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Min-Gyung S, Pel P, An CY, Park CW, Lee SH, Yang TJ, Chin YW. Chemical constituents from the roots of Cynanchum wilfordii with PCSK9 secretion inhibitory activities. PHYTOCHEMISTRY 2024; 226:114205. [PMID: 38971497 DOI: 10.1016/j.phytochem.2024.114205] [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: 02/23/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/08/2024]
Abstract
From the Cynanchum wilfordii roots, 32 compounds, including 5 previously undescribed (1, 4-6, 12) and 27 known (2, 3, 7-11, 13-32) compounds, were isolated, and their structures were elucidated using NMR spectroscopic data and MS data aided by ECD calculations or the modified Mosher's reaction. All isolates were tested for their inhibitory effects on proprotein convertase subtilisin/kexin type 9 (PCSK9) secretion. Among the isolates, compound 4, a methyl cholesterol analog, exhibited the most potent effect in reducing PCSK9 secretion, along with PCSK9 downregulation at the mRNA and protein levels via FOXO1/3 upregulation. Moreover, compound 4 attenuated statin-induced PCSK9 expression and enhanced the uptake of DiI-LDL low-density lipoprotein. Thus, compound 4 is suggested to be a potential candidate for controlling cholesterol levels.
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Affiliation(s)
- Son Min-Gyung
- Natural Products Research Institute and Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Pisey Pel
- Natural Products Research Institute and Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Chae-Yeong An
- Natural Products Research Institute and Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Chan-Woong Park
- Natural Products Research Institute and Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Sae Hyun Lee
- Department of Agriculture, Forestry and Bioresources, Plant Genomics & Breeding Institute, Research Institute of Agriculture and Life Sciences, College of Agriculture & Life Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Tae-Jin Yang
- Department of Agriculture, Forestry and Bioresources, Plant Genomics & Breeding Institute, Research Institute of Agriculture and Life Sciences, College of Agriculture & Life Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Young-Won Chin
- Natural Products Research Institute and Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea.
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MacDougall DE, Baum SJ, Ahmed CD, McGowan MP, Wilemon KA. Trends in Patient Access to and Utilization of Prescribed PCSK9 Inhibitors in a Large US Claims Database From 2015 to 2021. Circ Cardiovasc Qual Outcomes 2024; 17:e009988. [PMID: 38362767 PMCID: PMC10880926 DOI: 10.1161/circoutcomes.123.009988] [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: 02/17/2024]
Affiliation(s)
- Diane E. MacDougall
- Family Heart Foundation, Fernandina Beach, FL (D.E.M., S.J.B., C.D.A., M.P.M., K.A.W.)
| | - Seth J. Baum
- Family Heart Foundation, Fernandina Beach, FL (D.E.M., S.J.B., C.D.A., M.P.M., K.A.W.)
- Flourish Research, New York, NY (S.J.B.)
| | - Catherine D. Ahmed
- Family Heart Foundation, Fernandina Beach, FL (D.E.M., S.J.B., C.D.A., M.P.M., K.A.W.)
| | - Mary P. McGowan
- Family Heart Foundation, Fernandina Beach, FL (D.E.M., S.J.B., C.D.A., M.P.M., K.A.W.)
- Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.P.M.)
| | - Katherine A. Wilemon
- Family Heart Foundation, Fernandina Beach, FL (D.E.M., S.J.B., C.D.A., M.P.M., K.A.W.)
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Coppinger C, Pomales B, Movahed MR, Marefat M, Hashemzadeh M. Berberine: A Multi-Target Natural PCSK9 Inhibitor with the Potential to Treat Diabetes, Alzheimer's, Cancer and Cardiovascular Disease. Curr Rev Clin Exp Pharmacol 2024; 19:312-326. [PMID: 38361373 DOI: 10.2174/0127724328250471231222094648] [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: 08/25/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/17/2024]
Abstract
Berberine is a natural product with a wide range of pharmacological effects. It has antimicrobial, anti-cancer, anti-inflammatory, anti-hyperlipidemic, neuroprotective, and cholesterollowering properties, among others. It has been used in traditional Chinese and Ayurvedic medicine for 3000 years and is generally well-tolerated with few side effects. Its main drawback is low oral bioavailability, which has hindered widespread clinical use. However, recent interest has surged with the emergence of evidence that berberine is effective in treating cancer, diabetes, Alzheimer's disease, and cardiovascular disease via multiple mechanisms. It enhances insulin sensitivity and secretion by pancreatic β-cells in Type 2 Diabetes Mellitus in addition to reducing pro-inflammatory cytokines such as IL-6, IL-1β, TLR4 and TNF-α. These cytokines are elevated in Alzheimer's disease, cardiovascular disease, and diabetes. Reductions in pro-inflammatory cytokine levels are associated with positive outcomes such as improved cognition, reduced cardiovascular events, and improved glucose metabolism and insulin sensitivity. Berberine is a natural PCSK9 inhibitor, which contributes to its hypolipidemic effects. It also increases low-density lipoprotein receptor expression, reduces intestinal cholesterol absorption, and promotes cholesterol excretion from the liver to the bile. This translates into a notable decrease in LDL cholesterol levels. High LDL cholesterol levels are associated with increased cardiovascular disease risk. Novel synthetic berberine derivatives are currently being developed that optimize LDL reduction, bioavailability, and other pharmacokinetic properties.
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Affiliation(s)
- Caroline Coppinger
- Department of Chemistry, Pima College, Tucson, AZ, USA
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Briana Pomales
- Department of Chemistry, Pima College, Tucson, AZ, USA
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mohammad Reza Movahed
- Department of Medicine, University of Arizona, Tucson, AZ, USA
- Department of Medicine, University of Arizona College of Medicine, Phoenix, USA
| | | | - Mehrnoosh Hashemzadeh
- Department of Chemistry, Pima College, Tucson, AZ, USA
- Department of Medicine, University of Arizona College of Medicine, Phoenix, USA
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Dickson S, Gabriel N, Hernandez I. Changes In Net Prices And Spending For Pharmaceuticals After The Introduction Of New Therapeutic Competition, 2011-19. Health Aff (Millwood) 2023; 42:1062-1070. [PMID: 37549318 DOI: 10.1377/hlthaff.2023.00250] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Previous research has demonstrated that the introduction of a new brand-name pharmaceutical competitor does not lower list prices for existing competitive therapies. However, no study has systematically evaluated the impact of new therapeutic competition on net prices of pharmaceutical products. We identified new therapies approved during the period 2013-17 that were competitors for existing treatments. We used a novel peer-reviewed algorithm to estimate the net prices of existing therapies. We implemented regression models to estimate changes in these net prices after the approval of the new therapeutic competition during the period 2011-19. Across twelve therapeutic classes with new drug entrants in 2013-17, the introduction of new therapeutic competition was associated with a 4.2 percent decrease in annual net price growth. The introduction of new brand-name therapies in twelve therapeutic classes reduced net commercial spending on existing therapies by $10.4 billion-an 18.5 percent reduction in projected spending absent therapeutic competition. Our findings demonstrate that new therapeutic competition allows pharmacy benefit managers to use formulary management to decrease net prices and reduce drug spending, contrary to observed trends in list price increases.
