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Abstract
PURPOSE OF REVIEW Cholesterol on low-density lipoproteins (LDL-C) is one of the main drivers of atherosclerotic cardiovascular disease (ASCVD) and hence its measurement is critical in the management of patients at risk. Although LDL-C has routinely been either calculated by the Friedewald equation or measured with direct assays, these methods have limitations, particularly for patients with dyslipidaemias, low LDL-C, and hypertriglyceridemia. The focus of this review will be recent advances in the measurement of LDL for ASCVD risk management. RECENT FINDINGS We first describe the recent recommendations on how LDL-C is used in ASCVD risk assessment and management. We then review the current approaches to the measurement of LDL-C and recent developments on new more accurate equations for calculating LDL-C. Finally, we present new and emerging LDL assays that may be superior to LDL-C for risk assessment, such as LDL particle number and small dense LDL-C, and several LDL-based lipid tests in early development. SUMMARY LDL-C is valuable in ASCVD risk management but recent improvements in its measurement and the development of other LDL-related tests may further improve its value.
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Affiliation(s)
- Anna Wolska
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Alan T. Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
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102
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Pradhan A, Bhandari M, Sethi R. Ezetimibe and Improving Cardiovascular Outcomes: Current Evidence and Perspectives. Cardiol Res Pract 2020; 2020:9815016. [PMID: 32670636 PMCID: PMC7338976 DOI: 10.1155/2020/9815016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/11/2020] [Indexed: 02/05/2023] Open
Abstract
Low-density lipoprotein lowering with statins has convincingly and consistently proven to reduce cardiovascular events in both primary and secondary prevention. However, despite high-dose statin therapy, residual cardiovascular risk remains and many patients also do not tolerate statins. Ezetimibe was initially projected as a frontline alternative to statin. It is an intestinal cholesterol absorption inhibitor with modest LDL lowering effects. But, major studies failed to demonstrate any beneficial effect of CV outcomes, and the drug was relegated to oblivion. IMPROVE-IT, a contemporary, large, and well-designed trial, unequivocally demonstrated reduction in CV outcomes with ezetimibe when added to statin therapy. The benefits are seen in both sexes, elderly, CKD, diabetes mellitus, and in patients with prior CABG. It also reduces biomarkers and induces plaque regression like statins. The drug has now established itself as an add-on therapy to statin when monotherapy fails to achieve LDL goals and when it is not tolerated. The combination therapy has excellent safety and efficacy record. It has now been endorsed by major guidelines too in management of dyslipidemia. Yes, ezetimibe can indeed improve cardiovascular outcomes!
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Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
| | - Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
| | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh 226003, India
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103
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Giraldo-Gonzalez GC, Victoria AM, Vesga CE. Hypertension prevalence in Colombian Patients Evaluated with Ambulatory Blood Pressure Monitoring According to Changes in Clinical Guidelines Between 2017-2018. High Blood Press Cardiovasc Prev 2020; 27:309-313. [PMID: 32529380 DOI: 10.1007/s40292-020-00387-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/25/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The latest American College of Cardiology and American Heart Association (ACC/AHA) Guidelines for high blood pressure in adults bring changes with lower cut-off points, creating socioeconomic issues in low and middle income countries. It is necessary to consider the changes that would have the adherence to these new guidelines in diagnosis and hypertension (HTN) control with ambulatory blood pressure monitoring (ABPM), the gold standard for hypertension diagnosis. AIM To describe the changes in hypertension diagnosis and control according to the latest ACC/AHA guidelines, the European Society of Cardiology and European Society of Hypertension (ESC/ESH) and Latin-America Society of Hypertension (LASH) guidelines. METHODS Cross-sectional, descriptive, retrospective study of all patients who have had an ABPM during June 2017 and June 2018 according to cut-off points established by the ACC/AHA Guidelines compared to the ESC/LASH Guidelines. RESULTS 1957 patients evaluated with ABPM were included; median age was 57 years, 55% were female. The difference in diagnosis by 24-h ABPM, day-time, and night-time cycle was 21%, 42%, and 24% higher applying ACC/AHA guidelines vs ESC/ESH guidelines. There were no significant differences regarding the history of HTN, gender, and age in the circadian pattern. CONCLUSION If the measured value of blood pressure in the 24-h ABPM is taken into account, it would necessary to intervene pharmacologically 21.5% more individuals according to the ACC/AHA guidelines in our population, Individualization is awarded.
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Affiliation(s)
| | | | - Carlos E Vesga
- Internal Medicine Unit, Department of Non-Invasive Cardiology, Fundación Valle del Lili, 760032, Cali, Colombia
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104
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Eligibility for PCSK-9 inhibitors treatment in acute coronary syndrome, chronic coronary artery disease and outpatient dyslipidemic patients. Atherosclerosis 2020; 303:29-35. [PMID: 32505012 DOI: 10.1016/j.atherosclerosis.2020.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate potential eligibility for proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in patients with coronary artery disease and dyslipidaemia according to patient characteristics and variable criteria. METHODS We prospectively enrolled 2000 patients (acute coronary syndrome = 407, chronic coronary artery disease inpatients = 1087, outpatient Lipid's clinic = 506). To calculate PCSK-9 inhibitors real-world eligibility, a proprietary adjustable software was developed, which stores data and patient characteristics and can determine eligibility depending on different criteria. We tested four scenarios with different LDL thresholds according to ESC/EAS 2016 and 2019 Guidelines, 2017 American College of Cardiology Expert Consensus, and National criteria. RESULTS The eligible percentage was 18.85%, 9.75%, 8.55% and 2.15%, in the total population for the four classifications, respectively, and it varied according to clinical status. The increase toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter. CONCLUSIONS For the first time, a realistic estimation of PCSK-9 eligibility is provided via an adjustable predictive model in a population of 2000 patients with acute coronary syndrome, chronic coronary artery disease and dyslipidaemia. This can be a valuable tool for the incorporation of PCSK-9 inhibitors in health care systems.
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105
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Levinson SS. Non-High-Density Lipoprotein Cholesterol and Guidelines for Cholesterol Lowering in Recent History. Lab Med 2020; 51:14-23. [PMID: 31147695 DOI: 10.1093/labmed/lmz032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The National Cholesterol Education Program (NCEP) released guidelines for treating cholesterol in 1988, 1994, and 2002. After a hiatus, the guidelines were released again in 2013, 2016, 2017, and 2018. METHODS In this article, I review these guidelines, factors that affected their release, how they evolved, and why recommended treatment targets are reasonable. Also, to aid reader understanding, I briefly discuss biochemical mechanisms and the pathophysiology of beta-lipoproteins, focusing on the importance on non-high-density cholesterol (non-HDLC) in assessing risk and as a target for treatment. The concepts discussed are important to laboratory clinicians because those workers inscribe target values on the reports and may consult with medical staff members. CONCLUSIONS The newest recommendations, released in 2018, are an extension of the 2017 guidelines that defined non-HDLC as equivalent to low-density lipoprotein cholesterol (LDLC). For the reasons discussed herein, non-HDLC has advantages over LDLC. Laboratories reporting cholesterol results should include non-HDLC values and cutoffs in their reports.
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Affiliation(s)
- Stanley S Levinson
- Department of Veteran Affairs Medical Center, Louisville, Kentucky.,Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Louisville, Kentucky
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106
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Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidemia influenced the management of dyslipidemia? The MEJORALO-CV Project. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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107
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Cordero A, Rodríguez-Mañero M, Fácila L, Fernández-Olmo MR, Gómez-Martínez MJ, Valle A, Castellano JM, Toro MM, Seijas-Amigo J, Vicedo A, González-Juanatey JR. Prevention of myocardial infarction and stroke with PCSK9 inhibitors treatment: a metanalysis of recent randomized clinical trials. J Diabetes Metab Disord 2020; 19:759-765. [PMID: 33520801 DOI: 10.1007/s40200-020-00557-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
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%.
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Affiliation(s)
- Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital Universitario de San Juan, Carretera Valencia-Alicante sn, San Juan de Alicante, 03550 Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - Jose Mª Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospitales de Madrid, Madrid, Spain
| | | | - José Seijas-Amigo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Alvaro Vicedo
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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108
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Kim EJ, Wierzbicki AS. The history of proprotein convertase subtilisin kexin-9 inhibitors and their role in the treatment of cardiovascular disease. Ther Adv Chronic Dis 2020; 11:2040622320924569. [PMID: 32537117 PMCID: PMC7268157 DOI: 10.1177/2040622320924569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/15/2020] [Indexed: 12/22/2022] Open
Abstract
A consensus has formed based on epidemiological studies and clinical trials that intervention to reduce low density lipoprotein cholesterol (LDL-C) will reduce cardiovascular disease (CVD) events. This has progressively reduced the thresholds for intervention and targets for treatment. Whist statins are sufficient for many people in primary prevention, they only partially achieve the newer targets of secondary prevention for established CVD. Increasing use of statins has highlighted that 1–2% cannot tolerate these drugs. Other cholesterol-lowering drugs such as ezetimibe add to the benefits of statins but have limited efficacy. The discovery of activating mutations in proprotein convertase subtilisin kexin-9 (PCSK9) as a cause of familial hypercholesterolaemia while inactivating mutations lower LDL-C led to the idea to develop PCSK9 inhibitors as drugs. This article reviews the history of lipid-lowering therapies, the discovery of PCSK9 and the development of PCSK9 inhibitors. It reviews the key trials of the current antibody-based drugs and how these have influenced new guidelines. It also reviews the controversy caused by their cost and the increasing application of health economics to determine the optimum strategy for implementation of novel therapeutic pathways and surveys other options for targeting PCSK9 as well as other LDL-C lowering compounds in late development.
