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Safarova M, Bimal T, Soffer DE, Hirsh B, Shapiro MD, Mintz G, Cha A, Gianos E. Advances in targeting LDL cholesterol: PCSK9 inhibitors and beyond. Am J Prev Cardiol 2024; 19:100701. [PMID: 39070027 PMCID: PMC11278114 DOI: 10.1016/j.ajpc.2024.100701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 06/07/2024] [Accepted: 06/22/2024] [Indexed: 07/30/2024] Open
Abstract
There is a direct relationship between the duration and level of exposure to low density lipoprotein cholesterol (LDL-C) levels over one's lifespan and cardiovascular events. Early treatment to lower elevated LDL-C is crucial for better outcomes with multiple therapies currently available to reduce atherogenic lipoproteins. Statins remain the foundation of LDL-C lowering therapy as one of the most cost-effective drugs to reduce atherosclerotic events (ASCVD) and mortality. Nonetheless, LDL-driven goal attainment remains suboptimal globally, highlighting a considerable need for non-statin therapies to address residual risk related to statin intolerance, non-adherence, and inherited lipoprotein disorders. LDL-C lowering interventions beyond statins include ezetimibe, PCSK9 monoclonal antibodies, inclisiran and bempedoic acid with specific guideline recommendations as to when to consider each. For patients with homozygous familial hypercholesterolemia requiring more advanced therapy, lomitapide and evinacumab are available, providing mechanisms that are not LDL receptor dependent. Lipoprotein apheresis remains an effective option for clinical familial hypercholesterolemia as well as elevated lipoprotein (a). There are investigational therapies being explored to add to our current armamentarium including CETP inhibitors, a third-generation PCSK9 inhibitor (small recombinant fusion protein oral PCSK9 inhibitor) and gene editing which aims to directly restore or disrupt genes of interest at the DNA level. This article is a brief review of the pharmacotherapy options beyond statins for lowering LDL-C and their impact on ASCVD risk reduction. Our primary aim is to guide physicians on the role these therapies play in achieving appropriate LDL-C goals, with an algorithm of when to consider each based on efficacy, safety and outcomes.
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Affiliation(s)
- Maya Safarova
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI USA
| | - Tia Bimal
- Northwell, New Hyde Park, NY, Cardiovascular Institute, Lenox Hill Hospital, USA
| | - Daniel E. Soffer
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Benjamin Hirsh
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, USA
- Northwell, New Hyde Park, NY, Cardiovascular Institute, Sandra Atlas Bass Heart Hospital, USA
| | - Michael D. Shapiro
- Center for the Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Guy Mintz
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, USA
- Northwell, New Hyde Park, NY, Cardiovascular Institute, Sandra Atlas Bass Heart Hospital, USA
| | - Agnes Cha
- Northwell/Vivo Health Pharmacy, Ambulatory Pharmacy Services, Lake Success, NY, USA
| | - Eugenia Gianos
- Northwell, New Hyde Park, NY, Cardiovascular Institute, Lenox Hill Hospital, USA
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Hempstead, NY, USA
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Tschiderer L, Seekircher L, Izzo R, Mancusi C, Manzi MV, Baldassarre D, Amato M, Tremoli E, Veglia F, Tuomainen TP, Kauhanen J, Voutilainen A, Iglseder B, Lind L, Rundek T, Desvarieux M, Kato A, de Groot E, Aşçi G, Ok E, Agewall S, Beulens JWJ, Byrne CD, Calder PC, Gerstein HC, Gresele P, Klingenschmid G, Nagai M, Olsen MH, Parraga G, Safarova MS, Sattar N, Skilton M, Stehouwer CDA, Uthoff H, van Agtmael MA, van der Heijden AA, Zozulińska-Ziółkiewicz DA, Park HW, Lee MS, Bae JH, Beloqui O, Landecho MF, Plichart M, Ducimetiere P, Empana JP, Bokemark L, Bergström G, Schmidt C, Castelnuovo S, Calabresi L, Norata GD, Grigore L, Catapano A, Zhao D, Wang M, Liu J, Ikram MA, Kavousi M, Bots ML, Sweeting MJ, Lorenz MW, Willeit P. Association of Intima-Media Thickness Measured at the Common Carotid Artery With Incident Carotid Plaque: Individual Participant Data Meta-Analysis of 20 Prospective Studies. J Am Heart Assoc 2023:e027657. [PMID: 37301757 DOI: 10.1161/jaha.122.027657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023]
Abstract
Background The association between common carotid artery intima-media thickness (CCA-IMT) and incident carotid plaque has not been characterized fully. We therefore aimed to precisely quantify the relationship between CCA-IMT and carotid plaque development. Methods and Results We undertook an individual participant data meta-analysis of 20 prospective studies from the Proof-ATHERO (Prospective Studies of Atherosclerosis) consortium that recorded baseline CCA-IMT and incident carotid plaque involving 21 494 individuals without a history of cardiovascular disease and without preexisting carotid plaque at baseline. Mean baseline age was 56 years (SD, 9 years), 55% were women, and mean baseline CCA-IMT was 0.71 mm (SD, 0.17 mm). Over a median follow-up of 5.9 years (5th-95th percentile, 1.9-19.0 years), 8278 individuals developed first-ever carotid plaque. We combined study-specific odds ratios (ORs) for incident carotid plaque using random-effects meta-analysis. Baseline CCA-IMT was approximately log-linearly associated with the odds of developing carotid plaque. The age-, sex-, and trial arm-adjusted OR for carotid plaque per SD higher baseline CCA-IMT was 1.40 (95% CI, 1.31-1.50; I2=63.9%). The corresponding OR that was further adjusted for ethnicity, smoking, diabetes, body mass index, systolic blood pressure, low- and high-density lipoprotein cholesterol, and lipid-lowering and antihypertensive medication was 1.34 (95% CI, 1.24-1.45; I2=59.4%; 14 studies; 16 297 participants; 6381 incident plaques). We observed no significant effect modification across clinically relevant subgroups. Sensitivity analysis restricted to studies defining plaque as focal thickening yielded a comparable OR (1.38 [95% CI, 1.29-1.47]; I2=57.1%; 14 studies; 17 352 participants; 6991 incident plaques). Conclusions Our large-scale individual participant data meta-analysis demonstrated that CCA-IMT is associated with the long-term risk of developing first-ever carotid plaque, independent of traditional cardiovascular risk factors.
