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Leiter LA, Banach M, Catapano AL, Duell PB, Gotto AM, Laufs U, Mancini GBJ, Ray KK, Hanselman JC, Ye Z, Bays HE. Bempedoic acid in patients with type 2 diabetes mellitus, prediabetes, and normoglycaemia: A post hoc analysis of efficacy and glycaemic control using pooled data from phase 3 clinical trials. Diabetes Obes Metab 2022; 24:868-880. [PMID: 34981622 PMCID: PMC9306638 DOI: 10.1111/dom.14645] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/22/2021] [Accepted: 01/01/2022] [Indexed: 12/30/2022]
Abstract
AIM To evaluate the effect of bempedoic acid on glycaemic and lipid variables in patients with hypercholesterolaemia. METHODS A patient-level pooled analysis of four phase 3, randomized, double-blind, placebo-controlled trials evaluated changes in glycaemia, change from baseline in LDL-C, and adverse events. Patients (N = 3621) on maximally tolerated statins were randomized 2:1 to oral bempedoic acid 180 mg or placebo once daily for 12 to 52 weeks with the results analysed by baseline glycaemic status (diabetes, prediabetes, or normoglycaemia). RESULTS The annual rate of new-onset diabetes for bempedoic acid versus placebo in patients with normoglycaemia at baseline (n = 618) was 0.3% versus 0.8%, and for patients with prediabetes at baseline (n = 1868) it was 4.7% versus 5.9%. In patients with diabetes or prediabetes, bempedoic acid significantly (P < .0001) reduced HbA1c by -0.12% and -0.06%, respectively, and did not worsen fasting glucose versus placebo. Bempedoic acid significantly and consistently lowered LDL-C levels versus placebo, regardless of baseline glycaemic status (placebo-corrected difference range, -17.2% to -29.6%; P < .001 for each stratum). The safety of bempedoic acid was comparable with placebo and similar across glycaemic strata. CONCLUSIONS Bempedoic acid significantly lowered LDL-C across glycaemic strata and did not worsen glycaemic variables or increase the incidence of new-onset diabetes versus placebo over a median follow-up of 1 year.
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Affiliation(s)
- Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | | | | | | | | | | | | | | | | | - Zhan Ye
- Esperion Therapeutics Inc.Ann ArborMichiganUSA
| | - Harold E. Bays
- Louisville Metabolic and Atherosclerosis Research CenterLouisvilleKentuckyUSA
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52
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Kosten-Nutzen-Analyse neuer Lipidsenker. Herz 2022; 47:236-243. [DOI: 10.1007/s00059-022-05116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
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53
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Bajaj A, Cuchel M. Advancements in the Treatment of Homozygous Familial Hypercholesterolemia. J Atheroscler Thromb 2022; 29:1125-1135. [PMID: 35466160 PMCID: PMC9371762 DOI: 10.5551/jat.rv17065] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disorder with extreme elevations of low-density lipoprotein cholesterol (LDL-C) leading to premature atherosclerotic cardiovascular disease (ASCVD) as early as in childhood. Management of HoFH centers around aggressive and adequate reduction of LDL-C levels to slow the trajectory of ASCVD development. Historically, lowering LDL-C levels in HoFH has been challenging because of both the markedly elevated LDL-C levels (often >400 mg/dL) and reduced response to treatment options, such as statins, for which the mechanism of action requires a functional LDL receptor. However, the treatment landscape for HoFH has rapidly progressed over the last decade. While statins and ezetimibe remain first-line treatment, patients often require addition of multiple therapies to achieve goal LDL-C levels. The PCSK9 inhibitors are an important recent addition to the available treatment options, along with lomitapide, bile acid sequestrants, and, possibly, bempedoic acid. Additionally, ANGPTL3 has emerged as an important therapeutic target, with evinacumab being the first available ANGPTL3 inhibitor on the market for the treatment of patients with HoFH. For patients who cannot achieve adequate LDL-C reduction, lipoprotein apheresis may be necessary, with the added benefit of reducing lipoprotein(a) levels that carries an added risk if also elevated in patients with HoFH. Finally, gene therapy and genome editing using CRISPR/Cas-9 are moving through clinical development and may dramatically alter the future landscape of treatment for HoFH.