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Affiliation(s)
- Sean Dickson
- Sean Dickson, West Health Policy Center, Washington, D.C
| | - Nico Gabriel
- Nico Gabriel, University of California San Diego, La Jolla, California
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Kim OM, Givens TK, Tang EG, Schimmer JJ, Ramsey T, Boyd K, Delate T. Real-World Outcomes of Proprotein Convertase Subtilisin Kexin-9 Inhibitor Use. J Cardiovasc Pharmacol 2023; 81:339-347. [PMID: 36795508 DOI: 10.1097/fjc.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023]
Abstract
ABSTRACT Although the proprotein convertase subtilisin kexin-9 inhibitors (PCSK9i) were shown to significantly lower low-density lipoprotein and reduce atherosclerotic cardiovascular disease events in clinical trials, there is a dearth of use data on these agents in real-world settings. This study compares PCSK9i use in a population of real-world patients with atherosclerotic cardiovascular disease or familial hypercholesterolemia. This was a matched cohort study of adult patients who were dispensed a PCSK9i along with adult patients who did not receive a PCSK9i. PCSK9i patients were matched on a propensity to have received a PCSK9i score up to 1:10 to non-PCSK9i patients. The primary outcomes were changes in cholesterol levels. Secondary outcomes included a composite outcome of all-cause mortality, major cardiovascular events, and ischemic strokes along with health care utilization during follow-up. Adjusted conditional, multivariate Cox proportional hazards, and negative binomial modeling were performed. Ninety-one PCSK9i patients were matched to 840 non-PCSK9i patients. Seventy-one percent of PCSK9i patients either discontinued or switched PCSK9i therapy. PCSK9i patients had greater median reductions in low-density lipoprotein (-73.0 mg/dL vs. -30.0 mg/dL) and total (-77.0 vs. -31.0) cholesterol (both P < 0.001). No adjusted between-group differences in the composite outcome or individual components of the composite outcome were identified (all P > 0.05). PCSK9i patients had a lower rate of medical office visits during follow-up (adjusted incidence rate ratio = 0.61, P = 0.019). These findings support the effectiveness of PCSK9i therapy in real-world settings but suggest that use may be limited by PCSK9i adverse reactions and patient cost barriers.
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Affiliation(s)
- Olivia M Kim
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Tatyana K Givens
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
- Pharmacy Department, VillageMD, Atlanta, GA; and
| | - Emily G Tang
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
- Pharmacy Department, Yale New Haven Hospital, New Haven, CT
| | | | - Tanya Ramsey
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Kayla Boyd
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy Services, Aurora, CO
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Shakir A, Barron K, Modi K. Qualitative and Quantitative Effects of PCSK9 Inhibitors in familial Hypercholesterolemia: a Synthetic Review. Curr Probl Cardiol 2023; 48:101550. [PMID: 36529229 DOI: 10.1016/j.cpcardiol.2022.101550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Familial hypercholesterolemia (FH) is an autosomal dominant disease caused most commonly by mutations in the gene coding for LDL receptors. This results in increased circulating cholesterol, and clinical consequences of premature stroke, myocardial infarction, etc. FH remains underdiagnosed and thus undertreated, leading to a high health care burden. A newer group of agents, the PCSK9 inhibitors, effectively reduces plasma cholesterol, especially when combined with other lipid lowering agents. The purpose of this narrative review is to synthesize all existing qualitative and quantitative data on the utility of PCSK9 inhibitors in familial hypercholesterolemia, in order to clarify standards of care and identify areas needing further research. Through PubMed/MEDLINE keyword searching, we identified 12 existing randomized controlled trials comparing PCSK9 inhibitor to placebo in FH patients, and pooled their outcomes across a total 2533 patients. We also reviewed quantitative effect on ASCVD outcomes and cost/benefit ratios. In FH patients, PCSK9 inhibitors caused a mean LDL reduction of -49.1%, compared to -3.5% with placebo (weighted average was calculated to account for different study sizes). These findings are comparable to trial results in the non-FH ASCVD population. However, there are no data on PCSK9 inhibitors' effect on hard cardiovascular outcomes in FH. Furthermore, in order for PCSK9 inhibitors to qualify as high-value care, price must be significantly reduced or LDL goals increased. PCSK9 inhibitors are potent reducers of LDL in FH patients. However, dedicated randomized trials are needed to assess whether this translates into statistically significant ASCVD prevention long-term.
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Affiliation(s)
- Aamina Shakir
- Department of Internal Medicine, Section of Cardiology, Louisiana State University Health - Shreveport, Shreveport, LA.
| | - Kyle Barron
- Louisiana State University Health - Shreveport, School of Medicine, Shreveport, LA
| | - Kalgi Modi
- Department of Internal Medicine, Section of Cardiology, Louisiana State University Health - Shreveport, Shreveport, LA
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Sasidharan A, Bagepally BS, Kumar SS, Jagadeesh KV, Natarajan M. Cost-effectiveness of Ezetimibe plus statin lipid-lowering therapy: A systematic review and meta-analysis of cost-utility studies. PLoS One 2022; 17:e0264563. [PMID: 35709152 PMCID: PMC9202874 DOI: 10.1371/journal.pone.0264563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
In addition to statin therapy, Ezetimibe, a non-statin lipid-modifying agent, is increasingly used to reduce low-density lipoprotein cholesterol and atherosclerotic cardiovascular disease risk. Literature suggests the clinical effectiveness of Ezetimibe plus statin (EPS) therapy; however, primary evidence on its economic effectiveness is inconsistent. Hence, we pooled incremental net benefit to synthesise the cost-effectiveness of EPS therapy. We identified economic evaluation studies reporting outcomes of EPS therapy compared with other lipid-lowering therapeutic agents or placebo by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled Incremental Net Benefit (INB) in the US $ with a 95% confidence interval (CI). We used the modified economic evaluations bias checklist and GRADE quality assessment for quality appraisal. The pooled INB from twenty-one eligible studies showed that EPS therapy was significantly cost-effective compared to other lipid-lowering therapeutic agents or placebo. The pooled INB (95% CI) was $4,274 (621 to 7,927), but there was considerable heterogeneity (I2 = 84.21). On subgroup analysis EPS therapy is significantly cost-effective in high-income countries [$4,356 (621 to 8,092)], for primary prevention [$4,814 (2,523 to 7,106)], and for payers’ perspective [$3,255 (571 to 5,939)], and from lifetime horizon [$4,571 (746 to 8,395)]. EPS therapy is cost-effective compared to other lipid-lowering therapeutic agents or placebo in high-income countries and for primary prevention. However, there is a dearth of evidence from lower-middle-income countries and the societal perspective.
