Update on the efficacy of statin treatment in acute coronary syndromes

Statin Use and Major Adverse Cardiovascular Events Among Patients with Ischemic Heart Diseases: A Multi-Center Retrospective Study

Objective: The objective of this study was to evaluate the effects of adherence to the ACC/AHA 2018 dyslipidemia guidelines on patient management of lipid-lowering therapy in patients with ischemic heart diseases (IHD) and its correlation with major adverse cardiovascular events (MACEs), including non-fatal MI, stroke, death, hospitalization for revascularization, and peripheral arterial disease. Methods: A multi-center retrospective observational study was conducted in patients with IHD between January 2019 and December 2020, who were followed for two years. The primary objective was to assess statin utilization and adherence to the 2018 ACC/AHA guidelines and the associated influence on MACE outcomes. Inferential statistical analyses, including chi-square tests and the Mann-Whitney test, were conducted to assess the associations between adherence to the guidelines, MACE rates, and LDL-C goal achievement. Results: The study included 1011 patients with ischemic heart disease (IHD), predominantly male (78.2%), with a mean age of 59 ± 10.9 years. Non-adherent patients had higher baseline LDL-C levels (3.0 ± 1.1 mmol/L vs. 2.7 ± 1.2 mmol/L; p = 0.0005), while adherent patients were more likely to be on cardiovascular medications, including statins (78.4% vs. 57.4%), aspirin (74.2% vs. 56.3%), and P2Y12 inhibitors (69.5% vs. 48.4%), compared to non-adherent patients. Adherence was associated with lower non-fatal MI rates (9.3% vs. 21.1%, p < 0.0001) and fewer revascularizations (9.3% vs. 16.8%; p = 0.0024). Additionally, 49.2% of adherent patients achieved target LDL-C goals, compared to 30.5% of the non-adherent patients (p < 0.0001). Notably, there were no significant differences in stroke, peripheral arterial disease, or mortality rates. Conclusions: The achievement of target LDL-C goals and reduced MACEs was observed with adherence to the 2018 ACC/AHA dyslipidemia guidelines. However, lipid management in IHD patients remains sub-optimal, highlighting opportunities for further enhancement.

Aggressive lipid-lowering therapy after percutaneous coronary intervention - for whom and how?: Aggressive lipid-lowering therapy after PCI

Percutaneous coronary intervention (PCI) has been established as a definitive method to treat obstructive coronary artery disease. The procedure on its own, however, is insufficient to ensure optimal long-term patient outcomes as it is also necessary to achieve good control of relevant risk factors. The process of atherosclerosis as a result of dyslipidaemia is a risk continuum and secondary preventive measures for patients who have undergone PCI are of paramount importance to mitigate the risk of procedural failure and further cardiovascular events. This review aims to provide an overview of the landscape of lipid-lowering therapy for the purpose of secondary prevention by summarising recommendations derived from contemporary guidelines and highlighting the rationale and evidence behind the three main lipid-lowering therapies, namely statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. It also provides insights into real-world challenges and issues surrounding secondary prevention of dyslipidaemia such as suboptimal lipid goal attainment and nonadherence, and assesses the possible methods to overcome them.

Spectroscopic studies on photodegradation of atorvastatin calcium

In this work, the photodegradation process of atorvastatin calcium (ATC) is reported as depending on: (1) the presence and the absence of excipients in the solid state; (2) the chemical interaction of ATC with phosphate buffer (PB) having pH equal to 7 and 8; and (3) hydrolysis reaction of ATC in the presence of aqueous solution of NaOH. The novelty of this work consists in the monitoring of the ATC photodegradation by photoluminescence (PL). The exposure of ATC in solid state to UV light induces the photo-oxygenation reactions in the presence of water vapors and oxygen from air. According to the X-ray photoelectron spectroscopic studies, we demonstrate that the photo-oxygenation reaction leads to photodegradation compounds having a high share of C=O bonds compared to ATC before exposure to UV light. Both in the presence of PB and NaOH, the photodegradation process of ATC is highlighted by a significant decrease in the intensity of the PL and photoluminescence excitation (PLE) spectra. According to PLE spectra, the exposure of ATC in the presence of NaOH to UV light leads to the appearance of a new band in the spectral range 340-370 nm, this belonging to the photodegradation products. Arguments concerning the chemical compounds, that resulted in this last case, are shown by Raman scattering and FTIR spectroscopy.