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Affiliation(s)
- Archna Bajaj
- Division of Translational Medicine & Human Genetics, University of Pennsylvania
| | - Marina Cuchel
- Division of Translational Medicine & Human Genetics, University of Pennsylvania
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54
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Ferraro RA, Leucker T, Martin SS, Banach M, Jones SR, Toth PP. Contemporary Management of Dyslipidemia. Drugs 2022; 82:559-576. [PMID: 35303294 PMCID: PMC8931779 DOI: 10.1007/s40265-022-01691-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/30/2022]
Abstract
The treatment of dyslipidemia continues to be a dynamic and controversial topic. Even the most appropriate therapeutic range for lipid levels-including that of triglycerides and low-density lipoprotein cholesterol-remain actively debated. Furthermore, with ever-increasing options and available treatment modalities, the management of dyslipidemia has progressed in both depth and complexity. An understanding of appropriate lipid-lowering therapy remains an essential topic of review for practitioners across medical specialties. The goal of this review is to provide an overview of recent research developments and recommendations for patients with dyslipidemia as a means of better informing the clinical practice of lipid management. By utilizing a guideline-directed approach, we provide a reference point on optimal lipid-lowering therapies across the spectrum of dyslipidemia. Special attention is paid to long-term adherence to lipid-lowering therapies, and the benefits derived from instituting appropriate medications in a structured manner alongside monitoring. Novel therapies and their impact on lipid lowering are discussed in detail, as well as potential avenues for research going forward. The prevention of cardiovascular disease remains paramount, and this review provides a roadmap for instituting appropriate therapies in cardiovascular disease prevention.
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Affiliation(s)
- Richard A Ferraro
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thorsten Leucker
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth S Martin
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Lodz, Poland
| | - Steven R Jones
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter P Toth
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- CGH Medical Center, 101 East Miller Road, Sterling, IL, 61081, USA.
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55
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Pirillo A, Catapano AL. New insights into the role of bempedoic acid and ezetimibe in the treatment of hypercholesterolemia. Curr Opin Endocrinol Diabetes Obes 2022; 29:161-166. [PMID: 34980867 PMCID: PMC8915986 DOI: 10.1097/med.0000000000000706] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW A number of new cholesterol-lowering drugs have been recently developed and approved, enriching the pharmacological armamentarium beyond and above statins. Ezetimibe, available since two decades, and bempedoic acid, a new drug inhibiting the same biosynthetic pathway targeted by statins but at an early step, represent valuable tools for the treatment of hypercholesterolemia, particularly in specific groups of patients. RECENT FINDINGS Bempedoic acid, either alone or in combination with ezetimibe, appears to reduce significantly LDL-C levels, an effect that has been observed also in patients with statin intolerance. A Mendelian randomization study has anticipated a protective cardiovascular effect of bempedoic acid; a randomized clinical trial is currently assessing whether the pharmacological control of hypercholesterolemia with bempedoic acid translates into a clinical benefit. Bempedoic acid, as well as ezetimibe, does not appear to induce adverse events in muscles; moreover, whereas statins are associated with a modest, although significant, increased risk of new-onset diabetes, bempedoic acid does not, at least based on the available evidence. SUMMARY On the basis of available data, and while awaiting the results of the outcome trial, bempedoic acid appears to represent a valuable approach for the treatment of hypercholesterolemia, either alone or in combination in ezetimibe.
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Affiliation(s)
- Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo
- IRCCS MultiMedica, Sesto S. Giovanni
| | - Alberico L. Catapano
- IRCCS MultiMedica, Sesto S. Giovanni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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56
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Laufs U, Ballantyne CM, Banach M, Bays H, Catapano AL, Duell PB, Goldberg AC, Gotto AM, Leiter LA, Ray KK, Bloedon LT, MacDougall D, Zhang Y, Mancini GBJ. Efficacy and safety of bempedoic acid in patients not receiving statins in phase 3 clinical trials. J Clin Lipidol 2022; 16:286-297. [DOI: 10.1016/j.jacl.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/18/2022] [Accepted: 03/07/2022] [Indexed: 02/03/2023]
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Sharma J, McAlister J, Aggarwal NR, Wei J, Mehta PK, Quesada O, Mattina D, Scott NS, Michos ED, Mahmoud Z, Kurrelmeyer K, Moraes De Oliveira GM, Lindley KJ. Evaluation and Management of Blood Lipids Through a Woman's Life Cycle. Am J Prev Cardiol 2022; 10:100333. [PMID: 35345879 PMCID: PMC8956895 DOI: 10.1016/j.ajpc.2022.100333] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Abstract
There are currently no sex-specific guidelines for evaluation and management of lipids. Lipids are impacted by normal hormonal changes in women throughout their life cycle. Management of lipids should incorporate sex-specific cardiovascular risk factors at each stage. Future objectives should focus on increasing women's presence in trials of lipid-lowering therapies.
