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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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El Din Taha HS, Kandil H, Badran HM, Farag N, Khamis H, Nasr G, Samy M, Abdrabou M, Abuelezz M, Shaker MM. 2024 Egyptian consensus statement on the role of non-statin therapies for LDL cholesterol lowering in different patient risk categories. Egypt Heart J 2024; 76:131. [PMID: 39302613 DOI: 10.1186/s43044-024-00562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 09/15/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND The new millennium has witnessed increased understanding of cardiovascular (CV) risk factors and improvement in atherosclerotic cardiovascular disease (ASCVD) management. The role of LDL cholesterol and other atherogenic lipid particles in the development of atherosclerosis is now beyond doubt. MAIN BODY Statins have been widely used and recommended in guidelines for preventing and managing ischemic events. However, statins have side effects, and many patients do not achieve their low-density lipoprotein cholesterol (LDL-C) goals. In recent years, non-statin lipid-lowering agents have gained increasing use as adjuncts to statins or as alternatives in patients who cannot tolerate statins. This consensus proposes a simple approach for initiating non-statin lipid-lowering therapy and provides evidence-based recommendations. Our key advancements include the identification of patients at extreme risk for CV events, the consideration of initial combination therapy of statin and ezetimibe in very high-risk and extreme-risk groups and the extended use of bempedoic acid in patients not reaching LDL-C targets especially in resource-limited settings. CONCLUSIONS Overall, this consensus statement provides valuable insights into the expanding field of non-statin therapies and offers practical recommendations to enhance CV care, specifically focusing on improving LDL-C control in Egypt. While these recommendations hold promise, further research and real-world data are needed for validation and refinement.
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Affiliation(s)
| | | | | | - Nabil Farag
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Gamila Nasr
- Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mina Samy
- Faculty of Medicine, Cairo University, Cairo, Egypt
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Adeniji O, Olowoyo P, Akinyemi R, Fisher M, Owolabi M. Advances in Primordial, Primary, and Secondary Prevention of Stroke in Diverse Populations. Stroke 2024; 55:2359-2365. [PMID: 38445485 DOI: 10.1161/strokeaha.123.044231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Olaleye Adeniji
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
| | - Paul Olowoyo
- Neurology Unit, Department of Medicine, Afe Babalola University Ado Ekiti, Nigeria (P.O.)
| | - Rufus Akinyemi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Mayowa Owolabi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
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Gibson CM, Chi G, Duffy D, Bahit MC, White H, Korjian S, Alexander JH, Lincoff AM, Anschuetz G, Girgis IG, Nicolau JC, Lopes RD, Cornel JH, Bainey KR, Libby P, Sacks FM, Ridker PM, Goodman SG, Mahaffey KW, Nicholls SJ, Pocock SJ, Mehran R, Harrington RA. ApoA-I Infusions and Burden of Ischemic Events After Acute Myocardial Infarction: Insights From the AEGIS-II Trial. J Am Coll Cardiol 2024:S0735-1097(24)08038-0. [PMID: 39230545 DOI: 10.1016/j.jacc.2024.08.001] [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: 07/15/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Following an acute myocardial infarction (AMI), patients remain at risk for subsequent cardiovascular (CV) events. In the AEGIS-II trial, CSL112, a human apolipoprotein A-I derived from plasma that enhances cholesterol efflux, did not significantly reduce the first occurrence of CV death, myocardial infarction (MI), or stroke through 90 days compared with placebo. However, an analysis involving only the first event may not capture the totality of the clinical impact of an intervention because patients may experience multiple events. OBJECTIVES This prespecified exploratory analysis examines the effect of CSL112 on total burden of nonfatal ischemic events (ie, recurrent MI and stroke) and CV death. METHODS A total of 18,219 patients with AMI, multivessel coronary artery disease, and additional CV risk factors were randomized to either 4 weekly infusions of 6 g CSL112 (n = 9,112) or matching placebo (n = 9,107). A negative binomial regression model was applied to estimate the effect of CSL112 compared with placebo on the rate ratio (RR) of ischemic events. RESULTS For CV death, MI, and stroke, there were numerically fewer total events at 90 days (503 vs 545 events; rate ratio [RR]: 0.88; 95% CI: 0.76-1.03, P = 0.11), and nominally significantly fewer total events at 180 days (745 vs 821 events, RR: 0.87; 95% CI: 0.77-0.99; P = 0.04) and 365 days (1,120 vs 1,211 events; RR 0.89; 95% CI: 0.80-0.99; P = 0.04). Subsequent events constituted 13% of events at 90 days, 17% at 180 days, and 22% at 1 year. Similar findings were seen with the total occurrence of nonfatal MI and CV death. When type II MIs, unlikely to be modified by enhancing cholesterol efflux, were excluded, there were nominally significant reductions in the total occurrence of nonfatal MI (excluding type 2) and CV death at all timepoints (90 days: RR: 0.81; 95% CI: 0.68-0.97; P = 0.02; 180 days: RR: 0.82; 95% CI: 0.71-0.95; P < 0.01; 365 days: RR: 0.86; 95% CI: 0.76-0.98; P = 0.02). CONCLUSIONS In this prespecified exploratory analysis of the AEGIS-II trial, 4 weekly infusions of CSL112 among high-risk patients after AMI significantly reduced the total burden of nonfatal ischemic events and CV death at 180 and 365 days compared with placebo. (AEGIS-II [Study to Investigate CSL112 in Subjects With Acute Coronary Syndrome]; NCT03473223).
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Affiliation(s)
- C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Harvey White
- Green Lane Cardiovascular Service, Te Whatu Ora Health New Zealand, Te Toka Tumai Auckland and University of Auckland, Auckland, New Zealand
| | - Serge Korjian
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | | | | | - Jose C Nicolau
- Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina, USA; Brazilian Clinical Research Institute, Sao Paulo, Brazil
| | - Jan H Cornel
- Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Kevin R Bainey
- Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Peter Libby
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frank M Sacks
- Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul M Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Zena and The Michael A. Wiener Cardiovascular Institute, New York, New York, USA
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Jun JE, Jeong IK, Ahn KJ, Chung HY, Hwang YC. Combination of low- or moderate-intensity statin and ezetimibe vs. high-intensity statin monotherapy on primary prevention of cardiovascular disease and all-cause death: a propensity-matched nationwide cohort study. Eur J Prev Cardiol 2024; 31:1205-1213. [PMID: 38408362 DOI: 10.1093/eurjpc/zwae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Abstract
AIMS This study aims to compare the preventive effect of low- or moderate-statin with ezetimibe combination therapy and high-intensity statin monotherapy on cardiovascular disease (CVD) and all-cause death in a real-world setting. METHODS AND RESULTS Using the Korean National Health Insurance Service datasets, two cohorts comparing high-intensity statin monotherapy with low- or moderate-intensity statin and ezetimibe combination were constructed by 1:1 propensity score matching procedure. Primary outcome was a composite of myocardial infarction (MI), stroke, and all-cause death. Secondary outcome was an individual event. The study population was followed from baseline until the date of events, or the last health check-ups, whichever came first. Compared to high-intensity statin monotherapy, moderate-intensity statin with ezetimibe combination significantly reduced the risk of composite outcome [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.77-0.92, P < 0.001] as well as individual MI (HR 0.81, 95% CI 0.71-0.94, P = 0.005) and stroke (HR 0.78, 95% CI 0.65-0.93, P = 0.005), but not all-cause death. Low-intensity statin with ezetimibe also significantly reduced the risk of the composite outcomes (HR 0.80, 95% CI 0.66-0.97, P = 0.024) compared to high-intensity statin monotherapy, but the risk of individual outcome did not differ between two groups. Statin and ezetimibe combination demonstrated consistent effect across various subgroups. CONCLUSION Among people without pre-existing CVD, moderate-intensity statin with ezetimibe combination was superior to high-intensity statin monotherapy in preventing composite outcomes as well as each of MI and stroke. In contrast, low-intensity statin with ezetimibe combination reduced the risk of composite but not individual outcomes.
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Affiliation(s)
- Ji Eun Jun
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, #892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea
| | - In-Kyung Jeong
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, #892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea
| | - Kyu Jeong Ahn
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, #892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea
| | - Ho Yeon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, #892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea
| | - You-Cheol Hwang
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, #892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea
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Davidson MH, Hsieh A, Dicklin MR, Maki KC. The Imperative to Enhance Cost-Effectiveness for Cardiovascular Therapeutic Development. JACC Basic Transl Sci 2024; 9:1029-1040. [PMID: 39297137 PMCID: PMC11405807 DOI: 10.1016/j.jacbts.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 09/21/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality worldwide. Therapeutic agents, such as those that lower low-density lipoprotein cholesterol, have been a critical factor in mitigating CVD event risk and demonstrate the important role that drug discovery plays in reducing morbidity and mortality. However, rapidly rising development costs, diminishing returns, and an increasingly challenging regulatory environment have all contributed to a declining number of cardiovascular (CV) therapeutic agents entering the health care marketplace. For pharmaceutical companies, a traditional cardiovascular outcomes trial (CVOT) can be a major financial burden and impediment to CV agent development. They can take as long as a decade to conduct, delaying potential investment return while carrying risk of failure. For patients, lengthy CVOTs delay drug accessibility. Without cost-effective CVOTs, drug innovation may be compromised, with CV patients bearing the consequences. This paper reviews potential approaches for making CV drug development more cost-effective.
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Affiliation(s)
- Michael H Davidson
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
- NewAmsterdam Pharma, Naarden, the Netherlands
| | | | - Mary R Dicklin
- Midwest Biomedical Research, Addison, Illinois, and Boca Raton, Florida, USA
| | - Kevin C Maki
- Midwest Biomedical Research, Addison, Illinois, and Boca Raton, Florida, USA
- Indiana University School of Public Health, Bloomington, Indiana, USA
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7
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Faluk M, Wardhere A, Mohamoud A, Nor M, Bampastsias D, Oikonomou E, Almubaid Z, Al-Hemyari B. Evolution of LDL-C lowering medications and their cardiovascular benefits: Past, present, and future. Curr Probl Cardiol 2024; 49:102637. [PMID: 38735347 DOI: 10.1016/j.cpcardiol.2024.102637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/14/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Hyperlipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C) is one of the major risk factors for CVD. Major landmark cardiovascular outcome clinical trials demonstrated that LDL-C lowering medications reduce cardiovascular events, and the lower the LDL-C the better the outcome. This article discusses the evolution of LDL-C lowering medications starting from bile acid sequestrants (BAS), statin therapy, bempedoic acid, the proprotein convertase subtilisin kexin 9 (PCSK9) synthesis inhibitor, novel small interfering RNA-based therapy (inclisiran) to the most recent oral PCSK9 inhibitors (MK-0616) which is currently under phase 3 clinical trial studies.