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Affiliation(s)
- Lena Tschiderer
- Institute of Health Economics Medical University of Innsbruck Innsbruck Austria
| | - Lisa Seekircher
- Institute of Health Economics Medical University of Innsbruck Innsbruck Austria
| | - Raffaele Izzo
- Department of Advanced Biomedical Sciences Federico II University Naples Italy
| | - Costantino Mancusi
- Department of Advanced Biomedical Sciences Federico II University Naples Italy
| | - Maria V Manzi
- Department of Advanced Biomedical Sciences Federico II University Naples Italy
| | - Damiano Baldassarre
- Department of Medical Biotechnology and Translational Medicine University of Milan Milan Italy
- Centro Cardiologico Monzino Stituto di Ricovero e Cura a Carattere Scientifico Milan Italy
| | - Mauro Amato
- Centro Cardiologico Monzino Stituto di Ricovero e Cura a Carattere Scientifico Milan Italy
| | | | | | - Tomi-Pekka Tuomainen
- Institute of Public Health and Clinical Nutrition University of Eastern Finland Kuopio Finland
| | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition University of Eastern Finland Kuopio Finland
| | - Ari Voutilainen
- Institute of Public Health and Clinical Nutrition University of Eastern Finland Kuopio Finland
| | - Bernhard Iglseder
- Department of Geriatric Medicine Gemeinnützige Salzburger Landeskliniken Betriebsgesellschaft GmbH Christian-Doppler-Klinik Salzburg Austria
- Department of Geriatric Medicine Paracelsus Medical University Salzburg Austria
| | - Lars Lind
- Department of Medicine Uppsala University Uppsala Sweden
| | - Tatjana Rundek
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Moise Desvarieux
- Department of Epidemiology, Mailman School of Public Health Columbia University New York NY
- METHODS Core, Centre de Recherche Epidémiologie et Statistique Paris Sorbonne Cité Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1153 Paris France
| | - Akihiko Kato
- Blood Purification Unit Hamamatsu University Hospital Hamamatsu Japan
| | - Eric de Groot
- Imagelabonline and Cardiovascular Erichem the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center-Academic Medical Centre Amsterdam the Netherlands
| | - Gülay Aşçi
- Nephrology Department Ege University School of Medicine Bornova-Izmir Turkey
| | - Ercan Ok
- Nephrology Department Ege University School of Medicine Bornova-Izmir Turkey
| | - Stefan Agewall
- Department of Clinical Sciences, Danderyd Hospital Division of Cardiology Karolinska Institutet Stockholm Sweden
- Institute of Clinical Sciences University of Oslo Oslo Norway
| | - Joline W J Beulens
- Department of Epidemiology and Data Science, Amsterdam University Medical Center-Location Vrije Universiteit Medical Center Amsterdam the Netherlands
| | - Christopher D Byrne
- School of Human Development and Health, Faculty of Medicine University of Southampton Southampton UK
- Southampton National Institute for Health and Care Research, Biomedical Research Centre University Hospital Southampton Southampton UK
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine University of Southampton Southampton UK
- Southampton National Institute for Health and Care Research, Biomedical Research Centre University Hospital Southampton Southampton UK
| | - Hertzel C Gerstein
- Department of Medicine and Population Health Research Institute McMaster University Hamilton Ontario Canada
- Hamilton General Hospital Hamilton Ontario Canada
| | - Paolo Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine and Surgery University of Perugia Perugia Italy
| | | | - Michiaki Nagai
- Department of Internal Medicine General Medicine and Cardiology, Hiroshima City Asa Hospital Hiroshima Japan
| | - Michael H Olsen
- Department of Internal Medicine, Holbaek Hospital University of Southern Denmark Odense Denmark
| | - Grace Parraga
- Department of Medical Biophysics, Robarts Research Institute Western University London ON Canada
| | - Maya S Safarova
- Department of Cardiovascular Medicine University of Kansas Medical Center Kansas City KS
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Michael Skilton
- Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney NSW Australia
| | - Coen D A Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht Maastricht University Medical Centre Maastricht the Netherlands
| | - Heiko Uthoff
- Department of Angiology University Hospital Basel Basel Switzerland
| | - Michiel A van Agtmael
- Department of Internal Medicine Amsterdam University Medical Center, Vrije Universiteit Amsterdam the Netherlands
| | - Amber A van der Heijden
- Department of General Practice, Amsterdam University Medical Center-Location Vrije Universiteit Medical Center Amsterdam the Netherlands
| | | | - Hyun-Woong Park
- Division of Cardiology, Department of Internal Medicine Chungnam National University Sejong Hospital Sejong-si South Korea
| | - Moo-Sik Lee
- Department of Preventive Medicine, College of Medicine Konyang University Daejeon South Korea
- Department of Occupational and Environmental Medicine Konyang University Hospital Daejeon South Korea
| | - Jang-Ho Bae
- Heart Center, Konyang University Hospital Daejeon South Korea
- Department of Cardiology Konyang University College of Medicine Daejeon South Korea
| | - Oscar Beloqui
- Department of Internal Medicine University Clinic of Navarra Navarra Spain
| | - Manuel F Landecho
- Department of Internal Medicine University Clinic of Navarra Navarra Spain
| | - Matthieu Plichart
- Paris Cardiovascular Research Centre University Paris Descartes Paris France
- Fondation Santé Service, Hospital at Home Levallois-Perret France
| | | | | | - Lena Bokemark
- Wallenberg Laboratory for Cardiovascular Research University of Gothenburg Gothenburg Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Clinical Physiology Sahlgrenska University Hospital, Region Västragötaland Gothenburg Sweden
| | - Caroline Schmidt
- Wallenberg Laboratory for Cardiovascular Research University of Gothenburg Gothenburg Sweden
| | - Samuela Castelnuovo
- Centro Dislipidemie, Aziende Socio Sanitarie Territoriali Grande Ospedale Metropolitano Niguarda Milan Italy
| | - Laura Calabresi
- Department of Pharmacological and Biomolecular Sciences University of Milan Milan Italy
| | - Giuseppe D Norata
- Department of Pharmacological and Biomolecular Sciences University of Milan Milan Italy
- Società Italiana per lo Studio dell'Aterosclerosi Center for the Study of Atherosclerosis, Bassini Hospital Cinisello Balsamo Italy
| | - Liliana Grigore
- Stituto di Ricovero e Cura a Carattere Scientifico Multimedica Milan Italy
| | - Alberico Catapano
- Department of Pharmacological and Biomolecular Sciences University of Milan Milan Italy
- Stituto di Ricovero e Cura a Carattere Scientifico Multimedica Milan Italy
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing China
| | - Miao Wang
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing China
| | - M Arfan Ikram
- Department of Epidemiology Erasmus University Medical Center Rotterdam the Netherlands
| | - Maryam Kavousi
- Department of Epidemiology Erasmus University Medical Center Rotterdam the Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht the Netherlands
| | - Michael J Sweeting
- Department of Health Sciences University of Leicester Leicester UK
- Department of Public Health and Primary Care University of Cambridge Cambridge UK
| | - Matthias W Lorenz
- Klinik für Neurologie Krankenhaus Nordwest Frankfurt am Main Germany
- Department of Neurology Goethe University Frankfurt am Main Germany
| | - Peter Willeit
- Institute of Health Economics Medical University of Innsbruck Innsbruck Austria
- Department of Public Health and Primary Care University of Cambridge Cambridge UK
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Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT, Fonseca VA, Garber AJ, Grunberger G, Guerin CK, Bell DSH, Mechanick JI, Pessah-Pollack R, Wyne K, Smith D, Brinton EA, Fazio S, Davidson M. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE. Endocr Pract 2019; 23:1-87. [PMID: 28437620 DOI: 10.4158/ep171764.appgl] [Citation(s) in RCA: 632] [Impact Index Per Article: 126.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). METHODS Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. RESULTS The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence). CONCLUSION This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions. ABBREVIATIONS 4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.