There are currently no sex-specific guidelines for evaluation and management of blood lipids. While previous guidelines acknowledge sex-specific risk enhancing factors for lipid management in women for CVD prevention, this review focuses on how lipids are impacted during normal hormonal changes throughout a woman's life cycle- during adolescence, pre-pregnancy, pregnancy, pre- and perimenopause, menopause, and at older ages. In this review, the authors focus on management of primary prevention of CVD by examining sex-specific cardiovascular risk factors at each stage and pay special attention to statin use, statin side effects and non-statin therapies. Women need to understand their personalized cholesterol goals and ally with their clinicians to ensure successful management. Additionally, we highlight the biases that exist when treating dyslipidemia in women and the special care clinicians should take to ensure appropriate and aggressive therapies are made available to female patients. Finally, the authors recommend future research should focus on increasing enrollment of women in lipid trials. This is of paramount importance in discovering sex-specific difference in lipid management.
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58
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Tokgözoğlu L, Libby P. The dawn of a new era of targeted lipid-lowering therapies. Eur Heart J 2022; 43:3198-3208. [PMID: 35051271 PMCID: PMC9448630 DOI: 10.1093/eurheartj/ehab841] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/26/2021] [Accepted: 11/25/2021] [Indexed: 01/22/2023] Open
Abstract
Lipid risk factors for cardiovascular disease depend in part on lifestyle, but optimum control of lipids often demands additional measures. Low-density lipoprotein (LDL) doubtless contributes causally to atherosclerosis. Recent human genetic findings have substantiated a number of novel targets for lipid-lowering therapy including apolipoprotein C-III, angiopoietin-like protein 3 and 4, apolipoprotein V, and ATP citrate lyase. These discoveries coupled with advances in biotechnology development afford new avenues for management of LDL and other aspects of lipid risk. Beyond LDL, new treatments targeting triglyceride-rich lipoproteins and lipoprotein(a) have become available and have entered clinical development. Biological and RNA-directed agents have joined traditional small-molecule approaches, which themselves have undergone considerable refinement. Innovative targeting strategies have increased efficacy of some of these novel interventions and markedly improved their tolerability. Gene-editing approaches have appeared on the horizon of lipid management. This article reviews this progress offering insight into novel biological and therapeutic discoveries, and places them into a practical patient care perspective.
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Affiliation(s)
- Lale Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey
| | - Peter Libby
- Corresponding author. Tel: +1 617 525 4383, Fax: +1 617 525 4400,
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59
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Averna M, Bilato C, Sesti G. Clinical evaluation of bempedoic acid for the treatment of hyperlipidaemia. Nutr Metab Cardiovasc Dis 2022; 32:17-20. [PMID: 34802854 DOI: 10.1016/j.numecd.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 02/04/2023]
Abstract
UNLABELLED Bempedoic acid (BA) is a novel first-in-class oral lipid-lowering therapy. BA has been approved by the European Medicinal Agency and Food and Drug Administration and has been commercialised throughout Europe since the end of 2020 as an add-on therapy in patients at high/very-high cardiovascular risk that are not at LDL-C goals with current lipid-lowering treatments. Recently, Italian lipid management experts gathered to discuss several open questions on BA characteristics and BArelated practical clinical issues. The panel permitted collection of its opinions in a ten Q&A format. AIM The aim of this viewpoint is to discuss and answer several open questions on BA characteristics and BA-related practical clinical issues. DATA SYNTHESIS The data includes main phase III studies, subanalysis and meta-analysis on BA. CONCLUSIONS The panel permitted collection of its opinions in a ten Q&A format.
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Affiliation(s)
- Maurizio Averna
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
| | - Claudio Bilato
- Department of Cardiovascular Medicine, Azienda ULSS 8, Vicenza, Italy.
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University La Sapienza, Rome, Italy
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60
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Ugovšek S, Zupan J, Rehberger Likozar A, Šebeštjen M. Influence of lipid-lowering drugs on inflammation: what is yet to be done? Arch Med Sci 2022; 18:855-869. [PMID: 35832698 PMCID: PMC9266870 DOI: 10.5114/aoms/133936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Atherosclerosis is a chronic inflammatory disease that is associated with risk of cardiovascular events. The best-characterised and well-standardised clinical indicator of inflammation is C-reactive protein. Current evidence-based drug therapies for prevention and treatment of cardiovascular diseases are mainly focused on reduction of low-density lipoprotein cholesterol. However, these drugs do not provide sufficient protection against recurrent cardiovascular events. One of the possible mechanisms behind this recurrence might be the persistence of residual inflammation. For the most commonly used lipid-lowering drugs, the statins, their reduction of cardiovascular events goes beyond lowering of low-density lipoprotein cholesterol. Here, we review the effects of these lipid-lowering drugs on inflammation, considering statins, ezetimibe, fibrates, niacin, proprotein convertase subtilisin/kexin type 9 inhibitors, bempedoic acid, ethyl eicosapentaenoic acid and antisense oligonucleotides. We focus in particular on C-reactive protein, and discuss how the effects of the statins might be related to reduced rates of cardiovascular events.