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Affiliation(s)
- Mohammed Faluk
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Abdirahman Wardhere
- Division of Cardiovascular Medicine, University of Columbia Irving Medical Center, New York, NY, USA
| | - Abdilahi Mohamoud
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Mohammed Nor
- Department of Internal Medicine, Stamford Hospital, Stamford, CT, USA
| | - Dimitrios Bampastsias
- Division of Cardiovascular Medicine, University of Columbia Irving Medical Center, New York, NY, USA
| | - Ermioni Oikonomou
- School of Medicine, National and Kapodostrian University of Athens, Athens, Greece
| | - Zaid Almubaid
- John Sealy School of Medicine, University of Texas Medical branch Galveston, TX, USA
| | - Bashar Al-Hemyari
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Chen C, Wei FF, Dong Y, Liu C. Early Management of Blood Lipid Levels with Non-Statin Lipid-Lowering Drugs in Acute Coronary Syndrome: A Mini Review. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07587-9. [PMID: 38951453 DOI: 10.1007/s10557-024-07587-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 07/03/2024]
Abstract
Acute coronary syndrome (ACS) remains a major cause of morbidity and mortality, despite many improvements in its prevention and management. Lipid management is an important aspect of secondary prevention after ACS. Previous studies indicate that the early use of intensive statin therapy in patients with ACS may alleviate the risk of recurrent cardiovascular events and mortality. However, many patients do not reach the target low-density lipoprotein cholesterol (LDL-C) level of < 55 mg/dL with statin monotherapy, and muscle-related adverse effects caused by statins hinder adherence to treatment. Novel non-statin agents are recommended for patients who cannot achieve the target LDL-C levels with high-intensity statin therapy and those with statin intolerance. The combination of statins and non-statins may synergistically affect intensively lowering LDL-C through different mechanisms, which could lead to better cardiovascular outcomes than statin monotherapy. However, it remains uncertain whether the early use of combination lipid-lowering therapy is more beneficial. The present review summarizes the benefits of intensive statin monotherapy and their early combination with non-statin medications including ezetimibe, PCSK9 inhibitors, inclisiran, and bempedoic acid (BDA) in the management of ACS.
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Affiliation(s)
- Chen Chen
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China
| | - Fang-Fei Wei
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
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Fularski P, Czarnik W, Dąbek B, Lisińska W, Radzioch E, Witkowska A, Młynarska E, Rysz J, Franczyk B. Broader Perspective on Atherosclerosis-Selected Risk Factors, Biomarkers, and Therapeutic Approach. Int J Mol Sci 2024; 25:5212. [PMID: 38791250 PMCID: PMC11121693 DOI: 10.3390/ijms25105212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) stands as the leading cause of mortality worldwide. At its core lies a progressive process of atherosclerosis, influenced by multiple factors. Among them, lifestyle-related factors are highlighted, with inadequate diet being one of the foremost, alongside factors such as cigarette smoking, low physical activity, and sleep deprivation. Another substantial group of risk factors comprises comorbidities. Amongst others, conditions such as hypertension, diabetes mellitus (DM), chronic kidney disease (CKD), or familial hypercholesterolemia (FH) are included here. Extremely significant in the context of halting progression is counteracting the mentioned risk factors, including through treatment of the underlying disease. What is more, in recent years, there has been increasing attention paid to perceiving atherosclerosis as an inflammation-related disease. Consequently, efforts are directed towards exploring new anti-inflammatory medications to limit ASCVD progression. Simultaneously, research is underway to identify biomarkers capable of providing insights into the ongoing process of atherosclerotic plaque formation. The aim of this study is to provide a broader perspective on ASCVD, particularly focusing on its characteristics, traditional and novel treatment methods, and biomarkers that can facilitate its early detection.
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Affiliation(s)
- Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Witold Czarnik
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Bartłomiej Dąbek
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Wiktoria Lisińska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewa Radzioch
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Alicja Witkowska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Nicholls SJ, Nelson AJ, Lincoff AM, Brennan D, Ray KK, Cho L, Menon V, Li N, Bloedon L, Nissen SE. Impact of Bempedoic Acid on Total Cardiovascular Events: A Prespecified Analysis of the CLEAR Outcomes Randomized Clinical Trial. JAMA Cardiol 2024; 9:245-253. [PMID: 38231501 PMCID: PMC10794976 DOI: 10.1001/jamacardio.2023.5155] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/11/2023] [Indexed: 01/18/2024]
Abstract
Importance The ATP citrate lyase (ACL) inhibitor, bempedoic acid, reduces low-density lipoprotein cholesterol (LDL-C) level and major adverse cardiovascular events (MACE) by 13% in patients at high cardiovascular risk with intolerance of statin and high-intensity statin medications. The effects of bempedoic acid on total cardiovascular events remain unknown. Objective To determine the impact of bempedoic acid on the total incidence of MACE. Design, Setting, and Participants Included in this prespecified analysis of the Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen (CLEAR) Outcomes trial were patients with, or at high risk for, cardiovascular disease, with hypercholesterolemia and inability to take guideline-recommended statins. Study data were analyzed from December 2016 to November 2022. Interventions Patients were randomly assigned to treatment with bempedoic acid or placebo daily. Main Outcomes and Measures The primary end point was the time to first event for a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization (MACE-4). The key secondary end point was time to first event for cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke (MACE-3). This prespecified analysis compared the total number of cardiovascular events in the treatment groups. Results A total of 13 970 patients (mean [SD] age, 65 [9] years; 7230 male [51.8%]) were included in the study. A total of 9764 participants (69.9%) had prior atherosclerotic cardiovascular disease and a baseline LDL-C level of 139 mg/dL; treatment with bempedoic acid resulted in a 21% reduction in LDL-C level and a 22% reduction in high-sensitivity C-reactive protein (hsCRP) level at 6 months. Median (IQR) follow-up was 3.4 (3.1-3.9) years. A total of 1746 positively adjudicated first MACE-4 events and 915 additional MACE events in 612 patients were recorded, with coronary revascularization representing 32.8% (573 of 1746) of first events and 69.4% (635 of 915) of additional events. For the total incidence of cardiovascular events, treatment with bempedoic acid was associated with a reduction in risk of MACE-4 (hazard ratio [HR], 0.80; 95% CI, 0.72-0.89; P <.001), MACE-3 (HR, 0.83; 95% CI, 0.73-0.93; P = .002), myocardial infarction (HR, 0.69; 95% CI, 0.58-0.83; P < .001), and coronary revascularization (HR, 0.78; 95% CI, 0.68-0.89; P <.001), although no statistically significant difference was observed for stroke (HR, 0.80; 95% CI, 0.63-1.03). A lower HR for protection with bempedoic acid was observed with increasing number of MACE events experienced by patients. Conclusion and Relevance Lowering LDL-C level with bempedoic acid reduced the total number of cardiovascular events in patients with high cardiovascular risk, statin therapy intolerance, and elevated LDL-C levels.
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Affiliation(s)
- Stephen J. Nicholls
- The Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Adam J. Nelson
- The Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - A. Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Danielle Brennan
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Kausik K. Ray
- School of Public Health, Imperial College London, London, United Kingdom
| | - Leslie Cho
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Venu Menon
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Na Li
- Esperion Therapeutics, Ann Arbor, Michigan
| | | | - Steven E. Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
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Yadav S, Sawhney JPS. Treatment of dyslipidemia in acute coronary syndrome. Indian Heart J 2024; 76 Suppl 1:S51-S57. [PMID: 38307382 PMCID: PMC11019335 DOI: 10.1016/j.ihj.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/25/2023] [Accepted: 01/18/2024] [Indexed: 02/04/2024] Open
Abstract
Despite numerous improvements in the management of acute coronary syndrome(ACS), it is a major cause of mortality in India. Lipids play a critical role in pathogenesis of ACS and reduction of lipid parameters plays a pivotal role in secondary prevention. High total cholesterol and high low-density lipoprotein(LDL) are the major lipid abnormalities globally as well as in Indians. Among all the lipid parameters, LDL is the primary target of lipid-lowering therapies across the globe. High-dose statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and bempedoic acid are recommended therapies for LDL reduction in ACS patients. Statins have pleiotropic effects on the modulation of thrombogenesis, endothelial dysfunction, and myocardial protection. Multiple randomised controlled trials and meta-analyses have shown that the use of high-dose statin has significant benefits in ACS. LDL reduction goal is < 55 mg/dl or at least 50 % reduction from the baseline regardless of age or gender. Non-fasting LDL should be measured soon after the ACS as it varies minimally with food intake. The first line of therapy after ACS is to advise lifestyle modifications, combination therapy including high-dose statin with ezetimibe, and evaluation after 4-6 weeks of the index event. If the goal is not achieved then PCSK 9 inhibitors or Bempedoic acid should be used in combination with statins and ezetimibe to reduce recurrent ischaemic events. Despite the proven effect of these lipid-lowering therapies, undertreatment is still a big hurdle across the globe. Prohibitive costs, adverse effects, medication non-adherence, variation in health practice in different countries, and clinical inertia to prescribe this medication by physicians are the main reasons for the undertreatment.
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Tunnicliffe DJ, Palmer SC, Cashmore BA, Saglimbene VM, Krishnasamy R, Lambert K, Johnson DW, Craig JC, Strippoli GF. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2023; 11:CD007784. [PMID: 38018702 PMCID: PMC10685396 DOI: 10.1002/14651858.cd007784.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants). OBJECTIVES To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy. AUTHORS' CONCLUSIONS Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Brydee A Cashmore
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Kelly Lambert
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Shah AJ, Pavlatos N, Kalra DK. Preventive Therapies in Peripheral Arterial Disease. Biomedicines 2023; 11:3157. [PMID: 38137379 PMCID: PMC10741180 DOI: 10.3390/biomedicines11123157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Atherosclerosis, while initially deemed a bland proliferative process, is now recognized as a multifactorial-lipoprotein-mediated inflammation-driven pathway. With the rising incidence of atherosclerotic disease of the lower extremity arteries, the healthcare burden and clinical morbidity and mortality due to peripheral artery disease (PAD) are currently escalating. With a healthcare cost burden of over 21 billion USD and 200 million patients afflicted worldwide, accurate knowledge regarding the pathophysiology, presentation, and diagnosis of the disease is crucial. The role of lipoproteins and their remnants in atherosclerotic vessel occlusion and plaque formation and progression has been long established. This review paper discusses the epidemiology, pathophysiology, and presentation of PAD. PAD has been repeatedly noted to portend to poor cardiovascular and limb outcomes. We discuss major therapeutic avenues for the prevention of major cardiovascular adverse events and major limb adverse events in patients with PAD.
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Affiliation(s)
- Aangi J. Shah
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA; (A.J.S.); (N.P.)
| | - Nicholas Pavlatos
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA; (A.J.S.); (N.P.)
| | - Dinesh K. Kalra
- Division of Cardiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
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Guideline LDL-C Threshold Achievement in Acute Myocardial Infarction Patients: A Real-World Evidence Study Demonstrating the Impact of Treatment Intensification with PCSK9i. Cardiol Ther 2023; 12:327-338. [PMID: 36656500 DOI: 10.1007/s40119-022-00300-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/21/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION A high proportion of Canadian patients with acute myocardial infarction (AMI) do not achieve the threshold low-density lipoprotein cholesterol (LDL-C) levels recommended by the Canadian Cardiovascular Society in 2021. This increases the risk of subsequent atherosclerotic cardiovascular disease (ASCVD) events. Here, we assess LDL-C levels and threshold achievement among patients by lipid-lowering therapies (LLT) received post-AMI. METHODS A retrospective cohort study of patients identified with AMI between 2015 and 2019 was conducted using administrative health databases in Alberta, Canada. Patients were grouped by their highest-intensity LLT post-AMI (proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) + another LLT; PCSK9i alone; ezetimibe + statin; statins (high, moderate, low intensity); or ezetimibe alone), and available LDL-C levels were examined in the year before and after LLT dispense date. RESULTS The cohort included 15,283 patients. In patients on PCSK9i + LLT, the median [95% confidence interval (CI)] LDL-C levels decreased from 2.7 (2.3-3.4) before to 0.9 (0.5-1.2) mmol/l after treatment, the largest decrease among treatment groups. In the ezetimibe + statin and high-intensity statin groups, median (95% CI) values after treatment were 1.5 (1.5-1.6) and 1.4 (1.4-1.4) mmol/l, respectively. The proportion of patients below the 1.8 mmol/l threshold increased by 77.7% in the PSCK9i + LLT group after treatment, compared to 45.4 and 32.4% in the ezetimibe + statin and high-intensity statin groups, respectively. CONCLUSIONS Intensification with PCSK9i in AMI patients results in a greater proportion of patients achieving below the recommended LDL-C threshold versus statins and or ezetimibe alone. Increased focus on achieving below the LDL-C thresholds with additional LLT as required may benefit patient cardiovascular outcomes.
