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Muck MA, Fischer M, Hamerle M, Strack C, Holzhaeuer M, Pfeffer D, Hubauer U, Maier LS, Baessler A. Sex specific analysis of patients with and without reported statin intolerance referred to a specialized outpatient lipid clinic. Biol Sex Differ 2024; 15:67. [PMID: 39223591 PMCID: PMC11367976 DOI: 10.1186/s13293-024-00642-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Lowering LDL-cholesterol is a fundamental goal for both primary and secondary prevention of atherosclerotic cardiovascular diseases. Our study aims to analyse potential sex disparities regarding the tolerability and effectiveness of lipid-lowering therapy in patients with and without reported statin intolerance who are being treated at a lipid-outpatient clinic. METHODS From 2017 to 2022, n = 1062 patients (n = 612 men, n = 450 women) at high-risk were referred to our lipid-outpatient clinic because of difficulties in lipid control by primary healthcare providers. The main therapeutic objective was to optimize lipid-lowering therapy according to current treatment guidelines. RESULTS Patients presented with high LDL-C baseline levels (4.97 ± 1.81 mmol/l (192 ± 70 mg/dL) in men and 5.46 ± 2.04 mmol/l (211 ± 79 mg/dL) in women). Intolerance towards statins was reported more frequently by women (48.2%) than by men (38.9%, p = 0.004). LDL-C continuously decreased with individual treatment adjustments across follow-up visits. In total, treatment goals (LDL < 1.4 mmol/l (< 55 mg/dl) or < 1.8 mmol/l (< 70 mg/dl)) were accomplished in 75.8% of men and 55.5% of women after the last follow-up visit (p < 0.0001). In men, these data are almost identical in subjects with statin intolerance. In contrast, treatment goals were reached less frequently in women with statin intolerance compared to women tolerant to statin therapy. CONCLUSION Even if treated in a specialized lipid clinic, women are less likely to reach their target LDL-C than men, particularly when statin intolerant. Nevertheless, many patients with statin intolerance can be successfully treated using oral combination and PCSK9 inhibitor therapy. However, ongoing follow-up care to monitor progress and to adjust treatment plans is necessary to reach this goal.
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Affiliation(s)
- Maximilian A Muck
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Marcus Fischer
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
- Caritas Krankenhaus St. Lukas, Kelheim, 93309, Germany
| | - Michael Hamerle
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Christina Strack
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Maxime Holzhaeuer
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Dennis Pfeffer
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Ute Hubauer
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Lars S Maier
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany
| | - Andrea Baessler
- Klinik und Poliklinik für Innere Medizin 2, University of Regensburg, Regensburg, Germany.
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Kataoka T, Morishita T, Uzui H, Sato Y, Shimizu T, Miyoshi M, Yamaguchi J, Shiomi Y, Ikeda H, Tama N, Hasegawa K, Ishida K, Tada H. Very short-term effects of a single dose of a proprotein convertase subtilisin/kexin 9 inhibitor before percutaneous coronary intervention: A single-arm study. Atherosclerosis 2024:118581. [PMID: 39277430 DOI: 10.1016/j.atherosclerosis.2024.118581] [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: 04/25/2024] [Revised: 08/22/2024] [Accepted: 08/28/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND AND AIMS The short-term (within 6 weeks) effects of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors on lipid plaques have not been adequately evaluated. We aimed to investigate whether a single dose of a PCSK9 inhibitor before percutaneous coronary intervention (PCI) could reduce the abundance of lipid-core plaques identified via near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) at target lesions within a very short period. METHODS This prospective, single-arm, single-center interventional study enrolled 27 consecutive patients with coronary artery disease. These patients underwent NIRS-IVUS during coronary angiography and repeat NIRS-IVUS during PCI performed between 2 and 6 weeks after the single-dose administration of 420 mg evolocumab. Changes in lesion lipid-core burden index (LCBI) and maximal LCBI over any 4-mm segment (max-LCBI4mm) were assessed using NIRS at the target lesions, along with lipid profile. RESULTS The max-LCBI4mm significantly decreased from 387 before PCSK9 inhibitor administration to 315 after its administration (interquartile range [IQR]: 268-572 and 221-488, respectively; p = 0.02) within a very short period. The lesion LCBI also decreased from 161 to 117 (IQR: 105-263 and 65-226, respectively; p = 0.02). No significant changes were observed in the minimum lumen area and diameter. After PCSK9 inhibitor administration, low-density lipoprotein (LDL) cholesterol (p < 0.001), lipoprotein(a) (p = 0.001), and malondialdehyde-modified LDL (p < 0.001) levels decreased compared with those before its administration. CONCLUSIONS A single dose of the PCSK9 inhibitor administered before PCI reduced the abundance of lipid-core plaques identified via NIRS-IVUS at target lesions within a very short period of 2-6 weeks.
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Affiliation(s)
- Tatsuhiro Kataoka
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Tetsuji Morishita
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan; Department of Internal Medicine, Matsunami General Hospital, Gifu, 501-6062, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan; Department of Clinical Nursing, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan.
| | - Yusuke Sato
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Tomohiro Shimizu
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Machiko Miyoshi
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Junya Yamaguchi
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Yuichiro Shiomi
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Hiroyuki Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Naoto Tama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Kanae Hasegawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Kentaro Ishida
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, 910-1193, Japan
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3
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Yang J, Zhang R, Han B, Li H, Wang J, Xiao Y, Yu X, Guan S, Dai C, Yan H, Jiang T, Cui H, Yang S, Zheng Z, Dong Y, Wang A, Su G, Wang Y. Atherogenic lipid profile in patients with statin treatment after acute coronary syndrome: a real-world analysis from Chinese cardiovascular association database. Lipids Health Dis 2024; 23:271. [PMID: 39198852 PMCID: PMC11351259 DOI: 10.1186/s12944-024-02244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/07/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Adverse atherogenic lipid profile is associated with an increased risk of major adverse cardiac events in patients after acute coronary syndrome (ACS). Knowledge regarding the impact of statins on lipid profile remains limited. METHODS We retrospectively analysed multicenter, real-world data from the Chinese Cardiovascular Association Database-iHeart Project. Patients with a primary diagnosis of ACS from 2014 to 2021 during index hospitalisation and having at least one lipid panel record after discharge within 12 months were enrolled. We analysed target achievement of atherogenic lipid profile, including apolipoprotein B (< 80 mg/dL), low-density lipoprotein cholesterol (LDL-C) (< 1.8 mmol/L), lipoprotein(a) [Lp(a)] (< 30 mg/dL), triglycerides (< 1.7 mmol/L), remnant cholesterol (RC) (< 0.78 mmol/L), non-high-density lipoprotein cholesterol (< 2.6 mmol/L) at baseline and follow-up. Multivariate Cox regression models were employed to investigate the association between patient characteristics and target achievement. RESULTS Among 4861 patients, the mean age was 64.9 years. Only 7.8% of patients had all atherogenic lipids within the target range at follow-up. The proportion of target achievement was for LDL-C 42.7%, Lp(a) 73.3%, and RC 78.5%. Patients with female sex, younger age, myocardial infarction, hypertension, and hypercholesteremia were less likely to control LDL-C, Lp(a), and RC. An increase in the burden of comorbidities was negatively associated with LDL-C and Lp(a) achievements but not with RC. CONCLUSIONS A substantial gap exists between lipid control and the targets recommended by contemporary guidelines. Novel therapeutics targeting the whole atherogenic lipid profile will be warranted to improve cardiovascular outcomes.
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Affiliation(s)
- Jing Yang
- Department of Cardiology, Zhongshan-Xuhui Hospital, Shanghai Xuhui Central Hospital, Fudan University, Shanghai, 200237, China.
| | - Rui Zhang
- China Heart House, Suzhou, 215124, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical School of Southeast University, Xuzhou, Jiangsu, 221009, China
| | - Hui Li
- Department of Cardiology, the second affiliated hospital of Soochow University, Suzhou, 215004, China
| | - Jingfeng Wang
- Department of Cardiovascular Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Yihui Xiao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi' an Jiaotong University, Xi'an, 710061, China
| | - Xiaofan Yu
- Department of Cardiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Shaofeng Guan
- Department of Cardiology, Huadong Hospital, Fudan University, Shanghai, 200040, China
| | - Cuilian Dai
- School of Medicine, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, 361000, China
| | - Hua Yan
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, 430022, China
| | - Tingbo Jiang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Hanbin Cui
- Cardiology Center, The First Affiliated Hospital of Ningbo University, Ningbo, 315000, China
| | - Shuang Yang
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Zeqi Zheng
- Department of Cardiology, the first affiliated hospital of Nanchang University, Nanchang, 330006, China
| | - Yugang Dong
- Department of Cardiology, the first affiliated hospital of Sun Yat-sen University, Guangzhou, 510080, China
- NHC key Laboratory of assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China
| | - Annai Wang
- China Heart House, Suzhou, 215124, China
| | - Guohai Su
- Department of Cardiology, Jinan Central Hospital, Shandong First Medical University, Shandong, 250013, China.
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen University, Xiamen, 200080, China.
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Mach F, Visseren FLJ, Cater NB, Salhi N, Soronen J, Ray KK, Delgado V, Jukema JW, Laufs U, Zamorano JL, Ros E, Plat J, Gesztes AG, Tokgozoglu L, Packard C, Libby P. Addressing residual risk beyond statin therapy: New targets in the management of dyslipidaemias-A report from the European Society of Cardiology Cardiovascular Round Table. J Clin Lipidol 2024:S1933-2874(24)00209-5. [PMID: 39289123 DOI: 10.1016/j.jacl.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/28/2024] [Accepted: 07/01/2024] [Indexed: 09/19/2024]
Abstract
Cardiovascular (CV) disease is the most common cause of death in Europe. Despite proven benefits, use of lipid-lowering therapy remains suboptimal. Treatment goals are often not achieved, even in patients at high risk with atherosclerotic CV disease (ASCVD). The occurrence of CV events in patients on lipid-lowering drugs is defined as "residual risk", and can result from inadequate control of plasma lipids or blood pressure, inflammation, diabetes, and environmental hazards. Assessment of CV risk factors and vascular imaging can aid in the evaluation and management decisions for individual patients. Lifestyle measures remain the primary intervention for lowering CV risk. Where drug therapies are required to reach lipid treatment targets, their effectiveness increases when they are combined with lifestyle measures delivered through formal programs. However, lipid drug dosage and poor adherence to treatment remain major obstacles to event-free survival. This article discusses guideline-supported treatment algorithms beyond statin therapy that can help reduce residual risk in specific patient profiles while also likely resulting in substantial healthcare savings through better patient management and treatment adherence.
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Affiliation(s)
- François Mach
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland (Dr Mach).
| | - Frank L J Visseren
- Department of Internal Medicine, University Medical Center, Utrecht, the Netherlands (Dr Visseren)
| | - Nilo B Cater
- Global Medical Affairs, Pfizer, New York, NY, USA (Dr Cater)
| | - Nejoua Salhi
- Global Medical Affairs, AMGEN Europe GmbH, Rotkreuz, Switzerland (Dr Salhi)
| | - Jarkko Soronen
- Scientific Communication and Strategy, Daiichi-Sankyo Europe GmbH, Munich, Germany (Dr Soronen)
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK (Dr Ray)
| | - Victoria Delgado
- University Hospital Germans Trias i Pujol, Badalona, Spain (Dr Delgado)
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (Dr Jukema); Netherlands Heart Institute, Utrecht, the Netherlands (Dr Jukema)
| | - Ulrich Laufs
- Department of Cardiology, Leipzig University Hospital, Leipzig, Germany (Dr Laufs)
| | - Jose-Luis Zamorano
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain (Dr Zamorano)
| | - Emilio Ros
- Lipid Clinic, Department of Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain (Dr Ros)
| | - Jogchum Plat
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, the Netherlands (Dr Plat)
| | - Akos Gabor Gesztes
- SZÍVSN - Heartily (We help you) National Patient Association, Budapest, Hungary (Dr Gesztes)
| | - Lale Tokgozoglu
- Department of Cardiology, Hacettepe University, Ankara, Turkey (Dr Tokgozoglu)
| | - Chris Packard
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK (Dr Packard)
| | - Peter Libby
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Boston, MA, USA (Dr Libby)
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Baig S, Mughal S, Murad Y, Virdee M, Jalal Z. Exploring the Perceptions and Behaviours of UK Prescribers Concerning Novel Lipid-Lowering Agent Prescriptions: A Qualitative Study. PHARMACY 2024; 12:104. [PMID: 39051388 PMCID: PMC11270282 DOI: 10.3390/pharmacy12040104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/24/2024] [Accepted: 06/29/2024] [Indexed: 07/27/2024] Open
Abstract
Reducing low-density lipoprotein cholesterol levels lowers the risk of atherosclerotic cardiovascular disease. With the current and future portfolios of emerging lipid-lowering therapies included in various national and international guidelines, the objectives of this study were (i) to investigate the perceptions of UK prescribers', including doctors, pharmacists, and nurses, on current lipid management for cardiovascular diseases and prescriptions of novel lipid-lowering therapies, and (ii) to explore the challenges and facilitating factors of prescribing novel lipid-lowering therapies through qualitative interviews. Qualitative semi-structured interviews with twelve medical and non-medical prescribers were conducted, around 20-30 min in length. The interviews were audio-recorded and transcribed on an online platform. A thematic analysis was deployed. Four major themes emerged from the analysis: (1) prescribing barriers; (2) prescribing enablers; (3) inter-profession variability; and (4) health literacy. These themes highlighted the contrast between the need for optimal shared decision making and the various constraints in practice. Participants expressed their inexperience with novel lipid-lowering therapies and acknowledged the requirement and importance of these agents for primary cardiovascular disease prevention. Participants recognised confidence and competence as key drivers for prescribing therapies and welcomed further education and training to enhance their skillset. Patients' misconceptions towards current lipid-lowering therapies contributed to their refusal of newer agents, highlighting a requirement to improve patient education. Targeting communities through awareness campaigns was identified as a viable solution.
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Affiliation(s)
- Sarah Baig
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Birmingham B15 2TT, UK (Z.J.)
| | - Shahrauz Mughal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Birmingham B15 2TT, UK (Z.J.)
| | - Yousuf Murad
- Worcestershire Acute Hospital Trust Woodrow Drive, Redditch B98 7UB, UK;
| | - Mandeep Virdee
- Royal Wolverhampton NHS Trust, Wolverhampton WV10 0QP, UK;
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Birmingham B15 2TT, UK (Z.J.)
