Statin-induced coronary artery disease regression rates differ in men and women

The effect of probiotic fermented milk products on blood lipid concentrations: A systematic review and meta-analysis of randomized controlled trials

AIM

Fermented milk products are suggested as a supplementary therapy to help reduce blood lipid levels. However, the results of clinical studies are conflicting.

DATA SYNTHESIS

This study systematically reviewed 39 randomized controlled trials (n = 2237 participants) to investigate the effect of probiotic fermented milk products on blood lipids. A meta-analysis was performed using random effects models, with weighted mean differences (WMDs) and 95% confidence interval (CI). Statistically significant reductions in blood low-density lipoprotein cholesterol (LDL-C) (WMD: -7.34 mg/dL, 95% CI: from -10.04 to -4.65, and P < 0.001) and total cholesterol (TC) concentrations (WMD: -8.30 mg/dL, 95% CI: from -11.42 to -5.18, and P < 0.001) were observed. No statistically significant effect of probiotic fermented milk was observed on blood high-density lipoprotein cholesterol (HDL-C) and triacylglycerol (TAG) levels. The effect on TC and LDL-C level was more pronounced in men, and a greater reduction in TAG was observed in trials with longer interventions (≥8 weeks) as compared to their counterparts.

CONCLUSIONS

Available evidence suggests that probiotic fermented milk products may help to reduce serum TC and LDL-C cholesterol levels, particularly in men and when they are consumed for ≥8 weeks.

Relationship between Bell's Palsy and Previous Statin Use: A Case/Non-Case Study

We intended to determine the relationship between previous statin use and Bell’s palsy in a large study population receiving statins for the past 2 years. The Korean National Health Insurance Service—Health Screening Cohort data from 2002 to 2015 were collected. Participants with Bell’s palsy (n = 3203) were matched with participants without Bell’s palsy (n = 12,812). The number of days of previous statin use for 2 years before the onset of Bell’s palsy was analyzed using conditional logistic regression. Subgroups of age, sex, obesity, smoking, alcohol consumption, total cholesterol, and blood pressure were analyzed for any association between Bell’s palsy and prior statin use. The Bell’s palsy group reported greater statin use than the non-Bell’s palsy group (84.6 (standard deviation, SD = 201.7) vs. 74.4(SD = 189.4), p = 0.009). Previous statin use was associated with Bell’s palsy in the crude model (95% confidence intervals = 1.03–1.19, p = 0.006). However, this relationship disappeared when the possible covariates were adjusted for in model 2. All subgroups showed no increased odds for Bell’s palsy in previous statin users. We did not find an association between Bell’s palsy and previous statin use in this Korean population aged ≥40 years.

Sex Differences in Statin Prescribing in Diabetic and Heart Disease Patients in FQHCs: A Comparison of the ATPIII and 2013 ACC/AHA Cholesterol Guidelines

PURPOSE

The purpose of this study was to determine the difference in the rate of statin prescribing based on the Adult Treatment Panel (ATP) III and 2013 American College of Cardiology (ACC)/American Heart Association cholesterol guidelines across sex in Federally Qualified Health Centers (FQHCs), and to determine the proportion of patients on recommended statin dosage based on the 2013 cholesterol guideline.

METHODS

The Office Guidelines Applied to Practice (Office-GAP) study is a quasi-experimental, 2 FQHCs center study that enrolled patients with coronary heart disease and diabetes mellitus (DM). We computed 10-year atherosclerotic cardiovascular disease (ASCVD) risks scores based on ACC guidelines and determined the rate of statin prescribing across sex in FQHCs using both guidelines. Main outcomes measures were (1) rate of statin prescribing based on ATPIII and 2013 cholesterol guidelines across sex and (2) proportion of patients on recommended statin dosage based on the 2013 cholesterol guideline.

RESULTS

The 2013 cholesterol guideline did not increase the rate of eligibility of statin for men and women compared to ATPIII guideline. No significant difference between men and women in statin prescribing under ATPIII (67% vs 57%, P = .13) and 2013 cholesterol guidelines (66% vs 63%, P = .69) and in the recommended dosage of statin per the 2013 cholesterol guidelines between men and women in FQHCs (12% vs 22%, P = .22).

CONCLUSIONS

We found statin underprescribing for both men and women with ASCVD and DM in FQHCs. Utilizing both the ATPIII and the 2013 cholesterol guidelines, men with ASCVD and DM were prescribed statin more than women. However, fewer men were found to be on the recommended dosage of statin based on the 2013 cholesterol guideline. Our findings suggest that Office-GAP may have improved the prescription/use of statin in both men and women.