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Ward NC, Reid CM, Watts GF. Low-density lipoprotein-cholesterol lowering effect of a nutraceutical regimen with or without ezetimibe in hypercholesterolaemic patients with statin intolerance. Front Cardiovasc Med 2022; 9:1060252. [PMID: 36505352 PMCID: PMC9732015 DOI: 10.3389/fcvm.2022.1060252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022] Open
Abstract
Background Statins are the most widely prescribed medication to lower low-density lipoprotein cholesterol (LDL-c). However, a significant portion of patients are unable to tolerate them due to side effects, most commonly muscle related. Nutraceuticals, natural plant derivatives with lipid-lowering properties, may provide an alternative to lower LDL-c in these patients. Aims To investigate whether a nutraceutical regimen, either alone or in combination with ezetimibe, can lower LDL-c in patients with hypercholesterolemia who are intolerant to statins. Methods Participants were recruited into a double-blind, randomized, placebo-controlled intervention study. Treatments were (i) placebo, (ii) nutraceutical (500 mg berberine, 200 mg red yeast rice (RYR), 2 g plant sterols)/daily, (iii) ezetimibe (10 mg)/daily, or (iv) the combination of nutraceutical and ezetimibe/daily. At baseline and week 8, all participants provide a fasting blood sample for assessment of lipid profile and safety bloods. Results Fifty participants were randomized, with 44 completing the treatment period. Following adjustment for baseline levels and compared with placebo, LDL-c was significantly reduced (all p < 0.0001) with ezetimibe (-1.02 mmol/L), nutraceutical (-1.15 mmol/L) and the nutraceutical and ezetimibe combination (-1.92 mmol/L). Non-HDL cholesterol was significantly reduced (all p < 0.0001) with ezetimibe (-1.29 mmol/L), nutraceutical (-1.37 mmol/L) and the nutraceutical and ezetimibe combination (-2.18 mmol/L). Remnant cholesterol and triglycerides was significantly reduced with the nutraceutical and ezetimibe combination (p = 0.018). Conclusion A nutraceutical regimen (berberine, RYR and plant sterols) and ezetimibe independently and additively lower LDL-c in patients with hypercholesterolemia who are intolerant to statins.
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Affiliation(s)
- Natalie C. Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia, Perth, WA, Australia,*Correspondence: Natalie C. Ward,
| | | | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, WA, Australia,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
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Mueller L, Engelbertz C, Reinecke H, Freisinger E, Malyar NM, Meyborg M, Brix TJ, Varghese J, Gebauer K. Secondary Prevention in Lower Extremity Artery Disease Patients: Lipid-Lowering Therapy and Long-Term Guideline Adherence. J Clin Med 2022; 11:jcm11226838. [PMID: 36431315 PMCID: PMC9692475 DOI: 10.3390/jcm11226838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Lower extremity artery disease (LEAD) affects millions of elderly patients and is associated with elevated cardiovascular morbidity and mortality. Risk factor modification, including the therapy of dyslipidaemia, is mandatory to reduce cardiovascular event rates and to improve survival rates. However, only a minority achieve the recommended low-density lipoprotein cholesterol (LDL-C) target level < 55 mg/dL, according to the current ESC/EAS guidelines on the treatment of dyslipidaemia. This study elucidated the implementation of the lipid-lowering guideline recommendations of 400 LEAD patients with LDL-C > 100 mg/dL and their adherence to treatment adjustment during follow-up. Despite a sustained statin prescription in 93% of the patients, including 77% with high-intensity statins at follow-up, only 18% achieved the target level. Ezetimibe appeared in 21% and LDL-C goals were reached significantly more often with combination therapy. Recurrent revascularization appeared more often (28%) than coronary artery or cerebrovascular disease progression (14%) and 7% died. Despite the frequent use of high-intensity statins and expandable rates of ezetimibe, the progression of cardiovascular events remained inevitable. Only 18% of the patients had received recommendations on lifestyle modification, including dietary adaptations, which is key for a holistic approach to risk factor control. Thus, efforts for both pharmacological and behavioral strategies are needed to improve clinical outcomes and survival rates.
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Affiliation(s)
- Linda Mueller
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Christiane Engelbertz
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Eva Freisinger
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Nasser M. Malyar
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Matthias Meyborg
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
| | - Tobias J. Brix
- Institute of Medical Informatics, University of Muenster, 48149 Muenster, Germany
| | - Julian Varghese
- Institute of Medical Informatics, University of Muenster, 48149 Muenster, Germany
| | - Katrin Gebauer
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany
- Correspondence: ; Tel.: +49-251-8348411; Fax: +49-251-8345101
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Sykes AV, Patel N, Lee D, Taub PR. Integrating Advanced Lipid Testing and Biomarkers in Assessment and Treatment. Curr Cardiol Rep 2022; 24:1647-1655. [PMID: 36001215 DOI: 10.1007/s11886-022-01775-5] [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] [Accepted: 08/15/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Our ability to assess and stratify atherosclerotic disease risk in patients is evolving. Recent advances in advanced lipid testing have created opportunities for clinical application of novel biomarkers. RECENT FINDINGS Until recently, LDL-C has served largely as the singular biomarker of ASCVD and guide for decisions in treatment for high-risk groups. There are important evolutions in the measurement of LDL-C but even still, the pathogenesis of atherosclerosis and ASCVD is not solely driven by LDL-C. As atherosclerosis is driven by multiple complex pathways including inflammation, it is important to expand our focus beyond LDL-C and utilize multiple biomarkers in the assessment of this disease process. Non-HDL, ApoB, LDL-P, Lp(a), and hsCRP are unique tools to aid in cardiac risk evaluation, especially in higher risk patients, though not limited to this population. A multifaceted approach to advanced lipid testing with novel biomarkers will enhance comprehensive ASCVD risk assessments.
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Affiliation(s)
- Alexandra Vaio Sykes
- Internal Medicine UC San Diego, La Jolla, 200 W. Arbor Drive, San Diego, CA, 92103-8425, USA.
| | - Neeja Patel
- UC San Diego School of Medicine, La Jolla, San Diego, CA, USA
| | - Danielle Lee
- Family Medicine UC San Diego, La Jolla, San Diego, CA, USA
| | - Pam R Taub
- Cardiovascular Medicine, UC San Diego, La Jolla, San Diego, CA, USA
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Patel N, Mittal N, Choubdar PA, Taub PR. Lipoprotein(a)—When to Screen and How to Treat. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00698-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Schiele F, Pérez de Isla L, Arca M, Vlachopoulos C. Is it Time for Single-Pill Combinations in Dyslipidemia? Am J Cardiovasc Drugs 2022; 22:239-249. [PMID: 34549371 PMCID: PMC9061650 DOI: 10.1007/s40256-021-00498-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 12/15/2022]
Abstract
Despite the availability of lipid-lowering therapies (LLTs) that are safe and effective, the overall rate of low-density lipoprotein cholesterol (LDL-C) control at a population level in real-life studies is low. Higher-intensity treatment, earlier intervention, and longer-term treatment have all been shown to improve outcomes. However, in clinical practice, actual exposure to LLT is a product of the duration and intensity of, and adherence to, the treatment. To increase exposure to LLTs, the European Society of Cardiology guidelines recommended a stepwise optimization of LLTs by increasing statin intensity to the maximally tolerated dose, with subsequent addition of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Evidence from randomized controlled trials performed in a range of patients suggested that adding ezetimibe to statins rather than doubling the statin dose resulted in significantly more patients at LDL-C goal and significantly fewer patients discontinuing treatment because of adverse events. In addition, data showed that combination treatments effectively increased exposure to LLT. Despite these data and recommendations, optimization of LLT is often limited to increasing statin dose. Therapeutic inertia and poor treatment adherence are significant and prevalent barriers to increasing treatment exposure. They are known to be influenced by pill burden and complexity of treatment. Single-pill combinations provide a strategic approach that supports the intensification of treatment without increasing pill burden or treatment complexity. Single-pill combinations, compared with free associations, have been shown to increase the adherence to LLT and the percentage of patients at LDL-C goal.
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Berkowitz SD, Bauersachs RM, Szarek M, Nehler M, Debus ES, Patel MR, Anand S, Capell WH, Hess CN, Hsia J, Leeper NJ, Brasil D, Mátyás L, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Bonaca MP. Prevention of arterial and venous thrombotic events in symptomatic peripheral arterial disease patients after lower extremity revascularization in the VOYAGER PAD trial: Dual anticoagulant/antiplatelet regimen vs antiplatelet therapy alone. J Thromb Haemost 2022; 20:1193-1205. [PMID: 35170216 PMCID: PMC9314576 DOI: 10.1111/jth.15673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/10/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Vascular disease burden after lower extremity revascularization (LER) comprises more than the first event, more vascular beds than the local arteries, and more than one clinical event type. OBJECTIVES Assess total arterial and venous thrombotic burden after LER for symptomatic peripheral artery disease (PAD) and effect of low-dose anticoagulation added to low-dose antiplatelet therapy. PATIENTS/METHODS VOYAGER PAD randomized 6564 symptomatic PAD patients undergoing LER to rivaroxaban 2.5 mg twice-daily or placebo on aspirin background. Marginal proportional-hazards models used to generate treatment hazard ratios and associated 95% CIs for first and total events; non-thrombotic deaths treated as competing terminal events. Incidence rates calculated as number of events per 100 patient-years follow-up. RESULTS Over 2.5 years (median), first and total thrombotic event rates: 7.1 and 10.3 events/100 patient-years, respectively, in placebo group. Two-thirds (925/1372) of total thrombotic events (arterial 95%, venous 5%) were nonfatal first events. Nearly one-third of patients with first event had a second arterial or venous thrombotic event. Rivaroxaban plus aspirin reduced first and total arterial and venous thrombotic events to 5.4 and 7.9 events/100 patient-years, respectively, a reduction in total thrombotic events over aspirin of 23% (HR: 0.77, 95%CI: 0.67-0.89, p = .0005), preventing 6.1 total arterial and venous thrombotic events at 3 years. CONCLUSIONS Assessing total arterial and venous thrombotic events, not just first events, provides more complete information about disease burden and absolute on-treatment impact. Following LER, judicious modulation of more than one coagulation pathway can provide broader benefit than intensifying inhibition of one hemostatic system component.