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Affiliation(s)
- Akhil Sasidharan
- Health Technology Assessment Resource Centre, Indian Council of medical Research-National Institute of Epidemiology, Chennai, India
| | - Bhavani Shankara Bagepally
- Health Technology Assessment Resource Centre, Indian Council of medical Research-National Institute of Epidemiology, Chennai, India
- * E-mail:
| | - S. Sajith Kumar
- Health Technology Assessment Resource Centre, Indian Council of medical Research-National Institute of Epidemiology, Chennai, India
| | - Kayala Venkata Jagadeesh
- Health Technology Assessment in India Secretariat, Department of Health Research, Government of India, New Delhi, India
| | - Meenakumari Natarajan
- Health Technology Assessment Resource Centre, Indian Council of medical Research-National Institute of Epidemiology, Chennai, India
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Zhu L, Zheng J, Gao B, Jin X, He Y, Zhou L, Huang J. The correlation between lipoprotein(a) elevations and the risk of recurrent cardiovascular events in CAD patients with different LDL-C levels. BMC Cardiovasc Disord 2022; 22:171. [PMID: 35428179 PMCID: PMC9013030 DOI: 10.1186/s12872-022-02618-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lipoprotein(a) [Lp(a)] elevation is an important risk factor for coronary artery disease (CAD). However, the correlation between Lp(a) elevations and the risk of recurrent cardiovascular events in patients with established cardiovascular disease is controversial. Some studies have shown that Low-density lipoprotein cholesterol (LDL-C) levels may influence the association between Lp(a) and cardiovascular risk. Our study aims to explore the correlation between Lp(a) elevations and cardiovascular risk in patients with different LDL-C levels. Methods We included 516 patients who received coronary stents due to acute coronary syndrome (ACS) and followed them for three years. They were divided into low-Lp(a) group and high-Lp(a) group according to Lp(a) levels, and the incidence of major adverse cardiovascular events (MACE) and acute coronary events (ACE) was compared between the two groups. Then the patients were divided into three subgroups (S1:LDL-C ≥ 1.8 mmol/L; S2:1.4 ≤ LDL-C < 1.8 mmol/L; S3:LDL-C < 1.4 mmol/L). The correlation between Lp(a) elevations and cardiovascular risk in different subgroups was analysed by Cox proportional hazards models. Results The incidence of MACE and ACE in the high-Lp(a) group was significantly higher than those in the low-Lp(a) group (P < 0.05). Lp(a) elevations had independent prognostic value from the statistical point of view (MACE: HR = 1.63, 95%CI = 1.12–2.38, P = 0.012; ACE: HR = 1.70, 95%CI = 1.03–2.81, P = 0.037). Subgroup analysis showed that Lp(a) elevations increased cardiovascular risk when LDL-C ≥ 1.4 mmol/L. However, this correlation no longer existed when LDL-C levels were very low (< 1.4 mmol/L) (MACE: HR = 0.49, 95%CI = 0.17–1.42, P = 0.186; ACE: HR = 0.68, 95%CI = 0.18–2.61, P = 0.570). Conclusions Lp(a) elevations are associated with recurrent cardiovascular events when LDL-C levels are high, but this association may change when LDL-C levels are extremely low. CAD patients with combination of LDL-C ≥ 1.4 mmol/L and Lp(a) elevations shall be considered as high-risk groups and require further medication for the reduction of their LDL-C levels. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02618-5.
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Sáez-Jiménez R, Esteban-Hernández J, Herreros B, Huelmos A, Guijarro C, Guijarro C, Belinchón JC, Aranda C, Herreros B, González Anglada I, Téllez M, Huelmos AI, López-Bescós L, Sánchez C, Barriga F, Gutiérrez M, Puras E, Casas ML, Tolón R. La albuminuria y la enfermedad polivascular mejoran la capacidad predictiva de los modelos multivariados después de un evento cardiovascular agudo. Cohorte AIRVAG. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.01.008] [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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10
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Stone NJ, Smith SC, Orringer CE, Rigotti NA, Navar AM, Khan SS, Jones DW, Goldberg R, Mora S, Blaha M, Pencina MJ, Grundy SM. Managing Atherosclerotic Cardiovascular Risk in Young Adults: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:819-836. [PMID: 35210038 DOI: 10.1016/j.jacc.2021.12.016] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 02/08/2023]
Abstract
There is a need to identify high-risk features that predict early-onset atherosclerotic cardiovascular disease (ASCVD). The authors provide insights to help clinicians identify and address high-risk conditions in the 20- to 39-year age range (young adults). These include tobacco use, elevated blood pressure/hypertension, family history of premature ASCVD, primary severe hypercholesterolemia such as familial hypercholesterolemia, diabetes with diabetes-specific risk-enhancing factors, or the presence of multiple other risk-enhancing factors, including in females, a history of pre-eclampsia or menopause under age 40. The authors update current thinking on lipid risk factors such as triglycerides, non-high-density lipoprotein cholesterol, apolipoprotein B, or lipoprotein (a) that are useful in understanding an individual's long-term ASCVD risk. The authors review emerging strategies, such as coronary artery calcium and polygenic risk scores in this age group, that have potential clinical utility, but whose best use remains uncertain. Finally, the authors discuss both the obstacles and opportunities for addressing prevention in early adulthood.
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Affiliation(s)
- Neil J Stone
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Sidney C Smith
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Carl E Orringer
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Ann Marie Navar
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sadiya S Khan
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel W Jones
- University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Ronald Goldberg
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samia Mora
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott M Grundy
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Puri R, Mehta V, Duell P, Iyengar S, Yusuf J, Dalal J, Narasingan S, Kalra D, Kapoor A, Pradhan A, Mukhopadhyay S, Vijayaraghavan K, Aggarwal R, Muruganathan A, Prabhakar D, Misra S, Shetty S, Kasliwal RR, Bansal M, Khanna NN, Khan A, Melinkeri RP, Kumar S, Chakraborty RN, Bardoloi N, Sahoo P, Vinayagam P, Modi R, Nanda R, Wong ND. Evidence for Intensive LDL-C Lowering for Acute Coronary Syndrome: Recommendations from the Lipid Association of India. J Clin Lipidol 2022; 16:261-271. [PMID: 35508456 DOI: 10.1016/j.jacl.2022.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/28/2022] [Accepted: 03/20/2022] [Indexed: 02/08/2023]
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12
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Lebeau PF, Byun JH, Platko K, Saliba P, Sguazzin M, MacDonald ME, Paré G, Steinberg GR, Janssen LJ, Igdoura SA, Tarnopolsky MA, Wayne Chen SR, Seidah NG, Magolan J, Austin RC. Caffeine blocks SREBP2-induced hepatic PCSK9 expression to enhance LDLR-mediated cholesterol clearance. Nat Commun 2022; 13:770. [PMID: 35140212 PMCID: PMC8828868 DOI: 10.1038/s41467-022-28240-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/05/2022] [Indexed: 01/06/2023] Open
Abstract
Evidence suggests that caffeine (CF) reduces cardiovascular disease (CVD) risk. However, the mechanism by which this occurs has not yet been uncovered. Here, we investigated the effect of CF on the expression of two bona fide regulators of circulating low-density lipoprotein cholesterol (LDLc) levels; the proprotein convertase subtilisin/kexin type 9 (PCSK9) and the low-density lipoprotein receptor (LDLR). Following the observation that CF reduced circulating PCSK9 levels and increased hepatic LDLR expression, additional CF-derived analogs with increased potency for PCSK9 inhibition compared to CF itself were developed. The PCSK9-lowering effect of CF was subsequently confirmed in a cohort of healthy volunteers. Mechanistically, we demonstrate that CF increases hepatic endoplasmic reticulum (ER) Ca2+ levels to block transcriptional activation of the sterol regulatory element-binding protein 2 (SREBP2) responsible for the regulation of PCSK9, thereby increasing the expression of the LDLR and clearance of LDLc. Our findings highlight ER Ca2+ as a master regulator of cholesterol metabolism and identify a mechanism by which CF may protect against CVD.
