2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol

Prevention of myocardial infarction and stroke with PCSK9 inhibitors treatment: a metanalysis of recent randomized clinical trials

Purpose

Proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors treatment induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events. Clinical trials might have been underpowered to test the effect of PSCK9 inhibitors treatment on myocardial infarction and stroke, two of the most relevant cardiovascular events, since all analyzed a combined endpoint.

Methods

we performed a meta-analysis, with currently available studies involving PCSK9 inhibitors and event rate adjudication, with the aim of assessing treatment effects on myocardial infarction and stroke.

Results

We included 81,700 patients, 41,979 treated with a PSCK9 inhibitors: 17,244 with evolocumab; 13,720 with bococizumab and 11,015 with alirocumab. A total of 1,319 cases of myocardial infarctions were registered in the treatment group vs. 1,608 in controls, resulting in 19.0% reduction associated with PCSK9 treatment (RR: 0.81, 95% CI 0.76-0.87). Similarly, PCSK9 inhibitors treatment resulted in a 25% reduction of stroke (RR: 0.75, 95% CI 0.65-0.85) when all studies were analyzed together and the statistically significant heterogeneity was not observed in the analysis restricted to end-point based clinical trials. PCSK9 inhibitors treatment had no effect on mortality (RR: 0.95, 95% CI 0.86-1.04).

Conclusions

PCSK9 inhibitors reduce the incidence of myocardial infarction by 19% and stroke by 25%.

The Accuracy of Cardiovascular Pooled Cohort Risk Estimates in U.S. Older Adults

BACKGROUND

The ACC/AHA guidelines for primary prevention rely on the Pooled Cohort Risk Equations (PCE) risk estimates of atherosclerotic cardiovascular disease (ASCVD) to guide treatment decisions. In light of the PCE being derived in younger populations, their accuracy in older adults is uncertain.

OBJECTIVE

To evaluate the predictive accuracy and calibration of the PCE in older individuals.

DESIGN AND SETTING

We estimated CVD predicted and observed risk among individuals from four large prospective cohort studies: Cardiovascular Health Study, Multiethnic Study of Atherosclerosis, Framingham Original, and Framingham Offspring.

PARTICIPANTS

12,527 overall individuals without ASCVD, including 9864 individuals aged 40-74 years and 2663 aged ≥75 years.

MEASUREMENTS

We examined the operating characteristics of the PCE to estimate 5-year risk of stroke, MI, and CHD death overall and by age and sex strata. The associations between individual components of the PCE and cardiovascular events by age group (≥75 vs 40-74 years) were also evaluated.

RESULTS

The PCE had low discrimination for 5-year ASCVD risk in older (≥75 years) (c-statistic = 0.62, 95% CI 0.60-0.65) vs. younger (40-74 years) adults (c-statistic = 0.75, 95% CI 0.73-0.76). Calibration of the PCE was suboptimal in both older and younger adults, overestimating risk in the highest risk groups. Performance of the PCE in older adults was similarly poor when stratified by sex and age ≥ 80 years.

LIMITATIONS

Since the PCE were derived from similar cohorts, though using different age groups and exams, this analysis likely overestimates the performance of the PCE.

CONCLUSION

The performance of the PCE for ASCVD risk estimation in older adults is suboptimal; new models to effectively risk-stratify older adults are needed.

Implications of Kidney Disease in the Cardiac Patient

Cardiovascular and renal diseases share common pathophysiological grounds, risk factors, and therapies. The 2 entities are closely interlinked and often coexist. The prevalence of kidney disease among cardiac patients is increasing. Patients have an atypical clinical presentation and variable disease manifestation versus the general population. Renal impairment limits therapeutic options and worsens prognosis. Meticulous treatment and close monitoring are required to ensure safety and avoid deterioration of kidney and heart functions. This review highlights recent advances in the diagnosis and treatment of cardiac pathologies, including coronary artery disease, arrhythmia, and heart failure, in patients with decreased renal function.

Prevalence of Coronary Artery Calcification on Pre-Atrial Fibrillation Ablation CT Pulmonary Venograms and its Impact on Selection for Statin Therapy

Atherosclerotic cardiovascular disease (ASCVD) shares many risk factors with atrial fibrillation (AF). Obtaining computed tomography images of the pulmonary veins (CTPV) before AF ablation procedures is common and can incidentally detect coronary artery calcification (CAC). The purpose of this study was to investigate the prevalence of CAC on pre-ablation CTPV, the frequency of CAC reporting on CTPV reports, and its impact on statin therapy among patients hospitalized for AF procedures. We retrospectively evaluated consecutive patients undergoing CTPV and AF procedures from October 2016 to December 2017 in a single-center tertiary hospital. The patients’ demographic and clinical characteristics were analyzed. The CAC presence on CTPV was visually assessed. The severity was classified qualitatively. The statin therapy status was evaluated using the patient’s admission and discharge medication lists. A total of 638 subjects were included in our study, with 34.5% female. The mean age was 63.3 ± 10.8 years. CAC was detected in 70.1% of all patients, and in 58.1% of patients without a history of ASCVD. When present, CAC was documented in 92.6% of the clinical CTPV reports. While coronary artery atherosclerosis was present in a majority of AF patients, and its presence was widely reported, it was not associated with increased statin therapy at discharge.

Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted.

Cardiovascular disease in HIV patients: recent advances in predicting and managing risk

INTRODUCTION

Cardiovascular disease (CVD) is one of the leading causes of mortality in virally suppressed people living with HIV (PLWH) and with an aging population, is likely to become one of the leading challenges in maintaining good health outcomes in HIV infection. However, factors driving the risk of CVD in PLWH are multiple and may be different from those of the general population, raising challenges to predicting and managing CVD risk in this population.

AREAS COVERED

In this review, we examine the relevant data regarding CVD in HIV infection including CVD prevalence, pathogenesis, and other contributing factors. We review the data regarding CVD risk prediction in PLWH and summarize factors, both general and HIV specific, that may influence CVD risk in this population. And finally, we discuss appropriate management of CVD risk in PLWH and explore potential therapeutic pathways which may mitigate CVD risk in the future in this population.

