Very High-Risk ASCVD and Eligibility for Nonstatin Therapies Based on the 2018 AHA/ACC Cholesterol Guidelines

Trends in prevalence, risk factor control and medications in atherosclerotic cardiovascular disease among US Adults, 1999-2018

Objectives

Trends in prevalence and treatments of atherosclerotic cardiovascular disease (ASCVD) remains to be documented, with frequent update of relevant guidelines. We aimed to characterize trends in prevalence of ASCVD, and risk factor control and medications among ASCVD adults.

Methods

We conducted a cross-sectional analysis of data from 55,081 adults in the National Health and Nutrition Examination Surveys (NHANES) 1999-2018.

Results

The age-standardized prevalence of ASCVD did not change significantly from 1999-2002 (7.9 %, 95 % CI 7.1 %-8.7 %) to 2015-2018 (7.5 %, CI 6.8 %-8.3 %) (P for trend =0.18), representing an estimated 19.9 million individuals with ASCVD in 2015-2018. The prevalence of premature ASCVD was 2.0 % (CI, 1.6 %-2.5 %). Over 60.0 % of ASCVD participants were at very-high risk. From 1999-2002 to 2015-2018, the percentage with lipid control (non-high-density lipoprotein cholesterol <100 mg/dL) increased from 7.0 % (CI, 3.5 %-12.3 %) to 26.4 % (CI, 16.2 %-38.9 %). The percentage with blood-pressure control (<130/80 mmHg) increased from 51.2 % (CI, 41.0 %-61.3 %) in 1999-2002 to 57.2 % (CI, 48.4 %-65.6 %) in 2011-2014, but then declined to 52.8 % (CI, 44.4 %-81.3 %) in 2015-2018. The percentage with glycemic control (HbA1c <7.0 %) decreased from 95.0 % (CI, 90.2 %-97.9 %) to 84.0 % (CI, 75.9 %-90.3 %). The percentage who achieved all 3 targets was 18.6 % (CI, 8.2 %-33.8 %) in 2015-2018. The percentage of ASCVD participants who were taking statins increased from 1999-2002 to 2011-2014, but then leveled off. Approximately 60 % of individuals with ASCVD and less than 40 % of those with premature ASCVD were taking statins in 2015-2018. The utilization of blood-pressure-lowering drugs remained largely constant over time, whereas the use of glucose-lowering drugs increased.

Conclusions

Based on NHANES data from US adults, the estimated prevalence of ASCVD remained relatively stable between 1999 and 2018. Substantial undertreatment with stains was found in individuals with ASCVD, and the percentage achieving optimal lipid control was low.

Kawasaki Disease: A Never-ending Story?

The most severe complication of Kawasaki disease, an inflammatory disorder of young children, is the formation of coronary artery aneurysms. It is known that patients with coronary artery aneurysms, particularly those with medium and large lesions, have a higher risk of future major cardiovascular events. In contrast, there is a lack of data on the cardiovascular status in long-term follow-up for Kawasaki disease patients without coronary involvement or with self-limited coronary artery aneurysms, resulting in most patients being discharged after 5 years. Even though some paediatricians may believe these patients should not be followed at all, studies indicating a dysfunctional endothelium show the need for further investigation. Consequently, a review of the most significant aspects of Kawasaki disease, and the necessity of correctly identifying, treating and monitoring these patients, particularly those with a higher risk of complications, was conducted.

Leveraging Healthcare System Data to Identify High-Risk Dyslipidemia Patients

PURPOSE OF REVIEW

While randomized controlled trials have historically served as the gold standard for shaping guideline recommendations, real-world data are increasingly being used to inform clinical decision-making. We describe ways in which healthcare systems are generating real-world data related to dyslipidemia and how these data are being leveraged to improve patient care.

RECENT FINDINGS

The electronic medical record has emerged as a major source of clinical data, which alongside claims and pharmacy dispending data is enabling healthcare systems the ability to identify care gaps (underdiagnosis and undertreatment) in patients with dyslipidemia. Availability of this data also allows healthcare systems the ability to test and deliver interventions at the point-of-care. Real-world data possess great potential as a complement to randomized controlled trials. Healthcare systems are uniquely positioned to not only define care gaps and areas of opportunity, but to also to leverage tools (e.g., clinical decision support, case identification) aimed at closing them.