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Affiliation(s)
- Eun Ji Kim
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Anthony S Wierzbicki
- Department of Chemical Pathology, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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109
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Katsiki N, Mikhailidis DP, Bajraktari G, Miserez AR, Cicero AFG, Bruckert E, Serban MC, Mirrakhimov E, Alnouri F, Reiner Ž, Paragh G, Sahebkar A, Banach M. Statin therapy in athletes and patients performing regular intense exercise - Position paper from the International Lipid Expert Panel (ILEP). Pharmacol Res 2020; 155:104719. [PMID: 32087236 DOI: 10.1016/j.phrs.2020.104719] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
Acute and chronic physical exercises may enhance the development of statin-related myopathy. In this context, the recent (2019) guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) for the management of dyslipidemias recommend that, although individuals with dyslipidemia should be advised to engage in regular moderate physical exercise (for at least 30 min daily), physicians should be alerted with regard to myopathy and creatine kinase (CK) elevation in statin-treated sport athletes. However it is worth emphasizing that abovementioned guidelines, previous and recent ESC/EAS consensus papers on adverse effects of statin therapy as well as other previous attempts on this issue, including the ones from the International Lipid Expert Panel (ILEP), give only general recommendations on how to manage patients requiring statin therapy on regular exercises. Therefore, these guidelines in the form of the Position Paper are the first such an attempt to summary existing, often scarce knowledge, and to present this important issue in the form of step-by-step practical recommendations. It is critically important as we might observe more and more individuals on regular exercises/athletes requiring statin therapy due to their cardiovascular risk.
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Affiliation(s)
- Niki Katsiki
- First Department of Internal Medicine, Division of Endocrinology and Metabolism, Diabetes Center, Medical School, AHEPA University Hospital, Thessaloniki, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK
| | - Gani Bajraktari
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo, Serbia; Medical Faculty, University of Prishtina, Prishtina, Kosovo, Serbia; Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Andre R Miserez
- Diagene Research Institute, Reinach, Switzerland; University of Basel, Basel, Switzerland
| | - Arrigo F G Cicero
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | - Eric Bruckert
- Pitié-Salpêtrière Hospital and Sorbonne University, Cardio Metabolic Institute, Paris, France
| | - Maria-Corina Serban
- Department of Functional Sciences, Discipline of Pathophysiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Erkin Mirrakhimov
- Kyrgyz State Medical Academy, Named after Akhunbaev I.K., Bishkek, Kyrgyzstan
| | - Fahad Alnouri
- Cardiovascular Prevention Unit, Adult Cardiology Department, Prince Sultan Cardiac Centre Riyadh, Saudi Arabia
| | - Željko Reiner
- Department of Internal Diseases University Hospital Center Zagreb School of Medicine, Zagreb University, Zagreb, Croatia
| | - György Paragh
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland.
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110
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Hester EK, Caulder CR, Penzak SR. Impact of team‐based care on appropriate statin therapy prescribing in ***HIV‐infected patients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Elizabeth K. Hester
- Department of Pharmacy Practice Auburn University Harrison School of Pharmacy Auburn Alabama
| | - Celeste R. Caulder
- Department of Clinical Pharmacy and Outcomes Sciences University of South Carolina College of Pharmacy Columbia South Carolina
| | - Scott R. Penzak
- Department of Pharmacy Practice Auburn University Harrison School of Pharmacy Auburn Alabama
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111
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Buckley LF, Ting C, Fatani N, Fanikos J. Changes in nationwide Medicare and Medicaid expenditures on lipid-lowering therapies after proprotein convertase/subtilisin type 9 inhibitor availability. J Clin Lipidol 2020; 14:315-321.e4. [DOI: 10.1016/j.jacl.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022]
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112
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Saito Y, Nakayama A, Sato T, Morita H, Kawahara T, Itoh H, Komuro I. Lipid-lowering statin therapy is beneficial in elderly female patients with hypercholesterolaemia and diabetic retinopathy. Eur J Prev Cardiol 2020; 28:e7-e9. [PMID: 33611415 DOI: 10.1177/2047487320920761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yoshihiro Saito
- Department of Cardiovascular Medicine, The University of Tokyo, Japan
| | - Atsuko Nakayama
- Department of Cardiovascular Medicine, The University of Tokyo, Japan
| | - Tatsuyuki Sato
- Department of Cardiovascular Medicine, The University of Tokyo, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo, Japan
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113
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Yegezu Z, Mollon L, Alshayban DM, Bilal J, Bhattacharjee S. Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study. Res Social Adm Pharm 2020; 17:307-314. [PMID: 32360124 DOI: 10.1016/j.sapharm.2020.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/04/2020] [Accepted: 04/19/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Zufan Yegezu
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA.
| | - Lea Mollon
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA.
| | - Dhafer Mahdi Alshayban
- Pharmacy Practice Department, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Jawad Bilal
- Department of Medicine, Division of Rheumatology, University of Arizona, USA.
| | - Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA.
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114
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Lin YC, Lai TS, Wu HY, Chou YH, Chiang WC, Lin SL, Chen YM, Chu TS, Tu YK. Effects and Safety of Statin and Ezetimibe Combination Therapy in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Clin Pharmacol Ther 2020; 108:833-843. [PMID: 32320058 DOI: 10.1002/cpt.1859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/25/2020] [Indexed: 12/31/2022]
Abstract
The efficacy and safety of statin and ezetimibe combination therapy in patients with chronic kidney disease (CKD) remains unclear. To assess the effect of statin and ezetimibe combination therapy on controlling lipid profiles and reducing cardiovascular events in patients with CKD, we conducted a systematic review and meta-analysis. We selected randomized controlled trials comparing this combination therapy with statin monotherapy or placebo in patients with CKD from the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases published before September 1, 2018 on the Internet. Eight articles on seven studies, with a total of 14,016 patients with CKD, were selected from 412 full-text articles. Statin and ezetimibe combination therapy had beneficial effects on serum total cholesterol (weighted mean difference (WMD) -20.31 mg/dL, 95% confidence interval (CI), -26.87 to -13.75 mg/dL, P < 0.001), low-density lipoprotein cholesterol (WMD -17.22 mg/dL, 95% CI, -18.93 to -15.51 mg/dL, P < 0.001), and triglycerides (WMD -15.08 mg/dL, 95% CI, -23.41 to -6.75 mg/dL, P < 0.001) compared with statin monotherapy. Statin and ezetimibe combination therapy significantly reduced all-cause mortality and major adverse cardiovascular events (risk ratio 0.86, 95% CI, 0.77 to 0.97, P = 0.01). The incidence of adverse events was low, with no significant difference between statin and ezetimibe combination therapy and statin monotherapy. In conclusion, the statin and ezetimibe combination therapy significantly improved serum lipid profiles and reduced risks of all-cause deaths and major adverse cardiovascular events compared with the control group in patients with CKD.
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Affiliation(s)
- Yi-Chih Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Medicine, National Taiwan University Hospital Jinshan branch, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hon-Yen Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Hsiang Chou
- Department of Medicine, National Taiwan University Hospital Jinshan branch, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chih Chiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shuei-Liong Lin
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.,Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Ming Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Dentistry and Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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115
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Veerubhotla K, Lee CH. Emerging Trends in Nanocarbon‐Based Cardiovascular Applications. ADVANCED THERAPEUTICS 2020. [DOI: 10.1002/adtp.201900208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Krishna Veerubhotla
- Division of Pharmacology and Pharmaceutics Sciences School of Pharmacy University of Missouri–Kansas City Kansas City MO 64108 USA
| | - Chi H. Lee
- Division of Pharmacology and Pharmaceutics Sciences School of Pharmacy University of Missouri–Kansas City Kansas City MO 64108 USA
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Park EO, Bae EJ, Park BH, Chae SW. The Associations between Liver Enzymes and Cardiovascular Risk Factors in Adults with Mild Dyslipidemia. J Clin Med 2020; 9:E1147. [PMID: 32316417 PMCID: PMC7230762 DOI: 10.3390/jcm9041147] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 12/30/2022] Open
Abstract
Hypertension and dyslipidemia often occur as comorbidities, with both being strong risk factors for developing cardiovascular diseases (CVD). Abnormal liver function test could reflect a potential CVD risk even in patients with mild dyslipidemia. The aim of this study was to assess the compounding relationship between liver enzymes and cardiovascular risk factors in subjects with mild dyslipidemia. The present analysis was performed among 438 participants who had enrolled in at least one of the nine clinical studies done at the Chonbuk National University Hospital between 2009 and 2019. Significant linear increasing trends were observed in blood pressure level and other cardiovascular risk factors across quartiles of serum γ-glutamyltransferase (GGT) or alanine aminotransferase (ALT), with the increment in hypertension prevalence occurring across the quartiles of GGT and ALT. On multivariate logistic regression analyses, the odds ratios for hypertension, adjusted for smoking, drinking and obesity, in the highest quartiles of GGT, ALT, aspartate aminotransferase, and alkaline phosphatase were 3.688, 1.617, 1.372, and 1.166, respectively. Our study indicates that GGT is a superior marker for predicting CVD risk among liver enzymes. Routine screening of plasma GGT levels in patients with mild dyslipidemia will allow for early detection of CVD.
