Efficacy and Safety of Loading-Dose Rosuvastatin Therapy in Elderly Patients with Acute Coronary Syndromes Undergoing Elective Percutaneous Coronary Intervention

Treatment of dyslipidemia in acute coronary syndrome

Despite numerous improvements in the management of acute coronary syndrome(ACS), it is a major cause of mortality in India. Lipids play a critical role in pathogenesis of ACS and reduction of lipid parameters plays a pivotal role in secondary prevention. High total cholesterol and high low-density lipoprotein(LDL) are the major lipid abnormalities globally as well as in Indians. Among all the lipid parameters, LDL is the primary target of lipid-lowering therapies across the globe. High-dose statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and bempedoic acid are recommended therapies for LDL reduction in ACS patients. Statins have pleiotropic effects on the modulation of thrombogenesis, endothelial dysfunction, and myocardial protection. Multiple randomised controlled trials and meta-analyses have shown that the use of high-dose statin has significant benefits in ACS. LDL reduction goal is < 55 mg/dl or at least 50 % reduction from the baseline regardless of age or gender. Non-fasting LDL should be measured soon after the ACS as it varies minimally with food intake. The first line of therapy after ACS is to advise lifestyle modifications, combination therapy including high-dose statin with ezetimibe, and evaluation after 4-6 weeks of the index event. If the goal is not achieved then PCSK 9 inhibitors or Bempedoic acid should be used in combination with statins and ezetimibe to reduce recurrent ischaemic events. Despite the proven effect of these lipid-lowering therapies, undertreatment is still a big hurdle across the globe. Prohibitive costs, adverse effects, medication non-adherence, variation in health practice in different countries, and clinical inertia to prescribe this medication by physicians are the main reasons for the undertreatment.

Rosuvastatin plus ticagrelor decreases the risk of major adverse cardiovascular events and elevates cardiac function compared with ticagrelor alone in patients undergoing percutaneous coronary intervention: A meta‑analysis

Several previous studies have reported that rosuvastatin plus ticagrelor is superior to ticagrelor monotherapy in patients receiving percutaneous coronary intervention (PCI); several others, however, dispute this. The present meta-analysis summarized relevant studies, aiming to comprehensively explore the efficacy of rosuvastatin plus ticagrelor vs. ticagrelor monotherapy in patients receiving PCI. Published studies comparing the efficacy between rosuvastatin plus ticagrelor and ticagrelor alone among patients receiving PCI were searched in the CNKI, Wanfang, CQVIP, EMBASE, Cochrane and PubMed databases until January 2023. The present meta-analysis included 3 cohort studies and 4 randomized controlled trials with 426 patients receiving rosuvastatin plus ticagrelor and 424 patients receiving ticagrelor monotherapy. Rosuvastatin plus ticagrelor decreased the occurrence of major adverse cardiovascular events (MACE) compared with ticagrelor [relative risk (RR), 0.29; 95% confidence interval (CI), 0.18-0.47]. Subgroup analysis revealed similar findings in studies with a follow-up of <6 months (RR, 0.24; 95% CI, 0.13-0.47) and ≥6 months (RR, 0.36; 95% CI, 0.18-0.70), as well as in studies using 10 mg rosuvastatin (RR, 0.27; 95% CI, 0.15-0.50) and 20 mg rosuvastatin (RR, 0.33; 95% CI, 0.16-0.69). In addition, rosuvastatin plus ticagrelor decreased the left ventricular (LV) end-systolic diameter [mean difference (MD), -0.71; 95% CI, -(1.36-0.07)], LV end-diastolic diameter [MD, -1.17; 95% CI, -(1.91-0.43)] and N-terminal pro-B-type natriuretic peptide [MD, -2.97; 95% CI, -(4.55-1.38)], and increased the LV ejection fraction (MD, 0.99; 95% CI, 0.74-1.25). In conclusion, rosuvastatin plus ticagrelor was shown to decrease the risk of MACE and elevate cardiac function compared with ticagrelor monotherapy in patients receiving PCI.