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Affiliation(s)
- Sabina Ugovšek
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Zupan
- Department of Clinical Biochemistry, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | | | - Miran Šebeštjen
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Vascular Diseases, University Medical Centre, Ljubljana, Slovenia
- University Medical Centre Ljubljana, Department of Cardiology, Slovenia
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61
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Nelson AJ, Bubb K, Nicholls SJ. An update on emerging drugs for the treatment of hypercholesterolemia. Expert Opin Emerg Drugs 2021; 26:363-369. [PMID: 34842495 DOI: 10.1080/14728214.2021.2009801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Elevated levels of low-density lipoprotein (LDL) cholesterol have been unequivocally demonstrated to play a causal role in atherosclerotic cardiovascular disease. The last thirty years have witnessed a generation of clinical trials that have demonstrated a reduction in cardiovascular risk with the use of increasing intensive lipid lowering regimens involving statin therapy in combination with other agents. However, many patients fail to achieve treatment mandated LDL cholesterol goals. This highlights the need to develop additional approaches to lower LDL cholesterol levels. AREAS COVERED (i) Contemporary data highlighting the atherogenicity of LDL cholesterol and cardiovascular benefits of current lipid lowering therapies. (ii) Importance of statin intolerance and inability to achieve LDL cholesterol goals in driving ongoing cardiovascular risk. (iii) Emergence of new therapeutic agents designed to achieve more effective lowering of LDL cholesterol. EXPERT OPINION Effective lowering of LDL cholesterol plays a critical role in approaches to the prevention of cardiovascular disease. A greater number of patients will require combinations of agents to achieve optimal lipid control. Accordingly, new agents will be required to provide sufficient choice for patients at high cardiovascular risk.
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Affiliation(s)
- Adam J Nelson
- Victorian Heart Institute, Monash University, Clayton, Australia
| | - Kristen Bubb
- Victorian Heart Institute, Monash University, Clayton, Australia.,Biomedicine Discovery Institute, Monash University, Clayton, Australia
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Bays HE, Baum SJ, Brinton EA, Plutzky J, Hanselman JC, Teng R, Ballantyne CM. Effect of bempedoic acid plus ezetimibe fixed-dose combination vs ezetimibe or placebo on low-density lipoprotein cholesterol in patients with type 2 diabetes and hypercholesterolemia not treated with statins. Am J Prev Cardiol 2021; 8:100278. [PMID: 34746903 PMCID: PMC8550983 DOI: 10.1016/j.ajpc.2021.100278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/22/2021] [Accepted: 10/01/2021] [Indexed: 12/18/2022] Open
Abstract
In patients with T2DM and hypercholesterolemia untreated with lipid-lowering drugs: BA + EZE FDC lowered LDL-C levels by 38.8% at week 12 BA + EZE FDC significantly reduced LDL-C and non-HDL-C vs ezetimibe or placebo BA + EZE FDC significantly reduced hsCRP vs ezetimibe or placebo BA + EZE FDC was safe and generally well tolerated
Objective Statins are sometimes associated with worsened glycemic control. Patients with type 2 diabetes mellitus (T2DM) may require non-statin therapies to achieve low-density lipoprotein cholesterol (LDL-C) lowering goals. This study evaluated the efficacy and safety of bempedoic acid 180 mg plus ezetimibe 10 mg fixed-dose combination (BA + EZE FDC) in patients with T2DM and hypercholesterolemia who were not receiving background statins or other lipid-lowering therapy. Methods Patients with T2DM and elevated LDL-C levels were enrolled into this phase 2, double-blind study (NCT03531905). Patients received placebo during a 5-week washout period where background lipid-lowering therapies (including statins) were discontinued. Eligible patients were then randomized 1:1:1 to receive either BA + EZE FDC, ezetimibe 10 mg, or placebo once daily for 12 weeks. Assessments included the percent change from baseline to week 12 in LDL-C, other lipid parameters, and high-sensitivity C-reactive protein (hsCRP); and the monitoring of safety and tolerability. Results Among 179 randomized patients, baseline characteristics following the washout period were similar across treatment groups, with mean LDL-C levels of 142.6 mg/dL and mean glycated hemoglobin of 8.0%. At week 12, BA + EZE FDC therapy lowered mean LDL-C levels by 38.8%, significantly more than ezetimibe alone (19.2%; difference, 19.5% [95% confidence interval (CI), 13.4%–25.7%]; p < 0.001) or placebo (increase of 0.9%; difference, 39.6% [95% CI, 33.4%–45.8%]; p < 0.001). BA + EZE FDC significantly reduced hsCRP levels from baseline vs ezetimibe (29.2%; p = 0.005) and vs placebo (36.7%; p < 0.001). Incidence of treatment-emergent adverse events was low in all treatment groups, with no indication of worsened glycemic control. Conclusion In patients with T2DM and hypercholesterolemia who were not receiving statins or other lipid-lowering drugs, BA + EZE FDC significantly lowered LDL-C levels and was generally well tolerated.