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Affiliation(s)
- Eun-Ock Park
- Clinical Trial Center for Functional Foods, Chonbuk National University Hospital, Jeonju 54907, Jeonbuk, Korea;
| | - Eun Ju Bae
- College of Pharmacy, Chonbuk National University, Jeonju 54896, Jeonbuk, Korea;
| | - Byung-Hyun Park
- Department of Biochemistry and Molecular Biology, Chonbuk National University Medical School, Jeonju 54896, Jeonbuk, Korea
| | - Soo-Wan Chae
- Clinical Trial Center for Functional Foods, Chonbuk National University Hospital, Jeonju 54907, Jeonbuk, Korea;
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117
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Kim NH, Kim SG. Fibrates Revisited: Potential Role in Cardiovascular Risk Reduction. Diabetes Metab J 2020; 44:213-221. [PMID: 32347023 PMCID: PMC7188966 DOI: 10.4093/dmj.2020.0001] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 02/05/2020] [Indexed: 12/18/2022] Open
Abstract
Fibrates, peroxisome proliferator-activated receptor-α agonists, are potent lipid-modifying drugs. Their main effects are reduction of triglycerides and increase in high-density lipoprotein levels. Several randomized controlled trials have not demonstrated their benefits on cardiovascular risk reduction, especially as an "add on" to statin therapy. However, subsequent analyses by major clinical trials, meta-analyses, and real-world evidence have proposed their potential in specific patient populations with atherogenic dyslipidemia and metabolic syndrome. Here, we have reviewed and discussed the accumulated data on fibrates to understand their current status in cardiovascular risk management.
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Affiliation(s)
- Nam Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sin Gon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
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Bae J, Hong N, Lee BW, Kang ES, Cha BS, Lee YH. Comparison of Renal Effects of Ezetimibe-Statin Combination versus Statin Monotherapy: A Propensity-Score-Matched Analysis. J Clin Med 2020; 9:E798. [PMID: 32183405 PMCID: PMC7141215 DOI: 10.3390/jcm9030798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 01/13/2023] Open
Abstract
Neither lowering of blood lipid levels nor treatment with statins definitively improves renal outcomes. Ezetimibe, a non-statin antilipidemic agent, is known to not only decrease blood lipid levels but also reduce inflammatory response and activate autophagy. We evaluated the effect of adding ezetimibe to a statin on renal outcome compared with statin monotherapy by analyzing longitudinal data of 4537 patients treated with simvastatin 20 mg plus ezetimibe 10 mg (S + E) or simvastatin 20 mg alone (S) for more than 180 days. A propensity-score-based process was used to match baseline characteristics, medical history, and estimated glomerular filtration rate (eGFR) between S + E and S groups. Changes in serum creatinine and incidence of renal events, defined as doubling of serum creatinine to ≥1.5 mg/dL or occurrence of end-stage renal disease after the first day of treatment initiation, were compared between the groups. Among 3104 well-matched patients with a median follow-up of 4.2 years, the S + E group showed a significantly lower risk of renal events than the S group (hazard ratio 0.58; 95% CI 0.35-0.95, P = 0.032). In addition, the S + E group tended to preserve renal function compared with the S group throughout follow-up, as assessed by serum creatinine changes (P-values for time-group interactions <0.001). These data support the beneficial effects on renal function when combining ezetimibe with a statin.
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Affiliation(s)
- Jaehyun Bae
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
| | - Namki Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Byung-Wan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Bong-Soo Cha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong-ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (J.B.); (N.H.); (B.-W.L.); (E.S.K.); (B.-S.C.)
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea
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119
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Coronary plaque tissue characterization in patients with premature coronary artery disease. Int J Cardiovasc Imaging 2020; 36:1003-1011. [PMID: 32078097 PMCID: PMC7228958 DOI: 10.1007/s10554-020-01794-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
Premature coronary artery disease (CAD) studies rarely involve coronary plaque characterization. We characterize coronary plaque tissue by radiofrequency intravascular ultrasound (IVUS) in patients with premature CAD. From July 2015 to December 2017, 220 patients from the Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine with first occurrence of angina or myocardial infarction within 3 months were enrolled. Patients with premature CAD (n = 47, males aged < 55 years, and females aged < 65 years) or later CAD (n = 155) were retrospectively compared for cardiovascular risk factors, laboratory examination findings, coronary angiography data, gray-scale IVUS, and iMap-IVUS. The mean age was 53.53 ± 7.24 vs. 70.48 ± 8.74 years (p < 0.001). The groups were similar for traditional coronary risk factors except homocysteine (18.60 ± 5.15 vs. 17.08 ± 4.27 µmol/L, p = 0.043). After matching for baseline characteristics, LDL cholesterol (LDL-C) was higher for premature CAD than later CAD (2.50 ± 0.96 vs. 2.17 ± 0.80 mmol/L, p = 0.019). Before the matching procedure, the premature CAD group had shorter target lesion length [18.50 (12.60–32.00) vs. 27.90 (18.70–37.40) mm, p = 0.002], less plaque volume [175.59 (96.60–240.50) vs. 214.73 (139.74–330.00) mm3, p = 0.013] than the later CAD group. After the matching procedure, the premature CAD group appeared to be less plaque burden (72.69 ± 9.99 vs. 74.85 ± 9.80%, p = 0.005), and positive remodeling (1.03 ± 0.12 vs. 0.94 ± 0.18, p = 0.034), and lower high risk feature incidence (p = 0.006) than the later CAD group. At the plaque’s minimum lumen, premature CAD had more fibrotic (p < 0.001), less necrotic (p = 0.001) and less calcified areas (p = 0.012). Coronary plaque tissue was more fibrotic with less necrotic and calcified components in premature than in later CAD, and the range and degree of atherosclerosis were significantly lower.
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Yonetsu T, Hoshino M, Lee T, Kanaji Y, Yamaguchi M, Hada M, Sumino Y, Ohya H, Kanno Y, Hirano H, Horie T, Niida T, Matsuda J, Umemoto T, Sasaoka T, Hatano Y, Sugiyama T, Sasano T, Kakuta T. Plaque morphology assessed by optical coherence tomography in the culprit lesions of the first episode of acute myocardial infarction in patients with low low-density lipoprotein cholesterol level. J Cardiol 2020; 75:485-493. [PMID: 32085904 DOI: 10.1016/j.jjcc.2020.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/17/2019] [Accepted: 01/04/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND There remains a residual risk for acute myocardial infarction (AMI) even with low low-density lipoprotein cholesterol (LDL-C) levels. This study aimed to characterize the culprit lesion morphology of AMI by optical coherence tomography (OCT) in patients with low LDL-C. METHODS Four-hundred and nine culprit lesions of 409 patients with their first presentation of AMI imaged by OCT were investigated. OCT analysis included the presence of plaque rupture and thin-capped fibroatheroma (TCFA). Fibrous cap thickness and lipid length were also measured. Intravascular ultrasound (IVUS) was performed in 368 (90.0%) patients. OCT and IVUS findings were compared between patients with LDL-C < 100 mg/dl (lower-LDL group) and those with LDL ≥ 100 mg/dl (higher-LDL group). RESULTS Lower-LDL group included 93 (22.7%) patients. Plaque rupture (54.8% vs. 68.7%, p = 0.018) and TCFA (39.8% vs. 54.6%, p = 0.013) were less frequently observed in lower-LDL than in higher-LDL. Fibrous cap was thicker [73 (59-109) µm vs. 63 (57-83) µm, p = 0.028] and lipid length was smaller [5.4 (2.3-9.9) mm vs. 7.1 (4.1-10.5) mm, p = 0.012] in lower-LDL than in higher-LDL. There were no significant differences in IVUS parameters including plaque burden or remodeling index between the two groups. CONCLUSIONS Patients with lower LDL-C showed more prevalent intact fibrous cap and less vulnerable features in the culprit lesions, which may suggest the need for exploring a specific strategy for the prevention of plaque erosion in low LDL-C subjects.
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Affiliation(s)
- Taishi Yonetsu
- Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tetsumin Lee
- Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masao Yamaguchi
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yohei Sumino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hiroaki Ohya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshinori Kanno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hidenori Hirano
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tomoki Horie
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Takayuki Niida
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junji Matsuda
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoyuki Umemoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taro Sasaoka
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yu Hatano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
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121
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Mechanick JI, Farkouh ME, Newman JD, Garvey WT. Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:539-555. [PMID: 32029137 PMCID: PMC8168371 DOI: 10.1016/j.jacc.2019.11.046] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 02/07/2023]
Abstract
In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.