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Affiliation(s)
- Scott D. Berkowitz
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Divisions of Cardiology and HematologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Rupert M. Bauersachs
- Cardiovascular Center Bethanien CCBFrankfurtGermany
- Center of Thrombosis and HemostasisUniversity of MainzMainzGermany
| | - Michael Szarek
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- State University of New York Downstate Health Sciences UniversityBrooklynNew YorkUSA
| | - Mark R. Nehler
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of Vascular SurgeryDepartment of SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - E. Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery–Angiology–Endovascular TherapyUniversity of Hamburg‐EppendorfHamburgGermany
| | - Manesh R. Patel
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
- Division of CardiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Sonia S. Anand
- Department of Medicine & EpidemiologyMcMaster UniversityHamiltonOntarioCanada
- Population Health Research InstituteHamilton Health Sciences and McMaster UniversityHamiltonOntarioCanada
| | - Warren H. Capell
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of EndocrinologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Connie N. Hess
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Judy Hsia
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Nicholas J. Leeper
- Division of Vascular SurgeryDepartment of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - David Brasil
- FELUMA‐Faculdade de Ciencias Medicas de Minas Gerais School of MedicineBelo HorizonteBrazil
| | - Lajos Mátyás
- B‐A‐Z Central University Teaching County Hospital Vascular and Endovascular SurgeryMiskolcHungary
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica ‐ Instituto Cardiovascular de RosarioRosarioArgentina
| | | | | | | | - Marc P. Bonaca
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
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Nguy J, Hitchen SA, Lan NSR, Dwivedi G, Larbalestier R, Yeap BB, Fegan PG. Barriers to prescribing proprotein convertase subtilisin-kexin type 9 inhibitors after coronary revascularisation. Intern Med J 2022. [PMID: 35112773 DOI: 10.1111/imj.15700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Guidelines advocate for intensive lipid-lowering in patients with atherosclerotic cardiovascular disease (ASCVD). In May 2020, evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, became government subsidised in Australia for patients with ASCVD requiring further low-density lipoprotein cholesterol (LDL-C) lowering. AIM To identify barriers to prescribing PCSK9 inhibitors in hospitalised patients with ASCVD. METHODS A retrospective three-month, single-site, observational analysis was conducted in consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Lipid-lowering therapy prescriptions, including PSCK9 inhibitors, were assessed using electronic medical records, compared against the Australian Pharmaceutical Benefits eligibility criteria, and barriers to PCSK9 inhibitor use identified. RESULTS Of 331 patients, 244 (73.7%) underwent PCI and 87 (26.3%) underwent CABG surgery. A lipid profile during or within 8 weeks of admission was measured for 202 (82.8%) patients undergoing PCI and 59 (67.8%) undergoing CABG surgery. In patients taking high-intensity statins on admission (n=109), LDL-C ≥1.4, ≥1.8 and >2.6mmol/L were seen in 64 (58.7%), 44 (40.4%) and 19 (17.4%) respectively. High-intensity statin prescribing at discharge was high (>80%); however, ezetimibe was initiated in zero patients with LDL-C ≥1.4mmol/L. There was variable advice given by clinicians for LDL-C targets. No patients met criteria for subsidised PSCK9 inhibitor therapy, largely due to lack of qualifying lipid levels following combined statin and ezetimibe therapy. CONCLUSION Prescribing of non-statin LDL-C-lowering therapies remains low in patients with ASCVD. Under-prescribing of ezetimibe and suboptimal lipid testing rates are barriers to accessing subsidised PCSK9i therapy using current Australian eligibility criteria. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jenny Nguy
- Fiona Stanley Hospital, Department of Pharmacy, Perth, Western Australia, Australia.,Fiona Stanley Hospital, Department of Endocrinology and Diabetes, Perth, Western Australia, Australia
| | - Sarah A Hitchen
- Fiona Stanley Hospital, Department of Pharmacy, Perth, Western Australia, Australia.,Fiona Stanley Hospital, Department of Endocrinology and Diabetes, Perth, Western Australia, Australia
| | - Nick S R Lan
- Fiona Stanley Hospital, Department of Endocrinology and Diabetes, Perth, Western Australia, Australia.,Fiona Stanley Hospital, Department of Cardiology, Perth, Western Australia, Australia.,The University of Western Australia, Internal Medicine, Medical School, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Fiona Stanley Hospital, Department of Cardiology, Perth, Western Australia, Australia.,The University of Western Australia, Internal Medicine, Medical School, Perth, Western Australia, Australia.,Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Robert Larbalestier
- Fiona Stanley Hospital, Department of Cardiothoracic Surgery, Perth, Western Australia, Australia
| | - Bu B Yeap
- Fiona Stanley Hospital, Department of Endocrinology and Diabetes, Perth, Western Australia, Australia.,The University of Western Australia, Internal Medicine, Medical School, Perth, Western Australia, Australia
| | - P Gerry Fegan
- Fiona Stanley Hospital, Department of Endocrinology and Diabetes, Perth, Western Australia, Australia.,Curtin University, Medical School, Perth, Western Australia, Australia
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23
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Arrieta F, Pedro-Botet J, Iglesias P, Obaya JC, Montanez L, Maldonado GF, Becerra A, Navarro J, Perez JC, Petrecca R, Pardo JL, Ribalta J, Sánchez-Margalet V, Duran S, Tébar FJ, Aguilar M. Diabetes mellitus and cardiovascular risk: an update of the recommendations of the Diabetes and Cardiovascular Disease Working Group of the Spanish Society of Diabetes (SED, 2021). CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2022; 34:36-55. [PMID: 34330545 DOI: 10.1016/j.arteri.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/05/2021] [Indexed: 06/13/2023]
Abstract
This document is an update to the clinical practice recommendations for the management of cardiovascular risk factors (CVRF) in diabetes mellitus. The consensus has been developed by a multidisciplinary team made up of members of the Cardiovascular Risk Group of the Spanish Diabetes Society (SED). The work is a necessary update as, since the last review three years ago, there have been many clinical trials that have studied the cardiovascular outcomes of numerous drugs in the diabetic population. We believe that this guideline update may be of interest to all clinicians treating patients with diabetes.
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Affiliation(s)
- Francisco Arrieta
- Servicio de Endocrinología y Nutrición, Hospital Ramón y Cajal, Madrid, España.
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Hospital del Mar, Barcelona, España
| | - Pedro Iglesias
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, España
| | - Juan Carlos Obaya
- Centro de Salud CHOPERA, Atención Primaria Alcobendas, Gdt Enfermedades Cardiovasculares Semfyc, Madrid, España
| | - Laura Montanez
- Servicio de Endocrinología y Nutrición, Hospital Ramón y Cajal, Madrid, España
| | | | - Antonio Becerra
- Servicio de Endocrinología y Nutrición, Hospital Ramón y Cajal, Madrid, España
| | - Jorge Navarro
- Hospital Clínico Universitario de Valencia, Gdt Diabetes Semfyc, Valencia, España
| | - J C Perez
- Centro de Salud Rincón de la Victoria, Atención Primaria, Málaga, España
| | - Romina Petrecca
- Unidad de Nutrición y dietética, Hospital de la Princesa, Madrid, España
| | - José Luis Pardo
- Centro de Salud Orihuela I. Médico de Familia, Atención Primaria Alicante, Alicante, España
| | - Josep Ribalta
- Universidad Rovira i Vigili, IISPV, CIBERDEM, Tarragona, España
| | | | - Santiago Duran
- Servicio de Endocrinología y Nutrición, Hospital Virgen de Valme, Sevilla, España
| | - Francisco Javier Tébar
- Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - Manuel Aguilar
- Servicio de Endocrinología y Nutrición, Hospital Puerta del Mar, Cádiz, España
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24
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Cicero AF, Fogacci F, Zambon A, Toth PP, Borghi C. Efficacy and safety of inclisiran a newly approved FDA drug: a systematic review and pooled analysis of available clinical studies. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100127. [PMID: 38560059 PMCID: PMC10978220 DOI: 10.1016/j.ahjo.2022.100127] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 04/04/2024]
Abstract
Study objective This systematic review and meta-analysis aimed to assess the efficacy and safety profile of treatment with inclisiran, a drug that has been recently approved by the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Design A systematic literature search was conducted in order to identify randomized controlled trials (RCTs) assessing the effect on lipoproteins and the safety profile of inclisiran. Results Data were pooled from 5 RCTs, which included 4226 subjects. Meta-analyses of data suggested that the multiple-dose regimens of inclisiran yielded a significant reduction in serum levels of proprotein convertase subtilisin/kexin type 9 (MD = -78.23%, 95%CI: -86.74, -69.71) and low-density lipoprotein cholesterol (MD = -45.48%, 95%CI: -50.36%, -40.61%) throughout the studies. Furthermore, treatment with inclisiran significantly affected total cholesterol (MD = -13.67%, 95%CI: -20.78%, -6.57%), high-density lipoprotein cholesterol (MD = 8.29%, 95%CI: 4.66%,11.93%), non-HDL cholesterol (MD = -39.45%, 95%CI: -43.6%, -35.31%), apolipoprotein B (MD = -34.58%, 95%CI: -38.78%, -30.78%) and lipoprotein(a) (MD = -20.9%, 95%CI: -25.8%, -15.99%). Multiple-dose regimens of inclisiran were associated with increased risk of injection-site reactions (any reaction: OR = 5.86, 95%CI: 3.44, 9.98; mild reactions: OR = 5.19, 95%CI: 1.68, 16.07; moderate reactions: OR = 13.37, 95%CI: 3.17, 56.46), and bronchitis (OR = 1.58, 95%CI: 1.10, 2.26), while the incidence of the pre-specified exploratory CV endpoint significantly decreased at 18 months (OR = 0.74, 95%CI: 0.58, 0.94). Conclusion and relevance Inclisiran has favourable effects on serum lipid levels and an acceptable safety profile. Further well-designed RCTs are needed to explore its longer-term safety.
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Affiliation(s)
- Arrigo F.G. Cicero
- Hypertension and Cardiovascular Risk Factors Research Group, Medical and Surgical Sciences Department, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40138 Bologna, Italy
| | - Federica Fogacci
- Hypertension and Cardiovascular Risk Factors Research Group, Medical and Surgical Sciences Department, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40138 Bologna, Italy
| | - Alberto Zambon
- IRCCS MultiMedica, Via Milanese 300, 20099 Sesto S. Giovanni, MI, Italy
- Department of Medicine-DIMED, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Factors Research Group, Medical and Surgical Sciences Department, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40138 Bologna, Italy
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25
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Al Sayed N, Almahmeed W, Alnouri F, Al Waili K, Sabbour H, Sulaiman K, Zubaid M, Ray KK, Al-Rasadi K. Consensus clinical recommendations for the management of plasma lipid disorders in the Middle East – 2021 update. Atherosclerosis 2021; 343:28-50. [DOI: 10.1016/j.atherosclerosis.2021.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/20/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
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26
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DePhillips C, Parikh PB, Stevens GA. Dyslipidemia: Current Therapies and Strategies to Overcome Barriers for Use. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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27
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Oyama K, Giugliano RP, Blazing MA, Park JG, Tershakovec AM, Sabatine MS, Cannon CP, Braunwald E. Baseline Low-Density Lipoprotein Cholesterol and Clinical Outcomes of Combining Ezetimibe With Statin Therapy in IMPROVE-IT. J Am Coll Cardiol 2021; 78:1499-1507. [PMID: 34620406 DOI: 10.1016/j.jacc.2021.08.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The 2018 U.S. cholesterol management guideline recommends additional lipid-lowering therapy with ezetimibe for secondary prevention in very high-risk patients with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL despite maximally tolerated statin. OBJECTIVES The purpose of this study was to evaluate the relationship between baseline LDL-C above and below 70 mg/dL and the benefit of adding ezetimibe to statin in patients post-acute coronary syndrome (ACS). METHODS IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial) was a double-blind, placebo-controlled, randomized trial of ezetimibe/simvastatin vs placebo/simvastatin in post-ACS patients followed for 6 years (median). A total of 17,999 patients were stratified by LDL-C at qualifying event into 3 groups (50-<70, 70-<100, and 100-125 mg/dL). The primary endpoint was a composite of cardiovascular death, major coronary events, or stroke. RESULTS Absolute differences in median LDL-C achieved at 4 months between treatment arms were similar (17-20 mg/dL). The effect of ezetimibe/simvastatin vs placebo/simvastatin on primary endpoint was consistent regardless of baseline LDL-C of 50-<70 mg/dL (HR: 0.92 [95% CI: 0.80-1.05]), 70-<100 mg/dL (HR: 0.93 [95% CI: 0.87-1.01]), or 100-125 mg/dL (HR: 0.94 [95% CI: 0.86-1.03]; P interaction = 0.95). Normalized relative risk reductions per 1-mmol/L difference in achieved LDL-C at 4 months between treatment arms were 21% in patients with baseline LDL-C of 50-<70 mg/dL, 16% in those with 70-<100 mg/dL, and 13% in those with 100-125 mg/dL (P interaction = 0.91). No significant treatment interactions by baseline LDL-C were present for safety endpoints. CONCLUSIONS Adding ezetimibe to statin consistently reduced the risk for cardiovascular events in post-ACS patients irrespective of baseline LDL-C values, supporting the use of intensive lipid-lowering therapy with ezetimibe even in patients with baseline LDL-C <70 mg/dL. (IMPROVE-IT: Examining Outcomes in Subjects With Acute Coronary Syndrome: Vytorin [Ezetimibe/Simvastatin] vs Simvastatin [P04103]; NCT00202878).