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Affiliation(s)
- Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Inc., Louisville, KY, USA
| | - Seth J Baum
- Excel Medical Clinical Trials, Inc., Boca Raton, FL, USA
| | | | | | | | - Rujun Teng
- Esperion Therapeutics, Inc., Ann Arbor, MI, USA
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Ruscica M, Sirtori CR, Ferri N, Corsini A. New players in the treatment of hypercholesterolaemia: focus on bempedoic acid and inclisiran. Eur Heart J Suppl 2021; 23:E59-E62. [PMID: 34650356 PMCID: PMC8503511 DOI: 10.1093/eurheartj/suab090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dyslipidaemias and in particular elevated plasma low-density lipoprotein cholesterol (LDL-C) levels are major risk factors for atherosclerotic cardiovascular disease (ASCVD). Indeed, the more LDL-C is reduced the larger will be the ASCVD risk reduction. Although statins represent the first-line intervention to reduce the atherosclerotic burden driven by raised levels of LDL-C, adherence is not optimal and most patients do not follow guidelines and recommended doses. Thus, to achieve optimal LDL-C goals, especially in very high-risk patients, there is a need for new and safe agents, more tolerable than statins with low risk of myalgia. Thus, the present review will address the most recent clinical trials with bempedoic acid and inclisiran. Bempedoic acid is an oral drug acting at a biochemical step preceding hydroxymethylglutaryl-CoA reductase and not associated with muscular side effects. Inclisiran, the first-in-class small interfering RNA-based approach, has the ability to effectively reduce LDL-C by inhibiting the hepatic synthesis of proprotein convertase subtilisin/kexin type 9, with the advantage of requiring subcutaneous of a single dose on Day 1, Day 90, and every 6 months thereafter.
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Affiliation(s)
- Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Cesare Riccardo Sirtori
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy.,Centro Dislipidemie, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milano, Italy.,Department of Pharmaceutical and Pharmacological Sciences, Università degli Studi di Padova, Padova, Italy
| | - Nicola Ferri
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy.,IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
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Target Populations and Treatment Cost for Bempedoic Acid and PCSK9 Inhibitors: A Simulation Study in a Contemporary CAD Cohort. Clin Ther 2021; 43:1583-1600. [PMID: 34462126 DOI: 10.1016/j.clinthera.2021.07.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/18/2021] [Accepted: 07/26/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The lowered LDL-C treatment goal of the 2019 European Society of Cardiology dyslipidemia guidelines results in a significant increase in the projected need for cost-intensive proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Addition of bempedoic acid (BA) to established oral lipid-lowering medication (LLM) has the potential to enable affordable LDL-C goal attainment, particularly in patients with statin intolerance (SI). The goal of this study was to quantify the target populations for BA and PCSK9 inhibitors as well as the related treatment costs to achieve the LDL-C goal of <55 mg/dL and a ≥50% reduction assuming the addition of BA to LLM. METHODS This study included 1922 patients with coronary artery disease (CAD) from the contemporary observational cohort study INTERCATH. A Monte Carlo simulation incorporating an algorithm adding sequentially a statin, ezetimibe, optionally BA, and a PCSK9 inhibitor was applied to achieve the LDL-C treatment goal, with consideration of both partial and total SI. Two scenarios were simulated for both a moderate (2% full and 10% partial) and a high (12% full) rate of SI: (1) without BA; and (2) with BA. FINDINGS Patients' mean age was 69.3 years, and the median baseline LDL-C level was 86.0 mg/dL. The need for a PCSK9 inhibitor would be 41.4% for a moderate rate of SI and 46.1% for a high rate of SI. Addition of BA would: (1) reduce the need for a PCSK9 inhibitor to 25.3% and 29.4%, thus lowering the annual overall treatment cost incurred through PCSK9 inhibitor ± BA per 1 million patients with CAD by 13.3% and 10.5%; (2) lower the cost per prevented event in the entire cohort (-5.0% and -6.3%), although at the price of fewer prevented events (-8.7% and -4.5%); and (3) reduce the cost per prevented event (-6.8% for both rates of SI) while preventing more events (7.6% and 6.9%) in the subpopulation of patients with full SI. IMPLICATIONS Use of BA is projected to reduce the need for PCSK9 inhibitors as well as the treatment cost for add-on LLM. The subpopulation of patients with full SI might profit particularly.
