A Prospective, Randomized, Open-Label Trial of Atorvastatin versus Rosuvastatin in the Prevention of Contrast-Induced Acute Kidney Injury, Worsened Renal Function at 30 Days, and Clinical Events After Acute Coronary Angiography: the PRATO-ACS-2 Study

Comparative Efficacy of High-Dose Rosuvastatin and Atorvastatin in Preventing Cystatin C-Oriented Contrast-Induced Nephropathy in Patients With Acute Myocardial Infarction: RACCOON-AMI Registry

BACKGROUND

Prevention of contrast-induced nephropathy (CIN) is crucial in acute myocardial infarction (AMI) patients undergoing coronary interventions. Previous studies suggest that high-dose statins may aid in CIN prevention, yet comparative studies among different statin types using cystatin C (cysC) as a biomarker for CIN are absent. This study evaluated the effectiveness of high-dose rosuvastatin versus atorvastatin in preventing cysC-based CIN (cysC-CIN) in AMI patients.

METHODS

This multicenter registry included 431 patients (rosuvastatin 20 mg: n = 231, atorvastatin 40 mg: n = 200). The primary endpoint was cysC-CIN incidence within 48 hours post contrast; the secondary endpoints were creatinine-based CIN (cr-CIN) incidence within 72 hours post contrast and post 30 days adverse events.

RESULTS

The incidences of cysC-CIN (12.1% vs. 7.5%, P = 0.103) and cr-CIN (6.2% vs. 3.5%, P = 0.103) were higher in the atorvastatin group without significant statistical differences. Multivariable regression analysis, which was adjusted for CIN risk factors and the variables with univariate association, showed no increased odds ratio (OR) (OR, 2.185; 95% confidence interval [CI], 0.899, 5.315; P = 0.085) for cysC-CIN in the atorvastatin group compared to the rosuvastatin group. However, statin-naïve atorvastatin subgroup had significantly increased odds of cysC-CIN compared to the rosuvastatin group (OR, 2.977; 95% CI, 1.057, 8.378; P = 0.039). At post 30 days renal, cardiovascular, and mortality event rates were both low and similar between the two groups.

CONCLUSION

No significant difference in cysC-CIN incidence was found between the high-dose rosuvastatin and atorvastatin groups in AMI patients and cysC was more sensitive to the early detection of CIN than creatinine.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0003703.

Renal Safety Assessment of Lipid-Lowering Drugs: Between Old Certainties and New Questions

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). Quantitative and qualitative changes in plasma lipoprotein profiles are frequently associated with CKD and represent a significant risk factor for CVD in patients with CKD. Guidelines from the European Society of Cardiology and the European Atherosclerosis Society classify CKD as a condition with high or very high cardiovascular risk and set specific low-density lipoprotein cholesterol targets. Conventional lipid-lowering therapies (LLTs), such as statins, ezetimibe, and fibrates, can control CKD-associated dyslipidemia and, to some extent, prevent major atherosclerotic events in patients with CKD, but their use in clinical practice presents challenges because of the potential renal safety concerns. In recent years, novel therapies with the ability to lower both low-density lipoprotein cholesterol and triglycerides have been introduced to the market (e.g., proprotein convertase subtilisin/kexin type 9 inhibitors, bempedoic acid, lomitapide, volanesorsen) to improve our ability to control lipid abnormalities. However, their impact on kidney functionality has not been fully elucidated. The aim of this review was to examine the renal safety profiles of various LLTs, with special reference to novel medications, and to highlight important considerations and guidance for the use of these medications in overt CKD or in patients with some degree of renal function impairment. We underscore the lack of a comprehensive understanding of kidney safety, particularly for novel LLT therapies, and strongly emphasize the importance of future dedicated research to fully assess the safety and efficacy of these agents in patients with kidney abnormalities.

Influence of Worsening Renal Function and Baseline Chronic Kidney Disease on Clinical Outcomes in Patients With Chronic Coronary Syndromes: Insights From the REAL-CAD Study

BACKGROUND

The effect of worsening renal function and baseline chronic kidney disease (CKD) on outcomes in patients with chronic coronary syndrome in the setting of optimal medical therapy remains unknown.