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Affiliation(s)
- Jeffrey I Mechanick
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan D Newman
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York
| | - W Timothy Garvey
- Department of Nutrition Sciences and Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama; Geriatric Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, Alabama
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122
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Rana JS, Liu JY, Moffet HH, Sanchez RJ, Khan I, Karter AJ. Risk of Cardiovascular Events in Patients With Type 2 Diabetes and Metabolic Dyslipidemia Without Prevalent Atherosclerotic Cardiovascular Disease. Am J Med 2020; 133:200-206. [PMID: 31344341 DOI: 10.1016/j.amjmed.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The relationship between achieved low-density lipoprotein cholesterol (LDL-C) levels and risk of incident atherosclerotic cardiovascular disease events among patients with diabetes and metabolic dyslipidemia has not been well described. METHODS We conducted an observational cohort study of statin-treated adults (ages 21-90 years) with type 2 diabetes without established atherosclerotic cardiovascular disease (as of January 1, 2006) who had metabolic dyslipidemia (elevated triglycerides ≥150 mg/dL and low high-density lipoprotein cholesterol, <50 mg/dL [women] and <40 mg/dL [men]). All subjects were members of Kaiser Permanente Northern California, an integrated health care delivery system. Adjusted multivariable Cox models were specified to estimate hazard ratios (HRs) for incident atherosclerotic cardiovascular disease events by achieved LDL-C levels (<50, 50-<70, 70-<100, and ≥100 mg/dL). Incident atherosclerotic cardiovascular disease events were defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through December 31, 2013. RESULTS A total of 19,095 individuals met the selection criteria. Mean age was 63.4 years, 53.5% were women, and the mean follow-up was 5.9 years. Unadjusted rates of atherosclerotic cardiovascular disease events were not significantly different across specified LDL-C categories. In models adjusted for demographics and clinical characteristics, the risk was significantly lower with decreasing achieved LDL-C levels (P <0.0001 for trend). Relative to achieved LDL-C ≥100 mg/dL, LDL-C <50 mg/dL had an hazard ratio of 0.66 (95% confidence interval [CI] 0.52-0.82). CONCLUSION In a large, contemporary cohort of statin-treated patients with type 2 diabetes and metabolic dyslipidemia without established atherosclerotic cardiovascular disease, lower achieved LDL-C levels were associated with a monotonically lower risk of incident atherosclerotic cardiovascular disease events. The benefits of achieving very-low LDL-C (<50 mg/dL) in this population requires further evaluation in prospective interventional studies.
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Affiliation(s)
- Jamal S Rana
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, Calif; Department of Medicine, University of California, San Francisco; Division of Research, Kaiser Permanente Northern California, Oakland, Calif.
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Robert J Sanchez
- Health Economics and Outcomes Research, Medical Affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | - Irfan Khan
- Real-World Evidence and Clinical Outcomes, Sanofi, Bridgewater, NJ
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
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123
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Newman RA, Hameed AB. Matters of the Heart: Cardiovascular Health in Women Throughout Their Lifetimes. Obstet Gynecol Clin North Am 2020; 46:515-525. [PMID: 31378292 DOI: 10.1016/j.ogc.2019.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The authors' goal is to review the current recommendations for optimizing cardiovascular health beginning in adolescent years to adulthood, and to expand on the role that pregnancy complications may have as implications for future cardiovascular health. Attention to cardiac health begins in adolescence; however, most young patients are not screened. Pregnancy, with its increased cardiovascular demands and host of antepartum cardiopulmonary complications, may provide a window into future cardiac health. The distinct shift in cardiac risk that occurs once a woman enters menopause is largely ignored in routine screening guidelines.
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Affiliation(s)
- Rachel A Newman
- Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, 333 City Boulevard West, 14th Floor, Suite 1400, Orange, CA 92868, USA
| | - Afshan B Hameed
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of California, Irvine Medical Center, 333 City Boulevard West, 14th Floor, Suite 1400, Orange, CA 92868, USA.
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3944] [Impact Index Per Article: 986.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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125
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Navar AM, Mulder HM, Wojdyla DM, Peterson ED. Have the Major Cardiovascular Outcomes Trials Impacted Payer Approval Rates for PCSK9 Inhibitors? Circ Cardiovasc Qual Outcomes 2020; 13:e006019. [PMID: 31918581 PMCID: PMC7039320 DOI: 10.1161/circoutcomes.119.006019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Hillary M. Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel M. Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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126
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Atherosclerosis 2020; 290:140-205. [PMID: 31504418 DOI: 10.1016/j.atherosclerosis.2019.08.014] [Citation(s) in RCA: 585] [Impact Index Per Article: 146.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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127
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Gupta RD, Talukdar A, Haider SS, Haider MR. Prevalence and Associated Factors of Hypertension Subtypes Among the Adult Population in Nepal: Evidence from Demographic and Health Survey Data. Osong Public Health Res Perspect 2019; 10:327-336. [PMID: 31897361 PMCID: PMC6927420 DOI: 10.24171/j.phrp.2019.10.6.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objectives This study aims to determine the prevalence, and associated factors of undiagnosed hypertension [Systolic Diastolic Hypertension (SDH), Isolated Systolic Hypertension (ISH) and Isolated Diastolic Hypertension (IDH)] in the Nepalese adult population. Methods Nepal Demographic and Health Survey 2016 data from adults (≥ 18 years) was used in this study. The final weighted sample size was 13,393. Blood pressure (BP) was measured 3 times and the average of the second and third measurement was reported. SDH (systolic BP (SBP) ≥ 140 mmHg and diastolic BP (DBP) ≥ 90 mmHg), ISH (SBP ≥ 140 mmHg and DBP < 90 mmHg), and IDH (SBP < 140 mmHg and DBP ≥ 90 mmHg) were measured. Multilevel logistic regression analyses were conducted to find the association between the independent variables and the covariates. Results The prevalence of SDH, IDH and ISH were 8.1%, 7.5%, and 3.3% respectively. The odds of having SDH and ISH increased with old age. However, the odds of having IDH decreased with increasing age. Females has lower odds of having SDH and IDH compared with male participants. Individuals that had been married, resided in Province 4 (p < 0.05) or 5 (p < 0.01) were statistically significantly associated with having IDH. Being overweight or obese was statistically significantly associated with all 3 HTN subtypes (p < 0.001). Conclusion The necessary steps should be taken so that public health promotion programs in Nepal may prevent and control undiagnosed hypertension.
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Affiliation(s)
- Rajat Das Gupta
- Centre for Non-Communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh.,Centre for Science of Implementation & Scale-Up, BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Animesh Talukdar
- Centre for Non-Communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh.,CAPABLE Consortium, University of Cambridge, UK.,Public Health and Informatics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Shams Shabab Haider
- Centre for Science of Implementation & Scale-Up, BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Mohammad Rifat Haider
- Department of Social and Public Health, College of Health Sciences and Professions, Ohio University, Athens, USA
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Dissimilar Effects of Anagliptin and Sitagliptin on Lipoprotein Subclass in Standard or Strong Statin-Treated Patients with Type-2 Diabetes Mellitus: A Subanalysis of the REASON (Randomized Evaluation of Anagliptin versus Sitagliptin on Low-Density LipoproteiN Cholesterol in Diabetes) Trial. J Clin Med 2019; 9:jcm9010093. [PMID: 31905896 PMCID: PMC7019317 DOI: 10.3390/jcm9010093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 12/25/2022] Open
Abstract
The effects of antidiabetic agents on lipoprotein subclasses are assumed to be pivotal, but this assumption has not been studied. We evaluated lipoprotein subclasses in patients, randomly selected from REASON (Randomized Evaluation of Anagliptin versus Sitagliptin On low-density lipoproteiN cholesterol in diabetes) Trial participants, with type-2 diabetes treated with either anagliptin or sitagliptin. We measured total cholesterol (TC) and triglycerides (TG) in 4 (chylomicron (CM), very low-density lipoprotein (VLDL), low density lipoprotein (LDL), and high-density lipoprotein (HDL)) lipoprotein classes and 20 (2 CM, 5 VLDL, 6 LDL, and 7 HDL) lipoprotein subclasses. Between 0 and 52 weeks, TC and TG in lipoprotein and the lipoprotein subclass were distributed differently in patients treated with anagliptin and sitagliptin. The preferable changes in TC and TG levels were observed dominantly in the anagliptin-treated group under standard statin therapy, but the benefits were observed in both the anagliptin- and sitagliptin-treated groups, at least partially under strong statin therapy. In future studies, the atherogenic properties of lipoprotein subclasses might be considered when employing antidiabetic dipeptidyl peptidase-4 (DPP-4) inhibitors, especially in patients with type-2 diabetes who are at risk of atherosclerotic cardiovascular disease (ASCVD) or are undergoing statin treatment.
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Cedó L, Farràs M, Lee-Rueckert M, Escolà-Gil JC. Molecular Insights into the Mechanisms Underlying the Cholesterol- Lowering Effects of Phytosterols. Curr Med Chem 2019; 26:6704-6723. [DOI: 10.2174/0929867326666190822154701] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 01/18/2019] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
Dietary phytosterols, which comprise plant sterols and stanols, reduce plasma Low-Density Lipoprotein-Cholesterol (LDL-C) levels when given 2 g/day. Since this dose has not been reported to cause health-related side effects in long-term human studies, food products containing these plant compounds are used as potential therapeutic dietary options to reduce LDL-C and cardiovascular disease risk. Several mechanisms have been proposed to explain the cholesterol-lowering action of phytosterols. They may compete with dietary and biliary cholesterol for micellar solubilization in the intestinal lumen, impairing intestinal cholesterol absorption. Recent evidence indicates that phytosterols may also regulate other pathways. Impaired intestinal cholesterol absorption is usually associated with reduced cholesterol transport to the liver, which may reduce the incorporation of cholesterol into Very-Low- Density Lipoprotein (VLDL) particles, thereby lowering the rate of VLDL assembly and secretion. Impaired liver VLDL production may reduce the rate of LDL production. On the other hand, significant evidence supports a role for plant sterols in the Transintestinal Cholesterol Excretion (TICE) pathway, although the exact mechanisms by which they promote the flow of cholesterol from the blood to enterocytes and the intestinal lumen remains unknown. Dietary phytosterols may also alter the conversion of bile acids into secondary bile acids, and may lower the bile acid hydrophobic/hydrophilic ratio, thereby reducing intestinal cholesterol absorption. This article reviews the progress to date in research on the molecular mechanisms underlying the cholesterol-lowering effects of phytosterols.