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65
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Ballantyne CM, Bays H, Catapano AL, Goldberg A, Ray KK, Saseen JJ. Role of Bempedoic Acid in Clinical Practice. Cardiovasc Drugs Ther 2021; 35:853-864. [PMID: 33818688 PMCID: PMC8266788 DOI: 10.1007/s10557-021-07147-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 12/14/2022]
Abstract
Many patients do not achieve optimal low-density lipoprotein cholesterol (LDL-C) levels with statins alone; others are unable to tolerate statin therapy. Additional non-statin treatment options including ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and bile acid sequestrants are often necessary to further reduce the risk of atherosclerotic cardiovascular disease. This review provides practical guidance as to the use of bempedoic acid to lower LDL-C and includes direction as to which patients may benefit and advice for safety monitoring during treatment. Bempedoic acid, a new class of agent, is a prodrug converted to bempedoyl-CoA by very long-chain acyl-CoA synthetase 1, an enzyme with high expression in the liver but that is undetectable in the skeletal muscle. Bempedoic acid inhibits the enzyme adenosine triphosphate (ATP)-citrate lyase, which lies two steps upstream from β-hydroxy β-methylglutaryl-CoA reductase in the cholesterol biosynthesis pathway. In clinical trials conducted in patients with or at risk for atherosclerotic cardiovascular disease or familial heterozygous hypercholesterolemia, bempedoic acid in combination with statins and/or ezetimibe significantly reduced LDL-C, apolipoprotein B, and high-sensitivity C-reactive protein compared with placebo. Bempedoic acid is generally well tolerated with no clinically meaningful increase in muscle-related symptoms relative to placebo, even in patients taking maximally tolerated statins. A small increase in serum uric acid (mean increase 0.8 mg/dL) is the most noteworthy adverse effect. Bempedoic acid provides an effective and generally well-tolerated medication to further reduce LDL-C in patients taking maximally tolerated statins or manage LDL-C levels in those who are unable to take statins. The potential for a reduced incidence of major cardiovascular events with bempedoic acid is being investigated in the CLEAR Outcomes trial, with results expected in 2023.
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Affiliation(s)
- Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, BCM 285, Houston, TX, 77030, USA.
| | - Harold Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY, USA
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan and IRCCS Multimedica, Milan, Italy
| | - Anne Goldberg
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Joseph J Saseen
- Departments of Clinical Pharmacy and Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Virani SS, Morris PB, Agarwala A, Ballantyne CM, Birtcher KK, Kris-Etherton PM, Ladden-Stirling AB, Miller M, Orringer CE, Stone NJ. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021; 78:960-993. [PMID: 34332805 DOI: 10.1016/j.jacc.2021.06.011] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Diaconu CC, Iorga RA, Furtunescu F, Katsiki N, Stoian AP, Rizzo M. Statin intolerance: new data and further options for treatment. Curr Opin Cardiol 2021; 36:487-493. [PMID: 33929368 DOI: 10.1097/hco.0000000000000874] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Hypercholesterolemia is a major risk factor for cardiovascular diseases. Administration of statins represents the cornerstone of the prevention and treatment of cardiovascular disease, with demonstrated long-term safety and efficacy. This review aims to revisit statin intolerance mechanisms, as well as to discuss new data and therapeutic options. RECENT FINDINGS Although statins are well tolerated, myopathy and other adverse effects are a challenging problem, being the main reason for poor adherence to treatment and failure in lowering cardiovascular risk. Statin intolerance is the subject of ongoing research, as these drugs are widely used. There are alternative options of treatment if statin intolerance emerges, that is, lowering the dose, intermittent dosages, and/or combining a statin with other drugs, such as ezetimibe, proprotein convertase subtilisin-kexin type 9 inhibitors, bempedoic acid, angiopoietin-like 3 protein inhibitors, and nutraceuticals. If even the lowest statin dose cannot be tolerated, a nonstatin regimen is recommended to reduce LDL cholesterol levels. SUMMARY Treatment options in statin intolerance include combinations of a lower dose of statin with other lipid-lowering regimens or only nonstatin drugs in the presence of complete intolerance. New hypolipidemic therapies that address gene editing are emerging, and may prove useful in the future.