Improvement of evaluation in Chinese patients with atherosclerotic cardiovascular disease using the very-high-risk refinement: a population-based study

BACKGROUND

Continuous refinement of atherosclerotic cardiovascular disease (ASCVD) stratification has raised the definition of very-high-risk (VHR) recently, which has been underutilized in China. We aimed to identify patients at VHR and evaluate their performances in a Chinese population.

METHODS

A total of 9944 patients with ASCVD was continuously enrolled. Patients at VHR was identified according to 2018 AHA/ACC guideline. Median follow-up was 36.4 months. Clinical characteristics, low-density lipoprotein cholesterol (LDL-C) achievements, and the prognostic value of VHR mapping for cardiovascular events (CVEs) were evaluated.

FINDINGS

Overall, 26% (2542/9944) of patients were deemed as VHR, which were subsequently divided into two subgroups of VHR-1 [31% (779/2542)] and VHR-2 [69% (1763/2542)]. The rates of VHR were higher among patients of male (30%,2157/7268), young with age <45 years (46%,518/1130), and low-income regions (27%, 498/1838). Patients at VHR carried higher rates of risk factors than those at non-VHR (all p<0.001). However, only 3% (80/2542) of patients at VHR were prescribed with high-intensity of statins, and just 13% (321/2542) of them reached the LDL-C goal (<1.4mmol/L). Furthermore, of patients with coronary stenosis (n=9806), multiple-diseased vessels (47%, 1192/2523 vs. 36%,2587/7283) and occlusive lesions (36%, 902/2523 vs. 13%, 949/7283) were detected more commonly in those at VHR than non-VHR. The adjusted hazard ratios of VHR-1 and VHR-2 for primary CVEs were 2.58(1.61-4.14) and 2.23(1.55-3.20), respectively.

INTERPRETATION

Our study firstly reported that patients at VHR carried more severe ASCVD burden, lower LDL-C achievement, and higher CVEs risk, suggesting that the refinement of ASCVD might be considered in China to further understand patients at VHR.

FUNDING

Capital Health Development Fund and CAMS Major Collaborative Innovation Project.

High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better

Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well.

A simplified approach to identification of risk status in patients with atherosclerotic cardiovascular disease

OBJECTIVE

The 2018 American Heart Association/American College of Cardiology (AHA/ACC) Blood Cholesterol Guideline recommendation to classify patients with atherosclerotic cardiovascular disease (ASCVD) as very high-risk (VHR) vs not-VHR (NVHR) has important implications for escalation of medical therapy. We aimed to define the prevalence and clinical characteristics of these two groups within a large multi-state healthcare system and develop a simpler means to assist clinicians in identifying VHR patients using classification and regression tree (CART) analysis.

METHODS

We performed a retrospective analysis of all patients in a 28-hospital US healthcare system in 2018. ICD-10 codes were used to define the ASCVD population. Per the AHA/ACC Guideline, VHR status was defined by ≥2 major ASCVD events or 1 major ASCVD event and ≥2 high-risk conditions. CART analysis was performed on training and validation datasets. A random forest model was used to verify results.

RESULTS

Of 180,669 ASCVD patients identified, 58% were VHR. Among patients with a history of myocardial infarction (MI) or recent acute coronary syndrome (ACS), 99% and 96% were classified as VHR, respectively. Both CART and random forest models identified recent ACS, ischemic stroke, hypertension, peripheral artery disease, history of MI, and age as the most important predictors of VHR status. Using five rules identified by CART analysis, fewer than 50% of risk factors were required to assign VHR status.

CONCLUSION

CART analysis helped to streamline the identification of VHR patients based on a limited number of rules and risk factors. This approach may help improve clinical decision making by simplifying ASCVD risk assessment at the point of care. Further validation is needed, however, in more diverse populations.

Predictors of PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitor Prescriptions for Secondary Prevention of Clinical Atherosclerotic Cardiovascular Disease

BACKGROUND

Little is known about patterns of PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitor) use among patients with established clinical atherosclerotic cardiovascular disease. This study's objective was to describe PCSK9i prescribing patterns among patients with atherosclerotic cardiovascular disease.

METHODS

We used a national outpatient clinic registry linked to zip-code level on household income from the US Census to assess characteristics of patients with atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol) <190 mg/dL between September 1, 2015, and September 30, 2019, who did and did not receive PCSK9i prescriptions and practice-level and temporal variation in PCSK9i prescriptions. We assessed predictors of PCSK9i prescription with a multivariable mixed effects regression model which included patient covariates as fixed effects and the cardiology practice as a random effect. Adjusted practice-level variation in PCSK9i prescribing was evaluated with median odds ratio (OR).