Efficacy of Nutraceutical Combination of Monacolin K, Berberine, and Silymarin on Lipid Profile and PCSK9 Plasma Level in a Cohort of Hypercholesterolemic Patients

The guidelines for the treatment of dyslipidemias include the use of nutraceuticals (NUTs) in association with lifestyle modifications to achieve therapeutic goals. In NUT pill, different substances may be associated; in this study we investigated a combined NUT containing monacolin K (MonK)+KA (1:1), berberine (BBR), and silymarin. The aim of the study was to evaluate low-density lipoprotein cholesterol (LDL-C) reduction in 53 patients suffering from polygenic hypercholesterolemia, characterized by a low/intermediate cardiovascular risk calculated with SCORE algorithm. The effects on lipid profile of 2-month treatment with NUT containing MonK+KA (1:1), BBR, and sylimarin, were compared with Atorvastatin (ATO) 10 mg administrated in a matched control group. Serum proprotein convertase subtilisin/kexin type 9 (PCSK9) levels and the cholesterol loading capacity (CLC) were determined at baseline and at the end of the study in NUT-treated group; variations were assessed. NUT was effective as lipid-lowering agent with a wide interindividual response variability (mean LDL-C from 170.8 ± 19.9 to 123.8 ± 20.0 with a change of -47.0 ± 21.5 mg/dL; P < .001) and the effect was similar to that induced by ATO. The use of NUT significantly modified PCSK9 levels (P < .01) and CLC (P < .001), ultimately suppressing the serum-mediated foam cell generation directly measured on human macrophages. NUT reduces LDL-C levels with an effect similar to what is induced by 10 mg of ATO and ex vivo improves the functional profile of lipoproteins with antiatherogenic action.

An Emerging Cardiovascular Disease: Takotsubo Syndrome

Takotsubo syndrome (TTS) is a recently identified cardiac disease, which is far from being completely known. The aims of this narrative review are to provide a better understanding of the pathophysiological features of TTS and to update clinical findings in order to improve the management of subjects affected by this syndrome (according to the most recent consensus papers issued by the international scientific societies). We based our search on the material obtained via PubMed up to April 2019. The terms used were "Takotsubo Syndrome and Takotsubo cardiomyopathy" in combination with "heart failure, pathophysiology, complications, diagnosis, and treatment." TTS is a reversible form of ventricular dysfunction usually characterized by akinesia of the apex in the absence of obstructive coronary artery disease. In its initial phase, TTS may be indistinguishable from AMI and is usually triggered by a sudden emotional/physical stressor which abruptly increases catecholamine levels. However, the mechanisms by which catecholamines or other unidentified molecules can cause myocardial dysfunction is unknown. In-hospital stay may be hampered by various life-threatening complications, while data on long-term survival remain scarce and unclear. Furthermore, TTS may sometimes recur. We believe that TTS is clearly a much more complex condition than previously thought. Much remains to be discovered about its pathophysiologic mechanisms, the role of the link between the heart and brain and that of triggering factors and gender, and the reasons why this syndrome displays different phenotypes and sometimes recurs. Undoubtedly, preliminary evidence from pathophysiological studies (mainly genetic studies) has shown promising advances. However, prospective randomized clinical trials are still needed in order to identify and to tailor the best medical treatments for TTS patients.

Clinical Characteristics and Long-Term Mortality Rate in Female Patients with Takotsubo Syndrome Compared with Female Patients with ST-Elevation Acute Myocardial Infarction: A Retrospective Study from a Single Center

Background

Takotsubo syndrome (TTS) is characterized by acute transient, stress-induced, left ventricular systolic dysfunction, generally presenting with apical ballooning. It can mimic an acute coronary syndrome, but with a milder increase in cardiac enzymes and without culprit coronary artery disease on angiography. Data on long-term follow-up and survival in patients with TTS, compared with patients with ST-elevation myocardial infarction (STEMI), are scarce.

Purpose

To assess all-cause mortality rate and survival in a consecutive series of female patients with TTS compared with age- and sex-matched STEMI patients on long-term follow-up.

Methods and Results

We collected data of 65 TTS female patients (TTS group) with a mean age of 73.42 ± 11.35 years from 2001 to 2013. Collection of follow-up information was concluded for all patients in 2016. To compare the mortality and survival of TTS patients with those of the STEMI population, we used data from our STEMI Registry, a prospective registry of 7446 STEMI patients admitted from 2001 to 2013 to our cath-lab for primary percutaneous coronary intervention (p-PCI). From the registry, we selected 104 STEMI patients (STEMI group) comparable to our TTS group in terms of age (mean age of 72.33 ± 11.92 years) and sex. On follow-up examination after a median of 1000 days, the TTS group had a lower all-cause mortality rate than the STEMI group (7.69% versus 23.08%). This difference was statistically different between the two groups (log-rank test, p value = 0.03).