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan. https://twitter.com/KazumaOyama
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michael A Blazing
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeong-Gun Park
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Cannon
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/cpcannon
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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29
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Lopez-Sendon JL, Cyr DD, Mark DB, Bangalore S, Huang Z, White HD, Alexander KP, Li J, Nair RG, Demkow M, Peteiro J, Wander GS, Demchenko EA, Gamma R, Gadkari M, Poh KK, Nageh T, Stone PH, Keltai M, Sidhu M, Newman JD, Boden WE, Reynolds HR, Chaitman BR, Hochman JS, Maron DJ, O'Brien SM. Effects of initial invasive vs. initial conservative treatment strategies on recurrent and total cardiovascular events in the ISCHEMIA trial. Eur Heart J 2021; 43:148-149. [PMID: 34514494 DOI: 10.1093/eurheartj/ehab509] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/26/2021] [Accepted: 08/16/2021] [Indexed: 12/24/2022] Open
Abstract
AIMS The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial prespecified an analysis to determine whether accounting for recurrent cardiovascular events in addition to first events modified understanding of the treatment effects. METHODS AND RESULTS Patients with stable coronary artery disease (CAD) and moderate or severe ischaemia on stress testing were randomized to either initial invasive (INV) or initial conservative (CON) management. The primary outcome was a composite of cardiovascular death, myocardial infarction (MI), and hospitalization for unstable angina, heart failure, or cardiac arrest. The Ghosh-Lin method was used to estimate mean cumulative incidence of total events with death as a competing risk. The 5179 ISCHEMIA patients experienced 670 index events (318 INV, 352 CON) and 203 recurrent events (102 INV, 101 CON). A single primary event was observed in 9.8% of INV and 10.8% of CON patients while ≥2 primary events were observed in 2.5% and 2.8%, respectively. Patients with recurrent events were older; had more frequent hypertension, diabetes, prior MI, or cerebrovascular disease; and had more multivessel CAD. The average number of primary endpoint events per 100 patients over 4 years was 18.2 in INV [95% confidence interval (CI) 15.8-20.9] and 19.7 in CON (95% CI 17.5-22.2), difference -1.5 (95% CI -5.0 to 2.0, P = 0.398). Comparable results were obtained when all-cause death was substituted for cardiovascular death and when stroke was added as an event. CONCLUSIONS In stable CAD patients with moderate or severe myocardial ischaemia enrolled in ISCHEMIA, an initial INV treatment strategy did not prevent either net recurrent events or net total events more effectively than an initial CON strategy. CLINICAL TRIAL REGISTRATION ISCHEMIA ClinicalTrials.gov number, NCT01471522, https://clinicaltrials.gov/ct2/show/NCT01471522.
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Affiliation(s)
- Jose L Lopez-Sendon
- Cardiology department, Hospital Universitario La Paz, Idipaz, UAM, CIBER-CV, Paseo de la Castellana 261, Madrid 28046, Spain
| | - Derek D Cyr
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
| | - Daniel B Mark
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
| | - Sripal Bangalore
- NYU Grossman School of Medicine, 530 First Avenue, New York, NY, USA
| | - Zhen Huang
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
| | - Harvey D White
- Auckland City Hospital Green Lane Cardiovascular Services and University of Auckland, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Karen P Alexander
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
| | - Jianghao Li
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
| | - Rajesh Goplan Nair
- Government Medical College, 48/584, Subhag Sastrinagar, Thiruvananthapuram, Kerala 695002, India
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, Warsaw 04-628, Poland
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, As Xubias, 84, A Coruna 15006, Spain
| | - Gurpreet S Wander
- Dayanand Medical College & Hospital, Civil Lines, Tagore Nagar, Ludhiana, Punjab 141001, India
| | - Elena A Demchenko
- Almazov National Medical Research Centre, Ulitsa Akkuratova, 2, Saint-Petersburg 197341, Russia
| | - Reto Gamma
- Broomfield Hospital, Court Rd, Broomfield, Chelmsford CM1 7ET, UK
| | - Milind Gadkari
- Kem Hospital Maharashtra, 489, Mudaliar Rd, Rasta Peth, Pune, Maharashtra 411011, India
| | - Kian Keong Poh
- National University Heart Center Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, Singapore
| | - Thuraia Nageh
- Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Southend-on-Sea, Westcliff-on-Sea SS0 0RY, Southend, England, UK
| | - Peter H Stone
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, USA
| | - Matyas Keltai
- Semmelweis University, Budapest, Üllői út 26, 1085 Hungary
| | - Mandeep Sidhu
- Albany Medical College, 47 New Scotland Avenue, Physicians Pavilion, 2nd Floor, Albany, NY 12208, USA
| | - Jonathan D Newman
- NYU Grossman School of Medicine, 530 First Avenue, New York, NY, USA
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, 150 South Huntington Avenue, Boston, MA, USA
| | | | - Bernard R Chaitman
- St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, 1034 S. Brentwood Blvd., Suite 1120, St. Louis, MO, USA
| | - Judith S Hochman
- NYU Grossman School of Medicine, 530 First Avenue, New York, NY, USA
| | - David J Maron
- Department of Medicine, Stanford University, 300 Pasteur Drive, Falk CVRC 265, Stanford, CA 94305-5406, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, 300 W. Morgan Street, Durham, NC, USA
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30
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Sun C, Zheng W, Liang L, Liu Z, Sun W, Tang R. Ezetimibe Improves Rosuvastatin Effects on Inflammation and Vascular Endothelial Function in Acute Coronary Syndrome Patients Undergoing PCI. J Interv Cardiol 2021; 2021:2995602. [PMID: 34566523 PMCID: PMC8443370 DOI: 10.1155/2021/2995602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/26/2021] [Accepted: 08/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Little is known of the acute effects of ezetimibe in patients with acute coronary syndrome (ACS) undergoing PCI. We investigated whether ezetimibe improves inflammation and vascular endothelial function in patients with ACS undergoing PCI. METHODS We randomized 171 patients with ACS undergoing PCI to receive ezetimibe 10 mg/day plus rosuvastatin 20 mg/day (combination group, n = 81) versus rosuvastatin 20 mg/day (rosuvastatin group, n = 90). Lipid profile, type II secretory phospholipase A2 (sPLA2-IIa), interleukin-1β (IL-1β), vascular cell adhesion molecule-1 (VCAM-1), and intercellular cell adhesion molecule-1 (ICAM-1) were measured at baseline and after 7 days. Three months after PCI, clinical outcomes were examined. RESULT The levels of sPLA2-IIa and IL-1β reduced significantly in both groups, but more when ezetimibe and rosuvastatin were coadministered (sPLA2-IIa: 6.16 ± 2.67 vs. 7.42 ± 3.53 ng/ml, p=0.01; IL-1β: 37.39 ± 26.25 vs. 48.98 ± 32.26 pg/ml, p=0.01). A significant rise of VCAM-1 and ICAM-1 was observed on day 7 after PCI in the both groups, but was less in the combination group (VCAM-1: 918.28 ± 235.31 vs. 988.54 ± 194.41 ng/ml, p=0.03; ICAM-1: 213.01 ± 100.15 vs. 246.88 ± 105.71 ng/ml, p=0.03). Patients in the combination versus rosuvastatin group appeared to suffer from less major adverse events. Periprocedural therapy of ezetimibe improves rosuvastatin effects on proinflammatory responses and endothelial function associated with ACS patients undergoing PCI. This trial is registered with https://clinicaltrials.gov/ct2/show/ChiCTR-IPR-17012219 (Chinese Clinical Trial Registry, http://www.chictr.org.cn on 02/08/2017).
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Affiliation(s)
- Changqing Sun
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Wuyang Zheng
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Ling Liang
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Zuheng Liu
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Wenchao Sun
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Rong Tang
- Department of Cardiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
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31
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Fras Z, Mikhailidis DP. Have We Learnt all from IMPROVE-IT? Part I. Core Results and Subanalyses on the Effects of Ezetimibe Added to Statin Therapy Related to Age, Gender and Selected Chronic Diseases (Kidney Disease, Diabetes Mellitus and Non-Alcoholic Fatty Liver Disease). Curr Vasc Pharmacol 2021; 19:451-468. [DOI: 10.2174/1570161118999200727224946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/23/2020] [Accepted: 07/03/2020] [Indexed: 11/22/2022]
Abstract
IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) was
a randomized clinical trial (including 18,144 patients) that evaluated the efficacy of the combination of
ezetimibe with simvastatin vs. simvastatin monotherapy in patients with acute coronary syndrome
(ACS) and moderately increased low-density lipoprotein cholesterol (LDL-C) levels (of up to 2.6-3.2
mmol/L; 100-120 mg/dL). After 7 years of follow-up, combination therapy resulted in an additional
LDL-C decrease [to 1.8 mmol/L, or 70 mg/dL, within the simvastatin (40 mg/day) monotherapy arm
and to 1.4 mmol/L, or 53 mg/dL for simvastatin (40 mg/day) + ezetimibe (10 mg/day)] and showed an
incremental clinical benefit [composite of cardiovascular death, nonfatal myocardial infarction, unstable
angina requiring rehospitalization, coronary revascularization (≥30 days after randomization), or nonfatal
stroke; hazard ratio (HR) of 0.936, and 95% CI 0.887-0.996, p=0.016]. Therefore, for very high cardiovascular
risk patients “even lower is even better” regarding LDL-C, independently of the LDL-C
reducing strategy. These findings confirm ezetimibe as an option to treat very-high-risk patients who
cannot achieve LDL-C targets with statin monotherapy. Additional analyses of the IMPROVE-IT (both
prespecified and post-hoc) include specific very-high-risk subgroups of patients (those with previous
acute events and/or coronary revascularization, older than 75 years, as well as patients with diabetes
mellitus, chronic kidney disease or non-alcoholic fatty liver disease). The data from IMPROVE-IT also
provide reassurance regarding longer-term safety and efficacy of the intensification of lipid-lowering
therapy in very-high-risk patients resulting in very low LDL-C levels. We comment on the results of
several (sub) analyses of IMPROVE-IT.