RESULTS

Of 2 148 100 patients meeting study inclusion criteria, 27 249 (1.3%) received PCSK9i prescriptions. Receiving a PCSK9i prescription was associated with White race (versus non-White: OR, 1.78 [95% CI, 1.55-1.83]); high estimated household income (versus low income: OR, 1.18 [95% CI, 1.08-1.29]), and urban or suburban (versus rural) practice location (urban: OR, 1.47 [95% CI, 1.32-1.64]; suburban: OR, 1.25 [95% CI, 1.13-1.39]). Hispanics had lower odds of receiving PCSK9i prescriptions (OR, 0.66 [95% CI, 0.57-0.76]). The adjusted median odds ratio was 2.68 (95% CI, 2.46-2.94), consistent with clinically significant practice-level variation in PCSK9i prescriptions. No differences in quarterly PCSK9i prescription rates were observed before and after price reductions for evolocumab and alirocumab initiated during the fourth quarter of 2018 and first quarter of 2019, respectively.

CONCLUSIONS

This study highlights racial, socioeconomic, geographic, and practice-level variations in early PCSK9i prescriptions which persist despite adjustment for clinical and demographic factors. After adjustment, 2 randomly selected practices would differ in likelihood of PCSK9i prescription by a factor of >2.

Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study

AIMS

To estimate the proportion of patients with a recent myocardial infarction (MI) who would be eligible for additional lipid-lowering therapy according to the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias, and to simulate the effects of expanded lipid-lowering therapy on attainment of the low-density lipoprotein cholesterol (LDL-C) target as recommended by the guidelines.

METHODS AND RESULTS

Using the nationwide SWEDEHEART register, we included 25 466 patients who had attended a follow-up visit 6-10 weeks after an MI event, 2013-17. While most patients (86.6%) were receiving high-intensity statins, 82.9% of the patients would be eligible for expanded lipid-lowering therapy, as they had not attained the target of an LDL-C level of <1.4 mmol and a ≥50% LDL-C level reduction. When maximized use of high-intensity statins followed by add-on therapy with ezetimibe was simulated using a Monte Carlo model, the LDL-C target was reached in 19.9% using high-intensity statin monotherapy and in another 28.5% with high-intensity statins and ezetimibe, while 50.7% would still be eligible for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. When use of alirocumab or evolocumab was simulated in those who were eligible for PCSK9 inhibitors, around 90% of all patients attained the LDL-C target.

CONCLUSION

Our study suggests that, even with maximized use of high-intensity statins and ezetimibe, around half of patients with MI would be eligible for treatment with PCSK9 inhibitors according to the 2019 ESC/EAS guidelines. Considering the current cost of PCSK9 inhibitors, the financial implications of the new guidelines may be substantial.

Same evidence, varying viewpoints: Three questions illustrating important differences between United States and European cholesterol guideline recommendations

In 2018, the AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol was released. Less than one year later, the 2019 ESC/EAS Dyslipidemia Guideline was published. While both provide important recommendations for managing atherosclerotic cardiovascular disease (ASCVD) risk through lipid management, differences exist. Prior to the publication of both guidelines, important randomized clinical trial data emerged on non-statin lipid lowering therapy and ASCVD risk reduction. To illustrate important differences in guideline recommendations, we use this data to help answer three key questions: 1) Are ASCVD event rates similar in high-risk primary and stable secondary prevention? 2) Does imaging evidence of subclinical atherosclerosis justify aggressive use of statin and non-statin therapy (if needed) to reduce LDL-C levels below 55 ​mg/dL as recommended in the European Guideline? 3) Do LDL-C levels below 70 ​mg/dL achieve a large absolute risk reduction in secondary ASCVD prevention? The US guideline prioritizes both the added efficacy and cost implications of non-statin therapy, which limits intensive therapy to individuals with the highest risk of ASCVD. The European approach broadens the eligibility criteria by incorporating goals of therapy in both primary and secondary prevention. The current cost and access constraints of healthcare worldwide, especially amidst a COVID-19 pandemic, makes the European recommendations more challenging to implement. By restricting non-statin therapy to a subgroup of high- and, in particular, very high-risk individuals, the US guideline provides primary and secondary ASCVD prevention recommendations that are more affordable and attainable. Ultimately, finding a common ground for both guidelines rests on our ability to design trials that assess cost-effectiveness in addition to efficacy and safety.