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Hoe JK, Flege MM, Jimenez-Solem E, Hansen S, Olsen RH, Petersen J, Jensen CB. Monitoring and treatment of hypercholesterolemia after an atherosclerotic cardiovascular disease event in Denmark from 2015 to 2020. Int J Cardiol 2024; 402:131857. [PMID: 38360103 DOI: 10.1016/j.ijcard.2024.131857] [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: 09/04/2023] [Revised: 01/18/2024] [Accepted: 02/10/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND AIMS Lowering the blood concentration of low-density lipoprotein cholesterol (LDL-C), is a cornerstone in preventing atherosclerotic cardiovascular disease (ASCVD). Current European guidelines recommends LDL-C < 1.4 mmol/L for secondary prevention in high-risk patients. The aim of this study is to investigate monitoring and treatment of hypercholesterolemia one year after a ASCVD event. METHODS Danish patients with hypercholesterolemia and an incident ASCVD event from 2015 to 2020 were included in this nationwide cohort study. Patients' LDL-C measurements and lipid-lowering treatment were followed for one year after ASCVD event, or until death or migration. Imputation was used to estimate absolute LDL-values when patients were unmeasured. RESULTS A total of 139,043 patients were included in the study with a mean follow-up time of 10.4 months. During the one-year period, 120,020 (86%) patients had their LDL-C measured at least once, 83,723 (60%) patients were measured at least twice. During the period one to six months after ASCVD event 25,999 (19%) achieved an LDL-C < 1.4 mmol/L, 93,349 (67%) failed to achieve an LDL-C < 1.4 mmol/L, and 196,950 (14%) had died or migrated. Missing LDL-C values were estimated via imputation. At the end of month twelve, 60,583 (44%) patients were in statin monotherapy, 2926 (2%) were treated with other lipid-lowering treatment, 42,869 (31%) were in no treatment, and 32,665 (23%) had died or migrated. CONCLUSIONS Many Danish patients are not appropriately followed-up with LDL-C measurements, and a substantial number of patients are not in lipid-lowering treatment one year after an ASCVD event.
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Affiliation(s)
- Jakob Kronkvist Hoe
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Marius Mølsted Flege
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
| | - Espen Jimenez-Solem
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Susanne Hansen
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Rasmus Huan Olsen
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Janne Petersen
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Bjørn Jensen
- Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Altmann C, Burlacu NA, Preuss T, Hlousek A, Eddicks S. Prevalence of elevated lipoprotein(a) in cardiac rehabilitation patients - results from a large-scale multicentre registry in Germany. Clin Res Cardiol 2024:10.1007/s00392-024-02427-0. [PMID: 38619576 DOI: 10.1007/s00392-024-02427-0] [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: 11/29/2023] [Accepted: 02/27/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Lipoprotein(a) (Lp(a)) is an independent risk factor for myocardial infarction and aortic valve stenosis. European guidelines recommend assessing it at least once in a lifetime, particularly in premature atherosclerotic heart disease. METHODS A non-interventional registry was conducted at MEDIAN rehabilitation facilities in Germany to assess the frequency of Lp(a) testing in referring acute care hospitals and the prevalence of elevated Lp(a) levels in aortic valve stenosis or premature myocardial infarction. All consecutive patients referred after coronary intervention or aortic valve surgery were included in four cohorts: aortic valve intervention (cohort 1), current/previous myocardial infarction at < 60 years of age (cohorts 2a/2b), and myocardial infarction at ≥ 60 years of age (control). RESULTS The analysis included 3393 patient records (cohort 1, n = 1063; cohort 2a, n = 1351; cohort 2b, n = 381; control, n = 598). Lp(a) had been determined at the referring hospital in 0.19% (cohort 1), 4.96% (cohort 2a), 2.36% (cohort 2b), and 2.01% (control) of patients. Lp(a) levels were > 50 mg/dL or > 125 nmol/L in 28.79% (cohort 1), 29.90% (cohort 2a), and 36.48% (cohort 2b; p < 0.001) compared to 24.25% (control). Family history of premature cardiovascular disease was reported in 13.45% (cohort 1), 38.56% (cohort 2a), and 32.81% (cohort 2b) compared to 17.89% (control; p < 0.05 for each comparison). CONCLUSIONS Lp(a) had been rarely assessed in acute management of aortic valve stenosis or premature myocardial infarction despite expanding scientific evidence and guideline recommendation. Given the above-average incidence of elevated Lp(a) levels, awareness for Lp(a) has to increase substantially to better identify and manage high-risk patients.
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Affiliation(s)
- Christoph Altmann
- Department for Cardiology, MEDIAN Rehabilitation-Centre Bad Gottleuba, Königstr. 39, 01816, Bad Gottleuba-Berggießhübel, Germany.
| | - Nelu-Adrian Burlacu
- Department for Cardiology, MEDIAN Rehabilitation-Centre Bernkastel-Kues, Bernkastel-Kues, Germany
| | - Thomas Preuss
- Department for Research & Innovation, MEDIAN Headquarters, Berlin, Germany
| | - Annett Hlousek
- Department for Cardiology, MEDIAN Rehabilitation-Centre Bad Gottleuba, Königstr. 39, 01816, Bad Gottleuba-Berggießhübel, Germany
| | - Stephan Eddicks
- Department for Cardiology, MEDIAN Rehabilitation-Centre Bernkastel-Kues, Bernkastel-Kues, Germany
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Krychtiuk KA, Andersson TL, Bodesheim U, Butler J, Curtis LH, Elkind M, Hernandez AF, Hornik C, Lyman GH, Khatri P, Mbagwu M, Murakami M, Nichols G, Roessig L, Young AQ, Schilsky RL, Pagidipati N. Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank. Am Heart J 2024; 270:23-43. [PMID: 38242417 DOI: 10.1016/j.ahj.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.
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Affiliation(s)
| | | | | | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, TX
| | | | - Mitchell Elkind
- American Heart Association, Dallas, TX; Columbia University, New York, NY
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Kong X, He G, Quan X, Tan Z, Yan F, Chen X. The impact of the 2019 ESC/EAS dyslipidaemia guidelines on real-world initial lipid-lowering therapy in patients with acute myocardial infarction. Medicine (Baltimore) 2024; 103:e37637. [PMID: 38517999 PMCID: PMC10956955 DOI: 10.1097/md.0000000000037637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 02/26/2024] [Indexed: 03/24/2024] Open
Abstract
This study aimed to investigate the impact of the latest guidelines on the real-world clinical practice of initial lipid-lowering therapy, especially on the use of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in China. All adult patients diagnosed with acute myocardial infarction in our hospital between August 31, 2018, and August 31, 2020, were divided into the following 2 groups: those patients treated before the latest guideline release, and those patients treated after the release. A propensity score-matched method was used, and logistic regression was used to assess the association with intensive statin, ezetimibe and PCSK9 inhibitor usage together with treatment results between the 2 groups. A total of 325 patients were enrolled in this study, including 141 patients who were admitted before the release of the latest guideline and 184 patients who were admitted after the release. After a median follow-up time of 8.20 months, the mean low-density lipoprotein cholesterol was 1.87 ± 0.59 mmol/L (1.87 ± 0.55 in the before group vs 1.88 ± 0.62 in the after group, P = .829). After propensity score matching, the initial usage of intensive statin therapy was decreased after guideline release without statistical significance (17.00% vs 28.00%, P = .090), whereas the usage of ezetimibe and PCSK9 inhibitors was increased (19.00% vs 8.00%, P = .039; and 10.00% vs 3.00%, P = .085, respectively). In logistic regression models, the release of the guideline was associated with a statistically significantly increased use of ezetimibe (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.21, 3.02; P = .005), a marginally decreased use of intensive statins (OR: 0.68; 95% CI: 0.45, 1.03; P = .069) and a marginally increased use of PCSK9 inhibitors (OR: 1.31; 95% CI: 0.98, 1.76; P = .068). In this single-center, real-world data analysis, after the release of the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, an increasing number of patients with a recent acute myocardial infarction were initially receiving ezetimibe and PCSK9 inhibitors.
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Affiliation(s)
| | - Gang He
- Department of Traditional Chinese Medicine, Shenzhen People’s Hospital (The First Affiliated Hospital, Southern University of Science and Technology)
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10
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Stępień K, Żółciński M, Ząbczyk M, Zalewski J, Undas A. Effect of Three-Day Atorvastatin Administration on Coagulation Factors in Patients With Prior Venous Thromboembolism and Healthy Subjects: A Preliminary Study. J Cardiovasc Pharmacol 2024; 83:289-296. [PMID: 38117119 DOI: 10.1097/fjc.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Statins exert antithrombotic effects, which might contribute to reduced risk of venous thromboembolism (VTE). Rosuvastatin 20 mg/d administered for 4 weeks has been reported to decrease coagulation factors (F) VII, FVIII, and FXI in VTE patients. Moreover, in accordance with recent registry data in non-VTE subjects, statins usage was associated with lower FXI. We investigated whether 3 doses of a statin decrease coagulation factors activity and if such changes can alter fibrin clot properties in VTE patients and healthy subjects. We enrolled 28 consecutive first-ever prior VTE patients after 6 months of anticoagulation and 25 healthy controls well-matched for demographics and lipid profiles (aged 44 [interquartile range 34-51] years) in an interventional nonrandomized study. Before and after 3 doses of atorvastatin 40 mg/d, activity of FVII, FVIII, FIX, and FXI was measured, along with fibrin clot properties, including permeability (Ks) and clot lysis using 3 various assays. After a 3-day statin administration, we observed the decrease of FVII (by 6.2%, P = 0.046) and FXI (by 8.6%, P = 0.044), irrespective of low-density lipoprotein cholesterol reduction (by 24%, P < 0.001), whereas other coagulation factors remained unaltered. Reduction of FVII and FXI activity was inversely correlated with Ks alterations (R = -0.292, P = 0.034 and R = -0.335, P = 0.014, respectively). After adjustment for age, studied group, and fibrinogen level, the reduction of FXI was independently associated with an increase of fibrin clot permeability (B = -0.084, P = 0.027). In conclusion, a 3-day 40 mg atorvastatin administration is sufficient to reduce FVII and FXI activity in our pilot study, which is associated with favorable fibrin clot properties modification.
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Affiliation(s)
- Konrad Stępień
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Department of Coronary Artery Disease and Heart Failure, John Paul II Hospital, Kraków, Poland
| | | | - Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland ; and
| | - Jarosław Zalewski
- Department of Coronary Artery Disease and Heart Failure, John Paul II Hospital, Kraków, Poland
- Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland ; and
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Dalmau R, Cordero A, Masana L, Ruiz E, Sicras-Mainar A, González-Juanatey JR. The CNIC-polypill (acetylsalicylic acid, atorvastatin, and ramipril), an effective and cost-saving secondary prevention strategy compared with other therapeutic options in patients with ischaemic heart disease. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae027. [PMID: 38686352 PMCID: PMC11056486 DOI: 10.1093/ehjopen/oeae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 05/02/2024]
Abstract
Aims The retrospective NEPTUNO study evaluated the effectiveness of the Centro Nacional de Investigaciones Cardiovasculares (CNIC)-polypill (including acetylsalicylic acid, ramipril, and atorvastatin) vs. other therapeutic approaches in secondary prevention for cardiovascular (CV) disease. In this substudy, the focus was on the subgroup of patients with ischaemic heart disease (IHD). Methods and results Patients on four strategies: CNIC-polypill, its monocomponents as loose medications, equipotent medications, and other therapies. The primary endpoint was the incidence of recurrent major adverse CV events (MACEs) after 2 years. After matching, 1080 patients were included in each cohort. The CNIC-polypill cohort had a significantly lower incidence of recurrent MACE compared with monocomponents, equipotent drugs, and other therapies cohorts (16.1 vs. 24, 24.4, and 24.3%, respectively; P < 0.001). The hazard ratios (HRs) for recurrent MACE were higher in monocomponents (HR = 1.12; P = 0.042), equipotent drugs (HR = 1.14; P = 0.031), and other therapies cohorts (HR = 1.17; P = 0.016) compared with the CNIC-polypill, with a number needed to treat of 12 patients to prevent a MACE. The CNIC-polypill demonstrated a greater reduction in LDL cholesterol (LDL-c; -56.1 vs. -43.6, -33.3, and -33.2% in the monocomponents, equipotent drugs, and other therapies, respectively; P < 0.001) and systolic blood pressure (-13.7 vs. -11.5, -10.6, and -9.1% in the CNIC-polypill, monocomponents, equipotent drugs, and other therapies, respectively; P < 0.001) compared with other cohorts. The CNIC-polypill intervention was less costly and more effective than any other therapeutic option, with €2317-€2407 cost savings per event prevented. Conclusion In IHD, the CNIC-polypill exemplifies a guideline-recommended secondary prevention treatment linked to better outcomes and cost saving compared with other therapeutic options.
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Affiliation(s)
- Regina Dalmau
- Department of Cardiology, University Hospital La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain
- IdiPAZ (Instituto de Investigación Hospital Universitario la Paz), Pedro Rico 6, 28029 Madrid, Spain
| | - Alberto Cordero
- CIBERCV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Department of Cardiology, Hospital Universitario de San Juan, N-332 s/n, 03550 Sant Joan d’Alacant, Alicante, Spain
| | - Luís Masana
- Vascular Medicine and Metabolism Unit, Universitat Rovira i Virgili, Hospital Universitario Sant Joan, Vascular Medicine and Metabolism Unit, Avda Josep Laporte 2, 43204 Reus, Spain
- IISPV (Institut d’Investigació Sanitària Pere Virgili), Avda Josep Laporte 2, 43204 Reus, Spain
- CIBERDEM (Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Emilio Ruiz
- Corporate Medical Affairs, Ferrer International, Avenida Diagonal 549, 08029 Barcelona, Spain
| | - Antoni Sicras-Mainar
- Departament of Health Economics and Outcomes Research, Atrys Health, Provença 392, 08025 Barcelona, Spain
| | - José R González-Juanatey
- CIBERCV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Rúa da Choupana s/n, 15706 Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Rúa da Choupana s/n, 15706 Santiago de Compostela, Spain
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12
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Ferlini M, Munafò A, Varbella F, Delnevo F, Solli M, Trabattoni D, Piccaluga E, Cardile A, Canova P, Rossini R, Celentani D, Ugo F, Taglialatela V, Airoldi F, Rognoni A, Oliva F, Porto I, Carugo S, Castiglioni B, Lettieri C, Chinaglia A, Currao A, Patti G, Oltrona Visconti L, Musumeci G. Achievement of target LDL-cholesterol level in patients with acute coronary syndrome undergoing percutaneous coronary intervention: The JET-LDL registry. Int J Cardiol 2024; 397:131659. [PMID: 38101704 DOI: 10.1016/j.ijcard.2023.131659] [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: 08/20/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND In patients with acute coronary syndromes (ACS), current guidelines recommend a low-density lipoprotein cholesterol (LDL-C) level < 1.4 mmol/L (<55 mg/dL). METHODS The JET-LDL is a multicenter, observational, prospective registry created to investigate levels of LDL-C in consecutive patients with ACS undergoing PCI at 35 Italian hospitals, and to report their lipid lowering therapies (LLT). Follow-up was planned at 1 and 3 months. LDL-C reduction >50% from baseline or level < 55 mg/dL at 1-month was the primary endpoint. RESULTS A total of 1095 patients were included: median age was 67 (58-75); 33.7% were already on LLT. Baseline LDL-C levels was 105 (76.5-137) mg/dL. At hospital discharge all patients were on LLT: 98.1% received statins (as mono or combination therapy), ezetimibe and PCSK9i were used in 60.1% and 8.5% of cases, respectively. Primary endpoint was achieved in 62% (95% CI 58-65) of cases. At 1-month LDL-C levels dropped to 53 (38-70) mg/dL (p < 0.001 vs baseline) and it was <55 mg/dL in 53% (95% CI 49-57) of patients; however, PCSK9i were added to 7 further cases. At 3-months 58% (95% CI 55-62) of patients achieved the target level, but PCSK9i was added to only 11 new patients. CONCLUSIONS In this real-world registry of ACS patients undergoing PCI, recommend LDL-C levels were obtained in 62% of patients, but PCSK9i prescription was limited to 10% of cases. As LLT pattern appeared mainly improved at hospital discharge, an early and strong treatment should be considered.