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Affiliation(s)
- Paul F Lebeau
- Department of Medicine, Division of Nephrology, McMaster University, The Research Institute of St. Joe's Hamilton and the Hamilton Center for Kidney Research, Hamilton, ON, L8N 4A6, Canada
| | - Jae Hyun Byun
- Department of Medicine, Division of Nephrology, McMaster University, The Research Institute of St. Joe's Hamilton and the Hamilton Center for Kidney Research, Hamilton, ON, L8N 4A6, Canada
| | - Khrystyna Platko
- Department of Medicine, Division of Nephrology, McMaster University, The Research Institute of St. Joe's Hamilton and the Hamilton Center for Kidney Research, Hamilton, ON, L8N 4A6, Canada
| | - Paul Saliba
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Matthew Sguazzin
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Melissa E MacDonald
- Department of Medicine, Division of Nephrology, McMaster University, The Research Institute of St. Joe's Hamilton and the Hamilton Center for Kidney Research, Hamilton, ON, L8N 4A6, Canada
| | - Guillaume Paré
- Population Health Research Institute, McMaster University, Hamilton, ON, L8L 2X2, Canada.,The Departments of Medicine, Epidemiology and Pathology, McMaster University, Hamilton, ON, L8L 2X2, Canada.,The Thrombosis and Atherosclerosis Research Institute (TaARI), Department of Medicine, David Braley Research Institute, McMaster University, Hamilton, L8L 2X2, Canada
| | - Gregory R Steinberg
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, L8S 4L8, Canada.,Centre for Metabolism, Obesity and Diabetes Research, Department of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Luke J Janssen
- Firestone Institute for Respiratory Health, St. Joseph's Hospital, Hamilton, ON, L8S 4K1, Canada
| | - Suleiman A Igdoura
- Department of Biology and Pathology, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Mark A Tarnopolsky
- Department of Medicine/Neurology, McMaster University, Hamilton, ON, L8N 3Z5, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - S R Wayne Chen
- Libin Cardiovascular Institute of Alberta, Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, T2N 2T9, Canada
| | - Nabil G Seidah
- Laboratory of Biochemical Neuroendocrinology, Clinical Research Institute of Montreal, affiliated to the University of Montreal, Montreal, QC, H2W 1R7, Canada
| | - Jakob Magolan
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Richard C Austin
- Department of Medicine, Division of Nephrology, McMaster University, The Research Institute of St. Joe's Hamilton and the Hamilton Center for Kidney Research, Hamilton, ON, L8N 4A6, Canada. .,The Thrombosis and Atherosclerosis Research Institute (TaARI), Department of Medicine, David Braley Research Institute, McMaster University, Hamilton, L8L 2X2, Canada.
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Levintow SN, Orroth KK, Breskin A, Park AS, Flores-Arredondo JH, Dluzniewski P, Navar AM, Sørensen HT, Brookhart MA. Use of negative control outcomes to assess the comparability of patients initiating lipid-lowering therapies. Pharmacoepidemiol Drug Saf 2021; 31:383-392. [PMID: 34894377 DOI: 10.1002/pds.5396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Clinical trials have demonstrated efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing risk of cardiovascular disease events, but effectiveness in routine clinical care has not been well-studied. We used negative control outcomes to assess potential confounding in an observational study of PCSK9i versus ezetimibe or high-intensity statin. METHODS Using commercial claims, we identified U.S. adults initiating PCSK9i, ezetimibe, or high-intensity statin in 2015-2018, with other lipid-lowering therapy (LLT) use in the year prior (LLT cohort) or atherosclerotic cardiovascular disease (ASCVD) in the past 90 days (ASCVD cohort). We compared initiators of PCSK9i to ezetimibe and high-intensity statin by estimating one-year risks of negative control outcomes influenced by frailty or health-seeking behaviors. Inverse probability of treatment and censoring weighted estimators of risk differences (RDs) were used to evaluate residual confounding after controlling for covariates. RESULTS PCSK9i initiators had lower one-year risks of negative control outcomes associated with frailty, such as decubitus ulcer in the ASCVD cohort (PCSK9i vs. high-intensity statin RD = -3.5%, 95% confidence interval (CI): -4.6%, -2.5%; PCSK9i vs. ezetimibe RD = -1.3%, 95% CI: -2.1%, -0.6%), with similar but attenuated associations in the LLT cohort. Lower risks of accidents and fractures were also observed for PCSK9i, varying by cohort. Risks were similar for outcomes associated with health-seeking behaviors, although trended higher for PCSK9i in the ASCVD cohort. CONCLUSIONS Observed associations suggest lower frailty and potentially greater health-seeking behaviors among PCSK9i initiators, particularly those with a recent ASCVD diagnosis, with the potential to bias real-world analyses of treatment effectiveness.