Eligibility for PCSK9 inhibitors based on the 2019 ESC/EAS and 2018 ACC/AHA guidelines

AIMS

The 2018 American College of Cardiology (ACC)/American Heart Association (AHA) and 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) lipid guidelines recently updated their recommendations regarding proprotein convertase subtilisin/kexin-9 inhibitors (PCSK9i). We assessed the potential eligibility for PCSK9i according to the new guidelines in patients with acute coronary syndromes.

METHODS AND RESULTS

We analysed a contemporary, prospective Swiss cohort of patients hospitalised for acute coronary syndromes. We modelled a statin intensification effect and an incremental ezetimibe effect on low-density lipoprotein-cholesterol levels among patients who were not on high-intensity statins or ezetimibe. One year after the index acute coronary syndrome event, treatment eligibility for PCSK9i was defined as low-density lipoprotein-cholesterol of 1.4 mmol/l or greater according to ESC/EAS guidelines. For ACC/AHA guidelines, treatment eligibility was defined as low-density lipoprotein-cholesterol of 1.8 mmol/l or greater in the presence of very high-risk atherosclerotic cardiovascular disease, defined by multiple major atherosclerotic cardiovascular disease events and/or high-risk conditions. Of 2521 patients, 93.2% were treated with statins (53% high-intensity statins) and 7.3% with ezetimibe at 1 year, and 54.9% had very high-risk atherosclerotic cardiovascular disease. Low-density lipoprotein-cholesterol levels less than 1.8 mmol/l and less than 1.4 mmol/l at 1 year were observed in 37.5% and 15.7% of patients, respectively. After modelling the statin intensification and ezetimibe effects, these numbers increased to 76.1% and 49%, respectively. The proportion of patients eligible for PCSK9i was 51% according to ESC/EAS criteria versus 14% according to ACC/AHA criteria.

CONCLUSIONS

In this analysis, the 2019 ESC/EAS guidelines rendered half of all post-acute coronary syndrome patients potentially eligible for PCSK9i treatment, as compared to a three-fold lower eligibility rate based on the 2018 ACC/AHA guidelines.

Highlights from Selected Cardiovascular Disease Prevention Studies Presented at the 2019 European Society of Cardiology Congress

PURPOSE OF REVIEW

This review intends to highlight selected cardiovascular disease (CVD) prevention studies presented at the 2019 European Society of Cardiology (ESC) Congress.

RECENT FINDINGS

Results from the Inclisiran for Subjects with ASCVD or ASCVD-risk Equivalent and Elevated Low-density Lipoprotein Cholesterol (ORION-11) trial validate inclisiran's ability to significantly lower low-density lipoprotein cholesterol (LDL-C) levels in at-risk individuals on a background of maximally tolerated statin therapy. The EVOlocumab for Early Reduction of LDL-cholesterol Levels in Patients With Acute Coronary Syndromes (EVOPACS) trial provide additional support that a PCSK9 inhibitor can be initiated safely and effectively early after an acute coronary syndrome. A sub-study of the Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trial provides further support for stratification of secondary prevention patients to help define the magnitude of risk reduction associated with PCSK9 inhibitor therapy. A post hoc analysis from the Aspirin in Reducing Events in the Elderly (ASPREE) trial suggest that any benefits associated with aspirin utilizing a risk-based approach are overwhelmed by increased bleeding risk. In a large retrospective cohort study of patients with diabetes mellitus and obesity, the addition of metabolic (weight loss) surgery to standard care led to greater improvement in CVD outcomes, weight loss, and glycemic control. Results from the Prospective Urban Rural Epidemiology (PURE) study demonstrate that while hypertension and dyslipidemia exert additive lifelong effects on CVD risk, other less established risk factors such as low education, household pollution, and poor diet also have a strong impact on CVD outcomes, especially in middle- and low-income countries. Finally, in the Heart Outcomes Prevention and Evaluation (HOPE) 4 trial, a comprehensive model of care adapted to address multiple barriers of specific communities led to substantial improved blood pressure (BP) control, medication use, and adherence. A number of studies presented at the 2019 ESC Congress reinforced the value of preventative interventions in CVD risk reduction.