EXPERT OPINION

Following a comprehensive review of CVD risk in PLWH, we give our opinion on the primary issues in risk prediction and management of CVD in HIV infected individuals and discuss the future direction of CVD management in this population.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

A focused review of cardiovascular guideline related recommendations for the primary care physician in the USA

Primary care physicians in the USA serve the critical role of first contact for undiagnosed or mismanaged pathologies as well as providers of continuous care in multiple communities. Their scope of practice is broad from medication reconciliation to coordinating specialty care and even performing office procedures. Primary care physicians in the USA commonly encounter patients with diabetes and associated comorbidities related to prolonged insulin resistance. Mainly these include heart failure exacerbation or major adverse cardiovascular events. The demanding roles primary care physicians serve may render these providers encumbered to navigate through long, verbose and dynamic guidelines related to managing diabetes and cardiac diabetology sequelae. Our aim is to compose current, prominent evidence-based points from American medical societies such as the American College of Cardiology/American Heart Association and the American Diabetes Association central to lifestyle modifications, antiplatelet therapy, anti-hyperglycemic and SGLT2-inhibitor utilization, hypertension, dyslipidemia, and heart failure screening in a way that is both succinct and valuable to primary care physicians.

Efficacy of Aspirin in the Primary Prevention of Cardiovascular Diseases and Cancer in the Elderly: A Population-Based Cohort Study in Korea

INTRODUCTION

Aspirin is widely used to prevent cardiovascular diseases (CVDs). However, the balance of its benefits and risks in the primary prevention of CVDs and cancer is unclear, especially in elderly Asians. The present study aimed to evaluate the efficacy of aspirin in the primary prevention of major adverse cardiac and cerebrovascular events (MACCE), bleeding risk, and cancer in elderly Koreans with cardiovascular (CV) risk factors.

METHODS

This retrospective cohort study used data from the Korean National Health Insurance Service-Senior cohort database (2002-2015). Patients aged 60-90 years with hypertension, type 2 diabetes mellitus (T2DM), or dyslipidemia were identified. Aspirin users were compared with non-users using propensity score matching at a 1:3 ratio. The primary outcome was MACCE, a composite of CV mortality, myocardial infarction, and ischemic stroke. The secondary outcomes were the components of MACCE, all-cause mortality, angina pectoris, heart failure, the incidence and mortality of cancer, and the risks of hemorrhagic stroke and gastrointestinal bleeding. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a Cox proportional hazard model.

RESULTS

A total of 3366 aspirin users and 10,089 non-users were finally included in the study. During a mean follow-up of 7.8 years, the incidence of MACCE was 15.2% in aspirin users and 22.4% in non-users. The risk of MACCE was significantly lower in aspirin users than in non-users (HR 0.76; 95% CI 0.69-0.85), and this risk was significantly reduced in patients using aspirin over 5 years (HR 0.52; 95% CI 0.46-0.60). Aspirin use was associated with a 21% reduction in the risk of primary cancer (HR 0.79; 95% CI 0.70-0.88) and cancer-related mortality (HR 0.72; 95% CI 0.61-0.84). No significant differences in bleeding risks were observed between the two groups.

CONCLUSION

Aspirin reduced the risks of MACCE and cancer without increasing the bleeding risk in elderly Koreans with hypertension, T2DM, or dyslipidemia. Moreover, the benefits of the long-term use of aspirin in reducing the risks of MACCE were demonstrated. However, the decision of using aspirin for primary prevention must be carefully made on an individual basis, while estimating the benefit-risk balance of aspirin.

Preventive cardiology as a dedicated clinical service: The past, the present, and the (Magnificent) future

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Ischemic cardiovascular disease continues to be most common cause of death after age 55 everywhere in the world.

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As the average person is exposed over life to a variety of artery-damaging insults it is easy to predict that this trend will continue for decades.

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We face an unprecedented opportunity to consolidate, strengthen, and broaden the effort to prevent cardiovascular events, both ischemic and non ischemic.

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This effort requires professional lifestyle counseling, dietary interventions, use of natural supplements, pharmacotherapy, and efficient cross-referral strategies.

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The nascent subspecialty of preventive cardiology must reach uniformity in protocols of care, and must develop a system of training and certification for the next generation of expert providers.

Is there association between statin usage and contrast-associated acute kidney injury after intravenous administration of iodine-based contrast media in enhanced computed tomography?

OBJECTIVES

Contrast-induced acute kidney injury (CI-AKI) is one of the leading causes of new-onset renal failure in hospitalized patients. Statin has been evaluated for its protective effect against CI-AKI but rarely in patients receiving intravenous (IV) administrations of iodine-based contrast media for enhanced computed tomography (CT).

METHODS

In total, 12,371 patients who underwent contrast-enhanced abdominopelvic CT were retrospectively reviewed and stratified into statin users and statin nonusers. Subgroup analyses comparing high-intensity statins with low- to moderate-intensity statins were conducted within statin users and similar comparisons were performed within statin users stratified based on baseline eGFR.

RESULTS

Overall, CI-AKI events did not occur less in statin users compared with non-statin users (p = 0.342). Within statin users, CI-AKI events did not decrease in high-intensity statin users compared with low- to moderate-intensity statin users (p = 0.355). Moreover, no significant difference in CI-AKI events was found between high-intensity statin users and low- to moderate-intensity statin users even after stratifying the patients with baseline eGFR.

CONCLUSIONS

Collectively, statin was not significantly associated with the risk of CI-AKI events in patients undergoing contrast-enhanced abdominopelvic CT and high-intensity statins did not show significant association with CI-AKI over low- to moderate-intensity statins in the subgroup analysis.

KEY POINTS

• Statin is not associated with risk of CI-AKI events in patients undergoing intravenous administration of contrast-enhanced CT. • CI-AKI incidence among high-intensity statin users was not significantly different from that of low- to moderate-intensity statin users.

