discharge. Of those, 71% were dispensed an LLT prescription within 30 days (62% of them for high-intensity LLT). High-intensity LLT prescribing increased over time, from 12% in 2012 to 78% in 2018. During a median follow-up of 3 (IQR 2-5) years 73% continued to fill prescriptions for a statin, 26.3% temporarily or permanently discontinued, and 0.5% changed to non-statin LLT. Only 1.3% discontinued statin treatment permanently. Throughout observation, about 80% of patients showed good statin adherence (proportion of days covered ≥80%). LDL-C target attainment was 52% the first year and <50% during subsequent years. LDL-C goal attainment was highest among patients receiving high-intensity statin treatment and showing good treatment adherence. CONCLUSION In secondary prevention for patients with established coronary heart disease, the proportion of LDL-C target attainment was low throughout the time period of the study, despite increasing use of high-intensity LLT and good treatment persistence and adherence.
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Affiliation(s)
- Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute and Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institute, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institute, Stockholm, Sweden
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Rekić D, Azarov I, Knöchel J, Sokolov V, Nilsson C, Wernevik L, Han D, Rydén-Bergsten T, Ebrahimi A, Dota C, Carlsson B. AZD8233 Antisense Oligonucleotide targeting PCSK9 does not prolong QT interval AZD8233 ASO C-QT analysis. Br J Clin Pharmacol 2022; 88:4839-4844. [PMID: 35653229 DOI: 10.1111/bcp.15425] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
AZD8233 is a proprotein convertase subtilisin/kexin type 9 (PCSK9) antisense oligonucleotide under development for treatment of hypercholesterolemia. A prespecified concentration-QT analysis was performed based on data from a single ascending dose study that was prospectively designed to act as a TQT study substitute. Subcutaneous single doses ranging from 4 to 120 mg were evaluated in 73 adult healthy male subjects. Time-matched 12-lead digital ECG and plasma concentrations (n=15) were measured at baseline and up to 48 hours after dose in each subject. The analysis was performed using a linear mixed effect model, where change from baseline QTc (ΔQTc) was a dependent variable and time matched AZD8233 concentration was an independent variable. The high clinical exposure scenario was defined as 1.7-fold the expected Cmax following an assumed therapeutic dose of 60 mg, which corresponds to AZD8233 plasma concentration of 1.39 μg/mL. Estimated placebo-corrected and baseline-adjusted QTcF interval (ΔΔQTcF) at this concentration was -2.2 ms (90% CI: -4.11, -0.28). Furthermore, the upper 90% ΔΔQTcF confidence interval was estimated to be below 10 ms at all observed concentrations. As the effect on ΔΔQTcF is below the threshold for regulatory concern (10 ms), it can be concluded that AZD8233 does not induce QTcF prolongation at the high clinical exposure scenario.
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Affiliation(s)
- Dinko Rekić
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Jane Knöchel
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Catarina Nilsson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Linda Wernevik
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David Han
- PAREXEL, Glendale, Los Angeles, CA, USA
| | - Tina Rydén-Bergsten
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ahmad Ebrahimi
- Cardiovascular Safety Center of Excellence, Global Patient Safety, Oncology R&D, AZ, Gothenburg, Sweden
| | - Corina Dota
- Cardiovascular Safety Center of Excellence, Global Patient Safety, Oncology R&D, AZ, Gothenburg, Sweden
| | - Björn Carlsson
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Morieri ML, Lamacchia O, Manzato E, Giaccari A, Avogardo A. Physicians' misperceived cardiovascular risk and therapeutic inertia as determinants of low LDL-cholesterol targets achievement in diabetes. Cardiovasc Diabetol 2022; 21:57. [PMID: 35473579 PMCID: PMC9044595 DOI: 10.1186/s12933-022-01495-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/05/2022] [Indexed: 12/15/2022] Open
Abstract
Background Greater efforts are needed to overcome the worldwide reported low achievement of LDL-c targets. This survey aimed to dissect whether and how the physician-based evaluation of patients with diabetes is associated with the achievement of LDL-c targets. Methods This cross-sectional self-reported survey interviewed physicians working in 67 outpatient services in Italy, collecting records on 2844 patients with diabetes. Each physician reported a median of 47 records (IQR 42–49) and, for each of them, the physician specified its perceived cardiovascular risk, LDL-c targets, and the suggested refinement in lipid-lowering-treatment (LLT). These physician-based evaluations were then compared to recommendations from EAS/EASD guidelines. Results Collected records were mostly from patients with type 2 diabetes (94%), at very-high (72%) or high-cardiovascular risk (27%). Physician-based assessments of cardiovascular risk and of LDL-c targets, as compared to guidelines recommendation, were misclassified in 34.7% of the records. The misperceived assessment was significantly higher among females and those on primary prevention and was associated with 67% lower odds of achieving guidelines-recommended LDL-c targets (OR 0.33, p < 0.0001). Peripheral artery disease, target organ damage and LLT-initiated by primary-care-physicians were all factors associated with therapeutic-inertia (i.e., lower than expected probability of receiving high-intensity LLT). Physician-suggested LLT refinement was inadequate in 24% of overall records and increased to 38% among subjects on primary prevention and with misclassified cardiovascular risk. Conclusions This survey highlights the need to improve the physicians’ misperceived cardiovascular risk and therapeutic inertia in patients with diabetes to successfully implement guidelines recommendations into everyday clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01495-8.