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Park JG, Oh GT. Current pharmacotherapies for atherosclerotic cardiovascular diseases. Arch Pharm Res 2019; 42:206-223. [DOI: 10.1007/s12272-019-01116-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 01/11/2019] [Indexed: 12/19/2022]
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Zhan S, Tang M, Liu F, Xia P, Shu M, Wu X. Ezetimibe for the prevention of cardiovascular disease and all-cause mortality events. Cochrane Database Syst Rev 2018; 11:CD012502. [PMID: 30480766 PMCID: PMC6516816 DOI: 10.1002/14651858.cd012502.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) remains an important cause of mortality and morbidity, and high levels of blood cholesterol are thought to be the major modifiable risk factors for CVD. The use of statins is the preferred treatment strategy for the prevention of CVD, but some people at high-risk for CVD are intolerant to statin therapy or unable to achieve their treatment goals with the maximal recommended doses of statin. Ezetimibe is a selective cholesterol absorption inhibitor, whether it has a positive effect on CVD events remains uncertain. Results from clinical studies are inconsistent and a thorough evaluation of its efficacy and safety for the prevention of CVD and mortality is necessary. OBJECTIVES To assess the efficacy and safety of ezetimibe for the prevention of CVD and all-cause mortality. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and Web of Science on 27 June 2018, and two clinical trial registry platforms on 11 July 2018. We checked reference lists from primary studies and review articles for additional studies. No language restrictions were applied. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ezetimibe versus placebo or ezetimibe plus other lipid-modifying drugs versus other lipid-modifying drugs alone in adults, with or without CVD, and which had a follow-up of at least 12 months. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias and contacted trialists to obtain missing data. We performed statistical analyses according to the Cochrane Handbook for Systematic Reviews of Interventions and used the GRADE to assess the quality of evidence. MAIN RESULTS We included 26 RCTs randomising 23,499 participants. All included studies assessed effects of ezetimibe plus other lipid-modifying drugs compared with other lipid-modifying drugs alone or plus placebo. Our findings were driven by the largest study (IMPROVE-IT), which had weights ranging from 41.5% to 98.4% in the different meta-analyses.Ezetimibe with statins probably reduces the risk of major adverse cardiovascular events compared with statins alone (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.90 to 0.98; a decrease from 284/1000 to 267/1000, 95% CI 256 to 278; 21,727 participants; 10 studies; moderate-quality evidence). Trials reporting all-cause mortality used ezetimibe with statin or fenofibrate and found they have little or no effect on this outcome (RR 0.98, 95% CI 0.91 to 1.05; 21,222 participants; 8 studies; high-quality evidence). Adding ezetimibe to statins probably reduces the risk of non-fatal myocardial infarction (MI) (RR 0.88, 95% CI 0.81 to 0.95; a decrease from 105/1000 to 92/1000, 95% CI 85 to 100; 21,145 participants; 6 studies; moderate-quality evidence) and non-fatal stroke (RR 0.83, 95% CI 0.71 to 0.97; a decrease 32/1000 to 27/1000, 95% CI 23 to 31; 21,205 participants; 6 studies; moderate-quality evidence). Trials reporting cardiovascular mortality added ezetimibe to statin or fenofibrate, probably having little or no effect on this outcome (RR 1.00, 95% CI 0.89 to 1.12; 19457 participants; 6 studies; moderate-quality evidence). The need for coronary revascularisation might be reduced by adding ezetimibe to statin (RR 0.94, 95% CI 0.89 to 0.99; a decrease from 196/1000 to 184/1000, 95% 175 to 194; 21,323 participants; 7 studies); however, no difference in coronary revascularisation rate was observed when a sensitivity analysis was limited to studies with a low risk of bias.In terms of safety, adding ezetimibe to statins may make little or no difference in the risk of hepatopathy (RR 1.14, 95% CI 0.96 to 1.35; 20,687 participants; 4 studies; low-quality evidence). It is uncertain whether ezetimibe increase or decrease the risk of myopathy (RR 1.31, 95% CI 0.72 to 2.38; 20,581 participants; 3 studies; very low-quality evidence) and rhabdomyolysis, given the wide CIs and low event rate. Little or no difference in the risk of cancer, gallbladder-related disease and discontinuation due to adverse events were observed between treatment groups. For serum lipids, adding ezetimibe to statin or fenofibrate might further reduce the low-density lipoprotein cholesterol (LDL-C), total cholesterol and triglyceride levels and likely increase the high-density lipoprotein cholesterol levels; however, substantial heterogeneity was detected in most analyses.None of the included studies reported on health-related quality of life. AUTHORS' CONCLUSIONS Moderate- to high-quality evidence suggests that ezetimibe has modest beneficial effects on the risk of CVD endpoints, primarily driven by a reduction in non-fatal MI and non-fatal stroke, but it has little or no effect on clinical fatal endpoints. The cardiovascular benefit of ezetimibe might involve the reduction of LDL-C, total cholesterol and triglycerides. There is insufficient evidence to determine whether ezetimibe increases the risk of adverse events due to the low and very low quality of the evidence. The evidence for beneficial effects was mainly obtained from individuals with established atherosclerotic cardiovascular disease (ASCVD, predominantly with acute coronary syndrome) administered ezetimibe plus statins. However, there is limited evidence regarding the role of ezetimibe in primary prevention and the effects of ezetimibe monotherapy in the prevention of CVD, and these topics thus requires further investigation.
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Affiliation(s)
- Shipeng Zhan
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Min Tang
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Fang Liu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Peiyuan Xia
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Maoqin Shu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Cardiovascular DepartmentChongqingChina
| | - Xiaojiao Wu
- Third Military Medical University (Army Medical University)Department of Health Statistics, College of Preventive MedicineChongqingChina
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Mirzaee S, Thein PM, Nogic J, Nerlekar N, Nasis A, Brown AJ. The effect of combined ezetimibe and statin therapy versus statin therapy alone on coronary plaque volume assessed by intravascular ultrasound: A systematic review and meta-analysis. J Clin Lipidol 2018; 12:1133-1140.e15. [PMID: 30318063 DOI: 10.1016/j.jacl.2018.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/02/2018] [Accepted: 06/05/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported. METHODS Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model. RESULTS Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm3 (95% confidence interval: -5.98 to -1.44, P < .001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P = .10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P < .00001). CONCLUSION The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.
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Affiliation(s)
- Sam Mirzaee
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia.
| | - Paul M Thein
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia
| | - Jason Nogic
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia
| | - Arthur Nasis
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia
| | - Adam J Brown
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Monash University, Melbourne, Australia
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Wierzbicki AS. The challenges of proprotein convertase subtilisin-kexin-9 inhibitors for lipid guidelines and models of care. Curr Opin Lipidol 2017; 28:470-476. [PMID: 28806190 DOI: 10.1097/mol.0000000000000453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The article reviews the challenges facing cardiovascular disease (CVD) guidelines committees. RECENT FINDINGS Clinical trials in high-risk populations have shown additional CVD event reduction with ezetimibe and proprotein convertase subtilisin-kexin-9 inhibitors. These trials recruit middle-aged secondary prevention populations, whereas increasingly the population at risk of CVD comprises the elderly in primary prevention. Some major guidelines have moved from a lipid-target to a risk-based approach. Some guidelines wish to preserve treatment targets to optimize the risk profile of individual patients as opposed to using population-based approaches. A numbers needed to treat approach has been suggested as a way of prioritizing patients for treatment, while retaining an individual's LDL cholesterol risk. However, the main barrier to implementation of some novel therapies in medicine is not their efficacy or safety but their cost. Health economic approaches that consider both benefits and costs can help guideline committees to define populations mostly likely to benefit. SUMMARY The efficacy and expense of novel treatments is challenging traditional guideline development. Previously guideline committees used only to review clinical efficacy and safety endpoints but now they also have to consider costs to derive recommendations that are practical to implement.
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Affiliation(s)
- Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's and St Thomas' Hospitals, London, UK
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8
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Patel RS, Scopelliti EM, Savelloni J. Therapeutic Management of Familial Hypercholesterolemia: Current and Emerging Drug Therapies. Pharmacotherapy 2016; 35:1189-203. [PMID: 26684558 DOI: 10.1002/phar.1672] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Familial hypercholesterolemia (FH) is a genetic disorder characterized by significantly elevated low-density lipoprotein cholesterol (LDL-C) concentrations that result from mutations of the LDL receptor, apolipoprotein B (apo B-100), and proprotein convertase subtilisin/kexin type 9 (PCSK9). Early and aggressive treatment can prevent premature atherosclerotic cardiovascular disease in these high-risk patients. Given that the cardiovascular consequences of FH are similar to typical hypercholesterolemia, traditional therapies are utilized to decrease LDL-C levels. Patients with FH should receive statins as first-line treatment; high-potency statins at high doses are often required. Despite the use of statins, additional treatments are often necessary to achieve appropriate LDL-C lowering in this patient population. Novel drug therapies that target the pathophysiologic defects of the condition are continuously emerging. Contemporary therapies including mipomersen (Kynamro, Genzyme), an oligonucleotide inhibitor of apo B-100 synthesis; lomitapide (Juxtapid, Aegerion), a microsomal triglyceride transfer protein inhibitor; and alirocumab (Praluent, Sanofi-Aventis/Regeneron) and evolocumab (Repatha, Amgen), PCSK9 inhibitors, are currently approved by the U.S. Food and Drug Administration for use in FH. This review highlights traditional as well as emerging contemporary therapies with supporting clinical data to evaluate current recommendations and discuss the future direction of FH management.