Coronary artery calcium scoring in patients with hypertension

Coronary artery calcium (CAC) is increased by high blood pressure (BP), predicts new-onset hypertension, and is a powerful predictor of atherosclerotic cardiovascular disease events in patients with and without hypertension. Unlike other diseases (e.g., hypercholesterolemia), the clinical use of CAC scoring to personalize the treatment of high BP has not received much attention and therefore remains less well defined. Herein, we provide an updated review of studies investigating the relationship between CAC and BP. Finally, we propose a clinical algorithm to incorporate CAC into hypertension management, with a focus on its potential value in tailoring the timing of medication therapy and in helping to personalize BP goals.

Squeezing lipids: NMR characterization of lipoprotein particles under pressure

Determining the particle size and number of lipoprotein components found in blood plasma (HDL, LDL and VLDL) has become an important clinical tool in diagnosing risk of cardiovascular disease. Proton (1H) NMR spectroscopy methods to quantify lipoprotein particle subclasses have been advancing since NMR lineshape analysis of plasma samples was first proposed in the 1990's. NMR methods, including a more recent DOSY-based diffusion spectroscopy test, provide the foundation for the advanced lipoprotein tests, including Lipoprotein® and Liposcale® analyses available for clinical use to determine particle size and number. At the time of this submission, no NMR studies exist which explore physical parameters of individual lipoprotein fractions when they are deformed by pressure. This study reports 1H NMR frequency shifts and T2* measurements for the broad methyl peak attributed to terminal methyls (cholesteryl positions 26, 27 and terminal acyl methyl groups) in three primary lipoprotein fractions as a function of hydraulic pressure. This terminal CH3 resonance shifted linearly upfield as a function of pressure for HDL and VLDL (observed slopes of -0.014 Hz/bar). The LDL terminal CH3 resonance shows segmented behavior, with a shallow slope between 0-900 bar (-0.008 hz/bar) and a slope similar to HDL and VDL across the range from 1000 to 2400 bar (slope -0.016 Hz/bar). 1H T2* values measured for VLDL and HDL dropped linearly with increasing pressure. 1H T2* values for LDL demonstrated segmented behavior as a function of pressure. The unique behavior observed for LDL terminal CH3 frequency and 1H T2* trends suggests an approximate pressure at which phase transition occurs.

Comparison of Transatlantic Approaches to Lipid Management: The AHA/ACC/Multisociety Guidelines vs the ESC/EAS Guidelines

The 2018 American Heart Association/American College of Cardiology/Multisociety (AHA/ACC) guidelines and the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines on lipid management were published less than a year apart. Both guidelines focus on reducing cardiovascular risk, but they follow different approaches in terms of methods of risk estimation, definitions of at-risk groups, and treatment goals to achieve this common underlying objective. Both recommend achieving risk-based percentage reductions of low-density lipoprotein cholesterol (LDL-C) levels with statin therapy. The ESC/EAS guidelines additionally recommend target LDL-C levels and are more liberal in supporting the use of both statin and nonstatin therapies across broader patient groups. The AHA/ACC guidelines may be considered more conservative, reserving the addition of nonstatins to maximally tolerated statins for only select patient groups based on specific LDL-C thresholds. One of the main reasons for these differences is incorporation of cost value considerations by the AHA/ACC guidelines, whereas the ESC/EAS guidelines consider an ideal setting with unlimited resources while making recommendations. In this review, we discuss similarities and differences between the 2 lipid guidelines to help clinicians become more cognizant of these recommendations and provide the best individualized patient care.

Treat to Target in Axial Spondyloarthritis: Pros, Cons, and Future Directions

Treat to target describes a management paradigm that involves choosing a clinically relevant target, assessment with validated measures at a prespecified frequency, and a change in therapy if the target is not met. Although guidelines recommend treating to target in axial spondyloarthritis (axSpA), ideal methods to reach this target remain controversial. This review focuses on background for a treat-to-target strategy in axSpA. Potential targets of treatment, association of targets with outcomes, evidence of treatment impact on outcomes, and how treat to target has been incorporated into treatment guidelines are discussed. Treat-to-target trials and the research agenda for studies in axSpA are discussed.

PCSK9 Inhibitors in Secondary Prevention-An Opportunity for Personalized Therapy

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide. Low-density lipoprotein cholesterol (LDL-C) is the primary cause of ASCVD and reducing LDL-C levels with statin therapy significantly reduces ASCVD risk; however, significant residual risk remains. Two monoclonal antibodies (mAbs), alirocumab and evolocumab, that target proprotein convertase subtilisin/kexin-type 9 (PCSK9), reduce LDL-C levels by up to 60% when used in combination with statins and significantly reduce the risk of recurrent ASCVD events in both stable secondary prevention and acute coronary syndrome populations. Prespecified analyses of recent randomized controlled trials have shed light on how best to prioritize these therapies to maximize their value in select high-risk groups. These data have also informed recent clinical practice guidelines and scientific statements resulting in an expanded role for PCSK9-mAbs compared with previous guidelines, albeit there are notable differences between these recommendations. Ongoing research is exploring the long-term safety of PCSK9-mAbs and their role in the acute setting and patients without prior myocardial infarction or stroke. Novel therapies that inhibit PCSK9 synthesis via small interfering RNA, such as inclisiran, are also in development and may reduce LDL-C levels similar to PCSK9-mAbs, but with less frequent administration. Nonetheless, the PCSK9-mAbs are a breakthrough therapy and warrant consideration in very high-risk patients who are most likely to benefit. Such a personalized approach can help to ensure cost-effectiveness and maximize their value.

Sex Disparities in Cardiovascular Outcome Trials of Populations With Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

Sex differences have been described in diabetes cardiovascular outcome trials (CVOTs).

PURPOSE

We systematically reviewed for baseline sex differences in cardiovascular (CV) risk factors and CV protection therapy in diabetes CVOTs.