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Affiliation(s)
- Zlatko Fras
- Centre for Preventive Cardiology, Department of Vascular Medicine, Division of Medicine, University Medical Centre, Ljubljana, Slovenia
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College Medical School, University College London, London, United Kingdom
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2438] [Impact Index Per Article: 812.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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Ms Wolever T, Rahn M, Dioum E, Spruill SE, Ezatagha A, Campbell JE, Jenkins AL, Chu Y. An Oat β-Glucan Beverage Reduces LDL Cholesterol and Cardiovascular Disease Risk in Men and Women with Borderline High Cholesterol: A Double-Blind, Randomized, Controlled Clinical Trial. J Nutr 2021; 151:2655-2666. [PMID: 34236436 DOI: 10.1093/jn/nxab154] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/16/2021] [Accepted: 04/28/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND High-molecular-weight (MW) oat β-glucan (OBG), consumed at 3-4 g/d, in solid foods reduces LDL cholesterol by a median of ∼6.5%. OBJECTIVES We evaluated the effect of a beverage providing 3 g/d high-MW OBG on reduction of LDL cholesterol (primary endpoint) when compared with placebo. METHODS We performed a parallel-design, randomized clinical trial at a contract research organization; participants, caregivers, and outcome assessors were blinded to treatment allocation. Participants with LDL cholesterol between 3.0 and 5.0 mmol/L, inclusive [n = 538 screened, n = 260 ineligible, n = 23 lost, n = 48 withdrawn (product safety); n = 207 randomly assigned, n = 7 dropped out, n = 9 withdrawn (protocol violation); n = 191 analyzed; n = 72 (37.7%) male, mean ± SD age: 43.3 ± 14.3 y, BMI: 29.7 ± 5.2 kg/m2], were randomly assigned to consume, 3 times daily for 4 wk, 1 g OBG (n = 104, n = 96 analyzed) or rice powder (Control, n = 103, n = 95 analyzed) mixed into 250 mL water. Treatment effects were assessed as change from baseline and differences analyzed using a 2-sided t test via ANOVA with baseline characteristics as covariates. RESULTS After 4 wk, change from baseline least-squares-mean LDL cholesterol on OBG (-0.195 mmol/L) was less than on Control (0.012 mmol/L) by mean: 0.207 mmol/L (95% CI: 0.318, 0.096 mmol/L; P = 0.0003); the following secondary endpoints were also reduced as follows: total cholesterol (TC) (0.226 mmol/L; 95% CI: 0.361, 0.091 mmol/L; P = 0.001), TC:HDL cholesterol ratio (0.147; 95% CI: 0.284, 0.010; P = 0.036), non-HDL cholesterol (0.194 mmol/L; 95% CI: 0.314, 0.073 mmol/L; P = 0.002), and Framingham cardiovascular disease (CVD) risk (0.474; 95% CI: 0.900, 0.049, P = 0.029). Changes in HDL cholesterol, triglycerides, glucose, and insulin did not differ between treatment groups (P > 0.05). Lipid treatment effects were not significantly modified by age, sex, BMI, or hypertension treatment. There were no major adverse events, but both treatments transiently increased gastrointestinal symptoms. CONCLUSIONS Consuming a beverage containing 1 g high-MW OBG 3 times daily for 4 wk significantly reduced LDL cholesterol by ∼6% and CVD risk by ∼8% in healthy adults with LDL cholesterol between 3 and 5 mmol/L.This trial was registered at clinicaltrials.gov as NCT03911427.
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Affiliation(s)
- Thomas Ms Wolever
- INQUIS Clinical Research, Ltd. (formerly GI Labs), Toronto, Ontario, Canada
| | - Maike Rahn
- Quaker Oats Center of Excellence, PepsiCo R&D Nutrition, Barrington, IL, USA
| | - ElHadji Dioum
- Quaker Oats Center of Excellence, PepsiCo R&D Nutrition, Barrington, IL, USA
| | | | - Adish Ezatagha
- INQUIS Clinical Research, Ltd. (formerly GI Labs), Toronto, Ontario, Canada
| | - Janice E Campbell
- INQUIS Clinical Research, Ltd. (formerly GI Labs), Toronto, Ontario, Canada
| | | | - YiFang Chu
- Quaker Oats Center of Excellence, PepsiCo R&D Nutrition, Barrington, IL, USA
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Lempp D. An Evidence-Based Guideline for Treating Dyslipidemia in Statin-Intolerant Patients. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy. J Clin Med 2021; 10:jcm10132968. [PMID: 34279451 PMCID: PMC8268641 DOI: 10.3390/jcm10132968] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 02/06/2023] Open
Abstract
The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.
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He F, Su W, Wu R, Li H, Lou L, Wu A, Xie L, Du Y, Wu S. The effect of cold exposure on serum cholesterol is dependent upon ApoE. J Therm Biol 2021; 99:102972. [PMID: 34420615 DOI: 10.1016/j.jtherbio.2021.102972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several lines of evidence indicate that cold stimulation may not only activate brown adipose tissue (BAT) and the white adipose tissue (WAT), but also regulate the lipid metabolism and influence the development of atherosclerosis. However, the study of cold exposure affecting cholesterol metabolism have opposite results in different experiments, and Apolipoprotein E (ApoE) may play an important role. There is still a lack of complete research to illustrate this problem. METHODS In this study, we first analyzed and discussed the activation of interscapular brown adipose tissue (iBAT), inguinal white adipose tissue (iWAT) and epididymal white adipose tissue (eWAT) under cold exposure (4 °C) in male wild-type C57BL/6 J (WT) and ApoE-deficient mice (ApoE-/-) fed high-fat diet (HFD) for 4 weeks. Subsequently, we investigated the effect of cold exposure on blood lipid profiles in both models. We further explored whether cold exposure can reduce serum cholesterol. RESULTS In both WT and ApoE-/- mice, cold exposure activates iBAT and iWAT, as well as hardly affects eWAT. In WT mice,4 weeks cold exposure (4 °C) reduces serum triglyceride by 28%, cholesterol by 30% and LDL-cholesterol by 63%. In ApoE-/- mice, cold stimulation decreases serum triglyceride by 59%, but increases cholesterol by 20% and LDL-cholesterol by 25%. CONCLUSIONS Based on these findings, we conclude that cold exposure decreases serum cholesterol is dependent upon the existence of ApoE.
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Affiliation(s)
- Fang He
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Wenquan Su
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Rongrong Wu
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - He Li
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Lixia Lou
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Aiming Wu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Lifang Xie
- Susan Samueli Integrative Health Institute, School of Medicine, University of California Irvine, USA
| | - Yawei Du
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China.
| | - Shengxian Wu
- National Drug Clinical Trial Institution, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China.
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Liu HH, Li S, Cao YX, Guo YL, Zhu CG, Wu NQ, Li JJ. Association of triglyceride-rich lipoprotein-cholesterol with recurrent cardiovascular events in statin-treated patients according to different inflammatory status. Atherosclerosis 2021; 330:29-35. [PMID: 34225103 DOI: 10.1016/j.atherosclerosis.2021.06.907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS The association of triglyceride-rich lipoprotein-cholesterol (TRL-C) with recurrent cardiovascular events (RCVEs) has not been studied. Moreover, whether inflammation can affect TRL-C-associated cardiovascular risk is unknown. This study sought to examine the association between TRL-C and RCVEs, and whether this relationship is modulated by systemic inflammation in statin-treated patients with coronary artery disease (CAD) and nearly normal triglyceride. METHODS In this study, 6723 CAD patients were consecutively enrolled, following a first CVE with triglyceride <2.3 mmol/L. Baseline lipid profile and high-sensitivity C-reactive protein (hsCRP) levels were determined. All patients were searched for RCVEs. The risk of RCVEs was assessed across quartiles (Q) of baseline TRL-C and further stratified by the median of hsCRP. RESULTS Over a mean follow-up of 58.91 ± 17.79 months, 538 RCVEs were recorded. After adjustment for potential confounders, Q4 of TRL-C was significantly associated with the risk of RCVEs, which remained unchanged after hsCRP stratification. When subjects were grouped according to both TRL-C and hsCRP levels, patients with Q4 of TRL-C and hsCRP had the highest increase of the risk of RCVEs compared with the reference group (TRL-C Q1-3 and hsCRP Q1-3; HR, 1.90; 95%CI: 1.27-2.87). Furthermore, adding TRL-C to the original predicting model led to a slight but significant improvement. CONCLUSIONS The present analysis firstly showed that elevated TRL-C was associated with an increased RCVEs risk in statin-treated patients with CAD independent of systemic inflammation, suggesting that it might be a useful marker for risk stratification and a treatment target in this patient population.
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Affiliation(s)
- Hui-Hui Liu
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Sha Li
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Ye-Xuan Cao
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Yuan-Lin Guo
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Cheng-Gang Zhu
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Na-Qiong Wu
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China
| | - Jian-Jun Li
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, China.
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Zhou R, Stouffer GA, Smith SC. Targeting the Cholesterol Paradigm in the Risk Reduction for Atherosclerotic Cardiovascular Disease: Does the Mechanism of Action of Pharmacotherapy Matter for Clinical Outcomes? J Cardiovasc Pharmacol Ther 2021; 26:533-549. [PMID: 34138676 DOI: 10.1177/10742484211023632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Hypercholesterolemia is a well-established risk factor for atherosclerotic cardiovascular disease (ASCVD). Low-density lipoprotein cholesterol (LDL-C) has been labeled as "bad" cholesterol and high-density lipoprotein cholesterol (HDL-C) as "good" cholesterol. The prevailing hypothesis is that lowering blood cholesterol levels, especially LDL-C, reduces vascular deposition and retention of cholesterol or apolipoprotein B (apoB)-containing lipoproteins which are atherogenic. We review herein the clinical trial data on different pharmacological approaches to lowering blood cholesterol and propose that the mechanism of action of cholesterol lowering, as well as the amplitude of cholesterol reduction, are critically important in leading to improved clinical outcomes in ASCVD. The effects of bile acid sequestrants, fibrates, niacin, cholesteryl ester transfer protein (CETP) inhibitors, apolipoprotein A-I and HDL mimetics, apoB regulators, acyl coenzyme A: cholesterol acyltransferase (ACAT) inhibitors, cholesterol absorption inhibitors, statins, and proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors, among other strategies are reviewed. Clinical evidence supports that different classes of cholesterol lowering or lipoprotein regulating approaches yielded variable effects on ASCVD outcomes, especially in cardiovascular and all-cause mortality. Statins are the most widely used cholesterol lowering agents and have the best proven cardiovascular event and survival benefits. Manipulating cholesterol levels by specific targeting of apoproteins or lipoproteins has not yielded clinical benefit. Understanding why lowering LDL-C by different approaches varies in clinical outcomes of ASCVD, especially in survival benefit, may shed further light on our evolving understanding of how cholesterol and its carrier lipoproteins are involved in ASCVD and aid in developing effective pharmacological strategies to improve the clinical outcomes of ASCVD.
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Affiliation(s)
- Ruihai Zhou
- Division of Cardiology, Department of Medicine, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology, Department of Medicine, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sidney C Smith
- Division of Cardiology, Department of Medicine, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Soyoye DO, Abiodun OO, Ikem RT, Kolawole BA, Akintomide AO. Diabetes and peripheral artery disease: A review. World J Diabetes 2021; 12:827-838. [PMID: 34168731 PMCID: PMC8192257 DOI: 10.4239/wjd.v12.i6.827] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
Peripheral arterial disease (PAD) refers to partial or complete occlusion of the peripheral vessels of the upper and lower limbs. It usually occurs as part of systemic atherosclerosis in the coronary and cerebral arteries. The prevalence of PAD is expected to continue to increase in the foreseeable future owing to the rise in the occurrence of its major risk factors. Nonhealing ulcers, limb amputation and physical disability are some of its major complications. Diabetes mellitus (DM) remains a major risk for PAD, with DM patients having more than two-fold increased prevalence of PAD compared with the general population. The clinical presentation in people with DM also differs slightly from that in the general population. In addition, PAD in DM may lead to diabetic foot ulcers (DFUs), which precipitate hyperglycaemic emergencies and result in increased hospital admissions, reduced quality of life, and mortality. Despite the epidemiological and clinical importance of PAD, it remains largely under diagnosed and hence undertreated, possibly because it is largely asymptomatic. Emphasis has been placed on neuropathy as a cause of DFUs, however PAD is equally important. This review examines the epidemiology, pathophysiology and diagnosis of lower limb PAD in people with diabetes and relates these to the general population. It also highlights recent innovations in the management of PAD.