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Affiliation(s)
- Roshni S Patel
- Department of Pharmacy Practice, Thomas Jefferson University, Jefferson College of Pharmacy, Philadelphia, Pennsylvania
| | - Emily M Scopelliti
- Department of Pharmacy Practice, Thomas Jefferson University, Jefferson College of Pharmacy, Philadelphia, Pennsylvania
| | - Julie Savelloni
- Department of Pharmacy Practice, Thomas Jefferson University, Jefferson College of Pharmacy, Philadelphia, Pennsylvania
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Agrawal N, Freitas Corradi P, Gumaste N, Goldberg IJ. Triglyceride Treatment in the Age of Cholesterol Reduction. Prog Cardiovasc Dis 2016; 59:107-118. [PMID: 27544319 PMCID: PMC5364728 DOI: 10.1016/j.pcad.2016.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 08/15/2016] [Indexed: 01/28/2023]
Abstract
Cholesterol reduction has markedly reduced major cardiovascular disease (CVD) events and shown regression of atherosclerosis in some studies. However, CVD has for decades also been associated with increased levels of circulating triglyceride (TG)-rich lipoproteins. Whether this is due to a direct toxic effect of these lipoproteins on arteries or whether this is merely an association is unresolved. More recent genetic analyses have linked genes that modulate TG metabolism with CVD. Moreover, analyses of subgroups of hypertriglyceridemic (HTG) subjects in clinical trials using fibric acid drugs have been interpreted as evidence that TG reduction reduces CVD events. This review will focus on how HTG might cause CVD, whether TG reduction makes a difference, what pathophysiological defects cause HTG, and what options are available for treatment.
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Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, NY
| | - Patricia Freitas Corradi
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, NY
| | - Namrata Gumaste
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, NY
| | - Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, NY.
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10
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Abstract
The introduction of statins ≈ 30 years ago ushered in the era of lipid lowering as the most effective way to reduce risk of atherosclerotic cardiovascular disease. Nonetheless, residual risk remains high, and statin intolerance is frequently encountered in clinical practice. After a long dry period, the field of therapeutics targeted to lipids and atherosclerosis has entered a renaissance. Moreover, the demonstration of clinical benefits from the addition of ezetimibe to statin therapy in subjects with acute coronary syndromes has renewed the enthusiasm for the cholesterol hypothesis and the hope that additional agents that lower low-density lipoprotein will decrease risk of atherosclerotic cardiovascular disease. Drugs in the orphan disease category are now available for patients with the most extreme hypercholesterolemia. Furthermore, discovery and rapid translation of a novel biological pathway has given rise to a new class of cholesterol-lowering drugs, the proprotein convertase subtilisin kexin-9 inhibitors. Trials of niacin added to statin have failed to demonstrate cardiac benefits, and 3 cholesterol ester transfer protein inhibitors have also failed to reduce atherosclerotic cardiovascular disease risk, despite producing substantial increases in HDL levels. Although the utility of triglyceride-lowering therapies remains uncertain, 2 large clinical trials are testing the influence of omega-3 polyunsaturated fatty acids on atherosclerotic events in hypertriglyceridemia. Novel antisense therapies targeting apolipoprotein C-III (for triglyceride reduction) and apo(a) (for lipoprotein(a) reduction) are showing a promising trajectory. Finally, 2 large clinical trials are formally putting the inflammatory hypothesis of atherosclerosis to the test and may open a new avenue for cardiovascular disease risk reduction.
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Affiliation(s)
- Michael D Shapiro
- From the Knight Cardiovascular Institute, Center for Preventive Cardiology, Oregon Health & Science University, Portland, OR
| | - Sergio Fazio
- From the Knight Cardiovascular Institute, Center for Preventive Cardiology, Oregon Health & Science University, Portland, OR.
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11
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Effects of Combination of Ezetimibe and Rosuvastatin on Coronary Artery Plaque in Patients with Coronary Heart Disease. Heart Lung Circ 2016; 25:459-65. [DOI: 10.1016/j.hlc.2015.10.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/13/2015] [Accepted: 10/15/2015] [Indexed: 11/21/2022]
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12
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Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Despite the success of treatment of CVD with statin therapy, a number of patients remain at high risk for CVD. Ezetimibe is a non-statin agent that inhibits intestinal cholesterol absorption, leading to reductions in low-density lipoprotein cholesterol (LDL-C). A number of clinical studies evaluating the use of ezetimibe therapy have resulted in discordant data regarding its safety and efficacy. In this review, we discuss the findings from these studies as well as potential indications for the use of ezetimibe for LDL-C lowering and cardiovascular event reduction.
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DiNicolantonio JJ, Chatterjee S, Lavie CJ, Bangalore S, O'Keefe JH. Ezetimibe plus moderate-dose simvastatin after acute coronary syndrome: what are we IMPROVEing on? Am J Med 2015; 128:914.e1-4. [PMID: 25731133 DOI: 10.1016/j.amjmed.2015.01.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 12/21/2022]
Abstract
The recent IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) is the first study to demonstrate a significant benefit of another medication (ezetimibe) on top of statin therapy in patients who have recently experienced an acute coronary syndrome. Despite the fact that ezetimibe led to positive results on the primary endpoint, the clinical benefit translated to real-life practice is only modest at best. However, this is the first major trial to demonstrate a significant benefit of a lipid medication in addition to statins. We explore the strengths and weaknesses of IMPROVE-IT in the context of current-day acute coronary syndrome practice, where high-dose statins now are prescribed widely.
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Affiliation(s)
| | | | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, La
| | | | - James H O'Keefe
- Saint Luke's Mid America Heart Institute, Kansas City, Mo; University of Missouri, Kansas City, Mo
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Marbach JA, McKeon JL, Ross JL, Duffy D. Novel treatments for familial hypercholesterolemia: pharmacogenetics at work. Pharmacotherapy 2014; 34:961-72. [PMID: 24899514 DOI: 10.1002/phar.1441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The familial hypercholesterolemias (FHs) are inherited disorders of lipoprotein metabolism that are among the most prevalent genetically inherited disorders. Various genetic mutations ultimately lead to greatly increased low-density lipoprotein-cholesterol (LDL-C) levels over a lifetime. Consequently, patients with FH develop coronary artery disease at significantly earlier ages and at a greater frequency than the general population. Current therapies revolve around aggressive lifestyle modifications, cholesterol-lowering medications, and in some cases LDL apheresis. Despite maximal medical therapy, LDL-C is not sufficiently reduced in some patients, and they remain at a substantially increased risk of coronary heart disease. Recent advances in genetic-based pharmacology have enabled the development of three novel classes of medications for FH. Two of those compounds, mipomersen and lomitapide, result in decreased LDL-C production and were approved by the Food and Drug Administration in the past 18 months for treatment of homozygous FH. Mipomersen is an antisense oligonucleotide that inhibits the translation of apolipoprotein B-100, and lomitapide is an inhibitor of the microsomal triglyceride transfer protein, which prevents the incorporation of triglycerides into lipoproteins. A third class of drugs, the proprotein convertase subtilisin/kexin type 9 inhibitors, is still in development, although studies in patients with heterozygous or receptor-defective homozygous FH have demonstrated substantial reductions in LDL-C by decreasing the degradation of LDL receptors. Development of these novel treatments for hypercholesterolemia resulted from the application of known genetic mutations and is the focus of this review.
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Affiliation(s)
- Jeffrey A Marbach
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Huijgen R, Vissers MN, Defesche JC, Lansberg PJ, Kastelein JJP, Hutten BA. Familial hypercholesterolemia: current treatment and advances in management. Expert Rev Cardiovasc Ther 2014; 6:567-81. [PMID: 18402545 DOI: 10.1586/14779072.6.4.567] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Roeland Huijgen
- Academic Medical Center, Department of Vascular Medicine, Meibergreef 9 (Room F4-146), 1105 AZ, Amsterdam, The Netherlands.