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Affiliation(s)
- Lídia Cedó
- Institut d'Investigacions Biomediques (IIB) Sant Pau, Barcelona, Spain
| | - Marta Farràs
- Integrative Systems Medicine and Digestive Disease Division, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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130
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Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidaemia influenced the management of dyslipidaemia? The MEJORALO-CV Project. Rev Clin Esp 2019; 220:282-289. [PMID: 31744620 DOI: 10.1016/j.rce.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/14/2019] [Accepted: 08/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the management of dyslipidaemia in primary care after the publication of the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines and Valencian government's algorithm. METHOD We conducted a cross-sectional descriptive study that employed a survey of primary care physicians of the Community of Valencia between January and October 2016. RESULTS A total of 199 physicians (mean age, 48.9±11.0 years; experience, 21.3±11.1 years) participated in the survey. The most followed guidelines were those of the European Society of Cardiology (37.5% of respondents) and Valencian government (23.4% of respondents). Some 6.3% of the respondents followed the 2013 ACC/AHA guidelines, and 88.0% established objectives based on LDL cholesterol and cardiovascular risk. The choice of lipid-lowering drug was based on its LDL cholesterol lowering capacity (28.6% of respondents), on the Valencian government's algorithm (23.4%) and on the drug's safety (20.4%). Statins, ezetimibe and fibrates were the preferred hypolipemiant agents, and their combination (51% of respondents) and dosage increases (35%) were the strategies employed for poor control. Lipid profile and transaminase and creatine kinase levels were measured every 6 (59.5%, 52.3% and 54.3% of respondents, respectively) or 12 months (25.1%, 29.2% and 30.3%, respectively). Forty-one percent of the respondents were aware of the controversy surrounding the 2013 ACC/AHA guidelines. Although 60% of the respondents acknowledged its relevance, only 21% changed their daily practices accordingly. CONCLUSIONS The Valencian government's algorithm had a greater impact than the 2013 ACC/AHA guidelines in primary care in Valencia. Areas for improvement included the low use of validated guidelines and risk tables and the streamlining of laboratory test periodicity.
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131
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Baum SJ, Wade RL, Xiang P, Arellano J, Cerezo Olmos C, Nunna S, Chen CC, Carter CM, Desai NR. Demographic And Clinical Characteristics Of Patients Prescribed Proprotein Convertase Subtilisin/kexin Type 9 Inhibitor Therapy And Patients Whose Current Lipid-Lowering Therapy Was Modified. Ther Clin Risk Manag 2019; 15:1325-1332. [PMID: 32009789 PMCID: PMC6859120 DOI: 10.2147/tcrm.s216606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/13/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose Our objective was to describe the demographic and clinical characteristics of real-world patients in the US with elevated low-density lipoprotein cholesterol (LDL-C) whose lipid-lowering therapy (LLT) ─ both proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor and non-PCSK9 inhibitor ─ was actively modified. Methods This retrospective cohort study used linked laboratory (Prognos), pharmacy (IMS Formulary Impact Analyzer), and medical claims (IQVIA Dx/LRx or PharMetrics Plus) data. PCSK9 inhibitor–prescribed patients with LDL-C ≥70 mg/dL (multiply by 0.02586 for mmol/L) at the time of prescription were matched by LDL-C test date to patients whose non-PCSK9 inhibitor therapy was modified by intensifying statin therapy, switching statins without intensification, or augmenting with ezetimibe (N=12,345 in each cohort). Baseline demographics, use of LLT, LDL-C values, atherosclerotic cardiovascular disease (ASCVD) diagnoses and cardiovascular comorbidities, and occurrence of major adverse cardiovascular events (MACE) were assessed during the 2-year pre-index period. Results Mean age was 66.2 years in the PCSK9 inhibitor cohort and 64.1 years in the cohort whose LLT regimen was otherwise modified. Respectively, mean baseline LDL-C values were 150 and 121 mg/dL; 60.3% and 39.0% of patients had ASCVD diagnoses, and 9.6% and 5.1% had experienced a recent MACE. Prevalence of ASCVD diagnoses in the PCSK9 inhibitor and modified non-PCSK9 inhibitor cohorts, respectively, was 15.5% vs 9.1% for acute coronary syndrome, 20.7% vs 8.7% for coronary revascularization, and 22.2% vs 5.1% for possible familial hypercholesterolemia. In addition, 19.8% of patients in the PCSK9 inhibitor cohort were receiving both statins and ezetimibe vs 5.0% in the modified LLT cohort. Conclusion Physicians are prescribing PCSK9 inhibitor therapy to patients with markedly elevated LDL-C levels who also have comorbid risk factors for adverse cardiovascular events. These results may be of interest to payers and policymakers involved in devising access strategies for PCSK9 inhibitors.
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Affiliation(s)
- Seth J Baum
- Department of Integrated Medical Sciences, Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA.,Preventive Cardiology Inc, Boca Raton, FL, USA
| | - Rolin L Wade
- Medical and Scientific Services, IQVIA, Plymouth Meeting, PA, USA
| | - Pin Xiang
- Global Health Economics, Amgen Inc, Thousand Oaks, CA, USA
| | - Jorge Arellano
- Global Health Economics, Amgen Inc, Thousand Oaks, CA, USA
| | | | - Sasikiran Nunna
- Real-World Evidence Solutions, IQVIA, Plymouth Meeting, PA, USA
| | - Chi-Chang Chen
- Real-World Evidence Solutions, IQVIA, Plymouth Meeting, PA, USA
| | | | - Nihar R Desai
- Section of Cardiovascular Medicine, Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
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132
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Gray C, Stern C. Treatment of Blood Cholesterol to Reduce Atheroscelerotic Cardiovascular Risk in Adults. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2019. [DOI: 10.37901/jcphp18-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cholesterol is a fat-like substance our body needs to build cell membranes, make certain hormones and produce substances that aid in the digestion of fat. Two kinds of lipoproteins carry cholesterol throughout your body: low-density lipoproteins (LDL) and high-density lipoproteins (HDL). LDL cholesterol typically makes up 60–70 percent of the total serum cholesterol in our body and is the primary target of therapy. A high LDL level leads to a buildup of cholesterol in arteries.
Hyperlipidemia occurs when your blood has too many lipids (or fats), such as cholesterol and triglycerides. Hypercholesterolemia means there is too much LDL (bad) cholesterol in your blood,3 and that increases your risk of developing atherosclerosis, coronary heart disease, stroke, and peripheral vascular disease.2 LDL-cholesterol levels of <100 mg/dL are considered optimal. At near optimal levels, 100–129 mg/dL, atherogenesis, the formation of abnormal fatty or lipid masses in arterial walls, occurs. At borderline high levels, 130–159 mg/dL, atherogenesis proceeds at a significant rate. At high levels, 160–189 mg/dL, and very high levels, ≥190 mg/dL, atherogenesis is accelerated.2
Two main factors causing hyperlipidemia are lifestyle and genetic predispositions. An inherited condition called familial hypercholesterolemia (FH) causes very high LDL cholesterol.1
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Affiliation(s)
- Cori Gray
- University of Maryland School of Pharmacy
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133
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Kaufman TM, Warden BA, Minnier J, Miles JR, Duell PB, Purnell JQ, Wojcik C, Fazio S, Shapiro MD. Application of PCSK9 Inhibitors in Practice. Circ Res 2019; 124:32-37. [PMID: 30605414 DOI: 10.1161/circresaha.118.314191] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PCSK9i (protein convertase subtilisin/kexin type 9 inhibitors) are set to revolutionize the treatment of hypercholesterolemia in the management of atherosclerotic risk, but numerous reports have detailed unprecedented barriers to access for these drugs. To overcome these challenges, our group created a model to facilitate provision of this new therapy for patients who qualify according to Food and Drug Administration criteria. This report details the real-world follow-up experience of PCSK9i use in a large patient cohort structured to ensure rigor in data collection, analysis, and interpretation. The 271 patients approved and actively followed in our PCSK9i clinic between July 2015 and August 2018 represent a 97% approval rate from insurance, with 28% of prescriptions requiring at least one appeal. Over 50% of patients were statin intolerant. On average, there was a median lapse of 15 days between initial visit and insurance approval. PCSK9i therapy was affordable for most patients, with an average monthly out-of-pocket expense of $58.05 (median $0). Only 2.3% of patients were unable to initiate or continue therapy because of cost. Reductions from baseline in LDL (low-density lipoprotein) cholesterol and Lp(a) (lipoprotein [a])were comparable to published reports with median reductions of 60% and 23% at 1 year, respectively. PCSK9i therapy was well-tolerated overall, though 9% of patients reported adverse events, and 5% of patients discontinued due mostly to musculoskeletal and flu-like symptoms. Our practice model demonstrates that PCSK9i therapy can be accessed easily and affordably for the majority of eligible patients, resulting in dramatic improvement in lipid profile results. Moreover, our registry data suggest that results from the prospective clinical trials of PCSK9i on LDL and Lp(a) reduction and on tolerability are applicable to a real-world cohort.