Intensive vs non-intensive statin pretreatment before percutaneous coronary intervention in Chinese patients: A meta-analysis of randomized controlled trials

BACKGROUND

The results of intensive statin pretreatment before percutaneous coronary intervention (PCI) is inconsistent between Chinese and Western populations, and there are no corresponding meta-analyses involving hard clinical endpoints in the available published literature.

AIM

To evaluate the efficacy and safety of high-dose statin loading before PCI in Chinese patients through a meta-analysis.

METHODS

Relevant studies were identified by searching the electronic databases of PubMed, Embase and Cochrane’s Library to December 2019. The outcomes included an assessment of major adverse cardiovascular event (MACE), non-fatal myocardial infarction (MI), cardiac death, target vessel revascularization (TVR), myalgia /myasthenia and abnormal alanine aminotransferase (ALT) in all enrolled patients. Random effect model and fixed effect model were applied to combine the data, which were further analyzed by χ² test and I² test. The main outcomes were then analyzed through the use of relative risks (RR) and its 95% confidence interval (95%CI).

RESULTS

Eleven studies involving 3123 individuals were included. Compared with patients receiving placebo or no statin treatment before surgery, intensive statin treatment was associated with a clear reduction of risk of MACE (RR = 0.44, 95%CI: 0.31-0.61, P < 0.00001). However, compared with the patients receiving moderate-intensity statin before surgery, no advantage to intensive statin treatment was seen (RR = 1.04, 95%CI: 0.82-1.31, P = 0.74). In addition, no significant difference was observed between intensive statin therapy and non-intensive statin therapy on the incidence of TVR (RR = 0.43, 95%CI: 0.18-1.02, P = 0.06) , myalgia /myasthenia (RR = 1.35, 95%CI: 0.30-5.95, P = 0.69) and abnormal alanine aminotransferase (RR = 1.47, 95%CI: 0.54-4.02, P = 0.45) except non-fatal MI (RR = 0.54, 95%CI: 0.33-0.88, P = 0.01).

CONCLUSION

Compared with placebo or no statin pretreatment, intensive statin before PCI displayed reduced incidence of MACE. However, there was no significant benefit between high and moderate-intensity statin. In addition, no significant difference was observed between intensive statin therapy and non-intensive statin therapy on the incidence of TVR, myalgia/myasthenia and abnormal alanine aminotransferase except non-fatal MI.

Effect of Statins on Serum level of hs-CRP and CRP in Patients with Cardiovascular Diseases: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background. Several studies have reported that statins have anti-inflammatory effects. Nevertheless, results of clinical trials concerning the effect of statins on the levels of C-reactive protein (CRP) and high-sensitivity CRP (hs-CRP) have been inconsistent. Therefore, we performed a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the effect of statins on CRP and hs-CRP levels in patients with cardiovascular diseases (CVDs). Methods. Literature search of the major databases was performed to find eligible RCTs assessing the effect of statins on serum levels of CRP and hs-CRP from the inception until the last week of April 2021. The effect sizes were determined for weighted mean difference (WMD) and 95% confidence intervals (CI). Results. 26 studies were identified (3010 patients and 2968 controls) for hs-CRP and 20 studies (3026 patients and 2968 controls) for CRP. Statins reduced the serum levels of hs-CRP ( $\text{WMD}=-0.97\text{mg}/\text{L}$ ; 95% CI: -1.26 to -0.68 mg/L; $P<0.001$ ) and CRP ( $\text{WMD}=-3.05\text{mg}/\text{L}$ ; 95% CI: -4.86 to -1.25 mg/L; $P<0.001$ ) in patients with CVDs. Statins decreased the serum levels of hs-CRP in patients receiving both high-intensity and moderate/low-intensity treatments with these drugs. In addition, the duration of treatment longer than 10 weeks decreased hs-CRP levels. Only high-intensity statin treatment could marginally decrease serum levels of CRP in CVDs patients. Conclusions. This meta-analysis showed the efficacy of statins to reduce the concentrations of CRP and hs-CRP in patients with different types of CVDs.

