Clinical Benefit of Bempedoic Acid in Randomized Clinical Trials

Bempedoic acid is a selective inhibitor of the adenosine triphosphate citrate lyase that reduces low-density lipoprotein cholesterol (LDLc) levels by 17% to 28%. Although the Evaluation of Major Cardiovascular Events in Patients With, or at High Risk for, Cardiovascular Disease Who Are Statin Intolerant Treated With Bempedoic Acid (CLEAR-OUTCOMES) trials demonstrated the efficacy on cardiovascular outcomes there is a controversy related to the possible net clinical benefit. Thereafter, we performed an intention-to-treat meta-analysis in line with recommendations from the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome of the metanalysis was the incidence of major adverse cardiovascular events, defined by each study protocol. Secondary outcomes for the analyses were myocardial infarction, stroke, myocardial revascularization, cardiovascular death, and all-cause death. Results of 4 clinical trials evaluated contained a total of 17,324 patients; 9,236 received bempedoic acid for a median of 46.6 months. The mean baseline LDLc was 129.4 (22.8) mg/100 ml and treatment was associated with a mean LDLc reduction of 26.0 (12.6) mg/100 ml. Treatment with bempedoic acid significantly reduced the incidence of major adverse cardiovascular events (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.81 to 0.96), myocardial infarction (HR 0.76, 95% CI 0.66 to 0.89) and myocardial revascularization (HR 0.82, 95% CI 0.73 to 0.92); the crude incidence of stroke, cardiovascular or all-cause mortality were lower in patients in the bempedoic acid groups although no significant risk reduction was observed. No heterogeneity was observed in any of the end points. In conclusion, the metanalysis of the 4 clinical trials currently available with bempedoic acid provides reliable evidence of its clinical benefit with no signs of heterogeneity or harm.

Cardioprotective effect of empagliflozin in acute myocardial infarction: the role of ketone bodies availability

Background

The cardio-renal benefits of SGLT2i have been clearly established by clinical trials. Of interest, despite not having any effect on the incidence of classic atherothrombotic events (MI and strokes), patients receiving SGLT2i treatment had a higher chance of surviving myocardial infarction (MI).

Purpose

We aim to evaluate the cardioprotective potential of empagliflozin on acute myocardial infarction.

We postulate that the benefits of SGLT2-I are mediated via an increase in circulating ketone bodies (KBs) induced by SGLT2i, and its preferential myocardial utilization energetically benefits the heart to better withstand an ischemic event.

Methods

The study was undertaken in our non-diabetic porcine model of ischemia/reperfusion. Animals were allocated to either one-week pre-treatment with empagliflozin or placebo before MI-induction. A third group received IV infusion of KBs at the time of the MI- induction to serve as positive-control. The acute effects of the treatments were studied 24 hours after MI-induction by Cardiac Magnetic Resonance (CMR). Immediately post-CMR, animals were sacrificed and heart samples collected for molecular analysis.

Results

(see Table and Figure): Despite similar initial ischemic injury (area at risk) in all groups, empagliflozin was associated with a significantly higher myocardial salvage (MSI 23.7±9.7 vs 4.5±3.6%, p<0.001) and better preserved cardiac function (LVEF 41.3±3.1 vs 33±5.5%, p<0.009) compared with placebo. The infusion of KBs replicated in part the beneficial profile of the empagliflozin group (MSI 16.7±8.8 and LVEF 39.1±3.6%). Histological analysis showed less cardiomyocyte apoptosis and less oxidative stress

Conclusions

To the best of our knowledge, this is the first study evaluating in vivo the cardioprotective potential of a SGLT2 inhibitor in a well-stablished porcine translational model. Furthermore, effects are evaluated using the gold standard for visualization and quantification of MI, Cardiac Magnetic Resonance (CMR). Three are the main conclusions:

1. One-week treatment with empagliflozin raises circulating KBs levels and confers significant cardio-protection during a myocardial infarction. Acute post-MI benefits (greater myocardial salvage and better preserved cardiac function) are already seen within 24 hours as compared with placebo.

2. Periprocedural IV infusion of KBs induces similar benefits than the SGLT2-I group.

3. These observations strongly support our hypothesis that SGLT2 inhibition is associated with increased circulating KBs and its selective use as preferential myocardial source of energy as a potential mechanism of action involved in the cardio-renal benefits observed with SGLT2i.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology. Research Fellowship Grant.

Empagliflozin improves quality of life in nondiabetic HFrEF patients. Sub-analysis of the EMPATROPISM trial

BACKGROUND AND AIMS

Initially considered as just anti-diabetic agents, SGLT2-i show remarkable cardiac and renal benefits independently of its hypoglycemic activity.

METHODS

We used the Kansas City Cardiomyopathy Questionnaire (KCCQ), which has recently been qualified as a Clinical Outcome Assessment, in the EMPATROPISM trial.

RESULTS

A significant mean improvement of 22 points with KCCQ was seen with Empagliflozin versus only 2 points in the Placebo. The proportion of patients experiencing clinically important changes in the Empagliflozin group was higher. Patients with the lowest starting KCCQ score saw significantly greater improvements.

CONCLUSIONS

Empagliflozin benefits quality of life in the non-diabetic, ethnic minority represented, EMPATROPISM trial population.

LDL cholesterol-lowering therapies: emphasis on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors

Atherosclerotic cardiovascular disease is the leading cause of death all over the world. Its etiopathogenesis involves many correlated processes, with hypercholesterolemia being one of the main risk factors. Several large clinical trials have established the association between low-density lipoprotein cholesterol (LDL-C) levels and cardiovascular events. With the aim to take control over high LDL-C levels, several drugs with different targets in the cholesterol pathway have been developed. Statins are the cornerstone of pharmacological lipid-lowering treatment, although they are not always successful in attaining the recommended LDL-C levels. Therefore, newer and more potent therapies have been developed, being prominent among them ezetimibe and especially the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Recent trials with these new therapies have reaffirmed the theory of 'the lower, the better' when it comes to LDL-C levels, and 'the earlier, the better' when it comes to atherosclerotic physiopathology.

Dual versus triple antithrombotic therapy: is there a role for direct oral anticoagulants in arterial thrombosis?

The number of patients receiving dual antiplatelet therapy with an additional indication for long-term oral anticoagulation has substantially increased over time. This population is facing an unacceptable risk of bleeding events, particularly among elderly individuals, who are especially vulnerable to complications. Further strategies to minimize this bleeding risk, including various drug combinations, different dosage regimens and even numerous attempts to find the appropriate duration of the treatment, have been evaluated in a multitude of randomized control trials. Moreover, the recent incorporation of the direct oral anticoagulants (DOACs) to the therapeutic armamentarium may represent an alternative to treat such patients, since they have demonstrated to be noninferior to the classic vitamin K antagonists and with lower bleeding rates. The aim of this review is to summarize the most recent literature on the use of DOACs in patients with an indication for dual antiplatelet therapy (mostly subjects with coronary artery disease) and also an established indication for chronic anticoagulation (chiefly individuals with nonvalvular atrial fibrillation). The role of DOACs in ischemic heart disease alone is also discussed.