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Affiliation(s)
- Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Andrea Munafò
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Fabrizio Delnevo
- Cardiologia, Azienda Ospedaliera Ordine Mauriziano, Torino, Italy
| | - Martina Solli
- Università del Piemonte Orientale, Cardiologia, AOU Maggiore della Carità di Novara, Italy
| | - Daniela Trabattoni
- Interventional Cardiology Dept., Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | - Emanuela Piccaluga
- Cardiologia 1, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Antonino Cardile
- SC Cardiologia, ASST Bergamo Ovest - Ospedale Treviglio, Treviglio (BG), Italy
| | - Paolo Canova
- SC Cardiologia, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Fabrizio Ugo
- SC Cardiologia, Ospedale Sant'Andrea di Vercelli, Italy
| | | | - Falvio Airoldi
- SC Cardiologia, I.R.C.C.S. MultiMedica di Sesto San Giovanni, Italy
| | | | - Fabrizio Oliva
- Cardiologia 1, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Italo Porto
- SC Cardiologia, Ospedale San Martino Genova, Università degli studi di Genova, Italy
| | - Stefano Carugo
- Department of Clinical Sciences and Community Health, University of Milano, Italy, Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | | | - Corrado Lettieri
- SC Cardiologia, ASST Mantova, Ospedale Carlo Poma di Mantova, Italy
| | | | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Patti
- Università del Piemonte Orientale, Cardiologia, AOU Maggiore della Carità di Novara, Italy
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13
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Laufs U, Birkenfeld AL, Fraass U, Hohenstein B, Siegert C, Klotsche J, Steinhagen-Thiessen E, Pittrow D, Dexl S, Salmen S, Schettler VJJ, Parhofer KG. Novel Insights into the Management of Patients with Very High Cardiovascular Risk Eligible for PCSK9 Inhibitor Treatment: Baseline Findings from the PERI-DYS Study. Cardiovasc Drugs Ther 2024; 38:119-129. [PMID: 36178485 PMCID: PMC10876819 DOI: 10.1007/s10557-022-07386-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/30/2022]
Abstract
AIM The PERI-DYS study aims to characterize two groups of patients with dyslipidaemia at very high CV risk: PCSK9i receivers and patients qualifying for but not receiving PCSK9i. METHODS This is an observational study by office-based and clinic-based physicians, mainly cardiologists and other internists in Germany, with data extracted from patient charts. CLINICALTRIALS gov identifier NCT03110432. RESULTS A total of 1659 patients were enrolled across 70 sites. The majority of patients (91.0%) were reported as having mixed dyslipidaemia or non-familial or heterozygous familial hypercholesterolemia. At enrolment, 794 (47.9%) of patients were PCSK9i receivers (of these 65.9% ongoing, and 34.1% newly treated within 30 days before their baseline visit). Among PCSK9i receivers, the majority had evolocumab 140 mg (n = 632, 38.1% of total). PCSK9i receivers compared to non-receivers were about 2 years younger and had a lower proportion of males. In terms of comorbidities, they had (statistically significantly) more often CAD, and less often PAD, diabetes mellitus, arterial hypertension and chronic renal disease. The calculated untreated median LDL-C was 187 mg/dl (IQR 127; 270) in ongoing PCSK9i receivers, 212 mg/dl (IQR 132; 277) in newly treated PCSK9i receivers, and 179 mg/dl (IQR 129; 257) in non-receivers. Physician-reported statin intolerance was much more common in the two PCSK9i receiver groups as compared to non-receivers (67.3% versus 15.3%). Consequently, patients in the PCSK9i groups received fewer concomitant statins. Mean total cholesterol (143 vs. 172 mg/dl) and LDL-C (69 vs. 99 mg/dl) were considerably lower in ongoing PCSK9i receivers compared to non-receivers. CONCLUSIONS PCSK9i receivers are characterized by higher baseline LDL-C and a higher portion of statin intolerance compared to those qualified for but not-receiving PCSK9i treatment. On-treatment, LDL-C was lower in PCSK9i receivers. Ongoing follow-up will determine the prognostic importance of these findings.
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Affiliation(s)
- Ulrich Laufs
- Klinik und Poliklinik Für Kardiologie, Universitätsklinikum, Leipzig, Germany.
| | - Andreas L Birkenfeld
- Innere Medizin IV - Diabetologie, Endokrinologie Und Nephrologie Am Universitätsklinikum, Tübingen, Germany
- Institut Für Diabetesforschung und Metabolische Erkankungen (IDM) des Helmholtz Zentrums München, Partner des Deutschen Zentrums Für Diabetesforschung (DZD E.V.), Munich, Germany
| | | | - Bernd Hohenstein
- Nephrologisches Zentrum Villingen-Schwenningen, Göttingen, Germany
| | | | | | | | - David Pittrow
- Medizinische Fakultät, Technische Universität, Dresden, Germany
- Innovationszentrum Real-World Evidence, GWT-TUD GmbH, Dresden, Germany
| | | | | | | | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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14
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Katzmann JL, Stürzebecher PE, Kruppert S, Laufs U. LDL cholesterol target attainment in cardiovascular high- and very-high-risk patients with statin intolerance: a simulation study. Sci Rep 2024; 14:474. [PMID: 38172531 PMCID: PMC10764910 DOI: 10.1038/s41598-023-50847-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
The inability to tolerate sufficient doses of statins, statin intolerance (SI), contributes to the non-achievement of guideline-recommended low-density lipoprotein cholesterol (LDL-C) treatment targets. Patients with SI require alternative lipid-lowering therapies (LLT). We conducted a simulation study on LDL-C target achievement with oral LLT (ezetimibe, bempedoic acid) in patients with SI, using representative data of 2.06 million German outpatients. SI was defined using literature-informed definitions based on electronic medical records (EMR). Among n = 130,778 patients with hypercholesterolaemia, available LDL-C measurement, and high or very-high cardiovascular risk, 8.6% met the definition of SI. Among patients with SI, 7.7% achieved the LDL-C target at baseline. After simulation of the stepwise addition of treatment with ezetimibe and bempedoic acid, 22.6 and 52.0% achieved the LDL-C target, respectively. The median achieved LDL-C was 80 and 62 mg/dL, the corresponding reductions from baseline were 20.0 and 38.0%, respectively. A higher proportion of patients classified as high risk achieved the target compared to those at very-high risk (58.1 vs. 49.9%). In conclusion, in patients with increased cardiovascular risk meeting the definition of SI based on EMR, combination LLT with ezetimibe and bempedoic acid has the potential to substantially increase the proportion of patients achieving clinically relevant LDL-C reductions.
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Affiliation(s)
- Julius L Katzmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany.
| | | | | | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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15
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Lilja F, Wanhainen A, Mani K. Statin therapy after elective abdominal aortic aneurysm repair improves long-term survival. Br J Surg 2024; 111:znad383. [PMID: 38198155 PMCID: PMC10782213 DOI: 10.1093/bjs/znad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Patients with abdominal aortic aneurysms are at high risk of cardiovascular events. Although statin therapy is indicated for most of these patients, no specific recommendation regarding the intensity of therapy exists. The aim of this study was to assess the possible effect of statin therapy on survival of patients undergoing abdominal aortic aneurysm repair and to investigate if high-intensity statin therapy was superior to low-moderate-intensity therapy. METHODS Data from nationwide Swedish registers on hospital admissions, operations, and medications for patients undergoing elective abdominal aortic aneurysm repair from 2006 to 2018 were collected. The effect of statin use was evaluated in three separate propensity score matched cohorts: perioperative mortality was analysed according to whether patients were on statins before abdominal aortic aneurysm repair or not; long-term survival was assessed according to whether patients were on statins during follow-up or not; and, for those on statins after surgery, long-term survival was analysed according to whether patients were on high-intensity or low-moderate-intensity statin therapy. RESULTS Preoperative statin use did not reduce 90-day perioperative mortality (OR 0.99, 95% c.i. 0.77 to 1.28), whilst there was a marked benefit regarding long-term survival for postoperative statin users (HR 1.43, 95% c.i. 1.34 to 1.54). High-intensity statin therapy had no advantage over low-medium-intensity statin therapy with regards to long-term survival (HR 1.00, 95% c.i. 0.80 to 1.25). CONCLUSION In this nationwide propensity score matched cohort study, preoperative statin treatment had no benefit regarding 90-day perioperative survival, but postoperative statin treatment markedly improved long-term survival. No additional benefit regarding high-dose statin treatment could be confirmed in this analysis.
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Affiliation(s)
- Fredrik Lilja
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Perioperative and Surgical Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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16
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Wazir M, Olanrewaju OA, Yahya M, Kumari J, Kumar N, Singh J, Abbas Al-Itbi AY, Kumari K, Ahmed A, Islam T, Varrassi G, Khatri M, Kumar S, Wazir H, Raza SS. Lipid Disorders and Cardiovascular Risk: A Comprehensive Analysis of Current Perspectives. Cureus 2023; 15:e51395. [PMID: 38292957 PMCID: PMC10825376 DOI: 10.7759/cureus.51395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
The increasing worldwide prevalence of cardiovascular diseases (CVDs) highlights the need to understand the complex relationships between lipid abnormalities and elevated cardiovascular risk. This review thoroughly investigates the complex terrain of lipid abnormalities, highlighting their crucial significance in developing CVDs. Dyslipidemia, which is closely connected to atherosclerosis, is a significant risk factor for CVDs, including coronary artery disease, myocardial infarction, and stroke. This review thoroughly examines the intricate relationship between lipoproteins, cholesterol metabolism, and the inflammatory cascade, providing a detailed comprehension of the mechanisms that contribute to atherogenic processes. An extensive analysis of the occurrence and distribution of lipid diseases worldwide indicates a concerning high frequency, which calls for a reassessment of public health approaches. Dyslipidemia is caused by a combination of genetic predispositions, lifestyle factors, and metabolic abnormalities, as supported by significant data. Moreover, investigating different types of lipoproteins and their specific functions in the development of atherosclerosis provides insight into the complex causes of CVDs. In addition to conventional lipid profiles, newly identified biomarkers and advanced imaging techniques are being carefully examined for their ability to improve risk classification and treatment strategies' effectiveness. From a critical perspective, the review thoroughly examines the current state of lipid-modifying medicines, specifically statins, fibrates, and new therapeutic approaches. The text discusses the emerging concept of precision medicine, which involves tailoring treatment approaches to individuals based on their genetic and molecular characteristics. This approach has the potential to improve treatment outcomes. In addition, this study critically assesses the effects of lifestyle changes and nutritional interventions on lipid homeostasis, offering a comprehensive view of preventive strategies. This review consolidates current viewpoints on lipid diseases and their complex correlation with cardiovascular risk. This review contributes to the ongoing cardiovascular disease prevention and management dialogue by clarifying the molecular mechanisms, exploring new therapeutic options, and considering broader societal implications.
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Affiliation(s)
- Maha Wazir
- Department of Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | - Olusegun A Olanrewaju
- Department of Pure and Applied Biology, Ladoke Akintola University of Technology, Ogbomoso, NGA
- Department of General Medicine, Stavropol State Medical University, Stavropol, RUS
| | - Muhammad Yahya
- Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Jaya Kumari
- Department of Internal Medicine, Mehran Medical Centre, Karachi, PAK
| | - Narendar Kumar
- Department of Internal Medicine, Burjeel Hospital, Abu Dhabi, ARE
| | - Jagjeet Singh
- Department of Internal Medicine, Lahore General Hospital, Lahore, PAK
| | | | - Komal Kumari
- Department of Medicine, NMC Royal Family Medical Centre, Abu Dhabi, ARE
| | - Aqsa Ahmed
- Department of Medicine, Medicare Hospital, Faisalabad, PAK
| | - Tamur Islam
- Department of Internal Medicine, Allied Hospital, Faisalabad, PAK
| | | | - Mahima Khatri
- Department of Internal Medicine/Cardiology, Dow University of Health Sciences, Karachi, PAK
| | - Satesh Kumar
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Hina Wazir
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Syed S Raza
- Department of Physiology, Gajju Khan Medical College, Swabi, PAK
- Department of Physiology, Khyber Medical College, Peshawar, PAK
- Robert and Suzanne Tomsich Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Peshawar, PAK
- Department of Physiology, Gandhara University, Peshawar, PAK
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17
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Lee B, Hong SJ, Rha SW, Heo JH, Hur SH, Choi HH, Kim KJ, Kim JH, Kim HK, Kim U, Choi YJ, Lee YJ, Lee SJ, Ahn CM, Ko YG, Kim BK, Choi D, Hong MK, Jang Y, Kim JS. Moderate-intensity statin plus ezetimibe vs high-intensity statin according to baseline LDL-C in the treatment of atherosclerotic cardiovascular disease: A post-hoc analysis of the RACING randomized trial. Atherosclerosis 2023; 386:117373. [PMID: 37995599 DOI: 10.1016/j.atherosclerosis.2023.117373] [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: 05/03/2023] [Revised: 10/12/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND AND AIMS Whether the effect of a combination strategy rather than increasing doses of one drug to lower low-density lipoprotein cholesterol (LDL-C) levels is consistent across baseline LDL-C levels remains uncertain. METHODS In the RACING trial, which showed a non-inferiority of moderate-intensity statin with ezetimibe (rosuvastatin 10 mg with ezetimibe 10 mg) to high-intensity statin (rosuvastatin 20 mg) for the primary outcome (3-year composite of cardiovascular death, major cardiovascular event, or stroke), the heterogeneity in treatment effect according to baseline LDL-C levels was assessed for the primary and secondary outcomes (clinical efficacy and safety). RESULTS Of 3780 participants, 2817 participants (74.5%) had LDL-C <100 mg/dL, and 963 participants (25.5%) had LDL-C ≥100 mg/dL. The treatment effect of combination therapy versus high-intensity statin monotherapy was similar among the lower LDL-C subset (8.8% vs. 10.2%; hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.67 to 1.08, p = 0.19) and the higher LDL-C subset (10.8% vs. 9.6 %; HR 1.14, 95% CI 0.76 to 1.7, p = 0.53) without a significant interaction (interaction p = 0.22). Of the secondary outcomes, the 1-, 2-, and 3-year achievement of LDL-C <70 mg/dL was greater in the combination therapy group regardless of baseline LDL-C levels. CONCLUSIONS Among ASCVD patients, there was no heterogeneity in the effect of moderate-intensity statin plus ezetimibe combination therapy in the higher and lower baseline LDL-C levels for the 3-year composite of cardiovascular outcomes.