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Affiliation(s)
- Tina M Kaufman
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - Bruce A Warden
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - Jessica Minnier
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland.,OHSU-PSU School of Public Health (J.M.), Oregon Health & Science University, Portland
| | - Joshua R Miles
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - P Barton Duell
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - Jonathan Q Purnell
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - Cezary Wojcik
- Department of Family Medicine (C.W.), Oregon Health & Science University, Portland
| | - Sergio Fazio
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
| | - Michael D Shapiro
- From the Center for Preventive Cardiology, Knight Cardiovascular Institute (T.M.K., B.A.W., J.M., J.R.M., P.B.D., J.Q.P., S.F., M.D.S.), Oregon Health & Science University, Portland
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Steffens D, Bramlage P, Scheeff C, Kasner M, Hassanein A, Friebel J, Rauch-Kröhnert U. PCSK9 inhibitors and cardiovascular outcomes. Expert Opin Biol Ther 2019; 20:35-47. [PMID: 31593483 DOI: 10.1080/14712598.2020.1677604] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Dyslipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C), is a key risk factor for atherosclerotic cardiovascular disease (ASCVD), and lipid-lowering drugs are beneficial for the primary and secondary prevention of cardiovascular (CV) disease. While statins are clear first-line drugs, new drug developments such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes when added to statins. Evolocumab reduced the risk of cardiovascular events in patients with ASCVD when added to maximally tolerated statin therapy (± ezetimibe), and recent data from the ODYSSEY OUTCOMES trial indicate that alirocumab added to maximally tolerated statin therapy (± other lipid-lowering drugs) reduces the risk of cardiovascular events in patients with a recent acute coronary syndrome. In this article the authors review the available data on the effect of PCSK9 inhibitors on cardiovascular outcomes.Areas covered: This article reviews the available data on the effect of PCSK9 inhibitors on CV outcomes. Relevant papers were identified from a search of PubMed/Medline and the Cochrane Central Register of Controlled Trials (CENTRAL).Expert opinion: The authors conclude that PCSK9 inhibitors provide substantial and durable reductions in LDL-C levels and improve cardiovascular outcomes.
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Affiliation(s)
- Daniel Steffens
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Céline Scheeff
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Kasner
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Adel Hassanein
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Friebel
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
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135
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Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines. Kidney Int 2019; 97:266-278. [PMID: 31866114 DOI: 10.1016/j.kint.2019.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/06/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.
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136
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Martin SS, Giugliano RP, Murphy SA, Wasserman SM, Stein EA, Ceška R, López-Miranda J, Georgiev B, Lorenzatti AJ, Tikkanen MJ, Sever PS, Keech AC, Pedersen TR, Sabatine MS. Comparison of Low-Density Lipoprotein Cholesterol Assessment by Martin/Hopkins Estimation, Friedewald Estimation, and Preparative Ultracentrifugation: Insights From the FOURIER Trial. JAMA Cardiol 2019; 3:749-753. [PMID: 29898218 DOI: 10.1001/jamacardio.2018.1533] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Recent studies have shown that Friedewald underestimates low-density lipoprotein cholesterol (LDL-C) at lower levels, which could result in undertreatment of high-risk patients. A novel method (Martin/Hopkins) using a patient-specific conversion factor provides more accurate LDL-C levels. However, this method has not been tested in proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor-treated patients. Objective To investigate accuracy of 2 different methods for estimating LDL-C levels (Martin/Hopkins and Friedewald) compared with gold standard preparative ultracentrifugation (PUC) in patients with low LDL-C levels in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Patients With Elevated Risk (FOURIER) trial. Design, Setting, and Participants The FOURIER trial was a randomized clinical trial of evolocumab vs placebo added to statin therapy in 27 564 patients with stable atherosclerotic cardiovascular disease. The patients' LDL-C levels were assessed at baseline, 4 weeks, 12 weeks, 24 weeks, and every 24 weeks thereafter, and measured directly by PUC when the level was less than 40 mg/dL per the Friedewald method (calculated as non-HDL-C level - triglycerides/5). In the Martin/Hopkins method, patient-specific ratios of triglycerides to very low-density lipoprotein cholesterol (VLDL-C) ratios were determined and used to estimate VLDL-C, which was subtracted from the non-HDL-C level to obtain the LDL-C level. Main Outcomes and Measures Low-density lipoprotein cholesterol calculated by the Friedewald and Martin/Hopkins methods, with PUC as the reference method. Results For this analysis, the mean (SD) age was 62.7 (9.0) years; 2885 of the 12 742 patients were women (22.6%). A total of 56 624 observations from 12 742 patients had Friedewald, Martin/Hopkins, and PUC LDL-C measurements. The median difference from PUC LDL-C levels for Martin/Hopkins LDL-C levels was -2 mg/dL (interquartile range [IQR], -4 to 1 mg/dL) and for Friedewald LDL-C levels was -4 mg/dL (IQR, -8 to -1 mg/dL; P < .001). Overall, 22.9% of Martin/Hopkins LDL-C values were more than 5 mg/dL different than PUC values, and 2.6% were more than 10 mg/dL different than PUC levels. These were significantly less than respective proportions with Friedewald estimation (40.1% and 13.3%; P < .001), mainly because of underestimation by the Friedewald method. The correlation with PUC LDL-C was significantly higher for Martin/Hopkins vs Friedewald (ρ, 0.918 [95% CI 0.916-0.919] vs ρ, 0.867 [0.865-0.869], P < .001). Conclusions and Relevance In patients achieving low LDL-C with PCSK9 inhibition, the Martin/Hopkins method for LDL-C estimation more closely approximates gold standard PUC than Friedewald estimation does. The Martin/Hopkins method may prevent undertreatment because of LDL-C underestimation by the Friedewald method. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
- Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Evan A Stein
- Metabolic and Atherosclerosis Research Center, Cincinnati, Ohio
| | - Richard Ceška
- Center of Preventive Cardiology, 3rd Department Internal Medicine, University General Hospital and First Medical Faculty, Prague, Czech Republic
| | - José López-Miranda
- Lipids and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Cordoba, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObN), Cordoba, Spain
| | | | | | - Matti J Tikkanen
- Folkhälsan Research Center, University of Helsinki, Helsinki, Finland
| | - Peter S Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, England
| | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Deputy Editor
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Sabatine MS, Wiviott SD, Im K, Murphy SA, Giugliano RP. Efficacy and Safety of Further Lowering of Low-Density Lipoprotein Cholesterol in Patients Starting With Very Low Levels: A Meta-analysis. JAMA Cardiol 2019; 3:823-828. [PMID: 30073316 DOI: 10.1001/jamacardio.2018.2258] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance In the Cholesterol Treatment Trialists Collaboration (CTTC), in patients starting with low-density lipoprotein cholesterol (LDL-C) levels of approximately 3.4 mmol/L (131.5 mg/dL), there was a 22% reduction in major vascular events per 1-mmol/L (38.7-mg/dL) lowering of LDL-C. The magnitude of clinical benefit of further LDL-C lowering in patients already with very low LDL-C levels remains debated. Objective To evaluate efficacy and safety of further lowering LDL-C levels in patient populations presenting with median LDL-C levels of 1.8 mmol/L (70 mg/dL) or less. Data Sources and Study Selection The CTTC was used for statin data. For nonstatin therapy, Medline database was searched (2015-April 2018). Key inclusion criteria were a randomized, double-blind, controlled cardiovascular outcome trial of LDL-C lowering with data in populations starting with LDL-C levels averaging 1.8 mmol/L (70 mg/dL) or less. Data Extraction and Synthesis Two authors independently extracted data into standardized data sheets, and data were analyzed using meta-analysis. Main Outcomes and Measures The risk ratio (RR) of major vascular events (a composite of coronary heart death, myocardial infarction, ischemic stroke, or coronary revascularization) per 1-mmol/L (38.7-mg/dL) reduction in LDL-C level. Results In the subgroup of patients from the CTTC meta-analysis of statins with a mean LDL-C in the control arm of 1.7 mmol/L (65.7 mg/dL), 1922 major vascular events occurred and the RR for major vascular events per 1-mmol/L (38.7-mg/dL) reduction in LDL-C was 0.78 (95% CI, 0.65-0.94). For 3 trials of nonstatin LDL-C-lowering therapies added to statins, there were 50 627 patients, the median LDL-C in the control arms ranged from 1.6 mmol/L to 1.8 mmol/L (63 mg/dL to 70 mg/dL), and 9570 major vascular events occurred. Nonstatin therapy lowered LDL-C by 0.3 to 1.2 mmol/L (11 mg/dL to 45 mg/dL), and the RR for major vascular events per 1-mmol/L (38.7-mg/dL) reduction in LDL-C was 0.79 (95% CI, 0.70-0.88). For statins and nonstatins combined, the RR was 0.79 (95% CI, 0.71-0.87; P < .001). Low-density lipoprotein cholesterol lowering was not associated with an increased risk of serious adverse events, myalgias and/or myositis, elevation in the level of aminotransferases, new-onset diabetes, hemorrhagic stroke, or cancer. Conclusions and Relevance There is a consistent relative risk reduction in major vascular events per change in LDL-C in patient populations starting as low as a median of 1.6 mmol/L (63 mg/dL) and achieving levels as low as a median of 0.5 mmol/L (21 mg/dL), with no observed offsetting adverse effects. These data suggest further lowering of LDL-C beyond the lowest current targets would further reduce cardiovascular risk.