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Chrispin J, Martin SS, Hasan RK, Joshi PH, Minder CM, McEvoy JW, Kohli P, Johnson AE, Wang L, Blaha MJ, Blumenthal RS. Landmark lipid-lowering trials in the primary prevention of cardiovascular disease. Clin Cardiol 2013; 36:516-23. [PMID: 23722477 PMCID: PMC6649586 DOI: 10.1002/clc.22147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 04/25/2013] [Indexed: 01/20/2023] Open
Abstract
Although atherosclerotic cardiovascular disease (CVD) is the most common cause of morbidity and mortality in the world, the long disease latency affords ample opportunity for preventive care. Indeed, lifelong exposure to atherogenic apoliprotein B-containing lipoproteins has consistently been shown to increase the cumulative risk of suffering a CVD event, including myocardial infarction, stroke, and symptomatic peripheral arterial disease. Over the past 25 years, lipid-lowering therapies have been developed that are proven to not only lower cholesterol, but also to decrease adverse CVD events and CVD mortality. This review will highlight several key clinical trials encompassing several classes of lipid-lowering medications that have provided clinicians with an evidence-based framework for managing their patients' cardiovascular risk.
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Affiliation(s)
- Jonathan Chrispin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Seth S. Martin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Rani K. Hasan
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Parag H. Joshi
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - C. Michael Minder
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - John W. McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Payal Kohli
- Cardiology DivisionUniversity of California San FranciscoSan FranciscoCalifornia.
| | - Amber E. Johnson
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Libin Wang
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Michael J. Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
| | - Roger S. Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins School of MedicineBaltimoreMaryland
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Lin YC, Chiang CH, Chang LT, Sun CK, Leu S, Shao PL, Hsieh MC, Tsai TH, Chua S, Chung SY, Kao YH, Yip HK. Simvastatin attenuates the additive effects of TNF-α and IL-18 on the connexin 43 up-regulation and over-proliferation of cultured aortic smooth muscle cells. Cytokine 2013; 62:341-51. [DOI: 10.1016/j.cyto.2013.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 03/11/2013] [Accepted: 04/01/2013] [Indexed: 02/03/2023]
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18
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De Meyer I, Martinet W, De Meyer GRY. Therapeutic strategies to deplete macrophages in atherosclerotic plaques. Br J Clin Pharmacol 2012; 74:246-63. [PMID: 22309283 DOI: 10.1111/j.1365-2125.2012.04211.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Macrophages can be found in all stages of atherosclerosis and are major contributors of atherosclerotic plaque development, progression and destabilization. Continuous recruitment of monocytes drives this chronic inflammatory disease, which can be intervened by several strategies: reducing the inflammatory stimulus by lowering circulating lipids and promoting cholesterol efflux from plaque, direct and indirect targeting of adhesion molecules and chemokines involved in monocyte adhesion and transmigration and inducing macrophage death in atherosclerotic plaques in combination with anti-inflammatory drugs. This review discusses the outlined strategies to deplete macrophages from atherosclerotic plaques to promote plaque stabilization.
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Affiliation(s)
- Inge De Meyer
- Division of Physiopharmacology, University of Antwerp, Antwerp, Belgium.
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19
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Inhibition of cholesterol absorption: targeting the intestine. Pharm Res 2012; 29:3235-50. [PMID: 22923351 DOI: 10.1007/s11095-012-0858-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/06/2012] [Indexed: 01/06/2023]
Abstract
Atherosclerosis, the gradual formation of a lipid-rich plaque in the arterial wall is the primary cause of Coronary Artery Disease (CAD), the leading cause of mortality worldwide. Hypercholesterolemia, elevated circulating cholesterol, was identified as a key risk factor for CAD in epidemiological studies. Since the approval of Mevacor in 1987, the primary therapeutic intervention for hypercholesterolemia has been statins, drugs that inhibit the biosynthesis of cholesterol. With improved understanding of the risks associated with elevated cholesterol levels, health agencies are recommending reductions in cholesterol that are not achievable in every patient with statins alone, underlying the need for improved combination therapies. The whole body cholesterol pool is derived from two sources, biosynthesis and diet. Although statins are effective at reducing the biosynthesis of cholesterol, they do not inhibit the absorption of cholesterol, making this an attractive target for adjunct therapies. This report summarizes the efforts to target the gastrointestinal absorption of cholesterol, with emphasis on specifically targeting the gastrointestinal tract to avoid the off-target effects sometimes associated with systemic exposure.
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Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, Shepherd MD, Seibel JA. American Association of Clinical Endocrinologists' Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis. Endocr Pract 2012; 18 Suppl 1:1-78. [PMID: 22522068 DOI: 10.4158/ep.18.s1.1] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
The prevalence of peripheral artery disease is steadily increasing and is associated with significant morbidity, including a significant percentage of amputations. Peripheral artery disease often goes undiagnosed, making its prevention increasingly important. Patients with peripheral arterial disease are at increased risk of adverse cardiovascular outcomes which makes prevention even more important. Several risk factors have been identified in the pathophysiology of peripheral artery disease which should be modified to decrease risk. Smoking, hyperlipidemia, hypertension, and diabetes are among proven risk factors for the development of peripheral artery disease, thus smoking cessation, lipid control, blood pressure control, and glucose control have been tried and shown to be effective in preventing the morbidity associated with this disease. Pharmacologic agents such as aspirin and clopidogrel alone or in combination have been shown to be effective, though risk of bleeding might be increased with the combination. Anticoagulation use is recommended only for acute embolic cases. Other treatment modalities that have been tried or are under investigation are estrogen replacement, naftidrofuryl, pentoxifylline, hyperbaric oxygen, therapeutic angiogenesis, and advanced glycation inhibitors. The treatment for concomitant vascular diseases does not change in the presence of peripheral artery disease, but aggressive management of risk factors should be undertaken in such cases.
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Affiliation(s)
| | - Rohit Seth Loomba
- Children’s Hospital of Wisconsin/Medical College of Wisconsin Affiliated Hospitals, Wauwatosa, WI, USA
| | - Rohit Arora
- Department of Medicine, North Chicago VA Medical Center, North Chicago, IL, USA
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22
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Abstract
A surrogate end point is one that is used as a substitute for a clinical end point of more direct interest, usually for reasons of practicality, and that is expected to predict clinical benefit. Surrogate end points play a critical role in the advancement of all medical research, and cardiovascular (CV) research in particular. However, the relationship between a surrogate end point and its clinical end point is usually complex, and there are many examples where results based on surrogates have proved to be misleading. Secondary analyses of existing clinical trial data are likely to involve surrogate end points, if only because clinical end points will have been extensively studied as part of the primary analysis of a trial large enough to collect useful clinical end point data. Validation of a surrogate end point is a laudable goal for a secondary analysis of a large clinical end point trial (or meta-analysis of multiple smaller trials), and the result may be an important new tool for further study of a class of compounds in a particular disease context. Secondary analyses using surrogate end points may also provide new insight into disease or treatment mechanism, but as with any surrogate end point analysis, the results can mislead, and the existing literature is heavy on application and light on methodology. Surrogate end points often substitute efficiency for clarity, and while many interesting and potentially informative secondary analyses of CV trials will involve surrogates, results are likely to be ambiguous and should be interpreted with care.
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Affiliation(s)
- Kevin A Buhr
- Statistical Data Analysis Center, Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI 53726-2397, USA.