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Affiliation(s)
- Bom Lee
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Sung-Jin Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Jung Ho Heo
- Kosin University Gospel Hospital, Busan, South Korea
| | - Seung-Ho Hur
- Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Hyun Hee Choi
- Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea
| | - Kyung-Jin Kim
- Ewha Woman's University Mokdong Hospital, Seoul, South Korea
| | - Ju Han Kim
- Chonnam National University Hospital, Gwangju, South Korea
| | - Hyun Kuk Kim
- Chosun University Hospital, Gwangju, South Korea
| | - Ung Kim
- Yeungnam University Hospital, Daegu, South Korea
| | - Yu Jeong Choi
- Daejeon Eulji Medical Center, Eulji University, Daejeon, South Korea
| | - Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul-Min Ahn
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Guk Ko
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Myeong-Ki Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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18
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Andersson T, Nåtman J, Mourtzinis G, Bager JE, Bengtsson Boström K, Franzén S, Hjerpe P. The effect of statins on mortality and cardiovascular disease in primary care hypertensive patients without other cardiovascular disease or diabetes. Eur J Prev Cardiol 2023; 30:1883-1894. [PMID: 37368941 DOI: 10.1093/eurjpc/zwad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/01/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2023]
Abstract
AIMS Studies in primary healthcare (PHC) assessing the effect of primary prevention with statins on mortality and cardiovascular disease (CVD) are scarce. This study aimed to estimate the effect of statins on all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and stroke in individuals in PHC with hypertension without CVD or diabetes. METHODS AND RESULTS Using the Swedish PHC quality assurance register QregPV, the study included 13 193 individuals with hypertension without CVD or diabetes, who had filled a first statin prescription between 2010 and 2016, and 13 193 matched controls without a filled statin prescription at the index date. Controls were matched on sex and propensity score using clinical data and data from national registers on comorbidities, prescriptions, and socioeconomic status. The effect of statins was estimated in Cox regression models. During a median of 4.2 years of follow-up, 395 individuals in the statin group vs. 475 in the control group died, 197 vs. 232 died of cardiovascular disease, 171 vs. 191 had an MI, and 161 vs. 181 had a stroke. The treatment effect of statins was significant for all-cause mortality [hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.74-0.93] and cardiovascular mortality (HR 0.85, 95% CI 0.72-0.998). Overall, no significant treatment effect of statins was seen for MI (HR 0.89, 95% CI 0.74-1.07), but there was a significant interaction with sex (P = 0.008) with decreased risk of MI for women but not for men (HR 0.66, 95% CI 0.49-0.88 vs. HR 1.09, 95% CI 0.86-1.38). CONCLUSION Primary prevention with statins in PHC was associated with reduced risk of all-cause mortality, cardiovascular mortality, and in women, lower risk of MI.
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Affiliation(s)
- Tobias Andersson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens backe, Hus 7 Hälsovetarbacken, 413 90 Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Regionens hus, 541 80 Skövde, Sweden
| | | | - Georgios Mourtzinis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine and Emergency Mölndal, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan-Emil Bager
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Bengtsson Boström
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens backe, Hus 7 Hälsovetarbacken, 413 90 Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Regionens hus, 541 80 Skövde, Sweden
| | - Stefan Franzén
- Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hjerpe
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens backe, Hus 7 Hälsovetarbacken, 413 90 Gothenburg, Sweden
- Regionhälsan R&D Centre, Skaraborg Primary Care, Regionens hus, 541 80 Skövde, Sweden
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19
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Alunno A, Carubbi F, Campanozzi E, Bellisario F, Schoones JW, Mariani FM, Di Ruscio E, Altieri P, Ferri C. Untangling the relationship between bempedoic acid and gout: results from a systematic literature review. Front Cardiovasc Med 2023; 10:1234601. [PMID: 37953764 PMCID: PMC10634504 DOI: 10.3389/fcvm.2023.1234601] [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: 06/04/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Background Bempedoic acid (BA) is a small-molecule first-in-class of inhibitor of ATP citrate lyase that significantly lowers low-density lipoproteins cholesterol (LDL-c) in statin-intolerant and inadequate responders. Increased serum uric acid (SUA) levels and gout incidence have been described in BA-treated patients. The aim of this systematic review was to investigate the safety of BA regarding SUA levels and gout in randomised controlled trials (RCTs). Methods A search on 7 databases was performed from inception to May 4, 2023. RCTs of BA monotherapy or combination with other lipid-lowering treatment (LLT) in patients with increased LDL-c were included. Dual data extraction was performed with disagreements resolved through consensus. Due to the methodological purpose of this review risk-of-bias assessment of studies was not performed. Results 6 Phase 3 RCTs (N = 17,975 patients of which 9,635 received BA) 9 Phase 2 RCTs (N = 362 patients of which 170 received BA) and an open-label extension of a Phase 3 RCT were included. Gout and/or hyperuricemia were not mentioned as exclusion criteria, previous/current use of urate-lowering therapies (ULT) and/or colchicine and/or dietary patterns were not reported. Phase 3 RCTs: 2 studies specified the number of patients experiencing hyperuricemia over the study period (BA: 4.9%-11%; placebo: 1.9%-5.6%) and the effect size was significant only in 1 study (OR = 2.0, 95% CI 1.8-2.3). Four RCTs reported a higher incidence of gout in the BA arm however, when we calculated the effect size, it was small and often not significant. Two studies reported 0 cases of gout. The paucity of information about SUA levels at baseline and/or at the end of follow-up do not allow us to quantify the effect sizes for BA-induced SUA elevation. Data on gout from Phase 2 RCTs is scant. Conclusions Data from phase 2 and 3 RCTs do not allow for confirming a clear association between BA and gout. It is conceivable that a careful assessment of SUA levels/history of gout at baseline and the concomitant use of urate-lowering agents may be instrumental to minimise the risk of new-onset gout/gout flares in patients treated with BA.
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Affiliation(s)
- Alessia Alunno
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Francesco Carubbi
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Elena Campanozzi
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Federico Bellisario
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Jan W. Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, Netherlands
| | - Francesco Maria Mariani
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Evy Di Ruscio
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Piera Altieri
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Claudio Ferri
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
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20
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Singeisen H, Renström F, Laimer M, Lehmann R, Bilz S, Brändle M. An estimation of the consequences of reinforcing the 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines on current lipid-lowering treatment in patients with type 2 diabetes in tertiary care-a SwissDiab study. Eur J Prev Cardiol 2023; 30:1473-1481. [PMID: 37226890 DOI: 10.1093/eurjpc/zwad178] [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: 01/09/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/26/2023]
Abstract
AIMS In 2019, the European Society of Cardiology/European Atherosclerosis Society updated the 2016 guidelines for the management of dyslipidaemias recommending more stringent low-density lipoprotein cholesterol (LDL-C) targets in diabetes mellitus type 2 (DM2). Based on a real-world patient population, this study aimed to determine the feasibility and cost of attaining guideline-recommended LDL-C targets, and assess cardiovascular benefit. METHODS AND RESULTS The Swiss Diabetes Registry is a multicentre longitudinal observational study of outpatients in tertiary diabetes care. Patients with DM2 and a visit between 1 January 2018 and 31 August 2019 that failed the 2016 LDL-C target were identified. The theoretical intensification of current lipid-lowering medication needed to reach the 2016 and 2019 LDL-C target was determined and the cost thereof extrapolated. The expected number of major adverse cardiovascular events (MACE) prevented by treatment intensification was estimated. Two hundred and ninety-four patients (74.8%) failed the 2016 LDL-C target. The percentage of patients that theoretically achieved the 2016 and 2019 target with the indicated treatment modifications were high-intensity statin, 21.4% and 13.3%; ezetimibe, 46.6% and 27.9%; proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i), 30.6% and 53.7%; ezetimibe and PCSK9i, 1.0% and 3.1%; whereas one (0.3%) and five patients (1.7%) failed to reach target, respectively. Achieving the 2016 vs. 2019 target would reduce the estimated 4-year MACE from 24.9 to 18.6 vs. 17.4 events, at an additional annual cost of medication of 2140 Swiss francs (CHF) vs. 3681 CHF per patient, respectively. CONCLUSIONS For 68% of the patients, intensifying statin treatment and/or adding ezetimibe would be sufficient to reach the 2016 target, whereas 57% would require cost-intensive PCSK9i therapy to reach the 2019 target, with limited additional medium-term cardiovascular benefit.
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Affiliation(s)
- Hélène Singeisen
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Division of Endocrinology and Diabetes, Department of Internal Medicine, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Frida Renström
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Markus Laimer
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Roger Lehmann
- Division of Endocrinology, Diabetology and Clinical Nutrition, Zürich University Hospital, Zürich, Switzerland
| | - Stefan Bilz
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Michael Brändle
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Division of General Internal Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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21
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Brandts J, Ray KK. Novel and future lipid-modulating therapies for the prevention of cardiovascular disease. Nat Rev Cardiol 2023; 20:600-616. [PMID: 37055535 DOI: 10.1038/s41569-023-00860-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/15/2023]
Abstract
Lowering the levels of LDL cholesterol in the plasma has been shown to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Several other lipoproteins, such as triglyceride-rich lipoproteins, HDL and lipoprotein(a) are associated with atherosclerosis and ASCVD, with strong evidence supporting causality for some. In this Review, we discuss novel and upcoming therapeutic strategies targeting different pathways in lipid metabolism to potentially attenuate the risk of cardiovascular events. Key proteins involved in lipoprotein metabolism, such as PCSK9, angiopoietin-related protein 3, cholesteryl ester transfer protein and apolipoprotein(a), have been identified as viable targets for therapeutic intervention through observational and genetic studies. These proteins can be targeted using a variety of approaches, such as protein inhibition or interference, inhibition of translation at the mRNA level (with the use of antisense oligonucleotides or small interfering RNA), and the introduction of loss-of-function mutations through base editing. These novel and upcoming strategies are complementary to and could work synergistically with existing therapies, or in some cases could potentially replace therapies, offering unprecedented opportunities to prevent ASCVD. Moreover, a major challenge in the prevention and treatment of non-communicable diseases is how to achieve safe, long-lasting reductions in causal exposures. This challenge might be overcome with approaches such as small interfering RNAs or genome editing, which shows how far the field has advanced from when the burden of achieving this goal was placed upon patients through rigorous adherence to daily small-molecule drug regimens.
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Affiliation(s)
- Julia Brandts
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.
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22
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Makhmudova U, Samadifar B, Maloku A, Haxhikadrija P, Geiling JA, Römer R, Lauer B, Möbius-Winkler S, Otto S, Schulze PC, Weingärtner O. Intensive lipid-lowering therapy for early achievement of guideline-recommended LDL-cholesterol levels in patients with ST-elevation myocardial infarction ("Jena auf Ziel"). Clin Res Cardiol 2023; 112:1212-1219. [PMID: 36602598 PMCID: PMC10449699 DOI: 10.1007/s00392-022-02147-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS Currently, less than 20% of patients at very high-risk achieve ESC/EAS dyslipidemia guideline-recommended LDL-C target levels in Europe. "Jena auf Ziel-JaZ" is a prospective cohort study in which early combination therapy with atorvastatin 80 mg and ezetimibe 10 mg was initiated on admission in patients with ST-elevation myocardial infarction (STEMI) and lipid-lowering therapy was escalated during follow-up with bempedoic acid and PCSK9 inhibitors to achieve recommended LDL-C targets in all patients. Moreover, we evaluated side-effects of lipid-lowering therapy. METHODS Patients admitted with STEMI at Jena University Hospital were started on atorvastatin 80 mg and ezetimibe 10 mg on admission. Patients were followed for EAS/ESC LDL-C target achievement during follow-up. RESULTS A total of 85 consecutive patients were enrolled in the study. On discharge, 32.9% achieved LDL-C targets on atorvastatin 80 mg and ezetimibe 10 mg. After 4-6 weeks, 80% of all patients on atorvastatin 80 mg and ezetimibe started at the index event were on ESC/EAS LDL-C targets. In 20%, combined lipid-lowering therapy was escalated with either bempedoic acid or PCSK9 inhibitors. All patients achieved LDL-C levels of or below 55 mg/dL during follow-up on triple lipid-lowering therapy. Combined lipid-lowering therapy was well-tolerated with rare side effects. CONCLUSIONS Early combination therapy with a high-intensity statin and ezetimibe and escalation of lipid-lowering therapy with either bempedoic acid or PCSK9 inhibitors gets potentially all patients with STEMI on recommended ESC/EAS LDL-C targets without significant side effects.