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Affiliation(s)
- Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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138
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Stone ML, Richardson MR, Guevara L, Rand BG, Churilla JR. Elevated Serum Uric Acid and Self-Reported Heart Failure in US Adults: 2007-2016 National Health and Nutrition Examination Survey. Cardiorenal Med 2019; 9:344-353. [PMID: 31553984 DOI: 10.1159/000502438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There is limited evidence examining the relationship between elevated serum uric acid (sUA) concentration and heart failure (HF) in United States (US) adults. The aim of the present study was to examine the association(s) between elevated sUA and HF using a nationally representative sample of US adults. METHODS The final sample with complete data for this analysis (n = 17,349) included men and women aged ≥40 years who participated in the 2007-2016 National Health and Nutrition Examination Survey. Self-reported diagnosis of HF was assessed via interview. Elevated sUA was defined as values >6.0 mg/dL for women and >7.2 mg/dL for men. Multivariable gender-stratified logistic regression was utilized to examine the odds of self-reported HF. RESULTS The estimated prevalence of HF was 3.9 and 3.4% among men and women, respectively. Age-adjusted analysis revealed significantly increased odds of HF in men (OR 2.79; 95% CI 2.15-3.84, p < 0.01) and women (OR 3.24; 95% CI 2.37-4.44, p < 0.01) with elevated sUA. This relationship remained statistically significant following adjustment for age, race, education, income, alcohol consumption, smoking status, blood pressure, diabetes, physical activity level, cholesterol, creatinine level, and body mass index in men (OR 1.70; 95% CI 1.13-2.57 p < 0.05) and women (OR 1.74; 95% CI 1.18-2.58, p < 0.05). CONCLUSIONS In a representative sample of US adults, having an elevated sUA concentration was associated with significantly increased odds of HF when compared to adults with normal sUA.
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Affiliation(s)
- Michelle L Stone
- Department of Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida, USA,
| | - Michael R Richardson
- Department of Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida, USA
| | - Larry Guevara
- Department of Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida, USA
| | - Bethany G Rand
- Department of Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida, USA
| | - James R Churilla
- Department of Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida, USA
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139
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Vani A, Underberg JA. Lowering LDL-Cholesterol and CV Benefits: Is There a Limit to How Low LDL-C Needs to be for Optimal Health Benefits? Clin Pharmacol Ther 2019; 104:290-296. [PMID: 29882959 DOI: 10.1002/cpt.1133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/31/2018] [Indexed: 11/10/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the number one cause of morbidity and mortality worldwide. Low-density lipoprotein cholesterol (LDL-C) has been implicated as one of the major risk factors causing ASCVD based on multiple hierarchical levels of evidence. The advent of powerful LDL-C lowering therapies, such as the proprotein convertase subtilisin/kexin type 9 inhibitor, have raised the question of how low to target LDL-C and whether there are any adverse safety events associated with a very low LDL-C level. The present review summarizes the available evidence and concludes that even a very low LDL-C is associated with cardiovascular benefit, although the magnitude of benefit depends on baseline ASCVD risk and the absolute change in LDL-C with pharmacologic therapy. The safety data in patients treated for very low LDL-C is reassuring, although it is inconsistent and requires longer term follow-up.
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Affiliation(s)
- Anish Vani
- Department of Medicine, New York University Langone Medical Center, New York, New York, USA
| | - James A Underberg
- Department of Medicine, New York University Langone Medical Center, New York, New York, USA
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140
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Abstract
The 2013 ACC/AHA guidelines on blood cholesterol management were a major shift in the delineation of the main patient groups that could benefit from statin therapy and emphasized the use of higher-intensity statin therapies. In 2016, an expert consensus panel from the ACC recommended the use of nonstatin therapies (ezetimibe and PCSK9 inhibitors) in addition to maximally tolerated statin therapy in individuals whose LDL-cholesterol and non-HDL-cholesterol levels remained above certain thresholds after statin treatment. Given the substantial benefits of statin therapies in both primary and secondary prevention of cardiovascular disease, their long-term safety has become a concern. The potential harmful effects of statin therapy on muscle and liver have been known for some time, but new concerns have emerged regarding the risk of new-onset diabetes mellitus, cognitive impairment and haemorrhagic stroke associated with the use of statins and the risks of achieving very low levels of LDL cholesterol. The increased media attention on the adverse events associated with statins has unfortunately led to statin therapy discontinuation, nonadherence to therapy or concerns about initiating statin therapy. In this Review, we explore the safety of statin therapy in light of the latest evidence and provide clinicians with reassurance about the safety of statins. Overwhelming evidence suggests that the benefits of statin therapy far outweigh any real or perceived risks.
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Affiliation(s)
- Bhavin B Adhyaru
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Terry A Jacobson
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA. .,Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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141
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Parhofer KG, von Stritzky B, Pietschmann N, Dorn C, Paar WD. PEARL: A Non-interventional Study of Real-World Alirocumab Use in German Clinical Practice. Drugs Real World Outcomes 2019; 6:115-123. [PMID: 31280466 PMCID: PMC6702526 DOI: 10.1007/s40801-019-0158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Several lipid guidelines recommend that proprotein convertase subtilisin/kexin type 9 inhibitors should be considered for patients with atherosclerotic cardiovascular disease who are inadequately treated with maximally tolerated lipid-lowering treatment. OBJECTIVES The PEARL study assessed the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab in patients with hypercholesterolemia in a real-world setting. METHODS PEARL was an open, prospective, multicenter, non-interventional study conducted in Germany. Patients (n = 619) for whom treating physicians decided to use alirocumab 75 or 150 mg every 2 weeks according to German guidelines (low-density lipoprotein cholesterol > 1.8/2.6 mmol/L [> 70/100 mg/dL], depending on cardiovascular risk, despite maximally tolerated statin therapy with/without other non-alirocumab lipid-lowering therapy) were enrolled and followed for 24 weeks. Physicians could adjust the alirocumab dose based on their clinical judgment. The primary efficacy endpoint was low-density lipoprotein cholesterol reduction from baseline (prior to alirocumab therapy) to week 24. RESULTS Overall, 72.8% of patients reported complete or partial statin intolerance. Mean low-density lipoprotein cholesterol was 4.7 mmol/L (180.5 mg/dL) and 2.3 mmol/L (89.8 mg/dL) at baseline and week 24, respectively. Least-squares mean percentage change from baseline to week 24 in low-density lipoprotein cholesterol was - 48.6%. Initial alirocumab dose was 75 mg in 72.9% of patients and 150 mg in 24.5% of patients; 19.6% of patients received an alirocumab dose increase (75 to 150 mg) and 1.6% of patients received a dose decrease. Adverse events were reported in 10.3% of patients, with myalgia being the most common. CONCLUSIONS In a real-world setting in Germany, alirocumab was used in patients who had high baseline low-density lipoprotein cholesterol levels with/without statin intolerance. Efficacy and safety were consistent with findings observed in the ODYSSEY Phase III program.
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Affiliation(s)
- Klaus G Parhofer
- Medical Department IV-Grosshadern, University of Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | | | | | - Cornelia Dorn
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - W Dieter Paar
- Medical Department, Sanofi-Aventis Deutschland GmbH, Berlin, Germany
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142
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Abstract
An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations.
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143
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Abstract
PURPOSE OF REVIEW The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed. RECENT FINDINGS Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance. SUMMARY Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.
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144
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Berman AN, Blankstein R. Optimizing Dyslipidemia Management for the Prevention of Cardiovascular Disease: a Focus on Risk Assessment and Therapeutic Options. Curr Cardiol Rep 2019; 21:110. [PMID: 31378838 DOI: 10.1007/s11886-019-1175-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Primary prevention of incident atherosclerotic cardiovascular disease (ASCVD) as well as decreasing the risk of future events in those with established atherosclerosis is critical from a public health perspective. Management of dyslipidemias constitutes a key target in decreasing the risk of developing ASCVD events. While there have been great strides in the treatment of dyslipidemia over the last three decades, there are important recent developments and ongoing research that will expand the available therapeutic options and enable further cardiovascular risk reduction. PURPOSE OF REVIEW: The purpose of this paper is to review new developments relating to the primary prevention and management of ASCVD with a specific focus on optimizing the treatment of dyslipidemias. RECENT FINDINGS: In the realm of ASCVD risk prediction, mounting evidence over the last decade has demonstrated that coronary artery calcium testing is superior to any serum biomarker in the prediction of future ASCVD events and in discriminating future cardiovascular risk. As such, it has been incorporated into the most recent ACC/AHA primary prevention guideline to help guide management decisions in select patients. In terms of the management of dyslipidemias, PCSK9 inhibitors lower LDL-C by 50-70% and provide an additional 15% reduction in key cardiovascular events in high-risk patients with known ASCVD, as demonstrated in the ODYSSEY and FOURIER trials. Cholesteryl ester transfer protein (CETP) inhibitors, which significantly increase HDL-C levels, demonstrated mixed results in large clinical trials and have helped reframe HDL-C as a risk marker rather than a modifiable risk factor. In regard to the management of triglycerides, the REDUCE-IT trial demonstrated a nearly 5% absolute reduction in key cardiovascular events with a highly purified fish-oil derivative named icosapent ethyl in high-risk patients already on statin therapy. Finally, in regard to lipoprotein(a)-which is a strong risk factor for ASCVD-there are exciting developments in the therapeutic pipeline which reduce circulating lipoprotein(a) levels by nearly 90%. The management of dyslipidemias continues to be an exciting field with several ongoing cardiovascular outcomes trials, improvement in risk prediction models, and new therapeutic agents in the pipeline that will further mitigate residual cardiovascular risk in both primary and secondary prevention patients.