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Affiliation(s)
- Camelia C Diaconu
- Clinical Emergency Hospital of Bucharest
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | | | | | - Niki Katsiki
- Division of Endocrinology and Metabolism, First Department of Internal Medicine, Diabetes Center, AHEPA University Hospital, Thessaloniki, Greece
| | - Anca P Stoian
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Manfredi Rizzo
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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Rubino J, MacDougall DE, Sterling LR, Kelly SE, McKenney JM, Lalwani ND. Lipid lowering with bempedoic acid added to a proprotein convertase subtilisin/kexin type 9 inhibitor therapy: A randomized, controlled trial. J Clin Lipidol 2021; 15:593-601. [PMID: 34172394 DOI: 10.1016/j.jacl.2021.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) lower low-density lipoprotein cholesterol (LDL-C) in patients with hypercholesterolemia. However, some patients receiving PCSK9i therapy might require additional lipid-lowering therapy (LLT) to reach LDL-C goals. Bempedoic acid is an oral, once-daily, ATP-citrate lyase inhibitor that significantly lowers LDL-C in patients with hypercholesterolemia when given alone or as add-on therapy to statins and/or ezetimibe. OBJECTIVE Assess safety and efficacy of bempedoic acid added to PCSK9i (evolocumab) background therapy in patients with hypercholesterolemia. METHODS This phase 2, randomized, double-blind, placebo-controlled study was conducted in three phases: 1.5-month screening/washout period including discontinuation of all LLTs, a 3-month period wherein patients initiated background PCSK9i therapy, and a 2-month treatment period in which patients were randomized 1:1 to receive bempedoic acid 180 mg or placebo once daily while continuing PCSK9i therapy. RESULTS Of 59 patients randomized, 57 completed the study. Mean baseline LDL-C after 3 months of PCSK9i background therapy was 103.1 ± ± 30.4 mg/dL. Bempedoic acid added to background PCSK9i therapy significantly lowered LDL-C by 30.3% (P < .001) vs placebo. Compared with placebo, bempedoic acid significantly lowered apolipoprotein B, non-high-density lipoprotein cholesterol, and total cholesterol (nominal P < .001 for all), and high-sensitivity C-reactive protein (P = .029). When added to background PCSK9i therapy, the safety profile of bempedoic acid was comparable to that observed for placebo. CONCLUSIONS When added to a background of PCSK9i therapy, bempedoic acid significantly lowered LDL-C levels with a safety profile comparable to placebo in patients with hypercholesterolemia.
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Affiliation(s)
- John Rubino
- PMG Research of Raleigh, 3521 Haworth Dr, Raleigh, NC 27609, USA.
| | - Diane E MacDougall
- Esperion Therapeutics, Inc. 3891 Ranchero Dr, Suite 150, Ann Arbor, MI 48108 USA.
| | - Lulu Ren Sterling
- Sterling Bio-science Analytics, 39 College Ave, Los Gatos, CA 95030 USA.
| | - Stephanie E Kelly
- Esperion Therapeutics, Inc. 3891 Ranchero Dr, Suite 150, Ann Arbor, MI 48108 USA.
| | - James M McKenney
- Virginia Commonwealth University and National Clinical Research, Inc., 2809 Emerywood Parkway, Richmond, VA 23294 USA.
| | - Narendra D Lalwani
- Esperion Therapeutics, Inc. 3891 Ranchero Dr, Suite 150, Ann Arbor, MI 48108 USA.
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Shaya GE, Leucker TM, Jones SR, Martin SS, Toth PP. Coronary heart disease risk: Low-density lipoprotein and beyond. Trends Cardiovasc Med 2021; 32:181-194. [PMID: 33872757 DOI: 10.1016/j.tcm.2021.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 01/06/2023]
Abstract
Coronary heart disease (CHD) is the leading cause of morbidity and mortality world-wide and has been characterized as a chronic immunoinflammatory, fibroproliferative disease fueled by lipids. Great advances have been made in elucidating the complex mechanistic interactions among risk factors associated with CHD, yielding abundant success towards preventive measures and the development of pharmaceuticals to prevent and treat CHD via attenuation of lipoprotein-mediated risk. However, significant residual risk remains. Several potentially modifiable CHD risk factors ostensibly contributing to this residual risk have since come to the fore, including systemic inflammation, diabetes mellitus, high-density lipoprotein, plasma triglycerides (TG) and remnant lipoproteins (RLP), lipoprotein(a) (Lp[a]), and vascular endothelial dysfunction (ED). Herein, we summarize the body of evidence implicating each of these risk factors in residual CHD risk.