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Affiliation(s)
- Umidakhon Makhmudova
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Beasat Samadifar
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Aurel Maloku
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Pellumb Haxhikadrija
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jens-Arndt Geiling
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Robert Römer
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Bernward Lauer
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sven Möbius-Winkler
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sylvia Otto
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - P Christian Schulze
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Oliver Weingärtner
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
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23
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Makhmudova U, Wolf M, Willfeld K, Beier L, Weingärtner O. [Primary and secondary prevention in hypercholesterolemia: differences relevant to patient care in the PROCYON trial]. Dtsch Med Wochenschr 2023; 148:e101-e110. [PMID: 37604168 PMCID: PMC10946085 DOI: 10.1055/a-2117-6504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND Cardiovascular disease accounts for one third of deaths in Germany. Elevated levels of low-density lipoprotein cholesterol (LDL-C) are considered a major risk factor. Lowering LDL-C levels is therefore an integral part of the prevention of cardiovascular events. METHODS The aim of this work is to identify potential differences between primary prevention (PP) and secondary prevention (SP) by means of a post-hoc comparison of cross-sectional data from the PROCYON survey. Medical history, concomitant diseases, adherence, and disease awareness in relation to hypercholesterolemia were queried. RESULTS 5,494 patients had participated in the survey (PP: 3,798; SP: 1,696). Comparison of the results showed a numerically higher proportion of women (PP 70.7% vs. SP 42.5%) as well as more frequent comorbidities such as hypertension (PP 45.6% vs. SP 61.0%), obesity (PP 20.9% vs. SP 27.4%), and type 2 diabetes mellitus (PP 14.1% vs. SP 23.8%). In primary prevention, hypercholesterolemia was most often diagnosed during screening (PP 74.6%), and in secondary prevention, the diagnosis was most often made during cardiovascular-related hospitalization (SP 58.0%). A cardiologist was consulted by 16.3% (PP) and 54.0% (SP) of patients, respectively. At least semiannual LDL-C checks (PP 46.8% vs. SP 77.9%) and drug intervention (PP 43.0% vs. SP 87.0%) were more frequent in the secondary prevention group. In addition, differences in the implementation of lifestyle changes, improvement of LDL-C levels, adjustment of therapy as well as adherence, treatment satisfaction and patient knowledge were observed. CONCLUSION The comparison of primary and secondary prevention from the PROCYON survey shows overall better utilization of treatment options and higher intensity of care in the secondary prevention group. However, there is still great potential for improvement in both groups to ensure efficient prevention of cardiovascular events.
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Affiliation(s)
| | - Michaela Wolf
- Cholesterin & Co e. V.: Patientenorganisation für Patienten mit Familiärer Hypercholesterinämie oder anderen schweren genetischen Fettstoffwechselstörungen (CholCo e. V.), Frankfurt/M
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24
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Deo SV. Monte Carlo simulations to meet the ESC recommended low-density lipoprotein cholesterol targets. THE LANCET REGIONAL HEALTH. EUROPE 2023; 31:100670. [PMID: 37388944 PMCID: PMC10300384 DOI: 10.1016/j.lanepe.2023.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Salil V. Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, USA
- Case School of Medicine, Case Western Reserve University, Cleveland, USA
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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25
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Kovach CP, Mesenbring EC, Gupta P, Glorioso TJ, Ho PM, Waldo SW, Schwartz GG. Projected Outcomes of Optimized Statin and Ezetimibe Therapy in US Military Veterans with Coronary Artery Disease. JAMA Netw Open 2023; 6:e2329066. [PMID: 37638630 PMCID: PMC10463102 DOI: 10.1001/jamanetworkopen.2023.29066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/07/2023] [Indexed: 08/29/2023] Open
Abstract
Importance Many patients with coronary artery disease (CAD) do not achieve the guideline-directed goals for low-density lipoprotein cholesterol (LDL-C) levels. Objective To estimate reductions in the rates of adverse events associated with CAD in a large US military veteran population that may be achieved through use of optimized statin therapy alone or with ezetimibe compared with the prevailing lipid-lowering therapy (LLT). Design, Setting, and Participants In this observational cohort study, US military veterans with CAD were identified by coronary angiography between June 2015 and September 2020 across 82 US Department of Veterans Affairs health care facilities. Exposures The exposures were observed LLT, LLT with an optimized statin regimen, and LLT with optimized statin and ezetimibe. Main Outcomes and Measures Observed rates of death, myocardial infarction, stroke, and coronary revascularization, and potential reductions in those outcomes with optimized LLT based on expected further reductions in LDL-C levels and application of formulas from The Cholesterol Treatment Trialists' Collaboration. Results The analysis cohort comprised 111 954 veterans (mean [SD] age, 68.4 [8.8] years; 109 390 men [97.7%]; 91 589 White patients [81.8%]; 17 592 Black patients [15.7%]). The median (IQR) observation period for this study was 3.4 (2.1-4.0) years. At the time of index angiography, 66 877 patients (59.7%) were treated with statin therapy, and 623 patients (0.6%) were treated with ezetimibe. At 6 months, the number of patients with statin prescriptions increased to 74 400 (68.7%), but the number of patients with high-intensity statin prescriptions was only 57 297 (52.9%). At 6 months, ezetimibe use remained low (n = 1168 [1.1%]), and LDL-C levels were 70 mg/dL or more in 56 405 patients (52.1%). At 4 years, observed incidences of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (95% CI, 21.3%-21.8%), 5.0% (95% CI, 4.9%-5.2%), 2.2% (95% CI, 2.1%-2.3%), and 15.4% (95% CI, 15.2%-15.7%), respectively. With optimized statin treatment, projected absolute reductions in these incidences were 1.3% (95% CI, 0.9%-1.7%), 0.8% (95% CI, 0.7%-1.0%), 0.2% (95% CI, 0.1%-0.3%), and 2.3% (95% CI, 2.0%-2.7%), respectively. With optimized statin and ezetimibe treatment, projected absolute reductions were 1.8% (95% CI, 1.2%-2.4%), 1.1% (95% CI, 0.9%-1.3%), 0.3% (95% CI, 0.2%-0.4%), and 3.1% (95% CI, 2.6%-3.6%), respectively. Conclusions and Relevance In this cohort study of veterans with CAD, suboptimal LLT was prevalent in the clinical setting. Optimization of statin therapy was projected to produce clinically relevant reductions in the risks of death and cardiovascular events. Despite a lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level in conjunction with optimized statin therapy may be associated with further meaningful reductions in cardiovascular risk.
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Affiliation(s)
- Christopher P. Kovach
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Elise C. Mesenbring
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Denver Research Institute, Aurora, Colorado
| | - Prerna Gupta
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
| | - Thomas J. Glorioso
- Clinical Assessment, Reporting, and Tracking Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - P. Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Stephen W. Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Clinical Assessment, Reporting, and Tracking Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Gregory G. Schwartz
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
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Brandts J, Bray S, Villa G, Catapano AL, Poulter NR, Vallejo-Vaz AJ, Ray KK. 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. THE LANCET REGIONAL HEALTH. EUROPE 2023; 31:100665. [PMID: 37547279 PMCID: PMC10398584 DOI: 10.1016/j.lanepe.2023.100665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 08/08/2023]
Abstract
Background The impact of the stepwise implementation of the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) treatment algorithm on low-density lipoprotein cholesterol (LDL-C) goal attainment was simulated in patients from the DA VINCI study. Methods Monte Carlo simulation was used to evaluate treatment optimisation scenarios, based on a patient's risk category: statin intensification (step 1), addition of ezetimibe (step 2), and addition of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (step 3). Residual cardiovascular risk and predicted relative and absolute risk reduction (RRR and ARR) in cardiovascular events were assessed. Findings In DA VINCI, 2482 patients did not achieve their 2019 ESC/EAS LDL-C goals and were included in the simulation. In patients without atherosclerotic cardiovascular disease (ASCVD) (n = 962), 27.0% (n = 259) and 57.0% (n = 548) are likely to achieve their LDL-C goals at step 1 and step 2, respectively. Of those at very high risk without ASCVD (n = 74), 88.1% (n = 65) are likely to achieve their LDL-C goals at step 3. In patients with ASCVD (n = 1520), 12.0% (n = 183), 42.1% (n = 641) and 93.2% (n = 1416) are likely to achieve their LDL-C goals at steps 1, 2 and 3, respectively. In patients with and without ASCVD, treatment optimisation may result in mean simulated RRR of 24.0% and 17.7%, respectively, and ARR of 8.1% and 2.6%, respectively. Interpretation Most patients at high cardiovascular risk are unlikely to achieve LDL-C goals through statin optimisation and ezetimibe, and will require a PCSK9 inhibitor, leading to greater reduction in cardiovascular risk. Funding Amgen.
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Affiliation(s)
- Julia Brandts
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
- Department of Internal Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Sarah Bray
- Global Biostatistical Science, Amgen Ltd, Cambridge, UK
| | - Guillermo Villa
- Health Economics & Outcomes Research, Amgen (Europe) GmbH, Risch-Rotkreuz, Switzerland
| | - Alberico L. Catapano
- IRCCS MultiMedica, Milan, Italy
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Antonio J. Vallejo-Vaz
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
- Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
- Clinical Epidemiology and Vascular Risk, Institute of Biomedicine of Seville (IBiS), IBiS/Hospital Universitario Virgen del Rocío/University of Seville/CSIC, Seville, Spain
| | - Kausik K. Ray
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
- Imperial Clinical Trials Unit, Imperial College London, London, UK
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Pinsdorf D, Messiha D, Petrikhovich O, Bahar M, Steinmetz M, Mahabadi AA, Dykun I, Lortz J, Rassaf T, Rammos C. Differences in treatment strategies for LDL-cholesterol reduction in a university lipid clinic vs. standard care apart from the use of PCSK9 inhibitors. J Clin Lipidol 2023; 17:504-511. [PMID: 37271601 DOI: 10.1016/j.jacl.2023.05.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/01/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Lipid-lowering therapy (LLT) in patients with cardiovascular disease (CVD) is insufficient despite clear guideline recommendations. Lipid clinics have specialized in patients with dyslipidemia, but the magnitude and reduction of low-density lipoprotein cholesterol (LDL-C) in lipid clinics has not yet been studied in depth. OBJECTIVE To assess LDL-C reduction in very high-risk CVD patients achieved in a lipid clinic through different forms of LLT in comparison to standard care without the initiation of PSCK9 inhibitors. METHODS Data from 96 lipid clinic patients were analyzed retrospectively and compared to 84 standard care patients. Very high-risk patients were defined according to the European Society of Cardiology (ESC). Different combinations of LLT focusing on statins and ezetimibe were investigated. Achievement of LDL-C treatment goals according to ESC guidelines as well as LDL-C reduction were assessed. RESULTS Baseline and follow-up data of 180 very high-risk CVD patients (mean age 67.7 (±9.8) y; 60.6% male) were used. Achievement of the LDL-C goal in lipid clinic patients increased significantly from 14.6% at baseline to 41.7% at the latest visit (p<0.001) while standard care patients improved from 21.4% to 33.3% (p=0.08). The largest relative LDL-C reduction via an adjustment in LLT was achieved by initiation of high-intensity statins (50.8 ± 4.9%, n = 5, p < 0.05). CONCLUSION Treatment in a lipid clinic leads to a superior LDL-C goal achievement in very high-risk CVD patients as compared to standard care with the highest reduction under LLT with high-intensity statins and ezetimibe. Referral algorithms have to be established for high-risk patients.
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Affiliation(s)
- David Pinsdorf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Daniel Messiha
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Olga Petrikhovich
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Mikail Bahar
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Steinmetz
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Amir Abbas Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Iryna Dykun
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Julia Lortz
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany.
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Toplak H, Bilitou A, Alber H, Auer J, Clodi M, Ebenbichler C, Fließer-Görzer E, Gelsinger C, Hanusch U, Ludvik B, Maca T, Schober A, Sock R, Speidl WS, Stulnig TM, Weitgasser R, Zirlik A, Koch M, Wienerroither S, Wolowacz SE, Diamand F, Catapano AL. Simulation of bempedoic acid and ezetimibe in the lipid-lowering treatment pathway in Austria using the contemporary SANTORINI cohort of high and very high risk patients. Wien Klin Wochenschr 2023:10.1007/s00508-023-02221-4. [PMID: 37286910 DOI: 10.1007/s00508-023-02221-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/07/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The low-density lipoprotein cholesterol goals in the 2019 European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guidelines necessitate greater use of combination therapies. We describe a real-world cohort of patients in Austria and simulate the addition of oral bempedoic acid and ezetimibe to estimate the proportion of patients reaching goals. METHODS Patients at high or very high cardiovascular risk on lipid-lowering treatments (excluding proprotein convertase subtilisin/kexin type 9 inhibitors) from the Austrian cohort of the observational SANTORINI study were included using specific criteria. For patients not at their risk-based goals at baseline, addition of ezetimibe (if not already received) and subsequently bempedoic acid was simulated using a Monte Carlo simulation. RESULTS A cohort of patients (N = 144) with a mean low-density lipoprotein cholesterol of 76.4 mg/dL, with 94% (n = 135) on statins and 24% (n = 35) on ezetimibe monotherapy or in combination, were used in the simulation. Only 36% of patients were at goal (n = 52). Sequential simulation of ezetimibe (where applicable) and bempedoic acid increased the proportion of patients at goal to 69% (n = 100), with a decrease in the mean low-density lipoprotein cholesterol from 76.4 mg/dL at baseline to 57.7 mg/dL overall. CONCLUSIONS The SANTORINI real-world data in Austria suggest that a proportion of high and very high-risk patients remain below the guideline-recommended low-density lipoprotein cholesterol goals. Optimising use of oral ezetimibe and bempedoic acid after statins in the lipid-lowering pathway could result in substantially more patients attaining low-density lipoprotein cholesterol goals, likely with additional health benefits.