Sex disparity persists in the prevention of cardiovascular disease in women on statin therapy compared to that in men

BACKGROUND AND AIMS

The aim of this study was to assess whether women differ from men with regard to lowering lipid levels, achieving target of optimal lipid levels, and analyzing evidence-based dose and intensity of statin prescription in primary care patients.

METHODS AND RESULTS

A multicenter cross-sectional survey was conducted among 1046 patients with dyslipidemia (554 women) who were receiving statin therapy from the Primary Health Care of Andalucía (Spain). A random sample was obtained using data from the electronic health record system. The primary outcomes were the prescription of statin therapy (intensity and dose), lowering lipid levels, and achieving target of optimal lipid levels. Women were less likely to be treated with a more potent statin than men (9.2% vs. 14.4%, p = 0.009), and they received lower doses (45 ± 59 mg/day vs. 56 ± 71 mg/day, p = 0.004) than men. Total cholesterol and LDL-C levels were higher in women than in men (5.7 ± 1.3 mmol/l vs. 5.2 ± 1.2 mmol/l, p < 0.0001 and 3.5 ± 1.2 mmol/l vs. 3.1 ± 1.0 mmol/l, p < 0.0001, respectively). Compliance with established goals for total cholesterol (47.7% vs. 31.3%, p < 0.0001) and LDL-C (39.7% vs. 25.4%, p < 0.0001) was superior in men than in women. In multivariate analysis, adjusted for age, the variables male gender and CVD were associated with a higher compliance with total cholesterol and LDL-C target levels, and the variable diabetes mellitus 2 was associated with a lower compliance with HDL-C and triglycerides target levels.

CONCLUSIONS

Women were less likely to be prescribed high-intensity statin to achieve total cholesterol and LDL-C target levels, and mean doses of statin were lower in women than in men. Dyslipidemia is less closely controlled in women than in men.

Underutilization of Statin Therapy for Secondary Prevention of Cardiovascular Disease Among Older Adults

Secondary cardiovascular disease (CVD) clinical trials have demonstrated that higher intensity levels of statin therapy are more effective than lower levels in reducing mortality rates. Despite updated treatment guidelines, statin therapy may be underutilized, with evidence that females are treated less aggressively than males. The primary objective of this study was to determine the prevalence of statin utilization by varying therapy intensity by sex. The secondary objective was to document the benefits of statin therapy intensity levels on all-cause mortality for males and females. A 25% random sample of adults ≥65 years was utilized to identify those with established CVD. Inclusion criteria included: (1) 12-month pre period and (2) up to 30 months post period. Five categories of statin utilization were established: adherent to high-, moderate-, or low-intensity statin therapy, nonadherent, and no statins. Among eligible insureds (N = 49,530 males; N = 44,710 females), 20% of males and 12% of females were identified as high-intensity statin users. Mortality rates significantly increased similarly for males and females as statin therapy intensity decreased. Likewise, mortality hazard ratios indicated the most benefit from high-intensity statin therapy compared to all other categories. Statin therapy for secondary prevention of CVD is beneficial in reducing mortality for males and females but is underutilized, especially among females. Education programs among patients to increase heart health awareness and among physicians to promote the benefits of updated statin guidelines should be encouraged.

Sex Differences in the Coronary System

Cardiovascular disease remains the leading cause of morbidity and mortality for both women and men. Emerging evidence supports that ischemic heart disease (IHD) may manifest differently in women and men, in ways ranging from the clinical presentation, diagnosis, and management of disease to the basic biology and biomechanics of cardiomyocyte function and the coronary circulation. Women consistently present with a higher burden of symptoms and comorbidities as compared with men and experience worse outcomes. These data have proved perplexing given the decreased likelihood of women to demonstrate obstructive coronary artery disease (CAD) on coronary angiography. Reported sex differences have long been influenced by the practice of defining heart disease primarily as obstructive CAD, but obstructive plaque is now recognized as neither necessary nor sufficient to explain symptoms of IHD, and it is no longer adequate to tailor diagnostic and treatment strategies only to this subset of patients. To date, women remain underrepresented in guideline-changing heart disease research and trials, creating important limitations in the evidence base for cardiovascular medicine. Smaller epicardial coronary arteries in women as compared to men, coupled with differences in shear stress and inflammatory mediators over the life span, may modify the development of CAD in susceptible patients into a diffuse pattern with more contribution from coronary vasomotor dysfunction than focal obstruction. Newer studies corroborate that symptomatic women are more likely than men to present with nonobstructive CAD and coronary microvascular dysfunction. When present, these processes increase cardiovascular risk in both women and men but may constitute an especially malignant phenotype in a subset of severely affected women, with implications for the management of not only CAD but also heart failure with preserved ejection fraction. This represents a state-of-the-art review of sex differences in the coronary system, with an eye toward how diverse pathophysiological processes may contribute to IHD phenotypes prevalent in women and men. Beyond providing women and men with equitable optimal care according to current paradigms, understanding the pathophysiology of IHD beyond a conventional focus on obstructive CAD is needed to address what is likely a combination of biological as well as environmental determinants of their prognosis.

