Temporal trends, determinants, and impact of high-intensity statin prescriptions after percutaneous coronary intervention: Results from a large single-center prospective registry

Low-density lipoprotein cholesterol reduction and statin intensity in myocardial infarction patients and major adverse outcomes: a Swedish nationwide cohort study

Aims 

Clinical trials have demonstrated that a reduction in low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular (CV) events. This has, however, not yet been shown in a real-world setting. We aimed to investigate the association between LDL-C changes and statin intensity with prognosis after a myocardial infarction (MI).

Methods and results 

Patients admitted with MI were followed for mortality and major CV events. Changes in LDL-C between the MI and a 6- to 10-week follow-up visit were analysed. The associations between quartiles of LDL-C change and statin intensity with outcomes were assessed using adjusted Cox regression analyses. A total of 40 607 patients were followed for a median of 3.78 years. The median change in LDL-C was a 1.20 mmol/L reduction. Patients with larger LDL-C reduction (1.85 mmol/L, 75th percentile) compared with a smaller reduction (0.36 mmol/L, 25th percentile) had lower hazard ratios (HR) for all outcomes (95% confidence interval): composite of CV mortality, MI, and ischaemic stroke 0.77 (0.70–0.84); all-cause mortality 0.71 (0.63–0.80); CV mortality 0.68 (0.57–0.81); MI 0.81 (0.73–0.91); ischaemic stroke 0.76 (0.62–0.93); heart failure hospitalization 0.73 (0.63–0.85), and coronary artery revascularization 0.86 (0.79–0.94). Patients with ≥50% LDL-C reduction using high-intensity statins at discharge had a lower incidence of all outcomes compared with those using a lower intensity statin.

Conclusions 

Larger early LDL-C reduction and more intensive statin therapy after MI were associated with a reduced hazard of all CV outcomes and all-cause mortality. This supports clinical trial data suggesting that earlier lowering of LDL-C after an MI confers the greatest benefit.

Lipid Management in Patients Presenting With Acute Coronary Syndromes: A Review

Despite many improvements in its prevention and management, acute coronary syndrome (ACS) remains a major cause of morbidity and mortality in the developed world. Lipid management is an important part of secondary prevention after ACS, but many patients currently remain undertreated and do not attain guideline‐recommended levels of low‐density lipoprotein cholesterol reduction. This review details the current state of evidence on lipid management in patients presenting with ACS, provides directions for identification of patients who may benefit from early escalation of lipid‐lowering therapy, and discusses novel lipid‐lowering medication that is currently under investigation in clinical trials. Moreover, a treatment algorithm aimed at attaining guideline‐recommended low‐density lipoprotein cholesterol levels is proposed. Despite important advances in the initial treatment and secondary prevention of ACS, ≈20% of ACS survivors experience a subsequent ischemic cardiovascular event within 24 months, and 5‐year mortality ranges from 19% to 22%. Knowledge of the current state of evidence‐based lipid management after ACS is of paramount importance to improve outcomes after ACS.

Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines

The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients presenting without persistent ST-segment elevation myocardial infarction have incorporated the most recent breakthroughs and updates from large randomized controlled trials (RCT) on the diagnosis and management of this disease. The purpose of the present review is to describe the main novelties and the rationale behind these recommendations. Hence, we describe the accumulating evidence against P2Y12 receptors inhibitors pretreatment prior to coronary angiography, the preference for prasugrel as leading P2Y12 inhibitors in the setting of ACS, and the numerous available antithrombotic regimens based on various durations of dual or triple antithrombotic therapy, according to the patient ischemic and bleeding risk profiles. We also detail the recently implemented 0 h/1 h and 0 h/2 h rule in, rule out algorithms and the growing role of computed coronary tomography angiography to rule out ACS in patients at low-to-moderate risk.

High-intensity statin therapy yields better outcomes in acute coronary syndrome patients: a meta-analysis involving 26,497 patients

Background

Whether high-intensity statin treatment provides more clinical benefits compared with standard statin regimens in acute coronary syndrome (ACS) patients remains controversial. This meta-analysis aimed to comparatively assess high-intensity and standard statin regimens for efficacy and safety in patients with ACS.

Methods

The PubMed, EMBASE, and Cochrane Library databases were searched for studies assessing high-intensity vs. standard statin regimens for ACS treatment from inception to April 2020. The publication language was limited to English, and 16 randomized controlled trials were finally included in this study, with a total of 26,497 patients.

Results

Compared to the standard statin regimens, the relative ratio (RR) of major adverse cardiovascular events (MACE) in ACS patients treated by high-intensity statin was 0.77 (95%CI, 0.68–0.86; P < 0.00001; prediction interval, 0.56–1.07). In subgroup analysis, high-intensity statin therapy resulted in more clinical benefits regarding MACE compared with standard statin treatment in both Asian (RR = 0.77; 95%CI, 0.61–0.98; P = 0.03) and non-Asian (RR = 0.79; 95%CI, 0.71–0.89; P < 0.0001) patients. Although adverse events were acceptable in patients with ACS administered high-intensity statin therapy, this treatment was associated with a higher rate of adverse events (4.99% vs. 2.98%), including myopathy/myalgia and elevated liver enzymes, as reflected by elevated serum aminotransferase or aminotransferase amounts.

Conclusion

The current findings indicated that high-intensity statin therapy might be beneficial in patients with ACS, and close monitoring for adverse effects should be performed.

Temporal Trends in Statin Prescriptions and Residual Cholesterol Risk in Patients With Stable Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Intensive low-density lipoprotein cholesterol (LDL-C) reduction with statins is recommended after elective percutaneous coronary intervention (PCI). We aimed to evaluate adherence to guideline-recommended statin therapy (GRST) and the rate of residual cholesterol risk (RCR) at follow-up after elective PCI. All patients who underwent elective PCI between January 2010 and May 2016 were prospectively included in this single-center study. GRST was defined as high-intensity statin (HIS) therapy for patients ≤75 years old and moderate-intensity statin (MIS) or HIS therapy for patients >75 years. RCR at follow-up was defined as <50% decrease in LDL-C with HIS or <30% with MIS for statin-naïve patients and as LDL-C >70 mg/dL for nonstatin-naïve patients. A total of 2,653 patients were included, with 1,304 (49.2%) discharged with GRST. There was a significant increase in the number of patients discharged with GRST over time from 44.2% in 2010 to 63.0% in 2016 (p <0.001). Conversely, RCR at follow-up was present in 1,120 patients (42.2%) overall and remained stable over time. Risk factors of RCR at follow-up were female gender (odds ratio [OR]: 1.38; 95% confidence interval [CI] 1.13 to 1.70), previous myocardial infarction (OR: 1.37; 95% CI 1.12 to 1.64), smoking (OR: 1.30; 95% CI 1.01 to 1.67), higher LDL-C level at baseline (OR: 1.22; 95% CI 1.18 to 1.25). The presence of RCR was associated with an increased adjusted risk of death within 1 year of the second LDL-C measurement (adjHR: 2.78; 95% CI 1.15 to 6.67). In conclusion, although the rate of GRST at discharge has improved significantly over time in patients who underwent elective PCI, the prevalence of RCR at follow-up has not changed appreciably suggesting that further implementation of guidelines as well as novel or more intensive pharmacotherapy may be warranted.