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Affiliation(s)
- Hermann Toplak
- Department of Endocrinology and Diabetes, Clinic for Diabetology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | | | - Hannes Alber
- Department of Internal Medicine and Cardiology, KABEG Clinic Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Johann Auer
- Department of Internal Medicine I, Hospital St. Josef Braunau, Braunau, Austria
| | - Martin Clodi
- Hospital of Internal Medicine Brüder Linz, Linz, Austria
- Institute for Cardiovascular and Metabolic Research (ICMR), Johannes Kepler Universität Linz (JKU Linz), Linz, Austria
| | | | | | | | - Ursula Hanusch
- Centre for Clinical Studies Dr. Hanusch GmbH, Vienna, Austria
| | - Bernhard Ludvik
- Medical Department in Diabetology, Endocrinology and Nephrology and Karl Landsteiner Institute for Obesity and Metabolic Disorders, Landstraße Clinic, Vienna, Austria
| | - Thomas Maca
- Evangelical Hospital Vienna, Vienna, Austria
| | - Andreas Schober
- Department of Cardiology, Hospital North-Clinic Floridsdorf, Vienna, Austria
| | | | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas M Stulnig
- Department of Medicine III and Karl Landsteiner Institute for Metabolic Diseases and Nephrology, Clinic Hietzing, Vienna, Austria
| | - Raimund Weitgasser
- Department of Internal Medicine / Diabetology, Wehrle-Diakonissen Private Hospital, Salzburg, Austria
| | - Andreas Zirlik
- Clinical Department of Cardiology, University Clinic Graz, Graz, Austria
| | - Marina Koch
- Daiichi Sankyo Austria GmbH, Vienna, Austria
| | | | | | | | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan and Multimedica IRCCS, Milan, Italy
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Hong SJ, Lee YJ, Lee SJ, Hong BK, Kang WC, Lee JY, Lee JB, Yang TH, Yoon J, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK. Treat-to-Target or High-Intensity Statin in Patients With Coronary Artery Disease: A Randomized Clinical Trial. JAMA 2023; 329:1078-1087. [PMID: 36877807 PMCID: PMC9989958 DOI: 10.1001/jama.2023.2487] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023]
Abstract
Importance In patients with coronary artery disease, some guidelines recommend initial statin treatment with high-intensity statins to achieve at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C). An alternative approach is to begin with moderate-intensity statins and titrate to a specific LDL-C goal. These alternatives have not been compared head-to-head in a clinical trial involving patients with known coronary artery disease. Objective To assess whether a treat-to-target strategy is noninferior to a strategy of high-intensity statins for long-term clinical outcomes in patients with coronary artery disease. Design, Setting, and Participants A randomized, multicenter, noninferiority trial in patients with a coronary disease diagnosis treated at 12 centers in South Korea (enrollment: September 9, 2016, through November 27, 2019; final follow-up: October 26, 2022). Interventions Patients were randomly assigned to receive either the LDL-C target strategy, with an LDL-C level between 50 and 70 mg/dL as the target, or high-intensity statin treatment, which consisted of rosuvastatin, 20 mg, or atorvastatin, 40 mg. Main Outcomes and Measures Primary end point was a 3-year composite of death, myocardial infarction, stroke, or coronary revascularization with a noninferiority margin of 3.0 percentage points. Results Among 4400 patients, 4341 patients (98.7%) completed the trial (mean [SD] age, 65.1 [9.9] years; 1228 females [27.9%]). In the treat-to-target group (n = 2200), which had 6449 person-years of follow-up, moderate-intensity and high-intensity dosing were used in 43% and 54%, respectively. The mean (SD) LDL-C level for 3 years was 69.1 (17.8) mg/dL in the treat-to-target group and 68.4 (20.1) mg/dL in the high-intensity statin group (n = 2200) (P = .21, compared with the treat-to-target group). The primary end point occurred in 177 patients (8.1%) in the treat-to-target group and 190 patients (8.7%) in the high-intensity statin group (absolute difference, -0.6 percentage points [upper boundary of the 1-sided 97.5% CI, 1.1 percentage points]; P < .001 for noninferiority). Conclusions and Relevance Among patients with coronary artery disease, a treat-to-target LDL-C strategy of 50 to 70 mg/dL as the goal was noninferior to a high-intensity statin therapy for the 3-year composite of death, myocardial infarction, stroke, or coronary revascularization. These findings provide additional evidence supporting the suitability of a treat-to-target strategy that may allow a tailored approach with consideration for individual variability in drug response to statin therapy. Trial Registration ClinicalTrials.gov Identifier: NCT02579499.
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Affiliation(s)
- Sung-Jin Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | - Jong-Young Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Bae Lee
- Daegu Catholic University Medical Center, Daegu, South Korea
| | - Tae-Hyun Yang
- Inje University Busan Paik Hospital, Busan, South Korea
| | - Junghan Yoon
- Wonju Severance Christian Hospital, Wonju, South Korea
| | - Chul-Min Ahn
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Guk Ko
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- CHA University College of Medicine, Seongnam, South Korea
| | - Myeong-Ki Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Reibis RK. Lipidmanagement 2022 – von der Tradition zur Innovation. AKTUELLE KARDIOLOGIE 2023. [DOI: 10.1055/a-2005-5248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
ZusammenfassungLipoproteine niedriger Dichte (LDL-Cholesterin) spielen in der Pathogenese atherosklerotischer kardiovaskulärer Erkrankungen eine fundamentale Rolle. Moderne lipidmodifizierende Substanzen
ermöglichen additiv zur potenten LDL-C-Senkung durch pleiotrope Effekte eine Reduktion kardiovaskulärer Ereignisse und eine Prognoseverbesserung. Während Statine, Ezetimib und monoklonale
PCSK-9-Antikörper eine gesicherte Evidenz aufweisen, werden für die neueren nukleinsäurebasierten Substanzen die Endpunktdaten noch erwartet. Die langfristigen pharmakotherapeutischen
Effekte in der Lipidtherapie werden vorwiegend durch die Stringenz der Leitlinienumsetzung und der Patientenadhärenz determiniert.
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Martins J, Steyn N, Rossouw HM, Pillay TS. Best practice for LDL-cholesterol: when and how to calculate. J Clin Pathol 2023; 76:145-152. [PMID: 36650044 DOI: 10.1136/jcp-2022-208480] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/23/2022] [Indexed: 01/19/2023]
Abstract
The lipid profile is important in the risk assessment for cardiovascular disease. The lipid profile includes total cholesterol, high-density lipoprotein (HDL)-cholesterol, triglycerides (TGs) and low-density lipoprotein (LDL)-cholesterol (LDL-C). LDL-C has traditionally been calculated using the Friedewald equation (invalid with TGs greater than 4.5 mmol/L and is based on the assumption that the ratio of TG to cholesterol in very- low-density lipoprotein (VLDL) is 5 when measured in mg /dL). LDL-C can be quantified with a reference method, beta-quantification involving ultracentrifugation and this is unsuitable for routine use. Direct measurement of LDL-C was expected to provide a solution with high TGs. However, this has some challenges because of a lack of standardisation between the reagents and assays from different manufacturers as well as the additional costs. Furthermore, mild hypertriglyceridaemia also distorts direct LDL-C measurements. With the limitations of the Friedewald equation, alternatives have been derived. Newer equations include the Sampson-National Institutes of Health (NIH) equation 2 and the Martin-Hopkins equation. The Sampson-NIH2 equation was derived using beta-quantification in a population with high TG and multiple least squares regression to calculate VLDL-C, using TGs and non-HDL-C as independent variables. These data were used in a second equation to calculate LDL-C. The Sampson-NIH2 equation can be used with TGs up to 9 mmol/L. The Martin-Hopkins equation uses a 180 cell stratification of TG/non-HDL-C to determine the TG:VLDL-C ratio and can be used with TGs up to 4.5 mmol/L. Recently, an extended Martin-Hopkins equation has become available for TGs up to 9.04 mmol/L.This article discusses the best practice approach to calculating LDL-C based on the available evidence.
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Affiliation(s)
- Janine Martins
- Chemical Pathology, University of Pretoria, Pretoria, South Africa
| | - Nicolene Steyn
- Chemical Pathology, University of Pretoria, Pretoria, South Africa
| | - H Muller Rossouw
- Chemical Pathology, University of Pretoria, Pretoria, South Africa
| | - Tahir S Pillay
- Chemical Pathology, University of Pretoria, Pretoria, South Africa .,Chemical Pathology, University of Cape Town, Cape Town, South Africa
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Lipid Lowering in "Very High Risk" Patients Undergoing Coronary Artery Bypass Surgery and Its Projected Reduction in Risk for Recurrent Vascular Events: A Monte Carlo Stepwise Simulation Approach. J Cardiovasc Pharmacol 2023; 81:120-128. [PMID: 36315474 DOI: 10.1097/fjc.0000000000001374] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/17/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT 2018 AHA guidelines provide criteria to identify patients at very high risk (VHR) for adverse vascular events and recommend an low density lipoprotein-C (LDL-C) level <1.8 mmol/L. Data regarding the 10-year risk for adverse vascular events in coronary artery bypass grafting (CABG) patients at VHR and the need for nonstatin therapies in the VHR cohort are limited. We queried a national cohort of CABG patients to answer these questions. The projected reduction of LDL-C from stepwise escalation of lipid-lowering therapy (LLT) was simulated; Monte Carlo methods were used to account for patient-level heterogeneity in treatment effects. Data on preoperative statin therapy and LDL-C levels were obtained. In the first scenario, all eligible patients not at target LDL-C received high-intensity statins, followed by ezetimibe and then alirocumab; alternatively, bempedoic acid was also used. The 10-year risk for an adverse vascular event was estimated using a validated risk score. Potential risk reduction was estimated after simulating maximal LLT. Before CABG, 8948 of 27,443 patients (median LDL-C 85 mg/dL) were at VHR. In the whole cohort, 31% were receiving high-intensity statins. With stepwise LLT escalation, the proportion of patients at target were 60%, 78%, 86%, and 97% after high-intensity statins, ezetimibe, bempedoic acid, and alirocumab, respectively. The projected 10-year risk to suffer a vascular event reduced by 4.6%. A large proportion of CABG patients who are at VHR for vascular events fail to meet 2018 AHA LDL-C targets. A stepwise approach, particularly with the use of bempedoic acid, can significantly reduce the need for more expensive proprotein convertase subtilisin kexin 9 inhibitors.
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How Did the Updated 2019 European Society of Cardiology/European Atherosclerosis Society Risk Categorization for Patients with Diabetes Affect the Risk Perception and Lipid Goals? A Simulated Analysis of Real-life Data from EPHESUS Study. Anatol J Cardiol 2023; 27:78-87. [PMID: 36747449 PMCID: PMC9900409 DOI: 10.14744/anatoljcardiol.2022.2012] [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] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The recent 2019 European Society of Cardiology/European Atherosclerosis Society practice guidelines introduced a new risk categorization for patients with diabetes. We aimed to compare the implications of the 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines with regard to the lipid-lowering treatment use, low-density lipoprotein cholesterol goal attainment rates, and the estimated proportion of patients who would be at goal in an ideal setting. METHODS Patients with diabetes were classified into 4 risk categories according to 2019 European Society of Cardiology/European Atherosclerosis Society dyslipidemia guidelines from the database of EPHESUS (cross-sectional, observational, countrywide registry of cardiology outpatient clinics) study. The use of lipid-lowering treatment and low-density lipoprotein cholesterol goal attainment rates were then compared according to previous and new guidelines. RESULTS This analysis included a total of 873 diabetic adults. Half of the study population (53.8%) were on lipid-lowering treatment and almost one-fifth (19.1%) were on high-intensity statins. While low-density lipoprotein cholesterol goal was achieved in 19.5% and 7.5% of patients, 87.4% and 69.6% would be on target if their lipid-lowering treatment was intensified according to 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society lipid guidelines, respectively. The new target <55 mg/dL could only be achieved in 2.2% and 8.1% of very high-risk primary prevention and secondary prevention patients, respectively. CONCLUSION The control of dyslipidemia was extremely poor among patients with diabetes. The use of lipid-lowering treatment was not at the desired level, and high-intensity lipid-lowering treatment use was even lower. Our simulation model showed that the high-dose statin plus ezetimibe therapy would improve goal attainment; however, it would not be possible to get goals with this treatment in more than one-third of the patients.
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Khan Z, Gul A, Yousif Y, Gupta A. A Systematic Review of Lipid Management in Secondary Prevention and Comparison of International Lipid Management Pathways. Cureus 2023; 15:e35463. [PMID: 36994289 PMCID: PMC10042622 DOI: 10.7759/cureus.35463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 02/27/2023] Open
Abstract
Acute coronary syndrome remains a major cause of morbidity and mortality despite significant improvements in its prevention and management. Lipid management and other risk factors such as hypertension, diabetes, obesity, smoking and sedentary lifestyle stratification is the key to minimising this risk. Lipid management is an important part of secondary prevention and patients are historically undertreated after post-acute coronary syndrome. We performed a narrative review on observational studies on lipid management pathways post ACS on PubMed, Google Scholar, Journal Storage and ScienceDirect and excluded case reports, case series and randomized controlled trials. Our review showed that most patients following acute coronary syndrome receive suboptimal treatment for hypercholesterolemia. The role of statin in reducing future cardiac events risk is undisputable, however, statin intolerance remains a major concern. There is substantial variation in the management of lipids in patients following an acute cardiac event and patients were followed up in primary care in some countries and secondary care in others. The mortality risk is significantly high in patients with second or recurrent cardiac events and future cardiac events are associated with higher morbidity and mortality risk. There is significant variation in lipid management pathways in patients who suffer from cardiac events across the globe and lipid therapy optimization remains suboptimal in these patients, putting them at future risk of cardiovascular events. It is therefore imperative to optimally manage dyslipidemia in these patients in order to minimize the risk of subsequent cardiac events. Cardiac rehabilitation programs might be a way forward to incorporate lipid management for patients discharged from the hospital after having acute coronary events for lipid therapy optimization.
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Affiliation(s)
- Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
- Cardiology, Bart's Heart UK, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
| | - Amresh Gul
- General Practice, Lifeline Hospital, Salalah, OMN
| | - Yousif Yousif
- Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
| | - Animesh Gupta
- Acute Internal Medicine, Southend University Hospital NHS Trust, Southend on Sea, GBR
- Acute Internal Medicine/Intensive Care, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
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Makhmudova U, Wolf M, Willfeld K, Beier L, Weingärtner O. Different Perspectives of Patients and Physicians on LDL-C Target Achievement in the Treatment of Hypercholesterolemia: Results on Secondary Prevention from the German PROCYON Survey. Adv Ther 2023; 40:460-473. [PMID: 36355313 PMCID: PMC9898401 DOI: 10.1007/s12325-022-02357-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/12/2022] [Indexed: 11/12/2022]
Abstract
AIMS Low-density lipoprotein cholesterol (LDL-C) reduction in hypercholesterolemia patients at very high cardiovascular (CV) risk is essential in preventing future CV events. The objective was to assess the perception on hypercholesterolemia management in secondary prevention in Germany. METHODS PROCYON was a two-part online survey, including a patient questionnaire as well as a physician questionnaire. RESULTS A total of 109 general practitioners, internists, and cardiologists participated. The current ESC/EAS recommendation for high-risk patients is followed by 19.3% of the physicians. The majority (80.7%) reported an LDL-C target failure rate of at least 30%. More than two thirds (71.6%) have stated treating less than half of their patients with the maximum approved statin dose. The survey included 1696 secondary prevention patients. The majority (86.7%) consult their general practitioner for hypercholesterolemia; 54.0% consult a cardiologist (multiple answers allowed). Most patients (87.0%) were receiving lipid-lowering medication. Among these, 800 (54.2%) reported improved LDL-C levels since diagnosis, 569 (38.6%) reported no improvement, and 106 (7.2%) had no information. Of the treated patients with (N' = 800) and without (N' = 569) improvement, 34.3% vs. 37.3% were on their initial drug and dose, 24.8% vs. 23.7% received multiple drug therapy, 48.9% vs. 48.9% reported a dose change, and 16.1% vs. 14.2% had discontinued at least one drug (multiple answers). Disease knowledge was rated as good or very good by 29.8% of patients. CONCLUSION PROCYON demonstrated insufficient ESC/EAS guideline implementation regarding target levels and therapeutic escalation strategies. Furthermore, a lack of specialist involvement and patient education was identified.