METHODS AND RESULTS

The REAL-CAD (Randomized Evaluation of Aggressive or Moderate Lipid Lowering Therapy With Pitavastatin in Coronary Artery Disease) study is a prospective, multicenter, randomized trial of high-dose (pitavastatin 4 mg/day) or low-dose (pitavastatin 1 mg/day) statin therapy in 12 118 patients with chronic coronary syndrome. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or unstable angina requiring hospitalization (major adverse cardiac and cerebral events [MACCE]). CKD was defined as an estimated glomerular filtration rate [eGFR] <60 mL/min per 1.73 m2. WRF was defined as a decrease in eGFR ≥20% in the initial year; borderline renal function was an annual decrease of 0%

CONCLUSIONS

Baseline CKD was an independent predictor for MACCE in patients with CCS. WRF was a significant predictor for MACCE in patients with CKD. Because borderline renal function was an independent predictor for MACCE even in patients without CKD, mild-to-moderate annual declines of eGFR should be carefully monitored (NCT01042730).

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01042730.

Collapse

Key Words

• CCS
• CKD
• MACCE
• PCI
• deterioration

Collapse

MESH Headings

• Humans
• Male
• Female
• Renal Insufficiency, Chronic/physiopathology
• Renal Insufficiency, Chronic/complications
• Renal Insufficiency, Chronic/diagnosis
• Renal Insufficiency, Chronic/mortality
• Glomerular Filtration Rate
• Aged
• Middle Aged
• Prospective Studies
• Treatment Outcome
• Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage
• Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
• Kidney/physiopathology
• Quinolines/administration & dosage
• Quinolines/therapeutic use
• Risk Factors
• Disease Progression
• Coronary Artery Disease/drug therapy
• Coronary Artery Disease/mortality
• Time Factors

Collapse

Grants Collapse

Affiliation(s)

Yu Yoshiki Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Yukio Ozaki Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Mitsuru Abe Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
Tevfik F. Ismail King’s College London, LondonUK & Guy’s and St Thomas’ Hospital NHS Foundation TrustLondonUnited Kingdom
Hiroshi Takahashi Division of Medical StatisticsFujita Health University HospitalToyoakeAichiJapan
Masaharu Akao Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
Hideki Kawai Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Takashi Muramatsu Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Masahide Harada Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Masaya Ohta Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Yosuke Hashimoto Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Yuichiro Shiki Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Masayuki Koshikawa Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Keiichi Miyajima Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Hidemaro Takatsu Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Yudai Niwa Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Naoyuki Kawashima Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Reina Ozaki Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan Nagoya University Graduate School of MedicineNagoyaJapan
Naotake Tsuboi Department of NephrologyFujita Health University School of MedicineToyoakeAichiJapan
Satoshi Iimuro Teikyo Academic Research CenterTeikyo UniversityTokyoJapan
Hiroshi Iwata Department of Cardiovascular MedicineJuntendo University Graduate School of MedicineTokyoJapan
Ichiro Sakuma Caress Sapporo Hokko Memorial ClinicSapporoJapan
Yoshihisa Nakagawa Department of Cardiovascular MedicineShiga University of Medical Science HospitalOtsuJapan
Kiyoshi Hibi Division of CardiologyYokohama City University Medical CenterYokohamaJapan
Takafumi Hiro Division of Cardiology, Department of MedicineNihon University School of MedicineTokyoJapan
Yoshihiro Fukumoto Division of Cardiovascular Medicine, Department of Internal MedicineKurume University School of MedicineKurumeJapan
Seiji Hokimoto Department of Cardiovascular MedicineKumamoto University HospitalKumamotoJapan
Katsumi Miyauchi Department of Cardiovascular MedicineJuntendo University Graduate School of MedicineTokyoJapan
Hisao Ogawa Department of Cardiovascular MedicineKumamoto University HospitalKumamotoJapan
Hiroyuki Daida Department of Cardiovascular MedicineJuntendo University Graduate School of MedicineTokyoJapan
Hiroaki Shimokawa Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSendaiJapan
Hideo Izawa Department of CardiologyFujita Health University School of MedicineToyoakeAichiJapan
Takeshi Kimura Department of Cardiovascular MedicineKyoto University Graduate School of MedicineKyotoJapan
Ryozo Nagai Jichi Medical UniversityShimotsukeJapan
REAL‐CAD investigators

Collapse

A Meta-Analysis of Randomized Controlled Trials Comparing the Efficacy and Safety of Hydrophilic Versus Lipophilic Statins in Acute Coronary Syndrome Patients