DATA SOURCES

Randomized placebo-controlled trials examining the effect of diabetes medications on major adverse cardiovascular events in people ≥18 years of age with type 2 diabetes.

STUDY SELECTION

Included trials reported baseline sex-specific CV risks and use of CV protection therapy.

DATA EXTRACTION

Two reviewers independently abstracted study data.

DATA SYNTHESIS

We included five CVOTs with 46,606 participants. We summarized sex-specific data using mean differences (MDs) and relative risks (RRs) and pooled estimates using random effects meta-analysis. There were fewer women than men in included trials (28.5-35.8% women). Women more often had stroke (RR 1.28; 95% CI 1.09, 1.50), heart failure (RR 1.30; 95% CI 1.21,1.40), and chronic kidney disease (RR 1.33; 95% CI 1.17; 1.51). They less often used statins (RR 0.90; 95% CI 0.86, 0.93), aspirin (RR 0.82; 95% CI 0.71, 0.95), and β-blockers (RR 0.93; 95% CI 0.88, 0.97) and had a higher systolic blood pressure (MD 1.66 mmHg; 95% CI 0.90, 2.41), LDL cholesterol (MD 0.34 mmol/L; 95% CI 0.29, 0.39), and hemoglobin A_1c (MD 0.11%; 95% CI 0.09, 0.14 [1.2 mmol/mol; 1.0, 1.5]) than men.

LIMITATIONS

We could not carry out subgroup analyses due to the small number of studies. Our study is not generalizable to low CV risk groups nor to patients in routine care.

CONCLUSIONS

There were baseline sex disparities in diabetes CVOTs. We suggest efforts to recruit women into trials and promote CV management across the sexes.

Cardiovascular risk assessment: The foundation of preventive cardiology

The foundation of preventive cardiology begins with knowing the patient's baseline cardiovascular disease (CVD) risk from which the patient-clinician risk discussion informs on the best ways to lower risk through lifestyle management, as well as a decision about the initiation and intensity of pharmacologic therapy. Global CVD risk assessment involves estimation of cardiovascular risk using a basic panel of risk factors. The Framingham Heart Study championed the first such risk scores, followed by others around the world. Most recently, the Pooled Cohort Equations (PCE) have been recommended in the United States as a starting point in CVD risk assessment. Persons at low (<5%) 10-year risk are generally recommended for lifestyle management only and those at highest (>20%) 10-year risk are recommended for both lifestyle and pharmacologic therapy to reduce risk. Assessing the presence of one or more "risk enhancing" factors is intended to inform the treatment decision in those at borderline (5-<7.5%) or intermediate (7.5-20%) risk, with the use of coronary calcium scores to further refine the treatment decision. Moreover, not all those with ASCVD are treated equal, and recent guidelines provide criteria for identifying those at very high risk. While current techniques best predict long-term risk of CVD events, biomarkers strategies are being developed to predict near-term events, and other imaging techniques such as coronary CT angiography and vascular MRI hold promise to identify vulnerable plaque. Validation and incorporating into clinical practice such state of the art techniques will be vital to moving CVD risk assessment to the next level.

A Narrative Review and Expert Panel Recommendations on Dyslipidaemia Management After Acute Coronary Syndrome in Countries Outside Western Europe and North America

Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent atherosclerotic cardiovascular disease (CVD) events. Dyslipidaemia, a major risk factor for CVD, is poorly controlled post ACS in countries outside Western Europe and North America, despite the availability of effective lipid-modifying therapies (LMTs) and guidelines governing their use. Recent guideline updates recommend that low-density lipoprotein cholesterol (LDL-C), the primary target for dyslipidaemia therapy, be reduced by ≥ 50% and to < 1.4 mmol/L (55 mg/dL) in patients at very high risk of CVD, including those with ACS. The high prevalence of CVD risk factors in some regions outside Western Europe and North America confers a higher risk of CVD on patients in these countries. ACS onset is often earlier in these patients, and they may be more challenging to treat. Other barriers to effective dyslipidaemia control include low awareness of the value of intensive lipid lowering in patients with ACS, physician non-adherence to guideline recommendations, and lack of efficacy of currently used LMTs. Lack of appropriate pathways to guide follow-up of patients with ACS post discharge and poor access to intensive medications are important factors limiting dyslipidaemia therapy in many countries. Opportunities exist to improve attainment of LDL-C targets by the use of country-specific treatment algorithms to promote adherence to guideline recommendations, medical education and greater prioritisation by healthcare systems of dyslipidaemia management in very high risk patients.

Calibration and discrimination of the Framingham Risk Score and the Pooled Cohort Equations

BACKGROUND

Although accurate risk prediction is essential in guiding treatment decisions in primary prevention of atherosclerotic cardiovascular disease, the accuracy of the Framingham Risk Score (recommended by a Canadian guideline) and the Pooled Cohort Equations (recommended by US guidelines) has not been assessed in a large contemporary Canadian population. Our primary objective was to assess the calibration and discrimination of the Framingham Risk Score and Pooled Cohort Equations in Ontario, Canada.

METHODS

We conducted an observational study involving Ontario residents aged 40 to 79 years, without a history of atherosclerotic cardiovascular disease, who underwent cholesterol testing and blood pressure measurement from Jan. 1, 2010, to Dec. 31, 2014. We compared predicted event rates generated by the Framingham Risk Score and the Pooled Cohort Equations with observed event rates at 5 years using linkages from validated administrative databases.

RESULTS

Our study cohort included 84 617 individuals (mean age 56.3 yr, 56.9% female). Over a maximum follow-up period of 5 years, we observed 2162 (2.6%) events according to the outcome definition of the Framingham Risk Score, and 1224 (1.4%) events according to the outcome definition of the Pooled Cohort Equations. The predicted event rate of 5.78% by the Framingham Risk Score and 3.51% by the Pooled Cohort Equations at 5 years overestimated observed event rates by 101% and 115%, respectively. The degree of overestimation differed by age and ethnicity. The C statistics for the Framingham Risk Score (0.74) and Pooled Cohort Equations (0.73) were similar.