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Affiliation(s)
- Umidakhon Makhmudova
- grid.275559.90000 0000 8517 6224Klinik Für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Michaela Wolf
- Cholesterin & Co E. V.: Patientenorganisation Für Patienten Mit Familiärer Hypercholesterinämie Oder Anderen Schweren Genetischen Fettstoffwechselstörungen (CholCo), Frankfurt/M., Germany
| | - Kathy Willfeld
- grid.467675.10000 0004 0629 4302Novartis Pharma GmbH, Nuremberg, Germany
| | - Lea Beier
- grid.467675.10000 0004 0629 4302Novartis Pharma GmbH, Nuremberg, Germany
| | - Oliver Weingärtner
- Klinik Für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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Krychtiuk KA, Ahrens I, Drexel H, Halvorsen S, Hassager C, Huber K, Kurpas D, Niessner A, Schiele F, Semb AG, Sionis A, Claeys MJ, Barrabes J, Montero S, Sinnaeve P, Pedretti R, Catapano A. Acute LDL-C reduction post ACS: strike early and strike strong: from evidence to clinical practice. A clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), in collaboration with the European Association of Preventive Cardiology (EAPC) and the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:939-949. [PMID: 36574353 DOI: 10.1093/ehjacc/zuac123] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/02/2022] [Indexed: 12/28/2022]
Abstract
After experiencing an acute coronary syndrome (ACS), patients are at a high risk of suffering from recurrent ischaemic cardiovascular events, especially in the very early phase. Low density lipoprotein-cholesterol (LDL-C) is causally involved in atherosclerosis and a clear, monotonic relationship between pharmacologic LDL-C lowering and a reduction in cardiovascular events post-ACS has been shown, a concept termed 'the lower, the better'. Current ESC guidelines suggest an LDL-C guided, step-wise initiation and escalation of lipid-lowering therapy (LLT). Observational studies consistently show low rates of guideline-recommended LLT adaptions and concomitant low rates of LDL-C target goal achievement, leaving patients at residual risk, especially in the vulnerable post-ACS phase. In addition to the well-established 'the lower, the better' approach, a 'strike early and strike strong' approach in the early post-ACS phase with upfront initiation of a combined lipid-lowering approach using high-intensity statins and ezetimibe seems reasonable. We discuss the rationale, clinical trial evidence and experience for such an approach and highlight existing knowledge gaps. In addition, the concept of acute initiation of PCSK9 inhibition in the early phase is reviewed. Ultimately, we focus on hurdles and solutions to provide high-quality, evidence-based follow-up care in post-ACS patients.
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Affiliation(s)
- Konstantin A Krychtiuk
- Department of Internal Medicine II-Division of Cardiology, Medical University of Vienna, 1180 Vienna, Austria.,Duke Clinical Research Institute, Durham, NC 27701, USA
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, 50678 Cologne, Germany
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein.,Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Sigrun Halvorsen
- Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway.,Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Unit, Wilhelminenhospital, 1160 Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, 1090 Vienna, Austria.,Medical School, Sigmund Freud University, 1020 Vienna, Austria
| | - Donata Kurpas
- Family Medicine Department, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Alexander Niessner
- Department of Internal Medicine II-Division of Cardiology, Medical University of Vienna, 1180 Vienna, Austria
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, University of Franche-Comté, France and EA3920, Besancon, France
| | - Anne Grete Semb
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Division of Innovation and Research, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBER-CV, Centro de investigación Biomédica en Red de Enfermedades Cardiovasculares, 28029 Madrid, Spain
| | - Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - José Barrabes
- Acute Cardiac Care Unit, Cardiology Service, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERC-V, Centro de investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol. Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Peter Sinnaeve
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium
| | - Roberto Pedretti
- Director of Cardiovascular Department, Head of Cardiology Unit, IRCCS MultiMedica, Milan, Italy
| | - Alberico Catapano
- Professor of Pharmacology, Director Center of Epidemiology and Preventive Pharmacology, Director Laboratory of Lipoproteins, Immunity and Atherosclerosis Department of Pharmacological and Biomolecular Sciences Director Center for the Study of Atherosclerosis at Bassini Hospital University of Milan, Milan, Italy
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Crea F. Focus on trials: dementia, lipids, thrombosis, and heart failure. Eur Heart J 2022; 43:4965-4969. [PMID: 36542413 DOI: 10.1093/eurheartj/ehac746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Katzmann JL, Becker C, Bilitou A, Laufs U. Simulation study on LDL cholesterol target attainment, treatment costs, and ASCVD events with bempedoic acid in patients at high and very-high cardiovascular risk. PLoS One 2022; 17:e0276898. [PMID: 36301892 PMCID: PMC9612573 DOI: 10.1371/journal.pone.0276898] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/15/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND AIMS The LDL cholesterol (LDL-C) treatment goals recommended by the 2019 ESC/EAS guidelines are only achieved in a minority of patients. The study objective was to estimate the impact of bempedoic acid treatment on LDL-C target attainment, drug costs, and atherosclerotic cardiovascular disease (ASCVD) events. The simulation used a Monte Carlo approach in a representative cohort of German outpatients at high or very-high cardiovascular risk. Additionally to statins, consecutive treatment with ezetimibe, bempedoic acid, and a PCSK9 inhibitor was simulated in patients not achieving their LDL-C goal. Considered were scenarios without and with bempedoic acid (where bempedoic acid was replaced by a PCSK9 inhibitor when LDL-C was not controlled). RESULTS The simulation cohort consisted of 105,577 patients, of whom 76,900 had very-high and 28,677 high cardiovascular risk. At baseline, 11.2% of patients achieved their risk-based LDL-C target. Sequential addition of ezetimibe and bempedoic acid resulted in target LDL-C in 33.1% and 61.9%, respectively. Treatment with bempedoic acid reduced the need for a PCSK9 inhibitor from 66.6% to 37.8% and reduced drug costs by 35.9% per year on stable lipid-lowering medication. Compared to using only statins and ezetimibe, this approach is projected to prevent additional 6,148 ASCVD events annually per 1 million patients, whereas PCSK9 inhibition alone would prevent 7,939 additional ASCVD events annually. CONCLUSIONS A considerably larger proportion of cardiovascular high- and very-high-risk patients can achieve guideline-recommended LDL-C goals with escalated lipid-lowering medication. Bempedoic acid is projected to substantially decrease the need for PCSK9 inhibitor treatment to achieve LDL-C targets, associated with reduced drug costs albeit with fewer prevented events.
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Affiliation(s)
- Julius L. Katzmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | | | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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Abstract
PURPOSE OF REVIEW The aim of creating an orally active non-statin cholesterol-lowering drug was achieved with bempedoic acid, a small linear molecule providing both a significant low-density lipoprotein cholesterol (LDL-C) reduction and an anti-inflammatory effect by decreasing high-sensitivity C-reactive protein. Bempedoic acid antagonizes ATP citrate-lyase, a cytosolic enzyme upstream of HMGCoA reductase which is the rate-limiting step of cholesterol biosynthesis. Bempedoic acid is a pro-drug converted to its active metabolite by very-long-chain acyl-CoA synthetase 1 which is present mostly in the liver and absent in skeletal muscles. This limits the risk of myalgia and myopathy. The remit of this review is to give clinical insights on the safety and efficacy of bempedoic acid and to understand for whom it should be prescribed. RECENT FINDINGS Bempedoic acid with a single daily dose (180 mg) reduces LDL-C by a mean 24.5% when given alone, by 18% when given on top of a major statin and by 38-40% when given in a fixed-dose combination with ezetimibe. Bempedoic acid does not lead to the risk of new-onset diabetes, and moderately improves the glycaemic profile. The extensive knowledge on bempedoic acid mechanism, metabolism and side effects has led to an improved understanding of the potential benefits of this agent and offers a possible alternative to cardiologists and clinical practitioners somewhat worn out today by the occurrence of the muscular side effects of statins.
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Affiliation(s)
- Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences, Università Degli Studi Di Milano, Milan, Italy.
| | - Cesare R Sirtori
- Department of Pharmacological and Biomolecular Sciences, Università Degli Studi Di Milano, Milan, Italy
| | - Stefano Carugo
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Fondazione Ospedale Maggiore IRCCS Policlinico Di Milano, Milan, Italy
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, 93-338, Lodz, Poland
- Cardiovascular Research Centre, University of Zielona Gora, 65-046, Zielona Gora, Poland
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università Degli Studi Di Milano, Milan, Italy
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40
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Toth PP, Bray S, Villa G, Palagashvili T, Sattar N, Stroes ESG, Worth GM. Network Meta-Analysis of Randomized Trials Evaluating the Comparative Efficacy of Lipid-Lowering Therapies Added to Maximally Tolerated Statins for the Reduction of Low-Density Lipoprotein Cholesterol. J Am Heart Assoc 2022; 11:e025551. [PMID: 36073669 PMCID: PMC9683660 DOI: 10.1161/jaha.122.025551] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
Background Lowering low-density lipoprotein cholesterol (LDL-C) levels decreases major cardiovascular events and is recommended for patients at elevated cardiovascular risk. However, appropriate doses of statin therapy are often insufficient to reduce LDL-C in accordance with current guidelines. In such cases, treatment could be supplemented with nonstatin lipid-lowering therapy. Methods and Results A systematic literature review and network meta-analysis were conducted on randomized controlled trials of nonstatin lipid-lowering therapy added to maximally tolerated statins, including statin-intolerant patients. The primary objective was to assess relative efficacy of nonstatin lipid-lowering therapy in reducing LDL-C levels at week 12. Secondary objectives included the following: LDL-C level reduction at week 24 and change in non-high-density lipoprotein cholesterol and apolipoprotein B at week 12. There were 48 randomized controlled trials included in the primary network meta-analysis. All nonstatin agents significantly reduced LDL-C from baseline versus placebo, regardless of background therapy. At week 12, evolocumab, 140 mg every 2 weeks (Q2W)/420 mg once a month, and alirocumab, 150 mg Q2W, were the most efficacious regimens, followed by alirocumab, 75 mg Q2W, alirocumab, 300 mg once a month, inclisiran, bempedoic acid/ezetimibe fixed-dose combination, and ezetimibe and bempedoic acid used as monotherapies. Primary end point results were generally consistent at week 24, and for other lipid end points at week 12. Conclusions Evolocumab, 140 mg Q2W/420 mg once a month, and alirocumab, 150 mg Q2W, were consistently the most efficacious nonstatin regimens when added to maximally tolerated statins to lower LDL-C, non-high-density lipoprotein cholesterol, and apolipoprotein B levels and facilitate attainment of guideline-recommended risk-stratified lipoprotein levels.
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Affiliation(s)
- Peter P. Toth
- Cicarrone Center for the Prevention of Cardiovascular DiseaseJohns Hopkins University School of MedicineBaltimoreMD
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41
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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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Escobar-Cervantes C, Villa G, Campos-Tapias I, Sorio-Vilela F, Lozano J, Kahangire DA, Fernandez-Delgado M, Sicras-Navarro A, Sicras-Mainar A. Achieving Lower LDL-C Levels After a Recent Myocardial Infarction Might Be Associated with Lower Healthcare Resource Use and Costs in Spain. Adv Ther 2022; 39:3578-3588. [PMID: 35689725 PMCID: PMC9309133 DOI: 10.1007/s12325-022-02187-1] [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: 03/30/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There is little evidence on the relationship between achieved low-density lipoprotein cholesterol (LDL-C) levels and costs in patients on lipid-lowering therapy (LLT). We described healthcare resource use and costs (direct and indirect) by achieved LDL-C in patients receiving LLT after a recent myocardial infarction (MI) in Spain. METHODS This was a retrospective observational study of anonymized electronic medical records from seven regions in Spain (BIG-PAC® database; n = 1.9 million). Eligible patients were adults (≥ 18 years) hospitalized for an MI between January 2015 and December 2017, treated with a statin and/or ezetimibe, and having recorded LDL-C values at baseline and during follow-up. Healthcare resource use and direct and indirect costs (in 2018, €) were described by achieved LDL-C levels during a follow-up of 18 months. RESULTS Of 6025 patients (mean age, 69.7 years; 77% male), only 11% achieved LDL-C goals as defined in the 2016 ESC/EAS guidelines (< 70 mg/dL), and just 1% reached the lower target (< 55 mg/dL) in the current 2019 guidelines. Achieving lower LDL-C levels translated to lower healthcare resource use and costs. Mean total (direct and indirect) costs ranged from €5044 for patients with LDL-C < 55 mg/dL to €7567 for patients with LDL-C ≥ 130 mg/dL. CONCLUSION Very few patients achieved recommended LDL-C goals despite using LLT. Achieving lower LDL-C levels after an MI might be associated with lower healthcare resource use and costs. Use of more intensive LLT, leading to greater reductions in LDL-C, could therefore be beneficial both from a clinical and an economic perspective.
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Affiliation(s)
- Carlos Escobar-Cervantes
- Cardiology Department, University Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain.
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43
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Weingärtner O, Marx N, Klose G, Laufs U. [Therapeutic options to reduce LDL-cholesterol beyond statins]. Dtsch Med Wochenschr 2022; 147:1001-1012. [PMID: 35915886 DOI: 10.1055/a-1516-2631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Current dyslipidemia guidelines emphasize statins as the cornerstone of pharmacological lipid-lowering therapy. The cholesterol absorption inhibitor ezetimibe, PCSK9-antibodies, as well as bempedoic acid and inclisiran are newly available options to further reduce LDL-cholesterol. Since modern lipid-lowering therapy is characterized by an individual, "treat-to-target" approach the aim of this review is to provide a better understanding of cholesterol metabolism to guide decision-making and the rational for using early individualized combination therapies.
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Boytsov SA, Shakhnovich RM, Tereschenko SN, Erlikh AD, Kukava NG, Pevsner DV, Rytova YK. The prevalence of hyperlipidemia and features of lipid-lowering therapy in patients with myocardial infarction according to the Russian register of acute myocardial infarction REGION-MI. KARDIOLOGIIA 2022; 62:12-22. [PMID: 35989625 DOI: 10.18087/cardio.2022.7.n2051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/25/2022] [Indexed: 06/15/2023]
Abstract
Aim To study the prevalence of hyperlipidemia in patients with myocardial infarction (MI) in the Russian Federation; to assess the compliance with clinical practice guidelines of the lipid-lowering therapy prescribed upon discharge from the hospital; and to determine the number of patients who are indicated for the combination lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) goal.Material and methods REGION-MI is Russian rEGIstry Of acute myocardial iNfarction, a multicenter, retrospective and prospective observational study. The observation period was divided into 3 stages: observation during the stay in the hospital and at 6 and 12 months after the inclusion in the registry. Plasma total cholesterol (TC) and LDL-C were measured in all patients on admission. Evaluation of the prescribed lipid-lowering therapy included the intensity of the treatment.Results The study included 3 620 patients; 62.4 of them had hyperlipidemia on admission. Mean TC on admission was 5.29 mmol/l and LDl-C level was 3.35 mmol/l. Upon discharge, 95.4% of patients after myocardial infarction continued on or were prescribed statin therapy; ezetimibe was prescribed to 1.22% of patients. Patients with an extremely high level of LDL-C >5 mmol/l accounted for 10.7% of patients with hyperlipidemia. The target level of LDL-C ≤1.4 mmol/l cannot be achieved with the statin and ezetimibe combination therapy in these patients; drugs from the group of PCSK9 inhibitors are indicated for them.Conclusion According to the data of the Russian registry of acute myocardial infarction, REGION-MI, a high incidence of hyperlipidemia is observed in patients with acute MI. Despite multiple studies that have proven the importance of achieving a low LDL-C level and good tolerance and safety of ezetimibe and PCSK9 inhibitors, the prescription frequency of combination therapy remains unreasonably low. Results of a simulation study that was conducted in Sweden and the data of the REGION-MI registry showed that PCSK9 inhibitors as a part of the combination therapy are indicated for many patients. The combination therapy is presently the most powerful type of lipid-lowering treatment that allows, in most cases, achievement of the LDL-C goal.