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Affiliation(s)
- Adam N Berman
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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145
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Alkhalil M. Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors, Reality or Dream in Managing Patients with Cardiovascular Disease. Curr Drug Metab 2019; 20:72-82. [PMID: 30112987 DOI: 10.2174/1389200219666180816141827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/28/2018] [Accepted: 08/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Statins have been a major keystone in the management of patients with atherosclerotic cardiovascular disease. The benefits of inhibiting HMG CoA reductase, via statins, were translated into reduction in LDL-c with proportionate decrease in cardiovascular events in response to the magnitude of LDL-c reduction. Despite major advances in pharmacological treatments, including the use of high-dose statins, there are urgent need to further reduce future cardiovascular risk. This is in particularly important since 1 out of 5 high-risk atherosclerotic patients who achieve low LDL-c return with a second cardiovascular event within five years. Although this residual risk post-statin is largely heterogeneous, lowering LDL-c beyond 'normal' or guidelines-recommended level using novel therapies has resulted in further reduction in cardiovascular events. OBJECTIVE The current review will discuss the use of PCSK9 inhibitors in patients with atherosclerotic disease. PCSK9 inhibitors are a new class of lipid-lowering drugs that are either fully human monoclonal antibodies (evolocumab and alirocumab) or humanised monoclonal antibodies (bococizumab) that effectively reduce LDL-c to unprecedented level. By blocking circulating PCSK9, these drugs would preserve LDL receptors and prevent them from cellular degradation. This process promotes recycling of LDL receptors back to hepatocytes surface, leading into further reduction of LDL-c. Combining PCSK9 inhibitors with statin have led into lower LDL-c, reduction in plaque volume and more importantly reduction in future cardiovascular events. CONCLUSION These drugs are very promising, nonetheless, the unselective approach of applying these monoclonal antibodies may not prove to be cost-effective and potentially exposing some patients to unnecessary side effects.
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Affiliation(s)
- Mohammad Alkhalil
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.,Cardiology Department, Royal Victoria Hospital, Belfast HSC Trust, Belfast, United Kingdom
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146
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Januzzi JL, Ahmad T, Binder LG, Hucker WJ, Kumbhani DJ, Maddox TM, Marine JE, Morris PB. 2019 Methodology for Creating Expert Consensus Decision Pathways: A Report of the American College of Cardiology. J Am Coll Cardiol 2019; 74:1138-1150. [PMID: 31350041 DOI: 10.1016/j.jacc.2019.05.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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147
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Abstract
PURPOSE OF REVIEW To distinguish extreme and very high atherosclerotic cardiovascular disease (ASCVD) event risk based on prospective epidemiological studies and clinical trial results. RECENT FINDINGS Clinical practice guidelines have categorized patients with either a history of one or more "clinical ASCVD" events or "coronary heart disease (CHD) risk equivalency" to be at "very high risk" for a recurrence or a first event, respectively. A 20% or greater 10-year ASCVD risk for a composite 3-point "major" atherosclerotic cardiovascular event (MACE) of non-fatal myocardial infarction (MI), non-fatal stroke, or cardiovascular death can serve as an arbitrary definition of those at "very high risk." Exclusion of stroke may underestimate risk of "hard" endpoint 10-year ASCVD risk and addition of other potential endpoints, e.g., hospital admission for unstable angina or revascularization, a 5-point composite MACE, may overinflate the risk definitions and categorization. "Extreme" risk, a descriptor for even higher morbidity and mortality potential, defines a 30% or greater 10-year 3-point MACE (ASCVD) risk. In prospective, epidemiological studies and randomized clinical trial (RCT) participants with an initial acute coronary syndrome (ACS) within several months of entry into the study meet the inclusion criteria assignment for extreme risk. In survivors beyond the first year of an ASCVD event, "extreme" risk persists when one or more comorbidities are present, including diabetes, heart failure (HF), stage 3 or higher chronic kidney disease (CKD), familial hypercholesterolemia (FH), and poorly controlled major risk factors such as hypertension and persistent tobaccoism. "Extreme" risk particularly applies to those with progressive or multiple clinical ASCVD events in the same artery, same arterial bed, or polyvascular sites, including unstable angina and transient ischemic events. Identifying asymptomatic individuals with extensive subclinical ASCVD at "extreme" risk is a challenge, as risk engine assessment may not be adequate; individuals with genetic FH or those with diabetes and Agatston coronary artery calcification (CAC) scores greater than 1000 exemplify such threatening settings and opportunities for aggressive primary prevention. Heterogeneity exists among individuals at risk for clinical ASCVD events; identifying those at "extreme" risk, a more ominous ASCVD category, associated with greater morbidity and mortality, should prompt the most effective global cardiometabolic risk reduction.
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Affiliation(s)
- Paul D Rosenblit
- Department Medicine, Division Endocrinology, Diabetes, Metabolism, University California, Irvine (UCI), School of Medicine, Irvine, CA, 92697, USA.
- Diabetes Out-Patient Clinic, UCI Medical Center, Orange, CA, 92868, USA.
- Diabetes/Lipid Management & Research Center, 18821 Delaware St., Suite 202, Huntington Beach, CA, 92648, USA.
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148
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Wang Y, Nichol MB, Yan BP, Wu J, Tomlinson B, Lee VW. Descriptive analysis of real-world medication use pattern of statins and antiplatelet agents among patients with acute coronary syndrome in Hong Kong and the USA. BMJ Open 2019; 9:e024937. [PMID: 31315855 PMCID: PMC6661883 DOI: 10.1136/bmjopen-2018-024937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The objective was to explore the differences in medication use pattern of lipid-lowering drug (LLD) and antiplatelet agents among post-percutaneous coronary intervention patients with acute coronary syndrome aged <65 in Hong Kong (HK) and the USA. DESIGN Retrospective study. SETTING This study used deidentified claims data from Clinformatics Data Mart database (OptumInsight, Eden Prairie, Minnesota, USA) and electronic health records from HK Hospital Authority Clinical Data Analysis and Reporting System database. PARTICIPANTS We used 1 year prescription records of LLDs and antiplatelet agents among 1013 USA patients and 270 HK Chinese patients in 2011-2013. PRIMARY AND SECONDARY OUTCOME MEASURES Continuity was investigated on the assumption that one defined daily dose represented 1 day treatment. Medication possession ratio method was used to evaluate the adherence. Multivariate-adjusted logistic regressions were constructed to compare the good continuity and adherence levels in the merged database with the cutoffs set at 80%, and Cox proportional hazard models were built using the time to discontinuation as the dependent variable, to assess the persistence level. RESULTS HK Chinese patients were less adherent (67.41% vs 84.60%, adjusted odds ratio (AOR) for Americans over Chinese=2.23 (95% CI=1.60 to 3.12), p<0.001) to antiplatelet agents compared with American patients but better adherent to statins (90.00% vs 78.18%, AOR=0.37 (0.23 to 0.58), p<0.001). The discontinuation with statins was more common in American patients (13.33% vs 34.25%, adjusted hazard ratio (AHR)=2.95 (2.05 to 4.24), p<0.001). Low-to-moderate potency statins and clopidogrel were favoured by our HK local physicians, while American patients received higher doses of statins and prasugrel. CONCLUSIONS We seemed to find HK physicians tended to prescribe cheaper and lower doses of statins and antiplatelet agents when compared with the privately insured patients in the USA, though the adherence and persistence levels of HK patients with statins were relatively good.
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Affiliation(s)
- Yun Wang
- Peninsula Clinical School, Monash University, Clayton, Victoria, Australia
| | - Michael B Nichol
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Bryan Py Yan
- Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Joanne Wu
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Brian Tomlinson
- Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Vivian Wy Lee
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
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149
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TIMI risk score for secondary prevention of recurrent cardiovascular events in a real-world cohort of post-non-ST-elevation myocardial infarction patients. Postgrad Med J 2019; 95:372-377. [DOI: 10.1136/postgradmedj-2019-136404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 12/23/2022]
Abstract
BackgroundPatients who survive non-ST-elevation myocardial infarction (NSTEMI) are at heightened risk of recurrent cardiovascular events. Data on long-term secondary atherothrombotic risk stratification are limited.ObjectivesTo stratify post-NSTEMI patients for risk of recurrent cardiovascular events to maximise benefit from aggressive secondary prevention strategies using the TIMI Risk Score for Secondary Prevention (TRS 2°P) score in a real-world cohort of NSTEMI patients.Methods and resultsThis was a single-centre observational study of 891 post-NSTEMI patients (73.7 ± 12.7 years; male: 54.2%). The TRS 2°P is a nine-point risk stratification tool to predict cardiovascular events in patients with established cardiovascular disease. The primary outcome was a composite endpoint of cardiovascular death, non-fatal MI and non-fatal ischaemic stroke. After a median follow-up of 31 months (IQR: 11.4 – 60.2), 281 patients (31.5%) had developed a primary outcome (13.3%/year) including 196 cardiovascular deaths, 94 non-fatal MIs and 22 non-fatal strokes. The TRS 2°P score was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P score =0 was 1.6%, and increased progressively to 47.4% for those with a TRS 2°P score ≥6 (HR: 20.18, 95% CI: 4.85 to 84.05, p<0.001). Similar associations were also observed between the TRS 2°P score and cardiovascular death and MI (fatal and non-fatal), but not non-fatal ischaemic stroke.ConclusionThe TRS 2°P score stratified post-NSTEMI patients for risk of future cardiovascular events and potentially help guide the selection of more aggressive secondary prevention therapy.
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150
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Robinson JG, Jayanna MB, Brown AS, Aspry K, Orringer C, Gill EA, Goldberg A, Jones LK, Maki K, Dixon DL, Saseen JJ, Soffer D. Enhancing the value of PCSK9 monoclonal antibodies by identifying patients most likely to benefit. A consensus statement from the National Lipid Association. J Clin Lipidol 2019; 13:525-537. [DOI: 10.1016/j.jacl.2019.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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