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Affiliation(s)
- David Olubukunmi Soyoye
- Department of Medicine, Obafemi Awolowo University, Ile-Ife 220282, Osun State, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220282, Osun State, Nigeria
| | | | - Rosemary Temidayo Ikem
- Department of Medicine, Obafemi Awolowo University, Ile-Ife 220282, Osun State, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220282, Osun State, Nigeria
| | - Babatope Ayodeji Kolawole
- Department of Medicine, Obafemi Awolowo University, Ile-Ife 220282, Osun State, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220282, Osun State, Nigeria
| | - Anthony Olubunmi Akintomide
- Department of Medicine, Obafemi Awolowo University, Ile-Ife 220282, Osun State, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220282, Osun State, Nigeria
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Bauersachs RM, Szarek M, Brodmann M, Gudz I, Debus ES, Nehler MR, Anand SS, Patel MR, Hess CN, Capell WH, Rogers K, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR, Bonaca MP. Total Ischemic Event Reduction With Rivaroxaban After Peripheral Arterial Revascularization in the VOYAGER PAD Trial. J Am Coll Cardiol 2021; 78:317-326. [PMID: 34010631 DOI: 10.1016/j.jacc.2021.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER) are at high risk of major adverse limb and cardiovascular events. The VOYAGER PAD (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities) trial demonstrated that rivaroxaban 2.5 mg twice daily reduced first events by 15%. The benefit of rivaroxaban on total (first and subsequent) events in this population is unknown. OBJECTIVES This study sought to evaluate the total burden of vascular events in patients with PAD after LER and the efficacy of low-dose rivaroxaban on total events. METHODS VOYAGER PAD randomized patients with PAD undergoing LER to rivaroxaban 2.5 mg twice daily plus aspirin or aspirin alone. The primary endpoint was time to first event of acute limb ischemia, major amputation of a vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. The current analysis considered all events (first and subsequent) for components of the primary endpoint as well as additional vascular events including peripheral revascularizations and venous thromboembolism. HRs were estimated by marginal proportional hazards models. RESULTS Among 6,564 randomized events, there were 4,714 total first and subsequent vascular events including 1,614 primary endpoint events and 3,100 other vascular events. Rivaroxaban reduced total primary endpoint events (HR: 0.86; 95% CI: 0.75-0.98; P = 0.02) and total vascular events (HR: 0.86; 95% CI: 0.79-0.95; P = 0.003). An estimated 4.4 primary and 12.5 vascular events per 100 participants were avoided with rivaroxaban over 3 years. CONCLUSIONS Patients with symptomatic PAD who are undergoing LER have a high total event burden that is significantly reduced with rivaroxaban. Total event reduction may be a useful metric to quantify the efficacy of rivaroxaban in this setting. (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities [VOYAGER PAD]; NCT02504216).
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Affiliation(s)
- Rupert M Bauersachs
- CCB-Cardiovascular Center Bethanien, Frankfurt, Germany; Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Michael Szarek
- CPC Clinical Research, Aurora, Colorado, USA; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA; SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | | | - Ivan Gudz
- Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R Nehler
- Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Connie N Hess
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Warren H Capell
- Department of Medicine, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin Rogers
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eva Muehlhofer
- Bayer AG Research and Development, Pharmaceuticals, Wuppertal, Germany
| | | | - Scott D Berkowitz
- Thrombosis and Vascular Medicine, Clinical Development, Bayer US, Whippany, New Jersey, USA
| | - William R Hiatt
- CPC Clinical Research, Aurora, Colorado, USA; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, Colorado, USA; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Ticho AL, Calzadilla N, Malhotra P, Lee H, Anbazhagan AN, Saksena S, Dudeja PK, Lee D, Gill RK, Alrefai WA. NPC1L1-dependent transport of 27-alkyne cholesterol in intestinal epithelial cells. Am J Physiol Cell Physiol 2021; 320:C916-C925. [PMID: 33760662 PMCID: PMC8163569 DOI: 10.1152/ajpcell.00062.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 12/14/2022]
Abstract
Niemann-Pick C1 Like-1 (NPC1L1) mediates the uptake of micellar cholesterol by intestinal epithelial cells and is the molecular target of the cholesterol-lowering drug ezetimibe (EZE). The detailed mechanisms responsible for intracellular shuttling of micellar cholesterol are not fully understood due to the lack of a suitable NPC1L1 substrate that can be traced by fluorescence imaging and biochemical methods. 27-Alkyne cholesterol has been previously shown to serve as a substrate for different cellular processes similar to native cholesterol. However, it is not known whether alkyne cholesterol is absorbed via an NPC1L1-dependent pathway. We aimed to determine whether alkyne cholesterol is a substrate for NPC1L1 in intestinal cells. Human intestinal epithelial Caco2 cells were incubated with micelles containing alkyne cholesterol in the presence or absence of EZE. Small intestinal closed loops in C57BL/6J mice were injected with micelles containing alkyne cholesterol with or without EZE. Alkyne cholesterol esterification in Caco2 cells was significantly inhibited by EZE and by inhibitor of clathrin-mediated endocytosis Pitstop 2. The esterification was similarly reduced by inhibitors of the acyl-CoA cholesterol acyltransferase (ACAT). Alkyne cholesterol efficiently labeled the apical membrane of Caco2 cells and the amount retained on the membrane was significantly increased by EZE as judged by accessibility to exogenous cholesterol oxidase. In mouse small intestine, the presence of EZE reduced total alkyne cholesterol uptake by ∼75%. These data show that alkyne cholesterol acts as a substrate for NPC1L1 and may serve as a nonradioactive tracer to measure cholesterol absorption in both in vitro and in vivo models.
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Affiliation(s)
- Alexander L Ticho
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, Illinois
| | - Nathan Calzadilla
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Department of Bioengineering, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Pooja Malhotra
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Hyunjin Lee
- Department of Chemistry, College of Liberal Arts and Sciences, University of Illinois at Chicago, Chicago, Illinois
| | | | - Seema Saksena
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- The Jesse Brown VA Medical Center, Chicago, Illinois
| | - Pradeep K Dudeja
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- The Jesse Brown VA Medical Center, Chicago, Illinois
| | - Daesung Lee
- Department of Chemistry, College of Liberal Arts and Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Ravinder K Gill
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Waddah A Alrefai
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- The Jesse Brown VA Medical Center, Chicago, Illinois
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Packard C, Chapman MJ, Sibartie M, Laufs U, Masana L. Intensive low-density lipoprotein cholesterol lowering in cardiovascular disease prevention: opportunities and challenges. Heart 2021; 107:1369-1375. [PMID: 33795379 PMCID: PMC8374039 DOI: 10.1136/heartjnl-2020-318760] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 12/18/2022] Open
Abstract
Elevated levels of low-density lipoprotein cholesterol (LDL-C) are associated with increased risk of coronary heart disease and stroke. Guidelines for the management of dyslipidaemia from the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) were updated in late 2019 in light of recent intervention trials involving the use of innovative lipid-lowering agents in combination with statins. The new guidelines advocate achieving very low LDL-C levels in individuals at highest risk, within the paradigm of 'lower is better'. With the advent of combination therapy using ezetimibe and/or proprotein convertase subtilisin/kexin type 9 inhibitors in addition to statins, the routine attainment of extremely low LDL-C levels in the clinic has become a reality. Moreover, clinical trials in this setting have shown that, over the 5-7 years of treatment experience to date, profound LDL-C lowering leads to further reduction in cardiovascular events compared with more moderate lipid lowering, with no associated safety concerns. These reassuring findings are bolstered by genetic studies showing lifelong very low LDL-C levels (<1.4 mmol/L; <55 mg/dL) are associated with lower cardiovascular risk than in the general population, with no known detrimental health effects. Nevertheless, long-term safety studies are required to consolidate the present evidence base. This review summarises key data supporting the ESC/EAS recommendation to reduce markedly LDL-C levels, with aggressive goals for LDL-C in patients at highest risk, and provides expert opinion on its significance for clinical practice.
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Affiliation(s)
- Chris Packard
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - M John Chapman
- Endocrinology-Metabolism Division, Sorbonne University and Pitié-Salpetriere University Hospital, and National Institute for Health and Medical Research (INSERM), Paris, Île-de-France, France
| | | | - Ulrich Laufs
- Klinik und Poliklinik fur Kardiologie, University Clinic Leipzig, Leipzig, Sachsen, Germany
| | - Luis Masana
- Vascular Medicine and Metabolism Unit, Sant Joan University Hospital of Reus, Reus, Catalunya, Spain
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43
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de Vries TI, Westerink J, Bots ML, Asselbergs FW, Smulders YM, Visseren FLJ. Relationship between classic vascular risk factors and cumulative recurrent cardiovascular event burden in patients with clinically manifest vascular disease: results from the UCC-SMART prospective cohort study. BMJ Open 2021; 11:e038881. [PMID: 34006017 PMCID: PMC7942272 DOI: 10.1136/bmjopen-2020-038881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The aim of the current study was to assess the relationship between classic cardiovascular risk factors and risk of not only the first recurrent atherosclerotic cardiovascular event, but also the total number of non-fatal and fatal cardiovascular events in patients with recently clinically manifest cardiovascular disease (CVD). DESIGN Prospective cohort study. SETTING Tertiary care centre. PARTICIPANTS 7239 patients with a recent first manifestation of CVD from the prospective UCC-SMART (Utrecht Cardiovascular Cohort - Second Manifestations of ARTerial disease) cohort study. OUTCOME MEASURES Total cardiovascular events, including myocardial infarction, stroke, vascular interventions, major limb events and cardiovascular mortality. RESULTS During a median follow-up of 8.9 years, 1412 patients had one recurrent cardiovascular event, while 1290 patients had two or more recurrent events, with a total of 5457 cardiovascular events during follow-up. The HRs for the first recurrent event and cumulative event burden using Prentice-Williams-Peterson models, respectively, were 1.36 (95% CI 1.25 to 1.48) and 1.26 (95% CI 1.17 to 1.35) for smoking, 1.14 (95% CI 1.11 to 1.18) and 1.09 (95% CI 1.06 to 1.12) for non-high-density lipoprotein (HDL) cholesterol, and 1.05 (95% CI 1.03 to 1.07) and 1.04 (95% CI 1.03 to 1.06) for systolic blood pressure per 10 mm Hg. CONCLUSIONS In a cohort of patients with established CVD, systolic blood pressure, non-HDL cholesterol and current smoking are important risk factors for not only the first, but also subsequent recurrent events during follow-up. Recurrent event analysis captures the full cumulative burden of CVD in patients.