Bridging the gap for lipid lowering therapy: plaque regression, coronary computed tomographic angiography, and imaging-guided personalized medicine

INTRODUCTION

Lipid-lowering therapy effectively decreases cardiovascular risk on a population level, but it remains difficult to identify an individual patient's personal risk reduction while following guideline directed medical therapy, leading to overtreatment in some patients and cardiovascular events in others. Recent improvements in cardiac CT technology provide the ability to directly assess an individual's atherosclerotic disease burden, which has the potential to personalize risk assessment for lipid-lowering therapy. Areas covered: We review the current unmet need in identifying patients at elevated residual risk despite guideline directed medical therapy, the evidence behind plaque regression as a potential marker of therapeutic response, and highlight state-of-the-art advances in coronary computed tomographic angiography (CCTA) for measurement of quantitative and qualitative changes in coronary atherosclerosis over time. Literature search was performed using PubMed and Google Scholar for literature relevant to statin therapy and residual risk, coronary plaque regression measurement, and CCTA assessment of quantitative and qualitative change in coronary atherosclerosis. Expert commentary: We discuss the potential ability of CCTA to guide lipid-lowering therapy as a bridge between population and personalized medicine in the future, as well as the potential barriers to its use.

Resistant Atherosclerosis

Background and Purpose—

Recent studies indicate that patients with lower levels of low-density lipoprotein cholesterol (LDL-C) have greater regression of coronary plaque. In 2002, we found that carotid plaque progression doubled cardiovascular risk. In 2003, we therefore implemented a new approach, treating arteries instead of risk factors. Since then, we have seen many patients with carotid plaque progression despite very low levels of LDL-C, suggesting other causes of atherosclerosis. We studied the relationship of achieved LDL-C and change in LDL-C to progression/regression of atherosclerosis, before and after 2003.

Methods—

All 4512 patients in our clinic database with at least 2 measurements of LDL-C and carotid total plaque area approximately a year apart and complete data for analyses (n=2025 before and 2487 after December 31, 2003) were included in the study.

Results—

Baseline total plaque area was significantly higher after 2003 (129.56±134.32 versus 113.33±121.52 mm 2 ; P <0.0001), and plaque progression was significantly less after 2003 (2.94±37.11 versus 12.62±43.24 mm 2 ; P <0.0001). Many patients with LDL-C <1.8 mm had plaque progression (47.5%), and change in LDL-C was not correlated with plaque progression/regression. Increasing age and serum creatinine contributed to resistant atherosclerosis.

Conclusions—

Many patients have Resistant Atherosclerosis, failing to achieve regression of atherosclerosis despite low levels of LDL-C. Instead of relying on LDL-C, measuring plaque burden may be a more useful way of assessing individual response to therapy, particularly in resistant atherosclerosis.

Nonstatin Low-Density Lipoprotein-Lowering Therapy and Cardiovascular Risk Reduction-Statement From ATVB Council

Pharmacological reduction of low-density lipoprotein (LDL) cholesterol using statin drugs is foundational therapy to reduce cardiovascular disease (CVD) risk. Here, we consider the place of nonstatin therapies that also reduce LDL cholesterol in prevention of CVD. Among conventional nonstatins, placebo-controlled randomized clinical trials showed that bile acid sequestrants, niacin, and fibrates given as monotherapy each reduce CVD end points. From trials in which patients' LDL cholesterol was already well controlled on a statin, adding ezetimibe incrementally reduced CVD end points, whereas adding a fibrate or niacin showed no incremental benefit. Among emerging nonstatins, monoclonal antibodies against proprotein convertase subtilisin kexin type 9 added to a statin and given for ≤78 weeks showed preliminary evidence of reductions in CVD outcomes. Although these promising early findings contributed to the recent approval of these agents in Europe and in North America, much larger and longer duration outcomes studies are ongoing for definitive proof of CVD benefits. Other nonstatin agents recently approved in the United States include lomitapide and mipomersen, which both act via distinctive LDL receptor independent mechanisms to substantially reduce LDL cholesterol in homozygous familial hypercholesterolemia. We also address some unanswered questions, including measuring alternative biochemical variables to LDL cholesterol, evidence for treating children with monitoring of subclinical atherosclerosis, and potential risks of extremely low LDL cholesterol. As evidence for benefit in CVD prevention accumulates, we anticipate that clinical practice will shift toward more assertive LDL-lowering treatment, using both statins and nonstatins initiated earlier in appropriately selected patients.