Conclusions

In our study, TTS and STEMI patients displayed a statistically significant difference in long-term survival. Specifically, the TTS group had a lower mortality rate than the STEMI group. This seems to suggest that TTS and STEMI are two different clinical entities with two different clinical outcomes.

Low-density lipoprotein cholesterol target achievement in patients surviving an acute coronary syndrome in Hong Kong and Taiwan - findings from the Dyslipidemia International Study II

BACKGROUND

Individuals are at increased risk for cardiovascular events following an acute coronary syndrome (ACS). Effective management of hyperlipidemia, an associated risk factor, is essential for improving outcomes. We aimed to quantify the extent of hyperlipidemia and its treatment in ACS survivors in Hong Kong and Taiwan.

METHODS

The multinational, observational Dyslipidemia International Study (DYSIS) II included patients hospitalized for an ACS. Lipid levels and use of lipid-lowering therapy (LLT) were evaluated at baseline and 4 months post-discharge. The proportions of patients attaining the recommended LDL-C target for individuals at very high cardiovascular risk (<70 mg/dL) was assessed and potential predictors of this outcome evaluated.

RESULTS

In total, 270 patients were enrolled, 125 (46.3%) of which were being treated with LLT prior to hospitalization. Of these, 28.8% had an LDL-C level < 70 mg/dL, compared to only 6.9% of those not being treated. Statin monotherapy was the most commonly employed LLT, with a mean atorvastatin-equivalent dosage of 14 mg/day. By 4-month follow-up, target attainment had risen to 45.1% for patients treated with LLT at baseline, and 43.3% for those who had not been treated. LLT was being used by 88.4% of patients at follow-up, with a mean atorvastatin dosage of 18 mg/day. Use of statins in combination with ezetimibe/other non-statin was scarce. No predictors of LDL-C target attainment were identified.

CONCLUSIONS

In patients hospitalized with an ACS, rates of LDL-C target achievement were poor. While LLT was widely employed, statin intensity was low and combination therapy underused, indicating scope for improvement.

Predictors of LDL-cholesterol target value attainment differ in acute and chronic coronary heart disease patients: Results from DYSIS II Europe

Background

Patients with coronary heart disease (CHD) and survivors of acute coronary syndrome (ACS) are at very high risk for adverse cardiovascular events. Lowering low-density lipoprotein cholesterol (LDL-C) can reduce the risk, with effective lipid-lowering therapy (LLT) readily available; however, dyslipidemia remains prevalent throughout Europe.

Design

The observational Dyslipidemia International Study II (DYSIS II) aimed to identify unmet treatment needs in adult ACS and CHD patients. Data for the seven participating European countries are presented herein.

Methods

The study was carried out from December 2012 to November 2014. Use of LLT and attainment of European-guideline-recommended LDL-C targets were assessed. For ACS patients, changes in lipid levels and LLT were evaluated 4 months post-hospitalization.

Results

Of the 4344 patients enrolled, 2946 were attending a physician visit for the assessment of stable CHD, while 1398 had been hospitalized for an ACS event. In both patient sets, mean LDL-C levels were high (89.5 and 112.5 mg/dl, respectively) and <70 mg/dl target attainment extremely poor. The mean daily statin dosage (normalized to atorvastatin potency) was 27 ± 20 mg for CHD and 22 ± 17 mg for ACS patients. Treatment was intensified slightly for ACS subjects after hospitalization, with the dosage reaching 35 ± 24 mg/day. LDL-C target attainment was higher by the end of the 4-month follow up (30.9% and 41.5% for patients on LLT and without LLT at baseline, respectively; p < 0.05).

Conclusion

Elevated blood cholesterol levels are highly prevalent across Europe, with low numbers of coronary patients reaching their recommended LDL-C target. While use of LLT is widespread, there is significant scope for intensifying treatment.

Prevalence of lipid abnormalities and cholesterol target value attainment in Egyptian patients presenting with an acute coronary syndrome

Background

Effective management of hyperlipidemia is of utmost importance for prevention of recurring cardiovascular events after an acute coronary syndrome (ACS). Indeed, guidelines recommend a low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL for such patients. The Dyslipidemia International Study II (DYSIS II) - Egypt was initiated in order to quantify the prevalence and extent of hyperlipidemia in patients presenting with an ACS in Egypt.