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Affiliation(s)
- Sara N Levintow
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Alexander Breskin
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | - Ann Marie Navar
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - M Alan Brookhart
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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14
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Lewek J, Konopka A, Starostecka E, Penson PE, Maciejewski M, Banach M. Clinical Features of Familial Hypercholesterolemia in Children and Adults in EAS-FHSC Regional Center for Rare Diseases in Poland. J Clin Med 2021; 10:4302. [PMID: 34640319 PMCID: PMC8509252 DOI: 10.3390/jcm10194302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is a genetic autosomal co-dominant metabolic disorder leading to elevated circulating concentrations of low-density lipoprotein cholesterol (LDL-C). Early development of atherosclerotic cardiovascular disease (ASCVD) is common in affected patients. We aimed to evaluate the characteristics and differences in the diagnosis and therapy of FH children and adults. Methods: All consecutive patients who were diagnosed with FH, both phenotypically and with genetic tests, were included in this analysis. All patients are a part of the European Atherosclerosis Society FH-Study Collaboration (FHSC) regional center for rare diseases at the Polish Mother's Memorial Hospital Research Institute (PMMHRI) in Lodz, Poland. Results: Of 103 patients with FH, there were 16 children (15.5%) at mean age of 9 ± 3 years and 87 adults aged 41 ± 16; 59% were female. Children presented higher mean levels of total cholesterol, LDL-C, and high-density lipoprotein cholesterol (HDL-C) measured at the baseline visit (TC 313 vs. 259 mg/dL (8.0 vs. 6.6 mmol/L), p = 0.04; LDL 247 vs. 192 mg/dL (6.3 vs. 4.9 mmol/L), p = 0.02, HDL 53 vs. 48 mg/dL (1.3 vs. 1.2 mmol/L), p = 0.009). Overall, 70% of adult patients and 56% of children were prescribed statins (rosuvastatin or atorvastatin) on admission. Combination therapy (dual or triple) was administered for 24% of adult patients. Furthermore, 13.6% of adult patients and 19% of children reported side effects of statin therapy; most of them complained of muscle pain. Only 50% of adult patients on combination therapy achieved their treatment goals. None of children achieved the treatment goal. CONCLUSIONS Despite a younger age of FH diagnosis, children presented with higher mean levels of LDL-C than adults. There are still urgent unmet needs concerning effective lipid-lowering therapy in FH patients, especially the need for greater use of combination therapy, which may allow LDL-C targets to be met in most of the patients.
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Affiliation(s)
- Joanna Lewek
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland;
| | - Agnieszka Konopka
- Regional Rare Disease Centre, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland; (A.K.); (E.S.)
| | - Ewa Starostecka
- Regional Rare Disease Centre, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland; (A.K.); (E.S.)
| | - Peter E. Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK;
- Liverpool Centre for Cardiovascular Science, Liverpool L7 8TX, UK
| | - Marek Maciejewski
- Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland;
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland;
- Cardiovascular Research Centre, University of Zielona Gora, 65-046 Zielona Gora, Poland
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15
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Parthymos I, Kostapanos MS, Mikhailidis DP, Florentin M. Lipoprotein (a) as a treatment target for cardiovascular disease prevention and related therapeutic strategies: a critical overview. Eur J Prev Cardiol 2021; 29:739-755. [PMID: 34389859 DOI: 10.1093/eurjpc/zwab052] [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] [Received: 09/27/2020] [Revised: 11/30/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
Advances in several fields of cardiovascular (CV) medicine have produced new treatments (e.g. to treat dyslipidaemia) that have proven efficacy in terms of reducing deaths and providing a better quality of life. However, the burden of CV disease (CVD) remains high. Thus, there is a need to search for new treatment targets. Lipoprotein (a) [Lp(a)] has emerged as a potential novel target since there is evidence that it contributes to CVD events. In this narrative review, we present the current evidence of the potential causal relationship between Lp(a) and CVD and discuss the likely magnitude of Lp(a) lowering required to produce a clinical benefit. We also consider current and investigational treatments targeting Lp(a), along with the potential cost of these interventions.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
| | - Michael S Kostapanos
- Department of General Medicine, Lipid Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London NW3 2QG, UK
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
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16
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Sáez-Jiménez R, Esteban-Hernández J, Herreros B, Huelmos A, Guijarro C. Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort. Rev Clin Esp 2021; 222:138-151. [PMID: 34147423 DOI: 10.1016/j.rceng.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease. METHODS A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% PAD) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes. RESULTS After six years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (three territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI.326 [.036; .607]). CONCLUSIONS The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors.
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Affiliation(s)
- R Sáez-Jiménez
- Centro de Atención Primaria Presentación Sabio, Móstoles, Madrid, Spain; Área de Salud Pública y Medicina Preventiva, Facultad de Medicina, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - J Esteban-Hernández
- Área de Salud Pública y Medicina Preventiva, Facultad de Medicina, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
| | - B Herreros
- Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - A Huelmos
- Servicio de Cardiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - C Guijarro
- Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Madrid, Spain; Facultad de Medicina, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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Tomlinson B, Patil NG, Fok M, Lam CWK. Managing dyslipidemia in patients with Type 2 diabetes. Expert Opin Pharmacother 2021; 22:2221-2234. [PMID: 33823719 DOI: 10.1080/14656566.2021.1912734] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) is associated with increased risk for atherosclerotic cardiovascular disease (ASCVD) which is partly related to atherogenic dyslipidemia with raised triglycerides, reduced high-density lipoprotein cholesterol levels, and accompanying lipid changes. Treatment of this dyslipidemia is regarded as a priority to reduce the ASCVD risk in T2DM. AREAS COVERED This article reviews the relevant studies and guidelines from the publications related to this area. EXPERT OPINION Lifestyle modification should always be encouraged, and statin treatment is indicated in most patients with T2DM based on the outcome of randomized controlled trials. If LDL-C goals are not achieved, first, ezetimibe and subsequently proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors should be added. Patients with T2DM derive greater benefits from ezetimibe and PCSK9 inhibitors due to their higher absolute ASCVD risk compared to patients without T2DM. If triglyceride levels remain elevated, a high dose of eicosapentaenoic acid ethyl ester should be added. Fibrates should be used for severe hypertriglyceridemia to prevent acute pancreatitis. Novel treatments including pemafibrate and inclisiran are undergoing cardiovascular outcome trials, and RNA-based therapies may help to target residual hypertriglyceridemia and high lipoprotein(a) with the long acting treatments offering potential improved adherence to therapy.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau China
| | | | - Manson Fok
- Faculty of Medicine, Macau University of Science and Technology, Macau China
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18
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Lan NSR, Burns K, Bell DA, Watts GF. Best practice for treating dyslipidaemia in patients with diabetes based on current international guidelines. Curr Opin Endocrinol Diabetes Obes 2021; 28:104-113. [PMID: 33278128 DOI: 10.1097/med.0000000000000594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Dyslipidaemia is a major modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD) in type 2 diabetes. We provide an in-context overview of recent trials of lipid-lowering pharmacotherapies and of recommendations from international guidelines for managing dyslipidaemia in patients with diabetes. RECENT FINDINGS Clinical trials have demonstrated that patients with diabetes derive greater benefits from ezetimibe and proprotein convertase subtilisin-kexin type 9 inhibitors owing to the higher absolute ASCVD risk compared with patients without diabetes. Pure eicosapentaenoic acid ethyl ester therapy should be considered in high risk patients with diabetes and hypertriglyceridaemia who have well controlled low-density lipoprotein cholesterol on statin therapy. International guidelines from USA, Canada and Europe have been updated to support a more intensive approach to treating dyslipidaemia in diabetes. SUMMARY Dyslipidaemia should be identified and treated intensively as part of overall diabetes management to reduce ASCVD risk. Although lifestyle modifications and statin therapy remain the cornerstone of management, add-on therapies should be strongly considered depending on the absolute risk of ASCVD and the degree of dyslipidaemia.