Role of Lipid-Lowering Therapy in Low-Density Lipoprotein Cholesterol Goal Attainment: Focus on Patients With Acute Coronary Syndrome

Dyslipidemia is a major risk factor for cardiovascular (CV) disease, which is the leading cause of death globally. Acute coronary syndrome (ACS) is a common cause of death, accounting for nearly half of the global burden of CV mortality. Epidemiologic studies have identified low-density lipoprotein cholesterol (LDL-C) as an independent CV risk factor, and this is now the primary target for initiating and adjusting lipid-lowering therapies in most current guidelines. Evidence from pivotal studies supports the use of high-intensity statin therapy and a lower level for optimal LDL-C in secondary prevention of atherosclerotic CV disease, especially in patients with ACS undergoing percutaneous coronary intervention. However, current research has identified a gap between the target LDL-C goal attainment and target LDL-C levels recommended by the guidelines. Statins have proven benefits in the management of CV disease and are the cornerstone of lipid-lowering management in patients with ACS. Recent randomized controlled trials have also demonstrated the benefits of cholesterol absorption inhibitors and proprotein convertase subtilisin/kexin type 9 inhibitors. This review summarizes the current evidence for LDL-lowering therapy in patients with ACS, with an emphasis on the importance of LDL-C goal attainment, rapid LDL-C lowering, and duration of LDL-C–lowering therapy.

Statin loading in cardiovascular surgery: never too early to treat

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.

Reduction of Vascular Inflammation, LDL-C, or Both for the Protection from Cardiovascular Events?

BACKGROUND

Low density lipoprotein cholesterol (LDL-C) and low grade arterial inflammation are key pathogenic factors for atherosclerosis and its manifestation, cardiovascular disease (CVD).

OBJECTIVE

In this narrative review we assessed if decreasing LDL-C levels or inflammation or both is more effective in reducing CVD events.

RESULTS

In the Scandinavian Simvastatin Survival Study (4S), all statin trials of the 90s' and the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) the benefit came from the LDL-C reduction. In the GREak and Atorvastatin Coronary heart disease Evaluation (GREACE), the Treating to New Targets (TNT), and the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trials both mechanisms in combination produced significant benefits. In the Atorvastatin for Reduction of MYocardial Damage during Angioplasty (ARMYDA) trials and the Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) with a human antibody targeting IL-1β with no lipid lowering effect, the reduction in arterial inflammation played the only beneficial role because there was no change in lipids levels.

CONCLUSION

Both LDL-C and inflammation reduction are beneficial to the reduction of CVD risk. However, canakinumab is a very expensive drug that only induced a 15% reduction in CVD events, thus drastically reducing the possibility for it to be used in clinical practice. Besides, canakinumab is associated with increased infections, some fatal. A potent statin with anti-inflammatory effects is probably the best choice for the majority of those needing hypolipidaemic drug therapy.

Effect of Stains on LDL Reduction and Liver Safety: A Systematic Review and Meta-Analysis

Background and Aim

Statin is a class of medications used to decrease low-density lipoprotein cholesterol level to prevent cardiovascular disease. However, the risk of hepatic damage caused by statin therapy is still controversial. We conducted a systematic review and meta-analysis summarizing the existing evidence of the effect of statin therapy on incidence of liver injury to clarify whether statin therapy could lead to liver function test abnormalities.

Methods

We searched the Cochrane Library, PubMed, and Embase database for the relevant studies update till Jan. 2017 regarding statin therapy and liver injury. Two researchers screened the literature independently by the selection and exclusion criteria. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using random effects models, and subgroup analyses were performed by study characteristics. This meta-analysis was performed by STATA 13.1 software.

Results

Analyses were based on 74,078 individuals from 16 studies. The summary OR of statin therapy was 1.18 (95% CI: 1.01–1.39, p = 0.04; I² = 0.0%) for liver injury. Subgroup analysis indicated that fluvastatin increased the risk of liver injury significantly (OR, 3.50; 95% CI: 1.07–11.53, p = 0.039; I² = 0.0%) and dose over 40 mg/daily had an unfavorable effect on the liver damage (OR, 3.62; 95% CI: 1.52–8.65, p = 0.004; I² = 0.0%). The sensitivity analysis indicated that the results were robust.

Conclusion

Our findings confirm that statin therapy substantially increases the risk of liver injury, especially using fluvastatin over 40 mg/d.