INTERPRETATION

The Framingham Risk Score and Pooled Cohort Equations significantly overpredicted the actual risks of atherosclerotic cardiovascular disease events in a large population from Ontario. Our finding suggests the need for further refinement of cardiovascular disease risk prediction scores to suit the characteristics of a multiethnic Canadian population.

Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study

BACKGROUND

According to the American College of Cardiology/the American Heart Association (ACC/AHA) recommendations, health-related risk behaviors for secondary prevention of myocardial infarction (MI) are critical to determine.

OBJECTIVE

This study aimed to compare health-related risk behaviors between MI survivors and propensity-score-matched non-MI controls using nationally representative data.

METHODS

This cross-sectional, matched case-control study used publicly available Behavioral Risk Factor Surveillance System (BRFSS) 2017 data. Older adults with MI were propensity-score-matched to their non-MI controls. The 10 dependent variables included body mass index (BMI), smoking status, heavy alcohol consumption, influenza vaccine, length of time since last routine and cholesterol checkup, alcohol consumption, fruit and vegetable consumption, and physical activity. Chi-square tests and binomial logistic regression were used to examine the health-related risk behaviors differences between MI survivors and propensity-score-matched non-MI controls.

RESULTS

The final study sample consisted of 18,021 MI survivors and 54,063 non-MI controls after propensity score matching. Multivariable logistic regression analysis showed significant differences between MI survivors and matched non-MI controls in terms of cholesterol checkup, smoking status, and alcohol consumption. For example, multivariate analysis of health-related risk behaviors showed MI survivors were more likely to be smokers (AOR = 1.46, 95% CI: 1.28-1.68).

CONCLUSION

Based on this national survey of adults, MI survivors were more likely to be smokers but less likely to consume alcohol compared to their propensity-score-matched controls. Moreover, MI survivors were more likely to have their cholesterol checkup within the past 2 years compared to matched non-MI controls. Although lower alcohol consumption and greater chances of cholesterol checkups are reassuring health-related behaviors, interventions are needed to minimize the chances of smoking in this population.

Treating Dyslipidemias in the Primary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults with Diabetes Mellitus

People with diabetes mellitus (DM), especially those who are older, are at higher risk for premature morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD). Clinical practice guidelines recommend statin therapy for people with DM ages 40 to 75 years. The evidence for those greater than 75 years of age is relatively limited at present. Other health problems should be considered when planning ASCVD primary prevention in adults ages greater than 75 years with DM. Clinicians should discuss the risks and benefits of each plan with these patients and their caregivers.

Two Phase 3 Trials of Inclisiran in Patients with Elevated LDL Cholesterol

BACKGROUND

Inclisiran inhibits hepatic synthesis of proprotein convertase subtilisin-kexin type 9. Previous studies suggest that inclisiran might provide sustained reductions in low-density lipoprotein (LDL) cholesterol levels with infrequent dosing.

METHODS

We enrolled patients with atherosclerotic cardiovascular disease (ORION-10 trial) and patients with atherosclerotic cardiovascular disease or an atherosclerotic cardiovascular disease risk equivalent (ORION-11 trial) who had elevated LDL cholesterol levels despite receiving statin therapy at the maximum tolerated dose. Patients were randomly assigned in a 1:1 ratio to receive either inclisiran (284 mg) or placebo, administered by subcutaneous injection on day 1, day 90, and every 6 months thereafter over a period of 540 days. The coprimary end points in each trial were the placebo-corrected percentage change in LDL cholesterol level from baseline to day 510 and the time-adjusted percentage change in LDL cholesterol level from baseline after day 90 and up to day 540.

RESULTS

A total of 1561 and 1617 patients underwent randomization in the ORION-10 and ORION-11 trials, respectively. Mean (±SD) LDL cholesterol levels at baseline were 104.7±38.3 mg per deciliter (2.71±0.99 mmol per liter) and 105.5±39.1 mg per deciliter (2.73±1.01 mmol per liter), respectively. At day 510, inclisiran reduced LDL cholesterol levels by 52.3% (95% confidence interval [CI], 48.8 to 55.7) in the ORION-10 trial and by 49.9% (95% CI, 46.6 to 53.1) in the ORION-11 trial, with corresponding time-adjusted reductions of 53.8% (95% CI, 51.3 to 56.2) and 49.2% (95% CI, 46.8 to 51.6) (P<0.001 for all comparisons vs. placebo). Adverse events were generally similar in the inclisiran and placebo groups in each trial, although injection-site adverse events were more frequent with inclisiran than with placebo (2.6% vs. 0.9% in the ORION-10 trial and 4.7% vs. 0.5% in the ORION-11 trial); such reactions were generally mild, and none were severe or persistent.

CONCLUSIONS

Reductions in LDL cholesterol levels of approximately 50% were obtained with inclisiran, administered subcutaneously every 6 months. More injection-site adverse events occurred with inclisiran than with placebo. (Funded by the Medicines Company; ORION-10 and ORION-11 ClinicalTrials.gov numbers, NCT03399370 and NCT03400800.).

Indirect comparison of the efficacy and safety of alirocumab and evolocumab: a systematic review and network meta-analysis

AIMS

Although alirocumab and evolocumab have both been associated with improved outcomes in patients with dyslipidaemia or established atherosclerotic cardiovascular disease, data on their respective performances are scarce. This study aimed at providing an indirect comparison of the efficacy and safety of alirocumab vs. evolocumab.