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Affiliation(s)
- Nick S R Lan
- Departments of Internal Medicine and Cardiology, Royal Perth Hospital
| | - Kharis Burns
- Medical School, University of Western Australia
- Department of Endocrinology and Diabetes, Royal Perth Hospital
| | - Damon A Bell
- Departments of Internal Medicine and Cardiology, Royal Perth Hospital
- Medical School, University of Western Australia
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth and Fiona Stanley Hospitals
- Department of Biochemistry, Clinipath Pathology, Perth, Western Australia, Australia
| | - Gerald F Watts
- Departments of Internal Medicine and Cardiology, Royal Perth Hospital
- Medical School, University of Western Australia
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19
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Banach M, Penson PE, Vrablik M, Bunc M, Dyrbus K, Fedacko J, Gaita D, Gierlotka M, Jarai Z, Magda SL, Margetic E, Margoczy R, Durak-Nalbantic A, Ostadal P, Pella D, Trbusic M, Udroiu CA, Vlachopoulos C, Vulic D, Fras Z, Dudek D, Reiner Ž. Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP). Pharmacol Res 2021; 166:105499. [PMID: 33607265 DOI: 10.1016/j.phrs.2021.105499] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 01/05/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.
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Affiliation(s)
- Maciej Banach
- Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland; Department of Hypertension, Medical University of Lodz (MUL), Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland.
| | - Peter E Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Michal Vrablik
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Matjaz Bunc
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Krzysztof Dyrbus
- 3rd Department of Cardiology, School of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Jan Fedacko
- MEDIPARK, University Research Park for Preclinical and Clinical Research, Pavol Jozef Safarik University, Kosice, Slovakia
| | - Dan Gaita
- Institute of Cardiovascular Diseases, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania
| | - Marek Gierlotka
- Department of Cardiology, University Hospital in Opole, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Zoltan Jarai
- Department of Cardiology, Saint Imre University Teaching Hospital, Budapest, Hungary
| | - Stefania Lucia Magda
- University of Medicine and Pharmacy "Carol Davila" and University and Emergency Hospital, Department of Cardiology and Cardiovascular Surgery, Bucharest, Romania
| | - Eduard Margetic
- Clinic of Cardiovascular Diseases, University Hospital Center Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Roman Margoczy
- Middle Slovak Institute of Cardiovascular Diseases, Banska Bystrica, Slovakia
| | - Azra Durak-Nalbantic
- Department for Cardiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Petr Ostadal
- Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
| | - Daniel Pella
- 2nd Department of Cardiology Clinic of PJ Safarik University and East Slovak Institute for Cardiovascular Diseases, Košice, Slovakia
| | - Matias Trbusic
- Department of Cardiology, Sestre Milosrdnice University Hospital Center, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Cristian Alexandru Udroiu
- University of Medicine and Pharmacy "Carol Davila" and University and Emergency Hospital, Department of Cardiology and Cardiovascular Surgery, Bucharest, Romania
| | - Charalambos Vlachopoulos
- First Cardiology Department, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of Athens, Greece
| | - Dusko Vulic
- Faculty of Medicine, University of Banja Luka, Bosnia and Herzegovina
| | - Zlatko Fras
- Preventive Cardiology Unit, Department of Vascular Medicine, Division of Medicine, University Medical Centre Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Željko Reiner
- Department of Internal Medicine, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia.
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20
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Sobeski LM, Schumacher CA, Alvarez NA, Anderson KC, Bradley B, Crowe SJ, Merlo JR, Nyame A, Rivera KS, Shapiro NL, Spencer DD, Dril E. Medication access: Policy and practice opportunities for pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Adwoa Nyame
- American College of Clinical Pharmacy Lenexa Kansas USA
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21
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Zafrir B, Egbaria A, Stein N, Elis A, Saliba W. PCSK9 inhibition in clinical practice: Treatment patterns and attainment of lipid goals in a large health maintenance organization. J Clin Lipidol 2021; 15:202-211.e2. [PMID: 33243717 DOI: 10.1016/j.jacl.2020.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/30/2020] [Accepted: 11/09/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) effectively reduce low-density lipoprotein cholesterol (LDL-C), improving cardiovascular outcomes in clinical trials when added to statin therapy. OBJECTIVES As real-world evidence is lacking, we aimed to evaluate treatment and adherence patterns using PCSK9i in clinical practice. METHODS We investigated 1600 patients initiating PCSK9i between January 2016 and December 2019 in a large health maintenance organization. Treatment discontinuation was defined as a gap ≥60 days between last days' supply of one prescription and the start of the next. Re-initiation rates as well as proportion of days covered (PDC) over 1-year period and attainment of lipid goals under PCSK9i, were analyzed. RESULTS Evolocumab 140 mg was initiated by 50.7%, alirocumab 75 mg by 29.5% and 150 mg by 19.8%. Cumulative discontinuation rates were 28.1% after 6-months and 49.9% after 3-years. Overall, 58% of the patients that discontinued therapy have re-initiated PCSK9i (31% after 3-months from discontinuation). Mean PDC over 1-year of therapy was 56% ± 29, with PDC ≥80% evident in 29%. Of those with established cardiovascular disease (n = 991), 55% achieved LDL-C<70 mg/dL and 38% LDL-C<55 mg/dL. Attainment rates were lower in patients with PDC<80%, baseline LDL-C>190 mg/dL and in those not treated with concurrent statin therapy. CONCLUSIONS In real-world practice of patients treated by PCSK9i, high proportion of early treatment discontinuation was evident, with non-negligible re-initiation rates but overall low medication coverage over time. This have contributed to sub-optimal attainment of LDL-C treatment goals, particularly observed in patients with severe hypercholesterolemia, inadequate drug adherence, and those using PCSK9i as monotherapy.