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Affiliation(s)
- Mario Luca Morieri
- Diabetes Unit, Department of Medicine, University of Padova, via Giustiniani 2 IT, 35128, Padova, Padua, Italy.
| | - Olga Lamacchia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Enzo Manzato
- Diabetes Unit, Department of Medicine, University of Padova, via Giustiniani 2 IT, 35128, Padova, Padua, Italy
| | - Andrea Giaccari
- Center for Endocrine and Metabolic Diseases, Department of Surgical and Medical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS-and Università Cattolica del Sacro Cuore, Rome , Italy
| | - Angelo Avogardo
- Diabetes Unit, Department of Medicine, University of Padova, via Giustiniani 2 IT, 35128, Padova, Padua, Italy
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Kadesjö E, Roos A, Siddiqui AJ, Sartipy U, Holzmann MJ. Statin Therapy and Intensity: Prognosis in Patients with Myocardial Injury. Am J Med 2021; 134:1522-1529.e2. [PMID: 34343508 DOI: 10.1016/j.amjmed.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 06/29/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND No guideline-directed pharmacological therapy has been established for patients with myocardial injury without type 1 myocardial infarction. We investigated the impact of statin treatment in patients with myocardial injury. METHODS Patients with myocardial injury (nonischemic acute and chronic myocardial injury), type 2 myocardial infarction, and type 1 myocardial infarction with at least 1 emergency department visit for chest pain from 2011 to 2014 were included. Dispensed prescriptions of all types of statins with dosage within 180 days from the index visit were collected. In total, 2054 patients were divided into 3 groups: 1) acute myocardial injury (type 2 myocardial infarction, acute nonischemic myocardial injury), 2) chronic myocardial injury, and 3) type 1 myocardial infarction. We estimated the adjusted hazard ratio with 95% confidence interval for death with low- (reference), moderate-, and high-intensity statin therapy. RESULTS The mean follow-up was 4.2 ± 1.8 years. Only 13% of patients with acute and chronic myocardial injury and 30% with type 1 myocardial infarction were treated with high-intensity statins. Adjusted mortality rates were higher in patients with acute and chronic myocardial injury than in those with type 1 myocardial infarction across all statin intensity categories. In patients with type 1 myocardial infarction, the adjusted mortality risk was 20% (hazard ratio, 0.80; 95% confidence interval, 0.36-1.77) lower in patients with high-intensity therapy. Point estimates in the adjusted models indicated similar associations between statin intensity and mortality risk in patients with acute and chronic myocardial injury. CONCLUSION Patients with myocardial injury may benefit from high-intensity statin treatment, but the associations were not statistically significant when adjusting for confounders.
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Affiliation(s)
- Erik Kadesjö
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Andreas Roos
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Anwar J Siddiqui
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Martin J Holzmann
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Emergency and Reparative Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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9
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Morieri ML, Perrone V, Veronesi C, Degli Esposti L, Andretta M, Plebani M, Fadini GP, Vigili de Kreutzenberg S, Avogaro A. Improving statin treatment strategies to reduce LDL-cholesterol: factors associated with targets' attainment in subjects with and without type 2 diabetes. Cardiovasc Diabetol 2021; 20:144. [PMID: 34271920 PMCID: PMC8283985 DOI: 10.1186/s12933-021-01338-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This cross-sectional study aimed to identify actionable factors to improve LDL-cholesterol target achievement and overcome underuse of lipid-lowering treatments in high- or very-high-cardiovascular risk patients. METHODS We evaluated healthcare records of 934,332 subjects from North-Italy, including subjects with available lipid profile and being on statin treatments up to December 2018. A 6-month-period defined adherence with proportion-of-days-covered ≥ 80%. Treatment was classified as high-intensity-statin (HIS) + ezetimibe, HIS-alone, non-HIS (NHIS) + ezetimibe or NHIS alone. RESULTS We included 27,374 subjects without and 10,459 with diabetes. Among these, 30% and 36% were on secondary prevention, respectively. Adherence was high (78-100%) and increased with treatment intensity and in secondary prevention. Treatment intensity increased in secondary prevention, but only 42% were on HIS. 2019-guidelines LDL-cholesterol targets were achieved in few patients and more often among those with diabetes (7.4% vs. 10.7%, p < 0.001). Patients in secondary prevention had mean LDL-cholesterol levels aligned slightly above 70 mg/dl (range between 68 and 73 mg/dl and between 73 and 85 mg/dl in patients with and without diabetes, respectively). Moreover, the differences in mean LDL-cholesterol levels observed across patients using treatments with well-stablished different LDL-lowering effect were null or much smaller than expected (HIS vs. NHIS from - 3 to - 11%, p < 0.001, HIS + ezetimibe vs. HIS-from - 4 to + 5% n.s.). These findings, given the observational design of the study, might suggest that a "treat to absolute LDL-cholesterol levels" approach (e.g., targeting LDLc of 70 mg/dl) was mainly used by physicians rather than an approach to also achieve the recommended 50% reduction in LDL-cholesterol levels. Our analyses suggested that female sex, younger age, higher HDL-c, and elevated triglycerides are those factors delaying prescription of statin treatments, both in patients with and without diabetes and in those on secondary prevention. CONCLUSIONS Among patients on statin treatment and high adherence, only a small proportion of patients achieved LDL-cholesterol targets. Late initiation of high-intensity treatments, particularly among those with misperceived low-risk (e.g., female subjects or those with high HDL-cholesterol), appears as pivotal factors needing to be modified to improve CVD prevention.
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Affiliation(s)
- Mario Luca Morieri
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy. .,University Hospital of Padova , Padova, Italy.
| | | | - Chiara Veronesi
- CliCon S.R.L. Health Economics & Outcomes Research, Bologna, Italy
| | | | | | - Mario Plebani
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.,University Hospital of Padova , Padova, Italy
| | - Saula Vigili de Kreutzenberg
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.,University Hospital of Padova , Padova, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.,University Hospital of Padova , Padova, Italy
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