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Affiliation(s)
- Gabriel E Shaya
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Thorsten M Leucker
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Steven R Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Seth S Martin
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Peter P Toth
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA; Community Hospital General Medical Center, Sterling, IL, USA.
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Abstract
Purpose of review Based on the recent data of the DA VINCI study, it is clear that, besides utilization of statins, there is a need to increase non-statin lipid lowering approaches to reduce the cardiovascular burden in patients at highest risk. Recent findings For hypercholesterolemia, the small synthetic molecule bempedoic acid has the added benefit of selective liver activation, whereas inclisiran, a hepatic inhibitor of the PCSK9 synthesis, has comparable effects with PCSK9 monoclonal antibodies. For hypertriglyceridemia, cardiovascular benefit has been achieved by the use of icosapent ethyl, whereas results with pemafibrate, a selective agonist of PPAR-α, are eagerly awaited. In the era of RNA-based therapies, new options are offered to dramatically reduce levels of lipoprotein(a) (APO(a)LRX) and of triglycerides (ANGPTL3LRX and APOCIII-LRx). Summary Despite the demonstrated benefits of statins, a large number of patients still remain at significant risk because of inadequate LDL-C reduction or elevated blood triglyceride-rich lipoproteins or lipoprotein(a). The area of lipid modulating agents is still ripe with ideas and major novelties are to be awaited in the next few years.
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71
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Sunil B, Foster C, Wilson DP, Ashraf AP. Novel therapeutic targets and agents for pediatric dyslipidemia. Ther Adv Endocrinol Metab 2021; 12:20420188211058323. [PMID: 34868544 PMCID: PMC8637781 DOI: 10.1177/20420188211058323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023] Open
Abstract
Landmark studies have convincingly demonstrated that atherosclerosis begins in youth. While generally asymptomatic, an increasing number of youth with disorders of lipid and lipoprotein metabolism, such as familial hypercholesterolemia, are being identified through selective and universal screening. While a heart healthy lifestyle is the foundation of treatment for all youth with dyslipidemia, lipid-lowering therapy may be required by some to prevent morbidity and premature mortality, especially when initiated at a young age. When appropriate, use of statins has become standard of care for reducing low-density lipoprotein cholesterol, while fibrates may be beneficial in helping to lower triglycerides. Many therapeutic options commonly used in adults are not yet approved for use in youth less than 18 years of age. Although currently available lipid-lowering therapy is well tolerated and safe when administered to youth, response to treatment may vary and some conditions lack an efficient therapeutic option. Thus, newer agents are needed to aid in management. Many are in development and clinical trials in youth are currently in progress but will require FDA approval before becoming commercially available. Many utilize novel approaches to favorably alter lipid and lipoprotein metabolism. In the absence of long-term outcome data of youth who were treated beginning at an early age, clinical registries may prove to be useful in monitoring safety and efficacy and help to inform clinical decision-making. In this manuscript, we review currently available and novel therapeutic agents in development for the treatment of elevated cholesterol and triglycerides.
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Affiliation(s)
- Bhuvana Sunil
- Division of Pediatric Endocrinology &
Diabetes, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christy Foster
- Division of Pediatric Endocrinology &
Diabetes, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Don P. Wilson
- Cardiovascular Health and Risk Prevention,
Pediatric Endocrinology and Diabetes, Cook Children’s Medical Center, Fort
Worth, TX, USA
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Patel PN, Giugliano RP. Low-density lipoprotein cholesterol lowering therapy for the secondary prevention of atherosclerotic cardiovascular disease. Glob Cardiol Sci Pract 2020; 2020:e202039. [PMID: 33598499 PMCID: PMC7868100 DOI: 10.21542/gcsp.2020.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent and a major contributor to morbidity and mortality worldwide. Elevated blood cholesterol is a key driver of risk for atherosclerotic events, and patients with established ASCVD comprise a specific high-risk population in which low-density lipoprotein cholesterol (LDL-C) lowering therapy is strongly endorsed by multiple guidelines. An increasing number of medications across several pharmacologic classes are available today in clinical practice. Therefore, guidance on the appropriate use of these interventions is necessary for cost-effective solutions to managing residual atherothrombotic risk. In this review we summarize the key evidence supporting LDL-C lowering as described in the most recent 2018 multi-society Blood Cholesterol Guidelines, and provide a framework for optimizing LDL-C lowering therapy in secondary prevention populations.
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Affiliation(s)
- Parth N Patel
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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