Lipid Profile and Lipoprotein(a) Testing

Treatment pathways of lipid-lowering therapies in Germany 2016-2022

BACKGROUND

Despite the availability of effective LDL cholesterol (LDL-C)-lowering drugs, only a minority of patients achieves the guideline-recommended treatment targets. This analysis describes treatment pathways of lipid-lowering therapy (LLT) in Germany.

METHODS

Health claims data were used to identify patients at high or very-high cardiovascular risk who received a LLT prescription 2016-2022. Treatment pathways and the time to switch or discontinue LLT were analysed for statins, ezetimibe, bempedoic acid (BA), and PCSK9 inhibitors (PCSK9i).

RESULTS

Out of 3,487,827 insured persons, 247,529 met the inclusion criteria. The most frequent first-line LLT were statins in 96.3%. Ezetimibe, BA, and PCSK9i were first-line LLT in only 0.9%, 0.061%, and 0.046%, respectively. Only few patients experienced a change in their treatment regimen following LLT initiation. Prescriptions of BA and PCSK9i were mainly second-, third-, or fourth-line add-on treatment. Termination of treatment with BA and PCSK9i was less frequent compared to statins and ezetimibe. The median time to treatment discontinuation was 1.45, 1.04, 0.60, and 2.45 years for statins, ezetimibe, BA, and PCSK9i, respectively, and the median time to switch therapy was 4.81 and 4.87 years for ezetimibe and PCSK9i, respectively (median not reached for statins and BA).

CONCLUSIONS

Changes in LLT were only observed in a minority of patients. BA and PCSK9i were switched more frequently than statins and ezetimibe. BA was discontinued earlier, and PCSK9i later than the other agents. Continued efforts to maintain long-term adherence and overcome therapeutic inertia are needed to realise the potential of available LLT with proven cardiovascular benefit.

Associations between indicators of lipid and glucose metabolism and hypothyroidism

BACKGROUND

Hypothyroidism, a prevalent thyroid hormone abnormality identified by biochemical indicators, is prone to serious consequences because of its insidious clinical manifestations and easy underdiagnosis. This research aimed to elucidate the relationships between indicators of lipid and glucose metabolism and hypothyroidism and to assess the value of metabolic indicators for hypothyroidism.

METHODS

Prevalence surveys were conducted utilizing information from 3254 NHANES individuals who passed screening between 2007 and 2012. Comparisons of baseline characteristics, assessment of logistic regression and subgroup analyses, visualization of restricted cubic splines curves, and validation of causal mediation analyses were performed to obtain a comprehensive view of the relationships between indicators of lipid and glucose metabolism and hypothyroidism.

RESULTS

Lipid and glucose metabolism indicators, especially the unconventional parameters triglyceride‒glucose index (TyG) and remnant cholesterol (RC) and the conventional parameter triglyceride (TG), exhibited robust positive relationships with hypothyroidism and served as crucial mediators in the pathways by which hypothyroidism affects health outcomes. Indicators were varying suggestive for hypothyroidism in distinct populations, with TyG being relatively more valuable.

CONCLUSIONS

Indicators of lipid and glucose metabolism (TyG, TG, and RC) were intimately associated with hypothyroidism, with potential applications in the assessment and management of hypothyroidism.

Special Aspects of Cholesterol Metabolism in Women

BACKGROUND

Cardiovascular diseases due to arteriosclerosis are the most common causes of death and disability in both men and women. Hypercholesterolemia, a treatable risk factor, is often detected after a delay in women, and then inadequately treated. It is, therefore, important to know the sex-specific aspects of cholesterol metabolism and to address them specifically.

METHODS

We conducted a selective literature search in PubMed with particular attention to current guidelines.

RESULTS

In the population as a whole, the age-associated rise in serum cholesterol levels occurs approximately 10 years later in women than in men. Women are exposed to a higher cholesterol load than men at the beginning of their lives, and especially after menopause. This is correlated with a later, but nonetheless clinically relevant rise in the incidence of myocardial infarction in older women. Because women's LDL cholesterol and lipoprotein(a) levels rise after menopause, their lipid profiles should be re-evaluated at this time. Moreover, conditions that are specific to women such as polycystic ovary syndrome, contraception, and especially the phases of life-such as planning to become pregnant, pregnancy, and breastfeeding-need to be considered for both diagnostic and therapeutic purposes. Sex-specific differences and cholesterolassociated risks are particularly pronounced in women with familial hypercholesterolemia (prevalence 1:250).

CONCLUSION

Lowering high cholesterol levels, especially in postmenopausal women, may prevent the development of cardiovascular diseases.

Prevalence of elevated lipoprotein(a) in cardiac rehabilitation patients - results from a large-scale multicentre registry in Germany

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.