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Affiliation(s)
- Tamar Irene de Vries
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- UMC Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, ICIN-Netherlands Heart Institute, Durrer Center for Cardiogenetic Research, University Medical Centre Utrecht, Utrecht, The Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Yvo M Smulders
- Department of Internal Medicine, Amsterdam UMC, Location VU University, Amsterdam, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, Utrecht University, Utrecht, The Netherlands
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44
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Alings M, Descamps O, Guillon B, Leosdottir M, Maggioni AP, Recasens L, Speidl WS, Tripodi RV, Landmesser U, Catapano AL, Pirillo A. Implementation of clinical practices and pathways optimizing ACS patients lipid management: Focus on eight European initiatives. ATHEROSCLEROSIS SUPP 2021; 42:e59-e64. [PMID: 33589225 DOI: 10.1016/j.atherosclerosissup.2021.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Post-acute coronary syndrome (ACS) patients are at very high cardiovascular risk. Despite current guidelines strongly recommend to reduce LDL-C levels and initiation of high-intensity statins as early as possible in patients admitted with an ACS, less than half of ACS patients receive a high intensity statin, and a high percentage of has LDL-C well above the goal despite therapy. There are multiple reasons for that, including physician lack of guideline adherence, patient lack of compliance with treatment, and lack of standardized procedures. Furthermore, although the prevalence of familial hypercholesterolemia is higher among patients with ACS, this condition remains poorly estimated. To fill these gaps, some European countries have launched local initiatives for the in-hospital and post-discharge ACS patient lipid management. It appears that ensuring optimal therapy during hospitalization and dedicated follow-up protocols results in a significant improvement of lipid levels in these very high risk patients, which may translate into a reduced risk of recurrent future events.
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Affiliation(s)
- Marco Alings
- Department of Cardiology, UMC Utrecht, Netherlands
| | | | - Benoit Guillon
- CHU of Besançon, Cardiology Department, Besançon, France
| | | | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care & Research, Italy; ANMCO Research Center of the Heart Care Foundation, Florence, Italy
| | | | - Walter S Speidl
- Medical University of Vienna, Department of Internal Medicine II, Division of Cardiology, Vienna, Austria
| | | | - Ulf Landmesser
- Department of Cardiology, Charité University Medicine Berlin, German Center for Cardiovascular Research (DZHK), Partner Site Berlin; Berlin Institute of Health (BIH), Berlin, Germany
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy.
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45
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Inhibition of Interleukin-1β and Reduction in Atherothrombotic Cardiovascular Events in the CANTOS Trial. J Am Coll Cardiol 2021; 76:1660-1670. [PMID: 33004131 DOI: 10.1016/j.jacc.2020.08.011] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/23/2020] [Accepted: 08/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Inflammation reduction with the interleukin (IL)-1β inhibitor canakinumab significantly reduces the first major adverse cardiovascular event in patients with prior myocardial infarction (MI) and residual inflammatory risk (high-sensitivity C-reactive protein ≥ 2 mg/l). However, the effect of canakinumab on the total number of cardiovascular events, including recurrent events collected after a first event, is unknown. OBJECTIVES This study sought to determine whether randomly allocated canakinumab would reduce the total burden of serious cardiovascular events. METHODS We randomized 10,061 patients to placebo or canakinumab 50 mg, 150 mg, or 300 mg once every 3 months and compared the rates of the composite of all serious cardiovascular events (MI, stroke, coronary revascularization, and cardiovascular death) in active versus placebo groups. We used negative binomial regression to account for correlations among repeated events in the same person and to estimate rate ratios and 95% confidence intervals. RESULTS During a median of 3.7 years of follow-up, 3,417 total serious cardiovascular events occurred in 2,003 individuals among the 10,061 unique patients randomized. Canakinumab reduced the rates of total serious cardiovascular events, with rates per 100 person-years in the placebo, 50 mg, 150 mg, and 300 mg canakinumab groups of 10.4, 8.4, 8.3, and 8.2, respectively. The corresponding rate ratios (95% confidence intervals) compared with placebo were 0.80 (0.69 to 0.93) for 50 mg, 0.79 (0.68 to 0.92) for 150 mg, and 0.78 (0.67 to 0.91) for 300 mg. CONCLUSIONS Anti-inflammatory therapy with canakinumab significantly reduced the total number of cardiovascular events in patients with prior MI and evidence of residual inflammatory risk. (Cardiovascular Risk Reduction Study [Reduction in Recurrent Major CV Disease Events] (CANTOS); NCT01327846.
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46
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Marcuschamer I, Zusman O, Iakobishvili Z, Assali AR, Vaknin-Assa H, Goldenberg I, Cohen T, Shlomo N, Kornowski R, Eisen A. Outcome of patients with prior coronary bypass surgery admitted with an acute coronary syndrome. Heart 2021; 107:1820-1825. [PMID: 33462121 DOI: 10.1136/heartjnl-2020-318047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Patients with prior coronary artery bypass graft surgery (CABG) are at increased risk for recurrent cardiovascular ischaemic events. Advances in management have improved prognosis of patients with acute coronary syndrome (ACS), yet it is not known whether similar trends exist in patients with prior CABG. AIM Examine temporal trends in the prevalence, treatment and clinical outcomes of patients with prior CABG admitted with ACS. METHODS Time-dependent analysis of patients with or without prior CABG admitted with an ACS who enrolled in the ACS Israeli Surveys between 2000 and 2016. Surveys were divided into early (2000-2008) and late (2010-2016) time periods. Outcomes included 30 days major adverse cardiac events (30d MACE) (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularisation) and 1-year mortality. RESULTS Among 15 152 patients with ACS, 1506 (9.9%) had a prior CABG. Patients with prior CABG were older (69 vs 63 years), had more comorbidities and presented more with non-ST elevation-ACS (82% vs 51%). Between time periods, utilisation of antiplatelets, statins and percutaneous interventions significantly increased in both groups (p<0.001 for each). The rate of 30d MACE decreased in patients with (19.1%-12.4%, p=0.001) and without (17.4%-9.5%, p<0.001) prior CABG. However, 1-year mortality decreased only in patients without prior CABG (10.5% vs 7.4%, p<0.001) and remained unchanged in patients with prior CABG. Results were consistent after propensity matching. CONCLUSIONS Despite an improvement in the management and prognosis of patients with ACS in the last decade, the rate of 1-year mortality of patients with prior CABG admitted with an ACS remained unchanged.
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Affiliation(s)
- Ilan Marcuschamer
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Zusman
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Z Iakobishvili
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abid R Assali
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanah Vaknin-Assa
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Tal Cohen
- Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Nir Shlomo
- Israeli Association for Cardiovascular Trials, Sheba Medical Center, Ramat Gan, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashome, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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47
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Demarchi A, Somaschini A, Cornara S, Androulakis E. Peripheral Artery Disease in Diabetes Mellitus: Focus on Novel Treatment Options. Curr Pharm Des 2020; 26:5953-5968. [PMID: 33243109 DOI: 10.2174/1389201021666201126143217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/09/2020] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus (DM) and peripheral artery disease (PAD) are two clinical entities closely associated. They share many pathophysiological pathways such as inflammation, endothelial dysfunction, oxidative stress and pro-coagulative unbalance. Emerging data focusing on agents targeting these pathways may be promising. Moreover, due to the increased cardiovascular risk, there is a growing interest in cardiovascular and "pleiotropic" effects of novel glucose lowering drugs. This review summarizes the main clinical features of PAD in patients, the diagnostic process and current medical/interventional approaches, ranging from "classical treatment" to novel agents.
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Affiliation(s)
| | - Alberto Somaschini
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Emmanuel Androulakis
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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48
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Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, Saldmann F, Mazzolai L, Aboyans V. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 2020; 22:M35-M42. [PMID: 33664638 PMCID: PMC7916422 DOI: 10.1093/eurheartj/suaa162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.
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Affiliation(s)
- Emmanuel Messas
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonas Sitruk
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Tristan Mirault
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lina Khider
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Frederic Saldmann
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lucia Mazzolai
- Angiology Division, CHUV University Hospital, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, INSERM 1094 & IRD, Limoges, France
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49
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Skeik N, Nowariak ME, Smith JE, Alexander JQ, Manunga JM, Mirza AK, Sullivan TM. Lipid-lowering therapies in peripheral artery disease: A review. Vasc Med 2020; 26:71-80. [DOI: 10.1177/1358863x20957091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Peripheral artery disease (PAD) is estimated to affect approximately 8.5 million individuals in the US above the age of 40, and is associated with significant morbidity, mortality, and impairment. Despite the significant adverse limb and cardiovascular (CV) outcomes seen in patients with PAD, there is typically less attention paid to risk factor modification relative to other atherosclerotic diseases such as coronary artery disease (CAD) or stroke. In the current literature, statins have been shown to reduce mortality, major adverse CV events, major adverse limb events, and improve symptomatic outcomes in patients with PAD. In addition, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are emerging as an additional lipid-lowering therapy for patients with PAD. However, despite current guideline recommendations based on growing evidence, patients with PAD are consistently undertreated with lipid-lowering therapies. We provide an extensive literature review and evidence-based recommendations for the use of statins and PCSK9 inhibitors in patients with PAD.
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Affiliation(s)
- Nedaa Skeik
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, USA
| | | | - Jenna E Smith
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, USA
| | | | - Jesse M Manunga
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, USA
| | - Aleem K Mirza
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, USA
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50
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Shehab A, Bhagavathula AS, Al-Rasadi K, Alshamsi F, Al Kaab J, Thani KB, Mustafa R. Diabetes and Mortality in Acute Coronary Syndrome: Findings from the Gulf COAST Registry. Curr Vasc Pharmacol 2020; 18:68-76. [PMID: 30360744 DOI: 10.2174/1570161116666181024094337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/13/2018] [Accepted: 10/13/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND The prevalence of traditional risk factors such as diabetes mellitus (DM) and obesity are increasing in patients with acute coronary syndrome (ACS). Furthermore, outcomes after ACS are worse in patients with DM. The high prevalence of DM and an early age at onset of ACS have been described in prior publications from the Gulf Coast Database. AIMS We aimed to define the effect of DM on total mortality following ACS presentation at 30-days and 1 year based on the Gulf COAST registry database. METHODS The Gulf COAST registry is a prospective, multinational, longitudinal, observational cohort study conducted among Gulf citizens admitted with a diagnosis of ACS. The outcomes among patients with DM following ACS were stratified into 2 groups based on their DM status. Cumulative survival stratified by groups and subgroup categories was assessed by the Kaplan-Meier method. RESULTS Of 3,576 ACS patients, 2,730 (76.3%) presented with non ST-segment elevation myocardial infarction (NSTEMI) and 846 (23.6%) with STEMI. Overall, 1906 patients (53.3%) had DM. A significantly higher in-hospital (4.8%), 30-day (6.7%) and 1-year (13.7%) mortality were observed in patients with DM compared with those without DM. The Kaplan-Meier survival curve showed significant differences in survival of ACS patients with or without DM, with a short period of time-to-event for DM patients with STEMI (30-days) and the longest (1-year) for NSTEMI patients without DM. CONCLUSION DM patients presenting with ACS-STEMI have poor short-term outcomes while DMNSTEMI patients have poor long-term outcomes. This highlights the need for strategies to evaluate DM control and integration of care to control vascular risk among this high-risk population.
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Affiliation(s)
- Abdulla Shehab
- Department of Internal medicine, United Arab Emirates University- College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Akshaya Srikanth Bhagavathula
- Department of Internal medicine, United Arab Emirates University- College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Khalid Al-Rasadi
- Department of Biochemistry, Sultan Qaboos University Hospital, Muscat, Oman
| | - Fayez Alshamsi
- Department of Internal medicine, United Arab Emirates University- College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Juma Al Kaab
- Clinical affairs Internal Medicine, United Arab Emirates University - College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | | | - Ridha Mustafa
- Department of Medicine, Ministry of Health, Al-Adan, Kuwait
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