Methods

In this prospective, observational study, we documented patients presenting with an ACS at either of two participating centers in Egypt between November 2013 and September 2014. Individuals were included if they were over 18 years of age, had a full lipid profile available (recorded within 24 h of admission), and had either been taking lipid-lowering therapy (LLT) for ≥3 months at time of enrollment or had not taken LLT. Data regarding lipid levels and LLT were recorded on admission to hospital and at follow-up 4 months later.

Results

Of the 199 patients hospitalized for an ACS that were enrolled, 147 were on LLT at admission. Mean LDL-C at admission was 127.1 mg/dL, and was not significantly different between users and non-users of LLT. Only 4.0% of patients had an LDL-C level of <70 mg/dL, with the median distance to this target being 61.0 mg/dL. For the patients with LDL-C information available at both admission and follow-up, LDL-C target attainment rose from 2.8% to 5.6%. Most of the LLT-treated patients received statin monotherapy (98.6% at admission and 97.3% at follow-up), with the mean daily statin dose (normalized to atorvastatin) increasing from admission (30 mg/day) to follow-up (42 mg/day).

Conclusions

DYSIS II revealed alarming LDL-C goal attainment, with none of the patients with follow-up information available reaching the target of LDL-C <70 mg/dL, either at hospital admission or 4 months after their ACS event. Improvements in guideline adherence are urgently needed for reducing the burden of cardiovascular disease in Egypt. Strategies include the effective use of statins at high doses, or combination with other agents recommended by guidelines.

Involvement of IL-1β and IL-6 in antiarrhythmic properties of atorvastatin in ouabain-induced arrhythmia in rats

PURPOSE

Evidence show that statins possess wide beneficial cardioprotective and anti-inflammatory effects; therefore, in the present experiment, we investigated the antiarrhythmic properties of atorvastatin in ouabain-induced arrhythmia in isolated rat atria and the role of several inflammatory cytokines in this effect.

MATERIALS AND METHODS

Male rats were pretreated with either of atorvastatin (10 mg/kg) or vehicle, orally once daily for 6 weeks. After induction of anesthesia, we isolated the atria and after incubation with ouabain, time of onset of arrhythmia and asystole as well as atrial beating rate and contractile force were recorded. We also measured the atrial levels of IL-1β, IL-6, and TNF-α after the injection of ouabain to animals.

RESULTS

Pretreatment with atorvastatin significantly delayed the onset of arrhythmia and asystole compared with vehicle-treated group (p < .01, p < .001, respectively). Incubation of ouabain boosted both atrial beating rate and contractile force in vehicle-treated group (p < .05), while these responses in atorvastatin-treated group were not significant (p > .05). Injection of ouabain elevated the atrial levels of IL-1β, IL-6, and TNF-α, while pretreatment of animals with atorvastatin could reverse the ouabain-induced increase in atrial IL-1β and IL-6 (p < .01 and p < .05, respectively).

CONCLUSIONS

It is concluded that observed antiarrhythmic effects of atorvastatin might be attributed to modulation of some inflammatory cytokines, at least IL-1β and IL-6.

Chronic administration of atorvastatin could partially ameliorate erectile function in streptozotocin-induced diabetic rats

The efficacy of statins is related to the ‘common soil’ hypothesis, which proposes oxidative stress and inflammation as main pathophysiologic processes in the disease group of diabetes and endothelial dysfunction. This study evaluated the recovery of erectile function after administration of chronic statin alone in streptozotocin (STZ)-induced diabetes mellitus (DM) rats, focusing on the anti-oxidative effects and consequentially recuperated endothelial function. A total of 45 male Sprague-Dawley rats (8 weeks old) were divided into three groups (n = 15 each): an age-matched normal control group (Control group), an uncontrolled DM group (DM group), and a statin-treated group (Statin group). The rats in the DM and Statin group received an injection of STZ (60 mg/kg). Beginning 10 weeks after the establishment of DM, the Statin group received daily treatment with atorvastatin (10 mg/kg) via oral gavage for four weeks. After 14 weeks, the results of the experiment were evaluated. The ratios of intracavernosal pressure (ICP) to mean arterial pressure (MAP) were recorded with cavernosometry (20 Hz, 3 V, 0.2 msec for 30 seconds) before and after the intravenous administration of udenafil (1 mg/kg). Expression of alpha-smooth muscle actin (α-SMA) was evaluated using cavernosal tissue. In addition, changes in RhoA translocation ratio and myosin phosphatase target subunit 1 (MYPT1) phosphorylation were evaluated with western blot. Superoxide dismutase (SOD) and malondialdehyde (MDA) levels were also analyzed as measurements of oxidative stress levels. The ICP/MAP and area under the curve (AUC)/MAP ratios of the Statin group were obviously superior to the DM group, but were not comparable to the Control group (P<0.001). The level of oxidative stress, namely SOD activity, was also significantly lower in the Statin group than in the DM group (P = 0.015), and was comparable to the Control group. In contrast, MDA levels were not considerably different among the groups (P = 0.217). The RhoA translocation ratio was not significantly different among the groups (P = 0.668), whereas MYPT1 phosphorylation in the Statin group was significantly lower than in the DM group (P = 0.030), and similar to the Control group. Expression of α-SMA in the Statin group was higher than in the DM group (P<0.001), and comparable to the Control group. Chronic statin treatment alone showed anti-oxidative effects and helped to restore the erectile mechanism, but did not lead to the full recovery of erectile function in STZ-induced DM rats. Therefore, combination therapy rather than a single agent should be the preferred treatment strategy for DM-associated erectile dysfunction, especially in the setting of severe diabetes.