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24
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Vieira CL, Cury PR, Miname MH, Martinez LR, Bortolotto LA, Giuliano IB, Santos RD, Caramelli B. Severe Periodontitis Is Associated With Diastolic Blood Pressure Elevation in Individuals With Heterozygous Familial Hypercholesterolemia: A Pilot Study. J Periodontol 2011; 82:683-8. [DOI: 10.1902/jop.2010.100496] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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25
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Robinson JG, Goldberg AC. Treatment of adults with familial hypercholesterolemia and evidence for treatment: recommendations from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol 2011; 5:S18-29. [PMID: 21600526 DOI: 10.1016/j.jacl.2011.03.451] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 03/29/2011] [Indexed: 12/22/2022]
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26
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Foley PW, Hamaad A, El-Gendi H, Leyva F. Incidental cardiac findings on computed tomography imaging of the thorax. BMC Res Notes 2010; 3:326. [PMID: 21126380 PMCID: PMC3003672 DOI: 10.1186/1756-0500-3-326] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 12/03/2010] [Indexed: 12/29/2023] Open
Abstract
Background Investigation of pulmonary pathology with computed tomography also allows visualisation of the heart and major vessels. We sought to explore whether clinically relevant cardiac pathology could be identified on computed tomography pulmonary angiograms (CTPA) requested for the exclusion of pulmonary embolism (PE). 100 consecutive CT contrast-enhanced pulmonary angiograms carried out for exclusion of PE at a single centre were assessed retrospectively by two cardiologists. Findings Evidence of PE was reported in 5% of scans. Incidental cardiac findings included: aortic wall calcification (54%), coronary calcification (46%), cardiomegaly (41%), atrial dilatation (18%), mitral annulus calcification (15%), right ventricular dilatation (11%), aortic dilatation (8%) and right ventricular thrombus (1%). Apart from 3 (3%) reports describing cardiomegaly, no other cardiac findings were described in radiologists' reports. Other reported pulmonary abnormalities included: lung nodules (14%), lobar collapse/consolidation (8%), pleural effusion (2%), lobar collapse/consolidation (8%), emphysema (6%) and pleural calcification (4%). Conclusions CTPAs requested for the exclusion of PE have a high yield of cardiac abnormalities. Although these abnormalities may not have implications for acute clinical management, they may, nevertheless, be important in long-term care.
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Affiliation(s)
- Paul Wx Foley
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK.
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27
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Tsubakio-Yamamoto K, Nishida M, Nakagawa-Toyama Y, Masuda D, Ohama T, Yamashita S. Current therapy for patients with sitosterolemia--effect of ezetimibe on plant sterol metabolism. J Atheroscler Thromb 2010; 17:891-900. [PMID: 20543520 DOI: 10.5551/jat.4614] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Sitosterolemia is a rare, autosomal recessive inherited sterol storage disease associated with high tissue and serum plant sterol concentrations, caused by mutations in the adenosine triphosphate-bind-ing cassette (ABC) transporter ABCG5 or ABCG8 genes. Markedly increased serum concentration of plant sterols. such as sitosterol and campesterol, cause premature atherosclerosis and massive xanthomas. Hitherto known treatments for sitosterolemia, including a low-sterol diet, bile-salt binding resins, ileal bypass surgery and low density lipoprotein (LDL) apheresis have not yielded sufficient reduction of serum plant sterol levels and many patients show a sustained elevation of plant sterol levels, subsequently developing premature atherosclerotic cardiovascular diseases. Ezetimibe, an inhibitor of intestinal cholesterol absorption through its binding to Niemann-Pick C1-like 1 (NPC1L1), has been widely used for decreasing serum LDL-cholesterol levels in patients with hypercholesterolemia. Ezetimibe also reduces the gastrointestinal absorption of plant sterols, thereby also lowering the serum concentrations of plant sterols. This pharmacological property of ezetimibe shows its potential as a novel effective therapy for sitosterolemia. In the current review, we discuss the current therapy for patients with sitosterolemia and present two Japanese adolescent patients with this disease, one of whom underwent percutaneous coronary intervention for accelerated coronary atherosclerosis. Ezetimibe administration in addition to conventional drug therapy successfully reduced serum sitosterol levels by 51.3% and 48.9%, respectively, in the two patients, demonstrating ezetimibe as a novel and potent treatment agent for sitosterolemia that could work additively with conventional drug therapy.
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Affiliation(s)
- Kazumi Tsubakio-Yamamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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28
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Toutouzas K, Drakopoulou M, Skoumas I, Stefanadis C. Advancing therapy for hypercholesterolemia. Expert Opin Pharmacother 2010; 11:1659-72. [DOI: 10.1517/14656561003774080] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Ferrario CM. ARBITER 6-HALTS. Does it have the power to settle all matters? Ther Adv Cardiovasc Dis 2010; 4:77-81. [PMID: 20360390 DOI: 10.1177/1753944709359518] [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] Open
Affiliation(s)
- Carlos M Ferrario
- Department of Surgery, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA.
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Lavoie A, Uno K, Bayturan O, Nicholls SJ. Findings of clinical trials that evaluate the impact of medical therapies on progression of atherosclerosis. Curr Med Res Opin 2010; 26:745-51. [PMID: 20092391 DOI: 10.1185/03007990903547616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Arterial wall imaging has been increasingly employed in clinical trials to evaluate the impact of medical therapies on progression of atherosclerosis. SCOPE A selective overview of major findings from clinical trials that assessed the impact of medical therapies on atherosclerosis progression. FINDINGS Targeting established risk factors including LDL cholesterol, HDL cholesterol and blood pressure has a beneficial impact on disease progression. CONCLUSION As a result, vascular imaging has been employed in the early evaluation of experimental therapies.
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31
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Mallett C, Gardi L, Fenster A, Parraga G. Prospective cardiac gating of carotid three-dimensional ultrasound. Med Phys 2009; 36:3168-75. [DOI: 10.1118/1.3134243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Mallett C, House AA, Spence JD, Fenster A, Parraga G. Longitudinal ultrasound evaluation of carotid atherosclerosis in one, two and three dimensions. ULTRASOUND IN MEDICINE & BIOLOGY 2009; 35:367-375. [PMID: 18996639 DOI: 10.1016/j.ultrasmedbio.2008.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 08/14/2008] [Accepted: 09/10/2008] [Indexed: 05/27/2023]
Abstract
The aim of this study was to compare the sensitivity of three ultrasound phenotypes of carotid atherosclerosis in a longitudinal study of patients with diabetic nephropathy. B-mode ultrasound-derived intima-media thickness (IMT), total plaque area (TPA) as well as three-dimensional ultrasound (3DUS) vessel wall volume (VWV) of the common carotid artery (CCA) (VWV(CCA)) and internal carotid artery (ICA). (VWV(CCA+ICA)) were all evaluated in subjects enrolled in a randomized placebo-controlled double blind study of vitamin B therapy. Of 106 subjects randomized, 77 subjects were scanned at baseline and 2.3 +/- 1 y later (range: 0.5 to 4.5 y); of these subjects, 71 had images of sufficient quality for complete analysis of all three measurements. Subjects were analyzed according to the two treatment groups (A and B) and the analysis was performed blinded to treatment group description to prevent any potential for bias in future analyses. There were differences in sensitivity to longitudinal changes observed in all the ultrasound measurements. Specifically, there was no difference in IMT change between treatment groups (0.02 +/- 0.07 mm/y and 0.02 +/- 0.1 mm/y p = 0.15, group A and B, respectively, rates not different from zero [p > 0.05]) or TPA rate between treatment groups (0.09 +/- 0.2 cm(2)/y, significantly different from 0, p = 0.013 and -0.02 +/- 0.3 cm(2)/y in group A and B, respectively). However, the VWV(CCA+ICA) rate of change was significantly greater than 0 for group B (53 +/- 110 mm(3)/y) (p = 0.008), which was significantly (p = 0.034) higher than the rate of change of VWV(CCA+ICA) (nonsignificant, p = 0.6) for group A (-12 +/- 137 mm(3)/y). The relationship between DeltaVWV and DeltaIMT was significant, such that in group A, DeltaVWV(CCA) was positively associated with DeltaIMT (r = 0.44, p < 0.05), and in group B, DeltaVWV(CCA) was negatively correlated with DeltaIMT (r = -0.44, p < 0.01). These results suggest that 3DUS-derived VWV provides necessary and sufficient sensitivity and specificity to measure longitudinal changes in small numbers of carotid atherosclerosis patients at risk of disease progression and over short periods of time.
