EUROASPIRE V and uncontrolled risk factors in primary prevention: Atherosclerotic cardiovascular disease in the making

Efficacy and safety of bempedoic acid in acute coronary syndrome. Design of the clinical trial ES-BempeDACS

INTRODUCTION AND OBJECTIVES

Only about 1 out of every 3 patients with acute myocardial infarction (AMI) achieve low-density lipoprotein cholesterol (LDL-C) values <55mg/dL in the first year. The present study aims to evaluate the impact of early intensive therapy on lipid control after an AMI.

METHODS

An independent, prospective, pragmatic, controlled, randomized, open-label, evaluator-blinded clinical trial (PROBE design) will analyze the efficacy and safety of an oral lipid-lowering triple therapy: high-potency statin+bempedoic acid (BA) 180mg+ezetimibe (EZ) 10mg versus current European-based guidelines (high-potency statin±EZ 10mg), in AMI patients. LDL-C will be determined within the first 48hours. Patients with LDL-C ≥ 115mg/dL (without previous statin therapy), ≥ 100mg/dL (with previous low-potency or high-potency statin therapy at submaximal dose), or ≥ 70mg/dL (with previous high-potency statin therapy at high dose) will be randomly assigned 1:1 between 24 and 72hours post-AMI to the BA/EZ combination or to statin±EZ, without BA. The primary endpoint is the proportion of patients reaching LDL-C <55mg/dL at 8 weeks after treatment.

RESULTS

The results of this study will provide novel information for post-AMI LDL-C control by evaluating the usefulness of an early intensive lipid-lowering strategy based on triple oral therapy.

CONCLUSIONS

Early intensive lipid-lowering triple oral therapy vs the treatment recommended by current clinical practice guidelines could facilitate the achievement of optimal LDL-C levels in the first 2 months after AMI (a high-risk period).

IDENTIFICATION NUMBER

EudraCT 2021-006550-31.

Fixed Combination for the Treatment of Dyslipidaemia

PURPOSE OF REVIEW

It is clear from epidemiological studies that patients at high and very-high risk of atherosclerotic cardiovascular diseases (ASCVD) risk do not reach lipid guideline-recommended targets. Thus, fixed-dose combinations of statins/ezetimibe, bempedoic acid/ezetimibe and statins/fibrates may represent a further armamentarium in the field of lipid-lowering approaches in these individuals.

RECENT FINDINGS

The combination therapy of moderate-intensity statin with ezetimibe is not inferior to high-intensity statin monotherapy in reducing cardiovascular outcomes. Drug discontinuation or dose reduction is inferior with fixed-dose combination. The fixed-dose combination of bempedoic acid with ezetimibe is superior to bempedoic acid in monotherapy in lowering LDL-C and in reducing high-sensitivity C-reactive protein concentrations. The combination fenofibrate with atorvastatin is superior to monotherapies in lowering triglycerides. Lipid-lowering fixed-dose combinations may guarantee a higher therapy adherence, representing a better approach to control plasma lipids and thus ameliorate ASCVD burden. Additional studies will define the advantages on cardiovascular outcomes in high and very high-risk patients.

[Prognostic impact of cardiovascular risk factors in patients admitted for acute coronary syndrome]

INTRODUCTION AND OBJECTIVES

Cardiovascular prevention measures place the emphasis on controlling cardiovascular risk factors (CVRF). However, the most recent studies provide disappointing data, the impact of which remains to be determined. The objective of this study was to analyse the impact that the different CVRFs, and their degree of control, have on the prognosis of patients after acute coronary syndrome.

PATIENTS AND METHODS

Epidemiological, pharmacological, and CVRF control data were collected from 1,689 consecutive patients admitted from 2018 to 2020 for acute coronary syndrome to a tertiary hospital. Finally, the rate of major adverse cardiovascular events was calculated.

RESULTS

The patients admitted for acute coronary syndrome were predominantly men, with body mass index>25Kg/m2, smokers (or former smokers) and with poor CVRF control (50% for hypertension and diabetes and 35% for dyslipidaemia), especially those patients with a personal history of ischaemic heart disease. An underutilisation of useful drugs for CVRF control was found. A directly proportional relationship was observed between the number of CVRFs (or their poor control) and the incidence of major adverse cardiovascular events at 2 years, hypertension being the factor with the greatest cardiovascular impact. The SARS-CoV-2 lockdown worsened the degree of CVRF control and cardiovascular prognosis.

CONCLUSION

There is still room for improvement in the control of CVRF, which would translate into a prognostic benefit for patients with ischaemic heart disease. The implementation of cardiovascular prevention campaigns seems essential.