Low-density lipoprotein cholesterol in a global cohort of 57,885 statin-treated patients

BACKGROUND AND AIMS

There is an inconsistency between international guidelines on lipid-lowering treatment regarding whether to pursue LDL-C treatment targets or to focus on the intensity of treatment. While either approach is attractive, there is no recent global data on actual LDL-C values, treatment targets attained, and the intensity of treatment in statin-treated patients. We aimed to determine and compare the extent of treatment target attainment globally using standardized data collection.

METHODS

Analyses were based on the Dyslipidemia International Study (DYSIS), a cross-sectional study documenting statin-treated outpatients throughout 30 countries worldwide (across Europe, the Middle East, Canada, Africa, and Asia). Patients were classified as being at very high, high, or non-high cardiovascular risk based on the 2011 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines.

RESULTS

Data were available for a total of 57,885 patients with a median LDL-C value of 98.2 mg/dl (IQR: 76.6, 125.7 mg/dl). Overall, only 26.8% of patients were documented to have attained their risk-based target LDL-C level. Of the 76% of patients who were classified as being at very high risk, only 21.7% attained their LDL-C goal. Globally, the median distance to target was 33.0 mg/dl, ranging from 18.8 to 42.1 mg/dl across countries. We calculated that a further LDL-C reduction of just 10 mg/dl would result in an 11% increase in the proportion of very-high-risk and high-risk patients attaining their target level (9% for non-high risk patients).

CONCLUSIONS

In spite of statin therapy, LDL-C values were high, with a substantial distance to target that was even more pronounced in (very) high risk patients. These results call for the optimization of existing treatment strategies and a collaborative effort to improve the impact of treatment guidance on clinical practice.

Learning from the past and looking to the future: Emerging perspectives for improving the treatment of psychiatric disorders

Modern neuropsychopharmacology commenced in the 1950s with the serendipitous discovery of first-generation antipsychotics and antidepressants which were therapeutically effective yet had marked adverse effects. Today, a broader palette of safer and better-tolerated agents is available for helping people that suffer from schizophrenia, depression and other psychiatric disorders, while complementary approaches like psychotherapy also have important roles to play in their treatment, both alone and in association with medication. Nonetheless, despite considerable efforts, current management is still only partially effective, and highly-prevalent psychiatric disorders of the brain continue to represent a huge personal and socio-economic burden. The lack of success in discovering more effective pharmacotherapy has contributed, together with many other factors, to a relative disengagement by pharmaceutical firms from neuropsychiatry. Nonetheless, interest remains high, and partnerships are proliferating with academic centres which are increasingly integrating drug discovery and translational research into their traditional activities. This is, then, a time of transition and an opportune moment to thoroughly survey the field. Accordingly, the present paper, first, chronicles the discovery and development of psychotropic agents, focusing in particular on their mechanisms of action and therapeutic utility, and how problems faced were eventually overcome. Second, it discusses the lessons learned from past successes and failures, and how they are being applied to promote future progress. Third, it comprehensively surveys emerging strategies that are (1), improving our understanding of the diagnosis and classification of psychiatric disorders; (2), deepening knowledge of their underlying risk factors and pathophysiological substrates; (3), refining cellular and animal models for discovery and validation of novel therapeutic agents; (4), improving the design and outcome of clinical trials; (5), moving towards reliable biomarkers of patient subpopulations and medication efficacy and (6), promoting collaborative approaches to innovation by uniting key partners from the regulators, industry and academia to patients. Notwithstanding the challenges ahead, the many changes and ideas articulated herein provide new hope and something of a framework for progress towards the improved prevention and relief of psychiatric and other CNS disorders, an urgent mission for our Century.