METHODS AND RESULTS

We conducted a systematic review and network meta-analysis of randomized trials comparing alirocumab or evolocumab to placebo with consistent background lipid-lowering therapy up to November 2018. We estimated the relative risk (RR) and the 95% confidence intervals (CIs) using fixed-effect model in a frequentist pairwise and network meta-analytic approach. A total of 30 trials, enrolling 59 026 patients were included. Eligibility criteria varied significantly across trials evaluating alirocumab and evolocumab. Compared with evolocumab, alirocumab was associated with a significant reduction in all-cause death (RR 0.80, 95% CI 0.66-0.97) but not in cardiovascular death (RR 0.83, 95% CI 0.65-1.05). This study did not find any significant differences in myocardial infarction (RR 1.15, 95% CI 0.99-1.34), stroke (RR 0.96, 95% CI 0.71-1.28), or coronary revascularization (RR 1.13, 95% CI 0.99-1.29) between the two agents. Alirocumab was associated with a 27% increased risk of injection site reaction compared to evolocumab; however, no significant differences were found in terms of treatment discontinuations, systemic allergic reaction, neurocognitive events, ophthalmologic events, or new-onset of or worsening of pre-existing diabetes.

CONCLUSION

Alirocumab and evolocumab share a similar safety profile except for injection site reaction. No significant differences were observed across the efficacy endpoints, except for all-cause death, which may be related to the heterogeneity of the studied populations treated with the two drugs.

Triglycerides and remnant cholesterol associated with risk of aortic valve stenosis: Mendelian randomization in the Copenhagen General Population Study

Aims

We tested the hypothesis that higher levels of plasma triglycerides and remnant cholesterol are observationally and genetically associated with increased risk of aortic valve stenosis.

Methods and results

We included 108 559 individuals from the Copenhagen General Population Study. Plasma triglycerides, remnant cholesterol (total cholesterol minus low-density lipoprotein and high-density lipoprotein cholesterol), and 16 genetic variants causing such increased or decreased levels were determined. Incident aortic valve stenosis occurred in 1593 individuals. Observationally compared to individuals with triglycerides &lt;1 mmol/L (&lt;89 mg/dL), the multifactorially adjusted hazard ratio for aortic valve stenosis was 1.02 [95% confidence interval (CI) 0.87–1.19] for individuals with triglycerides of 1.0–1.9 mmol/L (89–176 mg/dL), 1.22 (1.02–1.46) for 2.0–2.9 mmol/L (177–265 mg/dL), 1.40 (1.11–1.77) for 3.0–3.9 mmol/L (266–353 mg/dL), 1.29 (0.88–1.90) for 4.0–4.9 mmol/L (354–442 mg/dL), and 1.52 (1.02–2.27) for individuals with triglycerides ≥5 mmol/L (≥443 mg/dL). By age 85, the cumulative incidence of aortic valve stenosis was 5.1% for individuals with plasma triglycerides &lt;2.0 mmol/L (77 mg/dL), 6.5% at 2.0–4.9 mmol/L (177–442 mg/dL), and 8.2% for individuals with plasma triglycerides ≥5.0 mmol/L (443 mg/dL). The corresponding values for remnant cholesterol categories were 4.8% for &lt;0.5 mmol/L (19 mg/dL), 5.6% for 0.5–1.4 mmol/L (19–57 mg/dL), and 7.4% for ≥1.5 mmol/L (58 mg/dL). Genetically, compared to individuals with allele score 13–16, odds ratios for aortic valve stenosis were 1.30 (95% CI 1.20–1.42; Δtriglycerides +12%; Δremnant cholesterol +11%) for allele score 17–18, 1.41 (1.31–1.52; +25%; +22%) for allele score 19–20, and 1.51 (1.22–1.86; +51%; +44%) for individuals with allele score 21–23.

Conclusion

Higher triglycerides and remnant cholesterol were observationally and genetically associated with increased risk of aortic valve stenosis.

Noninvasive vascular function tests for the future prediction of primary cardiovascular diseases

OBJECTIVES

Cardiovascular diseases (CVDs) still remain the main causes of death and disability in the US and worldwide, and the prediction for their future incidence is not well established. The utilization of the new cardiovascular risk score (CVRS) developed by the new ACC/AHA blood pressure treatment guidelines has improved the 10-year prediction of CVDs. However, its predictive value could be further increased with the addition of other risk factors identified with the use of several noninvasive vascular tests. These tests include, the older tests such as flow-mediated dilation (FMD), pulse wave velocity (PWV), pulse pressure (PP), and the newly developed noninvasive vascular tests of, reactive hyperemia-peripheral arterial tonometry (RH-PAT), cardio-ankle vascular index (CAVI), and the inter-arm/inter-leg pressure difference (IAPD/ILPD).

METHODS

In order to get a current perspective regarding the usefulness of these new noninvasive vascular tests for the future prediction of CVDs, a Medline search of the English language literature was conducted between 2014 and 2019 using the terms cardiovascular disease, coronary heart disease, noninvasive vascular tests, risk factors, and 26 pertinent papers were retrieved.

RESULTS

The analysis of results from these papers showed that these noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not well established, since there are no currently, available data from long-term clinical outcome studies.

CONCLUSION

The analysis of data from the retrieved papers demonstrated that the new noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not established as yet for the lack of long-term outcome studies. When the currently ongoing long-term trials are completed, it is quite possible that the data from these tests added to CVRS could enhance its predictive value.

Study, Design, and Rationale of Noncommunicable Diseases in Nepal (NCD Nepal) Study: A Community-Based Prospective Epidemiological and Implementation Study in Rural Nepal

BACKGROUND

Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-to-middle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal.

METHODS

We organize monthly mobile health clinics to screen NCDs among 40- to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling, pharmacotherapy or refer to higher level care, where appropriate; routinely follow participants with NCDs for continuity of care; and follow individuals without NCDs but with elevated glucose, prehypertension or other risk factors every year, and those without risk factors every 2 years. We will monitor participants in the community to reduce attrition and to track all-cause and disease-specific mortality.

DISCUSSION

Understanding the community burden of NCDs in resource-limited setting and testing effectiveness of community-based screening and management of NCDs will provide insights to develop national policy to address NCD burden in LMIC like Nepal.