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Affiliation(s)
- Barak Zafrir
- The Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel; The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel.
| | - Aya Egbaria
- The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel
| | - Nili Stein
- The Statistical Unit, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Avishay Elis
- The Department of Medicine, Beilinson Hospital, Rabin Medical Center, PetachTikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Walid Saliba
- The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel; The Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
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22
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Pharmacist-administered long-acting injectable PCSK9 service: A solution to improve patient access and adherence. J Am Pharm Assoc (2003) 2020; 61:e83-e85. [PMID: 33384242 DOI: 10.1016/j.japh.2020.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/02/2020] [Accepted: 12/06/2020] [Indexed: 11/22/2022]
Abstract
In 2015, 2 proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, were approved by Food and Drug Administration (FDA). Both therapies reduce low-density lipoprotein cholesterol (LDL-C) by approximately 60% and reduce atherosclerotic cardiovascular disease (ASCVD) risk in patients with established ASCVD when added to background statin therapy. The initial cost of these medications was approximately $15,000 per year, which made them largely cost-prohibitive for many patients and the overall health care system. In recent years, the cost of both agents has been reduced by 60%, and they are no longer only available through specialty pharmacies. In addition, a third PCSK9-modulating therapy, inclisiran, is nearing FDA approval. Ongoing inclisiran therapy only requires biannual subcutaneous administration and achieves LDL-C reductions of approximately 50%. As the use of PCSK9-modulating therapies increases, models that improve adherence and persistence over time will be critical to ensure patient access and maximize their value. Community pharmacists can play an important role helping patients not only obtain access to these therapies by navigating previous authorization requests but also adhere to therapy by offering administration. Community pharmacists can also provide therapeutic monitoring using point-of-care lipid testing to ensure efficacy over time. Such a service could potentially be sustained through reimbursement for administration and point-of-care lipid testing. Given the cost of these therapies, innovative models involving community pharmacists will be necessary to ensure patient access to these preventive therapies and minimize overall costs to the health care system.
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Brandts J, Ray KK. Clinical implications and outcomes of the ORION Phase III trials. Future Cardiol 2020; 17:769-777. [PMID: 33345605 DOI: 10.2217/fca-2020-0150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Inclisiran is a siRNA inhibiting hepatic PCSK9 synthesis. As a first-in-class therapy, inclisiran has been assessed within the ORION trial program for its low-density lipoprotein cholesterol (LDL-C) lowering efficacy and clinical safety. Phase II and III trials have shown that inclisiran lowers LDL-C by about 50% with an infrequent dosing schedule in patients with established atherosclerotic cardiovascular disease and those at high risk, including patients with heterozygous familial hypercholesterolemia. Ongoing Phase III trials will provide evidence on longer-term safety and effectiveness, and inclisiran's efficacy in patients with homozygous familial hypercholesterolemia. Furthermore, the ORION-4 trial will assess inclisiran's impact on cardiovascular outcomes.
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Affiliation(s)
- Julia Brandts
- Department of Medicine I, University Hospital RWTH Aachen, Aachen, Germany.,Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
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Claessen BE, Guedeney P, Gibson CM, Angiolillo DJ, Cao D, Lepor N, Mehran R. Lipid Management in Patients Presenting With Acute Coronary Syndromes: A Review. J Am Heart Assoc 2020; 9:e018897. [PMID: 33289416 PMCID: PMC7955383 DOI: 10.1161/jaha.120.018897] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite many improvements in its prevention and management, acute coronary syndrome (ACS) remains a major cause of morbidity and mortality in the developed world. Lipid management is an important part of secondary prevention after ACS, but many patients currently remain undertreated and do not attain guideline‐recommended levels of low‐density lipoprotein cholesterol reduction. This review details the current state of evidence on lipid management in patients presenting with ACS, provides directions for identification of patients who may benefit from early escalation of lipid‐lowering therapy, and discusses novel lipid‐lowering medication that is currently under investigation in clinical trials. Moreover, a treatment algorithm aimed at attaining guideline‐recommended low‐density lipoprotein cholesterol levels is proposed. Despite important advances in the initial treatment and secondary prevention of ACS, ≈20% of ACS survivors experience a subsequent ischemic cardiovascular event within 24 months, and 5‐year mortality ranges from 19% to 22%. Knowledge of the current state of evidence‐based lipid management after ACS is of paramount importance to improve outcomes after ACS.
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Affiliation(s)
- Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.,Noordwest Ziekenhuisgroep Alkmaar the Netherlands
| | - Paul Guedeney
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.,ACTION Study Group Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche Scientifique_1166 Cardiology Institute Pitié Salpêtrière Hospital ParisSorbonne University Paris France
| | | | | | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Norman Lepor
- Cedars-Sinai Heart InstituteGeffen School of Medicine-University of Califonia - Los Angeles Los Angeles CA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
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McCormick D, Bhatt DL, Bays HE, Taub PR, Caldwell KA, Guerin CK, Steinhoff J, Ahmad Z, Singh R, Moreo K, Carter J, Heggen CL, Sapir T. A regional analysis of payer and provider views on cholesterol management: PCSK9 inhibitors as an illustrative alignment model. J Manag Care Spec Pharm 2020; 26:1517-1528. [PMID: 33251993 PMCID: PMC10391214 DOI: 10.18553/jmcp.2020.26.12.1517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Multiple barriers exist for appropriate use of the proprotein convertase subtilisin/kexin type 9 enzyme inhibitors (PCSK9i) in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH) with inadequately controlled hypercholesterolemia despite standard therapies. Among these barriers, high payer rejection rates and inadequate prior authorization (PA) documentation by providers hinder optimal use of PCSK9i. OBJECTIVES: To (a) identify and discuss provider and payer discordances on barriers to authorization and use of PCSK9i based on clinical and real-world evidence and (b) align understanding and application of clinical, cost, safety, and efficacy data of PCSK9i. METHODS: Local groups of 3 payers and 3 providers met in 6 separate locations across the United States through a collaborative project of AMCP and PRIME Education. Responses to selected pre- and postmeeting survey questions measured changes in attitudes and beliefs regarding treatment barriers, lipid thresholds for considering PCSK9i therapy, and tactics for improving PA processes. Statistical analysis of inter- and intragroup changes in attitudes were performed by Cox proportional hazards test and Fisher's exact test for < 5 variables. RESULTS: The majority of providers and payers (67%-78%) agreed that high patient copayments and inadequate PA documentation were significant barriers to PCSK9i usage. However, payers and providers differed on beliefs that current evidence does not support PCSK9i cost-effectiveness (6% providers, 56% payers; P = 0.003) and that PA presents excessive administrative burden (72% providers, 44% payers; P = 0.09) Average increases pre- to postmeeting were noted in provider beliefs that properly documented PA forms expedite access to PCSK9i (22%-50% increase) and current authorization criteria accurately distinguish patients who benefit most from PCSK9i (6%-22%). Payers decreased in their belief that current authorization criteria accurately distinguish benefiting patients (72%-50%). Providers and payers increased in their belief that PCSK9i are cost-effective (44%-61% and 28%-50%, respectively) and were more willing to consider PCSK9i at the low-density lipoprotein cholesterol threshold of > 70 mg/dL for patients with ASCVD (78%-83% and 44%-67%, respectively) or FH (22%-39% and 22%-33%). Payers were more agreeable to less stringent PA requirements for patients with FH (33%-72%, P = 0.019) and need for standardized PA requirements (50%-83%, P = 0.034); these considerations remained high (89%) among providers after the meeting. Most participants supported educational programs for patient treatment adherence (83%) and physician/staff PA processes (83%-94%). CONCLUSIONS: Provider and payer representatives in 6 distinct geographic locations provided recommendations to improve quality of care in patients eligible for PCSK9i. Participants also provided tactical recommendations for streamlining PA documentation processes and improving awareness of PCSK9i cost-effectiveness and clinical efficacy. The majority of participants supported development of universal, standardized patient eligibility criteria and PA forms. DISCLOSURES: The study reported in this article was part of a continuing education program funded by an independent educational grant awarded by Sanofi US and Regeneron Pharmaceuticals to PRIME Education. The grantor had no role in the study design, execution, analysis, or reporting. AMCP received grant funding from PRIME to assist in the study, as well as in writing the manuscript. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad received an honorarium from PRIME for serving as faculty for the continuing education program. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad were involved as participants in the study. Bhatt discloses the following relationships: Advisory board: Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data monitoring committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site co-investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded research: FlowCo, Merck, Novo Nordisk, Takeda. Bays' research site has received research grants from 89Bio, Acasti, Akcea, Allergan, Alon Medtech/Epitomee, Amarin, Amgen, AstraZeneca, Axsome, Boehringer Ingelheim, Civi, Eli Lilly, Esperion, Evidera, Gan and Lee, Home Access, Janssen, Johnson and Johnson, Lexicon, Matinas, Merck, Metavant, Novartis, Novo Nordisk, Pfizer, Regeneron, Sanofi, Selecta, TIMI, and Urovant. Bays has served as a consultant/advisor for 89Bio, Amarin, Esperion, Matinas, and Gelesis, and speaker for Esperion. McCormick, Caldwell, Guerin, Ahmad, Singh, Moreo, Carter, Heggen, and Sapir have nothing to disclose.