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Affiliation(s)
- S A Boytsov
- Chazov National Medical Research Centre of Cardiology, Moscow
| | - R M Shakhnovich
- Chazov National Medical Research Centre of Cardiology, Moscow
| | - S N Tereschenko
- Chazov National Medical Research Centre of Cardiology, Moscow
| | - A D Erlikh
- Bauman Municipal Clinical Hospital №28, Moscow
| | - N G Kukava
- Chazov National Medical Research Centre of Cardiology, Moscow
| | - D V Pevsner
- Chazov National Medical Research Centre of Cardiology, Moscow
| | - Y K Rytova
- Chazov National Medical Research Centre of Cardiology, Moscow
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Citarella A, Cammarota S, Bernardi FF, Caliendo L, D’Andrea A, Fimiani B, Fogliasecca M, Pacella D, Pagnotta R, Trama U, Zito GB, Cillo M, Vercellone A. Exploring Contemporary Data on Lipid-Lowering Therapy Prescribing in Patients Following Discharge for Atherosclerotic Cardiovascular Disease in the South of Italy. J Clin Med 2022; 11:jcm11154344. [PMID: 35893434 PMCID: PMC9369296 DOI: 10.3390/jcm11154344] [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: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 02/01/2023] Open
Abstract
Current international guidelines strongly recommend the use of high-intensity lipid-lowering therapy (LLT) after hospitalization for atherosclerotic cardiovascular disease (ASCVD) events. With this study, our aim was to evaluate LLT prescribing in a large Italian cohort of patients after discharge for an ASCVD event, exploring factors associated with a lower likelihood of receiving any LLT and high-intensity LLT. Individuals aged 18 years and older discharged for an ASCVD event in 2019-2020 were identified using hospital discharge abstracts from two local health units of the Campania region. LLT treatment patterns were analyzed in the 6 months after the index event. Logistic regression models were developed for estimating patient predictors of any LLT prescription and to compare high-intensity and low-to-moderate-intensity LLT. Results: A total of 8705 subjects were identified. In the 6 months post-discharge, 56.7% of patients were prescribed LLT and, of those, 48.7% were high-intensity LLT. Female sex, older age, and stroke/TIA or PAD conditions were associated with a higher likelihood of not receiving high-intensity LLT. Similar predictors were found for LLT prescriptions. LLT utilization and the specific use of high-intensity LLT remain low in patients with ASCVD, suggesting a substantial unmet need among these patients in the contemporary real-world setting.
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Affiliation(s)
- Anna Citarella
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy; (S.C.); (M.F.)
- Correspondence: ; Tel.: +39-349-154-9284
| | - Simona Cammarota
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy; (S.C.); (M.F.)
| | | | - Luigi Caliendo
- Department of Cardiology, Santa Maria della Pietà Hospital, Nola, 80035 Naples, Italy;
| | - Antonello D’Andrea
- Department of Cardiology and Intensive Care Unit, Umberto I Hospital, Nocera Inferiore, 84014 Salerno, Italy;
| | - Biagio Fimiani
- Cardiology Service, Local Health Unit (LHU) Salerno, Associazioni Regionali Cardiologi Ambulatoriali (ARCA), 84129 Salerno, Italy;
| | - Marianna Fogliasecca
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy; (S.C.); (M.F.)
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy;
| | - Rita Pagnotta
- Department of Management Control, Local Health Unit (LHU) Naples 3 South, 80053 Naples, Italy;
| | - Ugo Trama
- Regional Pharmaceutical Unit, Campania Region, 80143 Naples, Italy; (F.F.B.); (U.T.)
| | - Giovanni Battista Zito
- Cardiology Service, Local Health Unit (LHU) Naples 3 South, Associazioni Regionali Cardiologi Ambulatoriali (ARCA), 80045 Naples, Italy;
| | - Mariarosaria Cillo
- Pharmaceutical Department, Local Health Unit (LHU) Salerno, 84124 Salerno, Italy;
| | - Adriano Vercellone
- Pharmaceutical Department, Local Health Unit (LHU) Naples 3 South, 80053 Naples, Italy;
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46
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Katzmann JL, Kieble M, Enners S, Böhm M, Mahfoud F, Laufs U, Schulz M. Trends in Ezetimibe Prescriptions as Monotherapy or Fixed-Dose Combination in Germany 2012–2021. Front Cardiovasc Med 2022; 9:912785. [PMID: 35770230 PMCID: PMC9234160 DOI: 10.3389/fcvm.2022.912785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/06/2022] [Indexed: 12/02/2022] Open
Abstract
Aims Addition of ezetimibe to statin therapy is recommended by current guidelines when low-density lipoprotein cholesterol (LDL-C) targets are not achieved with statin monotherapy. Fixed-dose combinations (FDC) improve medication adherence and facilitate risk factor control. We assessed prescription trends of ezetimibe as monotherapy or FDC with statins. Methods Data from the German Institute for Drug Use Evaluation (DAPI) containing dispensing data of >80% of community pharmacies were analyzed. Prescriptions over time of lipid-lowering agents at the expense of the statutory health insurance (SHI) were extrapolated to all SHI-insured persons, representing approximately 88% of the total German population. Drug utilization was expressed as defined daily doses per 1,000 SHI-insured persons per day (DID). Results Of all lipid-lowering drug prescriptions in 2021, 91.2% were statin monotherapy. Ezetimibe was prescribed as monotherapy or FDC with statin in 4.4 and 2.9%, respectively. DID steadily increased for statin (69%) and ezetimibe (424%) monotherapies between 2012 and 2021. In contrast, statin-ezetimibe FDC prescriptions exhibited only a minor increase (29%). The proportion of statin-ezetimibe FDC among all statin prescriptions was stable over time at approximately 3%. FDC prescription rates by specialists were higher compared to general practitioners and varied considerably between geographic areas. Conclusion Combination lipid-lowering therapy is prescribed to a minority of patients. Prescriptions of ezetimibe as monotherapy increased to a much greater extent than statin-ezetimibe FDC. Considering the low proportion of patients achieving their LDL-C target and improved adherence to FDC compared to separate pills, statin-ezetimibe FDC may be utilized to improve the management of dyslipidemia.
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Affiliation(s)
- Julius L. Katzmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
- *Correspondence: Julius L. Katzmann,
| | - Marita Kieble
- Deutsches Arzneiprüfungsinstitut e.V. (DAPI), Berlin, Germany
| | - Salka Enners
- Deutsches Arzneiprüfungsinstitut e.V. (DAPI), Berlin, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Martin Schulz
- Deutsches Arzneiprüfungsinstitut e.V. (DAPI), Berlin, Germany
- Institut für Pharmazie, Freie Universität Berlin, Berlin, Germany
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47
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Zhang S, Li ZF, Shi HW, Zhang WJ, Sui YG, Li JJ, Dou KF, Qian J, Wu NQ. Comparison of Low-Density Lipoprotein Cholesterol (LDL-C) Goal Achievement and Lipid-Lowering Therapy in the Patients With Coronary Artery Disease With Different Renal Functions. Front Cardiovasc Med 2022; 9:859567. [PMID: 35620524 PMCID: PMC9127229 DOI: 10.3389/fcvm.2022.859567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The aim of this study was to evaluate the relationship between renal function and low-density lipoprotein cholesterol (LDL-C) goal achievement and compare the strategy of lipid-lowering therapy (LLT) among the patients with coronary artery disease (CAD) with different renal functions. Methods In this study, we enrolled 933 Chinese patients with CAD from September 2020 to June 2021 admitted to the Cardiometabolic Center of Fuwai Hospital in Beijing consecutively. All individuals were divided into two groups based on their estimated glomerular filtration rate (eGFR). The multiple logistical regression analysis was performed to identify and compare the independent factors which impacted LDL-C goal achievement in the two groups after at least 3 months of treatment. Results There were 808 subjects with eGFR ≥ 60 ml/min/1.73 m2 who were divided into Group 1 (G1). A total of 125 patients with eGFR <60 ml/min/1.73 m2 were divided into Group 2 (G2). The rate of LDL-C goal attainment (LDL-C <1.4 mmol/L) was significantly lower in G2 when compared with that in G1 (24.00% vs. 35.52%, P = 0.02), even though there was no significant difference in the aspect of LLT between the two groups (high-intensity LLT: 82.50% vs. 85.60% P = 0.40). Notably, in G1, the proportion of LDL-C goal achievement increased with the intensity of LLT (23.36% vs. 39.60% vs. 64.52% in the subgroup under low-/moderate-intensity LLT, or high-intensity LLT without proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (PCSK9i), or high-intensity LLT with PCSK9i, respectively, P < 0.005). In addition, in G2, there was a trend that the rate of LDL-C goal achievement was higher in the subgroup under high-intensity LLT (26.60% in the subgroup under high-intensity LLT without PCSK9i and 25.00% in the subgroup under high-intensity LLT with PCSK9i) than that under low-/moderate-intensity LLT (15.38%, P = 0.49). Importantly, after multiple regression analysis, we found that eGFR <60 ml/min/1.73 m2 [odds ratio (OR) 1.81; 95%CI, 1.15–2.87; P = 0.01] was an independent risk factor to impact LDL-C goal achievement. However, the combination strategy of LLT was a protective factor for LDL-C goal achievement independently (statin combined with ezetimibe: OR 0.42; 95%CI 0.30–0.60; P < 0.001; statin combined with PCSK9i: OR 0.15; 95%CI 0.07–0.32; P < 0.001, respectively). Conclusion Impaired renal function (eGFR <60 ml/min/1.73 m2) was an independent risk factor for LDL-C goal achievement in the patients with CAD. High-intensity LLT with PCSK9i could improve the rate of LDL-C goal achievement significantly. It should be suggested to increase the proportion of high-intensity LLT with PCSK9i for patients with CAD, especially those with impaired renal function.
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48
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García-Fernández-Bravo I, Torres-Do-Rego A, López-Farré A, Galeano-Valle F, Demelo-Rodriguez P, Alvarez-Sala-Walther LA. Undertreatment or Overtreatment With Statins: Where Are We? Front Cardiovasc Med 2022; 9:808712. [PMID: 35571155 PMCID: PMC9105719 DOI: 10.3389/fcvm.2022.808712] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/29/2022] [Indexed: 12/26/2022] Open
Abstract
Statins, in addition to healthy lifestyle interventions, are the cornerstone of lipid-lowering therapy. Other low-density lipoprotein (LDL)-lowering drugs include ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. As new evidence emerges from new clinical trials, therapeutic goals change, leading to renewed clinical guidelines. Nowadays, LDL goals are getting lower, leading to the "lower is better" paradigm in LDL-cholesterol (LDL-C) management. Several observational studies have shown that LDL-C control in real life is suboptimal in both primary and secondary preventions. It is critical to enhance the adherence to guideline recommendations through shared decision-making between clinicians and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities. This narrative review summarizes the evidence regarding the benefits of lipid-lowering drugs in reducing cardiovascular events, the pleiotropic effect of statins, real-world data on overtreatment and undertreatment of lipid-lowering therapies, and the changing LDL-C in targets in the clinical guidelines of dyslipidemias over the years.
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Affiliation(s)
| | - Ana Torres-Do-Rego
- Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Grupo (departamento) de investigación Riesgo cardiovascular y lípidos, Instituto de investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio López-Farré
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Galeano-Valle
- Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Grupo (departamento) de investigación Riesgo cardiovascular y lípidos, Instituto de investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo Demelo-Rodriguez
- Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Grupo (departamento) de investigación Riesgo cardiovascular y lípidos, Instituto de investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Luis A. Alvarez-Sala-Walther
- Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Grupo (departamento) de investigación Riesgo cardiovascular y lípidos, Instituto de investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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49
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Kosten-Nutzen-Analyse neuer Lipidsenker. Herz 2022; 47:236-243. [DOI: 10.1007/s00059-022-05116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
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50
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Katzmann JL, Laufs U. [Modern lipid-lowering drugs-A means to counter the problem of undertreatment?]. Internist (Berl) 2022; 63:1316-1322. [PMID: 35391570 DOI: 10.1007/s00108-022-01322-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND An elevated low-density lipoproteincholesterol (LDL-C) level is one of the most important modifiable cardiovascular risk factors. Despite potent combination treatment, the LDL‑C target values are not achieved in many high-risk patients. OBJECTIVE Presentation of the rationale for lowering LDL‑C, the current status of lipid-lowering treatment and established and novel approaches to lower LDL‑C. CURRENT DATA Based on the large outcome trials with ezetimibe and antibodies against proprotein convertase subtilisin-kexin type 9 (PCSK9), the professional societies recommend LDL‑C target values depending on the individual cardiovascular risk. For patients with manifest atherosclerosis, the LDL‑C target value is < 55 mg/dL (1.4 mmol/L). The LDL‑C target values are only achieved in the minority of patients. The reasons for this include a lack of awareness among treating physicians, low medication adherence, restrictions in prescriptions and intolerance. On the basis of a healthy lifestyle, statins are the cornerstone of LDL-C-lowering treatment. If LDL‑C targets are not achieved, the cholesterol absorption inhibitor ezetimibe is additionally recommended. As a third step, PCSK9 antibodies are added. A novel drug to lower LDL‑C is the orally available bempedoic acid, which acts on the same metabolic pathway as statins but is specifically activated in the liver and not in the skeletal muscle. Another novel drug is inclisiran, which acts as an intracellular PCSK9 inhibitor through RNA interference. Inclisiran is administered subcutaneously only every 6 months and has potential advantages regarding adherence. According to the new recommendations, active substances should be combined and fixed-dose combinations should be used early for lowering of LDL‑C. CONCLUSION Using established and novel LDL-C-lowering drugs, the recommended LDL‑C target values can be achieved in the majority of patients with a high cardiovascular risk.
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Affiliation(s)
- Julius L Katzmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
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