Statins differ in their solubility. Some previous studies suggested a difference in clinical efficacy and adverse events between hydrophilic and lipophilic statins. The purpose of this study is to compare the efficacy and safety of hydrophilic and lipophilic statins in patients with acute coronary syndrome. The databases of MEDLINE/PubMed, Cochrane Library, the Web of Science, and Scopus were systemically searched for articles published from inception until the 18th of July 2024. The primary outcome included major adverse cardiac events (MACE), while the secondary outcomes included myocardial infarction (MI), unstable angina (UA), revascularization, stroke, all-cause mortality, cardiovascular deaths, and adverse events. The results were pooled as risk ratio (RR) along with their 95% confidence intervals (CI). Nine studies were included. Hydrophilic statins showed a significantly higher risk of MACE and UA compared to lipophilic statins (RR 1.11 [95% CI 1.02, 1.21] and 1.30 [95% CI 1.04, 1.62]), but subgroup analysis showed a lack of significant difference between statins of similar intensity (1.01 [95% CI 0.86, 1.18] and 0.98 [0.67, 1.45], respectively). Both statins showed comparable results regarding the occurrence of MI (1.18 [95% CI 0.98, 1.40]), revascularization (1.09 [95% CI 0.99, 1.20]), stroke (1.16 [95% CI 0.80, 1.66]), all-cause mortality (1.13 [95% CI 0.92, 1.38]), cardiovascular deaths (1.14 [95% CI 0.76, 1.72]), adverse events leading to discontinuation (1.03 [95% CI 0.56, 1.90]), increased alanine aminotransferase (0.61 [95% CI 0.32, 1.16]), increased creatine kinase (0.90 [95% CI 0.30, 2.72]), and increased serum creatinine (1.03 [95% CI 0.49, 2.19]). The efficacy and safety of hydrophilic and lipophilic statins are comparable when the cholesterol-lowering intensity of statins is similar. This suggests that intensity, rather than the lipophilicity of the statin, plays a more important role in the secondary prevention of MACE and individual adverse events.

Comparative efficacy and safety among high-intensity statins. Systematic Review and Meta-Analysis

Aim: To summarize the evidence in terms of efficacy and safety of head-to-head studies of high-intensity statins regardless of the underlying population. Materials & methods: A systematic review and meta-analysis was conducted to summarize the effect sizes in randomized controlled trials and cohort studies that compared high-intensity statins. Results: Based on 44 articles, similar effectiveness was observed across the statins in reducing LDL levels from baseline. All statins were observed to have similar adverse drug reactions (ADRs), although higher dosages were associated with more ADRs. Based on a pooled quantitative analysis of atorvastatin 80 mg versus rosuvastatin 40 mg, rosuvastatin was statistically more effective in reducing LDL. Conclusion: This review further confirms that high-intensity statins reduce LDL by ≥50%, favoring rosuvastatin over atorvastatin. Additional data are needed to confirm the clinical significance on cardiovascular outcomes using real-world studies.

Rationale and design of COLchicine On-admission to Reduce inflammation in Acute Coronary Syndrome (COLOR-ACS) study

AIMS

The aim of the colchicine on-admission to reduce inflammation in acute coronary syndrome (COLOR-ACS) study is to evaluate the effects of the addition of short-term, low-dose colchicine to high-dose atorvastatin in limiting levels of inflammatory markers, such as high-sensitivity C-reactive protein (hs-CRP), in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

The COLOR-ACS study is a multicenter, randomized, open-label, two-arm trial. Statin-naive patients with NSTE-ACS, scheduled for an early invasive strategy, are randomized on admission to receive standard treatment of atorvastatin 80 mg or standard treatment plus colchicine (1 mg loading dose followed by 0.5 mg/day until discharge). The main exclusion criteria are prior statin and/or colchicine treatment, current treatment with potent inhibitors of CYP3A4, P-glycoprotein or immunosuppressive drugs, known active malignancy, severe kidney, cardiac, liver disease. There is clinical and biochemical follow-up at 30 days after discharge and telephone interview at 6 months. The primary end point is the change in hs-CRP from admission to discharge. Secondary end points include: incidence of acute kidney injury; MB fraction of creatine kinase peak value; glomerular filtration rate change from baseline to 30 days; persistence of hs-CRP ≥2 mg/dl at 30 days; adverse clinical events within 30 days; tolerance to colchicine.

CONCLUSION

The COLOR-ACS study will provide evidence on the efficacy of early short-term treatment with colchicine in addition to high-dose atorvastatin compared to atorvastatin alone in ACS patients. The potential anti-inflammatory action of colchicine plus atorvastatin is expected to limit hs-CRP increase with resultant clinical benefits.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05250596.

Contrast-induced acute kidney injury and its contemporary prevention

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.