Early identification and treatment of women's cardiovascular risk factors prevents cardiovascular disease, saves lives, and protects future generations: Policy recommendations and take action plan utilizing policy levers

Cardiovascular diseases (CVD) including heart attacks, strokes, heart failure, and uncontrolled hypertension are leading causes of death among women of all ages. Despite efforts to increase awareness about CVD among women, over the past decade there has been stagnation in the reduction of CVD in women, and CVD among younger women and women of color has in fact increased. We recommend taking action using policy levers to address CVD in women including: (1) Promoting periodic screening for risk factors including blood pressure, lipids/cholesterol, diabetes for all women starting at 18-21 years, with calculated atherosclerotic CVD (ASCVD) risk score use among women 40 years or older. (2) Considering coronary artery calcium (CAC) screening for those with intermediate risk per current guidelines. (3) Enhancing Obstetrics and Gynecology and primary care physician education on reproductive age CVD risk markers, and that follow-up is needed, including extended postpartum follow-up. (4) Offering Health Coaching/motivational Interviewing to support behavior change. (5) Funding demonstration projects using different care models. (6) Creating a Stop High Blood Pressure consult line (for providers and patients) and providing other support resources with actions consumers can take, modeled after the California tobacco quit line. And (7) Requiring inclusion of adverse pregnancy outcomes in all Electronic Health Records, with reminder systems to follow-up on hypertension post-partum.

NMR, LC-MS Characterization of Rydingia michauxii Extracts, Identification of Natural Products Acting as Modulators of LDLR and PCSK9

Rydingia michauxii (Briq.) Scheen and V.A.Albert (Lamiaceae) is used in Iranian traditional medicine to treat malaria, diabetes, hyperlipidemia, rheumatism and cardiovascular diseases. NMR and LC-DAD-MSn analyses were used to establish extract composition and phenylethanoid, flavonoid glycosides, lignans, labdane diterpenes and iridoids were identified and quantified. The main constituents were isolated, and structures were elucidated based on NMR, polarimetric and MS measurements. A new natural compound, ent-labda-8(17),13-dien-18-glucopyranosyl ester-15,16-olide is described here. The effects of ent-labda-8(17),13-dien-18-oic acid-15,16-olide (1), ent-labda-8(17),13-dien-18-glucopyranosyl es-ter-15,16-olide (2), antirrhinoside (3), echinacoside (4), verbascoside (5), and apigenin 6,8-di-C-glucoside (6), on the low-density lipoprotein receptor (LDLR) and proprotein convertase subtilisin/kexin type 9 (PCSK9), were studied in the human hepatocarcinoma cell line Huh7. Among the six constituents, (3) showed the strongest induction of the LDLR (3.7 ± 2.2 fold vs. control) and PCSK9 (3.2 ± 1.5 fold vs. control) at a concentration of 50 µM. The in vitro observations indicated a potential lipid lowering activity of (3) with a statin-like mechanism of action.

Challenges of Statin Therapy in Clinical Practice (According to Outpatient Register «PROFILE» Data)

Aim. To identify the main problems of statin therapy in patients with high and very high cardiovascular (CV) risk in real clinical practice.

Material and methods. The general information of the study was based on data from 2,457 patients who were included in the register before November 30, 2020: 1,250 men (50.9%) and 1,207 (49.1%) women. A more detailed analysis was performed for groups of patients with high          and very high CV risk who had indications for statin treatment at the time of inclusion in the register: out of 2457 patients, 1166 people had very high CV risk, 395 was at high CV risk (a total of 1561 people, the average age of patients was 64.4±11.0 years).

Results. Information on the parameters of the lipidogram – the level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) was available in 1918 (78.1%) and 1546 (62.9%) patients, respectively. Of 1561 patients with high and very high CV risk, TC and LDL-C levels were analyzed in 1221 (78.2%) and 956 (61.2%) cases, statistically significantly more often in patients with high CV risk (p<0.05). Statins were recommended only to 823 (52.7%) patients with high and very high CV risk. Patients with very high CV risk received such appointments 4 times more often than patients with high CV risk: odds ratio (OR) 4.2; 95% confidence interval (CI) 3.2-5.3 (p<0.001). Doctors preferred atorvastatin in prescriptions (n=456, 55.4%), rosuvastatin (n=244, 29.7%) and simvastatin (n=121, 14.7%) were in second and third places. The target level of LDLC was 2 times more often achieved in patients with high CVR, compared with patients with very high CV risk: OR = 2.0, 95% CI 1.4-3.0 (p<0.001).

Conclusion. The main problems of statin treatment in real clinical practice remain the non-assignment of these drugs to patients who have indications for such therapy and the failure to achieve the target levels of lipidogram indicators, which may probably be due to the clinical inertia of doctors regarding titration of statin doses, and in some cases caused by the choice of drugs that are not the most effective in reducing LDL cholesterol. Patients with very high CV risk are 4 times more likely to receive a recommendation to take statins compared to patients with high CV risk, but the target level of LDL cholesterol is reached in them 2 times less often.