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Affiliation(s)
- Christiane Mallett
- Imaging Research Laboratories, Robarts Research Institute, London, Canada
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Tiwari A. Current and emerging paradigms in the therapeutic management of atherosclerosis. Expert Opin Ther Targets 2009; 12:1523-46. [PMID: 19007321 DOI: 10.1517/14728220802544061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The pathogenesis of atherosclerosis lies in abnormalities in lipoprotein metabolism leading to pathological interactions with vessel walls and the release of inflammatory components, which further aggravate the disease condition. OBJECTIVE To elucidate current and emerging trends in drug discovery towards the development of new entities regulating lipoprotein metabolism and inflammatory components to combat the progression of atherosclerosis. METHODS Research/review articles in the public domain and press releases were employed. RESULTS/CONCLUSION With the recent failure of torcetrapib and succinobucol, drug discovery and development efforts towards the treatment of atherosclerosis have received a big jolt and have been slowed down to a certain extent [corrected]. But this could be a starting point for several new mechanisms that are emerging to discover new drugs to combat the disease.
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Affiliation(s)
- Atul Tiwari
- Jubilant Biosys Ltd., CardioMetabolic Disorder Group, Drug Discovery Unit-Biology, #96, 2nd Stage, Industrial Suburb, Yeshwantpur, Bangalore-560022, Karnatka, India.
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Do R, Kiss RS, Gaudet D, Engert JC. Squalene synthase: a critical enzyme in the cholesterol biosynthesis pathway. Clin Genet 2009; 75:19-29. [DOI: 10.1111/j.1399-0004.2008.01099.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cannon CP, Giugliano RP, Blazing MA, Harrington RA, Peterson JL, Sisk CM, Strony J, Musliner TA, McCabe CH, Veltri E, Braunwald E, Califf RM. Rationale and design of IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial): comparison of ezetimbe/simvastatin versus simvastatin monotherapy on cardiovascular outcomes in patients with acute coronary syndromes. Am Heart J 2008; 156:826-32. [PMID: 19061694 DOI: 10.1016/j.ahj.2008.07.023] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2007] [Accepted: 07/28/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Reduction in low-density lipoprotein cholesterol (LDL-C) improves clinical outcomes in patients with chronic coronary artery disease and acute coronary syndromes (ACSs). The combination of ezetimibe/simvastatin produces greater reductions in LDL-C compared to simvastatin monotherapy. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) is a multicenter, randomized, double-blind, active-control trial designed to test the hypothesis that the addition of ezetimibe to statin therapy, using ezetimibe/simvastatin, will translate into increased clinical benefit on cardiovascular outcomes relative to simvastatin monotherapy in patients with ACS. STUDY DESIGN The study will recruit up to 18,000 moderate- to high-risk patients stabilized after ACS. Patients are randomized in a 1:1 ratio to once-daily doses of either ezetimibe/simvastatin 10/40 mg or simvastatin monotherapy 40 mg. Follow-up visits are at 1 and 4 months, and every 4 months thereafter. If consecutive measures of LDL-C are >79 mg/dL at follow-up visits, the simvastatin dose will be increased to 80 mg in a double-blind manner. The primary end point is the first occurrence of cardiovascular death, nonfatal myocardial infarction, rehospitalization for unstable angina, coronary revascularization (occurring at least 30 days after randomization), or stroke. Patients will be followed for a minimum of 2.5 years and until at least 5,250 patients experience a primary end point. SUMMARY IMPROVE-IT will determine whether the addition of ezetimibe to statin therapy, using ezetimibe/simvastatin, improves cardiovascular outcomes compared with simvastatin monotherapy in patients after ACS. In addition, the difference in achieved LDL-C levels between the groups will provide data on whether the target for LDL-C lowering should be reduced further.
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Egger M, Krasinski A, Rutt BK, Fenster A, Parraga G. Comparison of B-mode ultrasound, 3-dimensional ultrasound, and magnetic resonance imaging measurements of carotid atherosclerosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:1321-1334. [PMID: 18716142 DOI: 10.7863/jum.2008.27.9.1321] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE We compared the intraobserver and interscan variability of carotid atherosclerosis measured using B-mode ultrasound for quantifying intima media thickness (IMT), 3-dimensional ultrasound (3DUS) for quantifying vessel wall volume (VWV) and total plaque volume (TPV), and magnetic resonance imaging (MRI) for measuring VWV. We also evaluated the associations of these measurements and sample sizes required to detect specific changes in patients with moderate atherosclerosis. METHODS Ten patients were evaluated with B-mode ultrasound, MRI, and 3DUS twice within 14 +/- 2 days. Measurements of IMT, MRI VWV, 3DUS VWV, and 3DUS TPV were performed by single observers using manual (VWV and TPV) and semiautomated (IMT) segmentation. RESULTS Intraobserver coefficients of variation were 3.4% (IMT), 4.7% (3DUS VWV), 6.5% (MRI VWV), and 23.9% (3DUS TPV). Interscan coefficients of variation were 8.1% (MRI VWV), 8.9% (IMT), 13.5% (3DUS VWV), and 46.6% (3DUS TPV). Scan-rescan linear regressions were significant for 3DUS TPV (R(2) = 0.57), 3DUS VWV (R(2) = 0.59), and IMT (R(2) = 0.75) and significantly different (P < .05) for MRI VWV (R(2) = 0.87). CONCLUSIONS B-mode ultrasound-derived IMT provided the highest intraobserver and interscan reproducibility. Three-dimensional measurements of VWV derived from 3DUS and MRI provided both high sensitivity and high intraobserver and interscan reliability.
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Affiliation(s)
- Micaela Egger
- Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
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Friedewald VE, Ballantyne CM, Davidson MH, Guyton JR, Roberts WC. The editor's roundtable: lipid management beyond statins-reducing residual cardiovascular risk. Am J Cardiol 2008; 102:559-67. [PMID: 18721512 DOI: 10.1016/j.amjcard.2008.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 06/24/2008] [Indexed: 10/21/2022]
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Torres do Rego A, Álvarez-Sala Walter L, Conthe Gutiérrez P. Lípidos y enfermedad cerebrovascular. El papel de las estatinas. Nuevas opciones hipolipemiantes en investigación. Rev Clin Esp 2008. [DOI: 10.1016/s0014-2565(08)71784-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Atherosclerosis is a chronic, progressive, inflammatory disease with a long asymptomatic phase. Disease progression can lead eventually to the occurrence of acute cardiovascular events such as myocardial infarction, unstable angina pectoris and sudden cardiac death. While the disease is still in a subclinical stage, however, the presence of atherosclerosis can be identified by several methods, including coronary angiography, intravascular ultrasonography, B-mode ultrasonography, computed tomography and magnetic resonance imaging. Based on the results of imaging studies, statin therapy can slow, halt or even reverse the progression of atherosclerotic disease, depending on the intensity of treatment. Whether to screen and treat patients for subclinical atherosclerosis remains controversial. Although atheromatous plaque burden reduction has not yet been definitively correlated with significant decreases in risk for acute coronary events in asymptomatic patients, statin therapy contributes significantly to the risk reduction observed in clinical trials in patients with and without overt coronary disease.
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Affiliation(s)
- P P Toth
- Sterling Rock Falls Clinic, Sterling, and University of Illinois College of Medicine, Peoria, IL 61008, USA.
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Toutouzas P, Richter D. Carotid intima-media thickness (cIMT): a useful clinic tool or research luxury? Another view of the ENHANCE trial. Angiology 2008; 59:77S-9S. [PMID: 18628278 DOI: 10.1177/0003319708321748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ENHANCE trial was the first trial of ezetimibe- simvastatin with a surrogate marker as a primary endpoint. The combination of the 2 drugs is highly effective in reducing total cholesterol and low-density lipoprotein cholesterol levels and with a positive profile on high-density lipoprotein cholesterol. However, there are no data as yet about the clinical effectiveness of the addition of ezetimibe on statin therapy and whether this provides a further reduction of cardiovascular events. The answer to the clinical hard endpoints question will be provided in 2012 by the IMPROVE-IT trial comparing the effectiveness of simvastatin 40 mg plus ezetimibe versus simvastatin 40 mg on 18,000 acute coronary syndrome patients. The ENHANCE study failed in its primary endpoint, carotid intima-media thickness reduction, but has various methodological weaknesses that makes it very difficult to accept the American College of Cardiology statement that ezetimibe should be the last resort after trying all other available treatments.