Caring for Women After Hypertensive Pregnancies and Beyond: Implementation and Integration of a Postpartum Transition Clinic

Purpose We developed a postpartum transition clinic to better support women after hypertensive pregnancy. Description Our program goals were (1) early postpartum hypertension medical management, (2) patient and provider education around CVD risk, (3) transition to primary care provider (PCP) and (4) a sustainable clinical model reimbursed by private and public insurances. We focused on women immediately postpartum in this analysis. Assessment Over the course of 5 years, a racially and socioeconomically diverse population of 412 immediately postpartum women received care for one, two or more appointments. Referral diagnoses included antepartum preeclampsia (PET) 51% (210/412), postpartum preeclampsia/hypertension (PP-PET) 22.3% (92/412), preeclampsia superimposed on chronic hypertension (siPET) 10.2% (42/412), chronic hypertension (cHTN) 8.8% (37/412), and gestational hypertension (gHTN) 7.8% (31/412). Almost half of women had 2-3 visits 47.3% (195/412) with no difference by diagnosis (p = 0.18). No show rates were consistently around 25%. Acquisition of home blood pressure monitors increased from 56.8% (44/94) to 93.8% (61/65) over the 5 years (p < 0.0001). Nearly half of patients seen had antihypertensive medication adjustments 48.3% (199/412). Of those patients scheduled, 86.8% (79/91) attended a nutrition consultation. For patients with PCPs within our system, 79.5% (105/132) kept their scheduled follow up PCP appointments. Conclusion We report a postpartum transition clinic after hypertensive pregnancy. In this diverse population, patients attended 2-3 visits, incorporated home blood pressure monitoring, adjusted antihypertensive medications and initiated prevention measures such as nutrition referrals and PCP follow-up. An internist salary was sustained through billings and collections from private and public insurance.

PCSK9 Monoclonal Antibodies: An Overview

PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.

Failure of Traditional Risk Factors to Adequately Predict Cardiovascular Events in Older Populations

BACKGROUND

Accurate assessment of atherosclerotic cardiovascular disease (ASCVD) risk across heterogeneous populations is needed for effective primary prevention. Little is known about the performance of standard cardiovascular risk factors in older adults.

OBJECTIVE

To evaluate the performance of the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) risk model, as well as the underlying cardiovascular risk factors, among adults older than 65 years.

DESIGN AND SETTING

Retrospective cohort derived from a regional referral system's electronic medical records.

PARTICIPANTS

A total of 25 349 patients who were 65 years or older at study baseline (date of the first outpatient lipid panel taken between 2007 and 2010).

MEASUREMENTS

Exposures of interest were traditional cardiovascular risk factors, as defined by inclusion in the PCE model. The primary outcome was major ASCVD events, defined as a composite of myocardial infarctions, stroke, and cardiovascular death.

RESULTS

The PCE and internally estimated models produced similar risk distributions for white men aged 65 to 74 years. For all other groups, PCE predictions were generally lower than those of the internal models, particularly for African Americans. Discrimination of the PCE was poor for all age groups, with concordance index (95% confidence interval) estimates of 0.62 (0.60-0.64), 0.56 (0.54-0.57), and 0.52 (0.49-0.54) among patients aged 65 to 74, 75 to 84, and 85 years and older, respectively. Reestimating relationships within these age groups resulted in better calibration but negligible improvements in discrimination. Blood pressure, total cholesterol, and diabetes either were not associated at all or had inverse associations in the older age groups.

CONCLUSION

Traditional clinical risk factors for cardiovascular disease failed to accurately characterize risk in a contemporary population of Medicare-aged patients. Among those aged 85 years and older, some traditional risk factors were not associated with ASCVD events. Better risk models are needed to appropriately inform treatment decision making for the growing population of older adults. J Am Geriatr Soc 68:754-761, 2020.

Proceedings of the Guideline Workshop 2019 - Strategies for the optimization of guideline processes in diabetes, cardiovascular diseases and kidney diseases

The Guideline Workshop 2019, held in October 2019 in Munich, Germany, had the purpose of facilitating discussion on strategies for optimization of guideline processes in diabetes amongst a group of representatives of renown national and international societies in the field of diabetes, cardiology, and nephrology. Results of this panel's discussions are presented in this manuscript and comprise a variety of suggestions for improving the quality and usability of guidelines, as well as to accelerate the development and responsiveness of guidelines to newly published, relevant data from clinical trials such as cardiovascular outcome trials in diabetes mellitus. These include, but are not limited to, recommendations to optimize presentation of content in guidelines, use of the GRADE-approach to rating the quality of evidence to harmonize guidelines, and utilization of digital health technologies to accelerate, streamline, and optimize communication on relevant data and development of clinical guidelines and necessary updates, while reducing costs. Recognizing that achieving alignment in guideline development among various medical organizations will be a long-term process, representatives from cross-sectional medical organizations relevant to cardio-renal metabolic disease and experts in guideline methodology will work together in the future. Among other activities, it is planned to continue the activity and organize a Guideline Workshop in 2020.

Evolocumab in HIV-Infected Patients With Dyslipidemia: Primary Results of the Randomized, Double-Blind BEIJERINCK Study

BACKGROUND

People living with human immunodeficiency virus (PLHIV) are at increased risk of atherosclerotic cardiovascular disease (ASCVD) and are prone to statin-related adverse events from drug-drug interactions with certain antiretroviral regimens.

OBJECTIVES

This study sought to evaluate the efficacy and safety of evolocumab in dyslipidemic PLHIV.

METHODS

BEIJERINCK (EvolocumaB Effect on LDL-C Lowering in SubJEcts with Human Immunodeficiency VirRus and INcreased Cardiovascular RisK) is a randomized, double-blind, multinational trial comparing monthly subcutaneous evolocumab 420 mg with placebo in PLHIV with hypercholesterolemia/mixed dyslipidemia taking maximally-tolerated statin therapy. The primary endpoint was the percent change (baseline to week 24) in low-density lipoprotein cholesterol (LDL-C); secondary endpoints included achievement of LDL-C <70 mg/dl and percent change in other plasma lipid and lipoprotein levels. Treatment-emergent adverse events were also examined.