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Affiliation(s)
- P Toutouzas
- Department of Cardiology, Hellenic Heart Foundation, University of Athens, Athens, Greece
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Safety and Efficacy of Ezetimibe With Low Doses of Simvastatin in Heart Transplant Recipients. J Heart Lung Transplant 2008; 27:685-8. [DOI: 10.1016/j.healun.2008.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Revised: 02/11/2008] [Accepted: 02/17/2008] [Indexed: 11/20/2022] Open
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Smith D. Making sense of ENHANCE: ezetimibe (Zetia) lowers LDL cholesterol but doesn't decrease carotid intima-media thickness. ACTA ACUST UNITED AC 2008; 75:143-7. [PMID: 18500716 DOI: 10.1002/msj.20031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Donald Smith
- Lipids and Metabolism, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, NY, USA.
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Bays HE, Neff D, Tomassini JE, Tershakovec AM. Ezetimibe: cholesterol lowering and beyond. Expert Rev Cardiovasc Ther 2008; 6:447-70. [PMID: 18402536 DOI: 10.1586/14779072.6.4.447] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ezetimibe is a cholesterol absorption inhibitor that blocks the intestinal absorption of both biliary and dietary cholesterol. It appears to exert its effect by blocking intestinal sterol transporters, specifically Niemann-Pick C1-like 1 proteins, thereby inhibiting the intestinal absorption of cholesterol, phytosterols and certain oxysterols. Ezetimibe monotherapy and in combination with statin therapy is primarily indicated for lowering LDL-cholesterol levels. In addition, it may favorably affect other parameters that could potentially further reduce atherosclerotic coronary heart disease risk, such as raising HDL-cholesterol and lowering levels of triglycerides, non-HDL-cholesterol, apolipoprotein B and remnant-like particle cholesterol. Further effects of ezetimibe include a reduction in circulating phytosterols and oxysterols and, when used in combination with statins, a reduction in high-sensitivity C-reactive protein. The clinical significance of the LDL-cholesterol lowering and other effects of ezetimibe is being evaluated in clinical outcome studies.
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Affiliation(s)
- Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville, KY 40213, USA.
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Kastelein JJP, Akdim F, Stroes ESG, Zwinderman AH, Bots ML, Stalenhoef AFH, Visseren FLJ, Sijbrands EJG, Trip MD, Stein EA, Gaudet D, Duivenvoorden R, Veltri EP, Marais AD, de Groot E. Simvastatin with or without ezetimibe in familial hypercholesterolemia. N Engl J Med 2008; 358:1431-43. [PMID: 18376000 DOI: 10.1056/nejmoa0800742] [Citation(s) in RCA: 854] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ezetimibe, a cholesterol-absorption inhibitor, reduces levels of low-density lipoprotein (LDL) cholesterol when added to statin treatment. However, the effect of ezetimibe on the progression of atherosclerosis remains unknown. METHODS We conducted a double-blind, randomized, 24-month trial comparing the effects of daily therapy with 80 mg of simvastatin either with placebo or with 10 mg of ezetimibe in 720 patients with familial hypercholesterolemia. Patients underwent B-mode ultrasonography to assess the intima-media thickness of the walls of the carotid and femoral arteries. The primary outcome measure was the change in the mean carotid-artery intima-media thickness, which was defined as the average of the means of the far-wall intima-media thickness of the right and left common carotid arteries, carotid bulbs, and internal carotid arteries. RESULTS The primary outcome, the mean (+/-SE) change in the carotid-artery intima-media thickness, was 0.0058+/-0.0037 mm in the simvastatin-only group and 0.0111+/-0.0038 mm in the simvastatin-plus-ezetimibe (combined-therapy) group (P=0.29). Secondary outcomes (consisting of other variables regarding the intima-media thickness of the carotid and femoral arteries) did not differ significantly between the two groups. At the end of the study, the mean (+/-SD) LDL cholesterol level was 192.7+/-60.3 mg per deciliter (4.98+/-1.56 mmol per liter) in the simvastatin group and 141.3+/-52.6 mg per deciliter (3.65+/-1.36 mmol per liter) in the combined-therapy group (a between-group difference of 16.5%, P<0.01). The differences between the two groups in reductions in levels of triglycerides and C-reactive protein were 6.6% and 25.7%, respectively, with greater reductions in the combined-therapy group (P<0.01 for both comparisons). Side-effect and safety profiles were similar in the two groups. CONCLUSIONS In patients with familial hypercholesterolemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima-media thickness, as compared with simvastatin alone, despite decreases in levels of LDL cholesterol and C-reactive protein. (ClinicalTrials.gov number, NCT00552097 [ClinicalTrials.gov].).
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Affiliation(s)
- John J P Kastelein
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
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Kushner PR. Can intensive statin therapy halt the progression of atherosclerosis? Recent evidence and potential implications for patient management. ACTA ACUST UNITED AC 2008; 22:207-13. [PMID: 18059198 DOI: 10.1111/j.0889-7204.2007.06575.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A number of studies using various imaging techniques have demonstrated that intensive lipid lowering with statins can halt or delay the progression of atherosclerosis and even, in some cases, lead to plaque regression. Improvements in atheroma burden with intensive statin therapy appear to be related not just to decreasing low-density lipoprotein cholesterol but also to anti-inflammatory and antiproliferative effects. Clinical trial results also suggest that achieving low-density lipoprotein cholesterol levels even lower than those currently recommended can produce improved clinical outcomes across a range of patient types. Given this body of evidence, it appears appropriate to use intensive statin therapy to treat dyslipidemic patients at high risk for coronary heart disease.
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Affiliation(s)
- Pamela R Kushner
- From the Department of Family Medicine, University of California at Irvine, Irvine, CA, USA.
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Abstract
OBJECTIVE Ezetimibe is a relatively new lipid lowering agent, which is indicated for the treatment of primary hypercholesterolaemia, either as monotherapy or in combination with other hypolipidaemic drugs. The objective of the present article was to review the side effects attributed to ezetimibe administration and discuss their possible underlying mechanisms. Moreover, we aimed to comment on the possible drug interactions of ezetimibe and present current guidelines regarding its safe use. METHODS Relevant articles were identified through a PubMed search (up to June 2007). RESULTS Compelling evidence from the majority of the data reviewed here showed that adverse effects associated with ezetimibe use are few and mild without having been associated with serious clinical outcomes. In most studies ezetimibe has not been associated with increased rates of myopathy or rhabdomyolysis, whether used alone or in combination with statins, although there have been some case reports of myopathy attributed to this agent. Moreover, ezetimibe has been associated with mild elevations of liver transaminases, mainly in combination with a statin. Other side effects are extremely rare. It should be noted, however, there are no long-term safety data or outcome studies for ezetimibe yet. CONCLUSIONS Ezetimibe is a safe alternative option for hyperlipidaemic patients intolerant to other lipid lowering drugs as well as a beneficial supplementary agent for patients who do not reach the recommended serum cholesterol level with their current hypolipidaemic treatment. However, as is the case with all new medications, physicians should be alert to recognise adverse effects associated with ezetimibe and report them to regulatory authorities.
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Affiliation(s)
- M Florentin
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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DALMORA SL, OLIVEIRA PR, BARTH T, TODESCHINI V. Development and Validation of a Stability-indicating Micellar Electrokinetic Chromatography Method for the Determination of Ezetimibe in Pharmaceutical Formulations. ANAL SCI 2008; 24:499-503. [DOI: 10.2116/analsci.24.499] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sérgio L. DALMORA
- Department of Industrial Pharmacy, Health Science Centre, Federal University of Santa Maria
| | - Paulo R. OLIVEIRA
- Department of Industrial Pharmacy, Health Science Centre, Federal University of Santa Maria
| | - Thiago BARTH
- Department of Industrial Pharmacy, Health Science Centre, Federal University of Santa Maria
| | - Vítor TODESCHINI
- Department of Industrial Pharmacy, Health Science Centre, Federal University of Santa Maria
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