RESULTS

A total of 464 patients were analyzed (mean age of 56.4 years, 82.5% male, mean duration with HIV of 17.4 years). ASCVD was documented in 35.6% of patients, and statin intolerance/contraindications to statin use were present in 20.7% of patients. Evolocumab reduced LDL-C by 56.9% (95% confidence interval: 61.6% to 52.3%) from baseline to week 24 versus placebo. An LDL-C level of <70 mg/dl was achieved in 73.3% of patients in the evolocumab group versus 7.9% in the placebo group. Evolocumab also significantly reduced other atherogenic lipid levels, including non-high-density lipoprotein cholesterol, apolipoprotein B, and lipoprotein(a) (all p < 0.0001). Evolocumab was well tolerated, and treatment-emergent adverse events patient incidence was similar among evolocumab and placebo groups.

CONCLUSIONS

Evolocumab was safe and significantly reduced lipid levels in dyslipidemic PLHIV on maximally-tolerated statin therapy. Evolocumab is an effective therapy for lowering atherogenic lipoproteins in PLHIV with high cardiovascular risk. (Safety, Tolerability & Efficacy on LDL-C of Evolocumab in Subjects With HIV & Hyperlipidemia/Mixed Dyslipidemia; NCT02833844).

Assessment of the Efficacy of Lowering LDL Cholesterol with Rosuvastatin 10 mg in Four Korean Statin Benefit Groups as per ACC/AHA Guidelines (NewStaR4G)

The American College of Cardiology and American Heart Association (ACC/AHA) guidelines identified four statin benefit groups on the basis of atherosclerotic cardiovascular disease risk reduction and proposed statin therapy by evidence-based intensity. Although these guidelines used randomized controlled trials with hard outcomes as exclusive evidence for its recommendations, a limited number of studies conducted in Asian countries makes its application of treatment strategy, intensity, and statin doses uncertain in these population. This prospective, multicenter study aimed to evaluate the efficacy of rosuvastatin 10 mg in the four statin benefit groups requiring high- or moderate-intensity statin therapy according to the ACC/AHA guidelines in the Korean population. The primary endpoint was percentage reduction in low-density lipoprotein (LDL) cholesterol. Secondary endpoints were percentage reduction in other lipids and achievement of ≥50% reduction in LDL cholesterol. Rosuvastatin 10 mg lowered LDL cholesterol by 61.4 mg/dL, a 44.9% decrease from baseline after eight weeks. Reduction of LDL cholesterol ≥50% was achieved in 46.3% of patients. Rosuvastatin 10 mg was generally well tolerated. In the Korean population, rosuvastatin 10 mg was favorable and tolerant in lowering LDL cholesterol in the four statin benefit groups requiring high- or moderate-intensity statin therapy according to the ACC/AHA guidelines.

Efficacy and Safety of High-intensity Statins in Patients With Acute Myocardial Infarction: An Asian Perspective

BACKGROUND

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends high-intensity statin (HIS) in patients with atherosclerotic cardiovascular disease, but little is known about the efficacy and safety of HIS in Asian ethnicity. We assessed the effects of HIS in Taiwanese with acute myocardial infarction (AMI).

METHODS

Consecutive patients admitted for new AMI between January 2010 and December 2013 without prior statin use were enrolled from the Taiwan National Health Insurance Research Database. Patients were grouped based on the intensity of statin they took after discharge. The primary endpoint was the composite outcome of all-cause mortality, recurrent myocardial infarction, and stroke. We also compared the incidences of severe hepatitis and myopathy that need admission between HIS and non-HIS groups. We used propensity score analysis to match covariates between groups and Cox proportional hazards models with adjustment to estimate the risks of clinical outcomes.

RESULTS

After 1:4 propensity score match, there were 4402 patients in the HIS group and 17,608 patients in the non-HIS group. After follow-up for 3 years, 668 patients (15.2%) in the HIS group and 2749 (15.6%) in the non-HIS group had the primary composite endpoint. Cox proportional-hazards analyses showed that HIS did not further reduce composite endpoint (adjusted hazard ratio, 0.975; 95% confidence interval, 0.896-1.062); however, HIS patients had a lower risk of ischemic stroke at 3-year follow-up. Regarding safety, HIS did not increase hospitalization rates for severe hepatitis and myopathy.

CONCLUSIONS

Patients with AMI in Taiwan with HIS had similar clinical outcomes to those with non-HIS. Using HIS for the effective reduction of low-density lipoprotein cholesterol is safe in Taiwan.

Elevated Lipoprotein A in South Asians and the Associated Risk of Cardiovascular Disease: A Systematic Review

BACKGROUND

South Asians have a premature risk of cardiovascular disease and increased lipoprotein A which enhances their risk.

METHODS

This systematic review evaluates the role of elevated lipoprotein A in cardiovascular disease risk for South Asians. It discusses the pathophysiology, clinical studies, and treatment of elevated lipoprotein A using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

A total of 72 articles was incorporated which consisted of clinical studies, case-control and cohort studies, meta-analysis, reviews, and editorials. Cardiovascular disease and myocardial infarction occurs prematurely in South Asians, which is further enhanced with an elevated lipoprotein A.

CONCLUSIONS

South Asians with an elevated lipoprotein A have an increased risk of coronary artery disease so they should have early enactment of lifestyle modification and aggressive medical management.

Translating evidence from clinical trials of omega-3 fatty acids to clinical practice

The REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) study recently demonstrated that administration of high doses of omega-3 fatty acids confers cardiovascular benefit in high-risk patients with the modest hypertriglyceridemia. This provided optimism for a therapeutic area that has challenged the field of cardiovascular prevention for 2 decades. However, it raises a number of questions including understanding the mechanism underscoring this benefit, how best to use these therapies and whether similar results will be observed with alternative omega-3 fatty acid preparations. Contemporary clinical trials of omega-3 fatty acids and their attempt to prevent cardiovascular events will be reviewed.