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Affiliation(s)
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY
| | - Pam R Taub
- Division of Cardiovascular Medicine, University of California San Diego School of Medicine
| | | | - Chris K Guerin
- Tri-City Medical Center and University of California San Diego School of Medicine
| | - Jeff Steinhoff
- Largo Medical Center, Largo, FL; HCA Healthcare/USF Morsani College of Medicine, Tampa, FL; and Nova Southeastern University, Davie, FL
| | - Zahid Ahmad
- Division of Nutrition and Metabolic Disease, UT Southwestern Medical Center, Dallas, TX
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Feldman DI, Michos ED, Stone NJ, Gluckman TJ, Cainzos-Achirica M, Virani SS, Blumenthal RS. Same evidence, varying viewpoints: Three questions illustrating important differences between United States and European cholesterol guideline recommendations. Am J Prev Cardiol 2020; 4:100117. [PMID: 34327477 PMCID: PMC8315633 DOI: 10.1016/j.ajpc.2020.100117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- David I Feldman
- The Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erin D Michos
- The Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil J Stone
- Departments of Medicine (Cardiology) and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, OR, USA.,The Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA.,The Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; And Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Roger S Blumenthal
- The Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Barrios V, Escobar C, Arrarte V, García E, Fernández MR, Rincón LM, Roldán C. First national registry on the effectiveness and safety of evolocumab in clinical practice in patients attended in cardiology in Spain. The RETOSS-CARDIO study. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2020; 32:231-241. [PMID: 32605806 DOI: 10.1016/j.arteri.2020.05.002] [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: 12/26/2019] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To present the first registry used to analyse the clinical profile of patients treated with evolocumab in Spain, including the effectiveness on the lipid profile and safety in the «real world» setting. METHODS Multicentre, retrospective, and observational study of patients starting treatment with evolocumab from February 2016 to May 2017 in clinical practice in Spanish cardiology units. RESULTS A total of 186 patients (mean age 60.3 ± 9.8 years were included, 35.5% with familial hypercholesterolaemia, and 94.1% with a previous cardiovascular event) from 31 cardiology units. Baseline lipid profile: Total cholesterol 219.4 ± 52.2 mg/dL, LDL-cholesterol 144.0 ± 49.0mg/dL, HDL-cholesterol 47.7 ± 13.0mg/dL, and triglycerides 151.0 ± 76.2mg/dL. At the time of initiating evolocumab, 53.8% of patients were taking statins (50% had partial or total intolerance to statins), and 51.1% ezetimibe. In all cases, the dose of evolocumab used was 140 mg, mainly every 2 weeks (97.3%). Evolocumab compliance was high (92.3%). Treatment with evolocumab was interrupted in 6 patients (3.2%), with only 1 (0.5%) due to a probable side effect. Evolocumab significantly reduced total cholesterol (30.9% at week 2, and 39.3% at week 12; P<.001), LDL cholesterol (44.4% and 57.6%, respectively; P<.001), and triglycerides (14.8% and 5.2%, respectively; P<001), with no significant changes in HDL-cholesterol (6.7% and 2.0%; P=.14). CONCLUSIONS In clinical practice, evolocumab is associated with reductions in LDL cholesterol, with nearly 60% after 12 weeks of treatment, and with low rates of interruptions due to side effects and high medication compliance. These results are consistent with those reported in randomised clinical trials.
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Affiliation(s)
- Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España.
| | - Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, España
| | - Vicente Arrarte
- Servicio de Cardiología, Hospital General Universitario, Alicante, España
| | - Eusebio García
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, España
| | | | - Luis Miguel Rincón
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España
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28
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Robinson JG, Jayanna MB, Bairey Merz CN, Stone NJ. Clinical implications of the log linear association between LDL-C lowering and cardiovascular risk reduction: Greatest benefits when LDL-C >100 mg/dl. PLoS One 2020; 15:e0240166. [PMID: 33119602 PMCID: PMC7595281 DOI: 10.1371/journal.pone.0240166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/21/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The log linear association between on-treatment LDL-C levels and ASCVD events is amplified in higher risk patient subgroups of statin versus placebo trials. OBJECTIVES Update previous systematic review to evaluate how the log linear association influences the magnitude of cardiovascular risk reduction from intensifying LDL-C lowering therapy. METHODS MEDLINE/PubMED, Clinical trials.gov, and author files were searched from 1/1/2005 through 10/30/2019 for subgroup analyses of cardiovascular outcomes trials of moderate versus high intensity statin, ezetimibe, and PCSK9 mAbs with an ASCVD endpoint (nonfatal myocardial infarction or stroke, cardiovascular death). Annualized ASCVD event rates were used to extrapolate 5-year ASCVD risk for each treatment group reported in subgroup analyses, which were grouped into a priori risk groups according to annualized placebo/control rates of ≥4%, 3-3.9%, or <3% ASCVD risk. Data were pooled using a random-effects model. Weighted least-squares regression was used to fit linear and log-linear models. RESULTS Systematic review identified 96 treatment subgroups from 2 trials of moderate versus high intensity statin, 2 trials of a PCSK9 mAb versus placebo, and 1 trial of ezetimibe versus placebo. A log linear association between on-treatment LDL-C and ASCVD risk represents the association between on-treatment LDL-C levels and ASCVD event rates, especially in higher risk subgroups. Greater relative and absolute cardiovascular risk reductions from LDL-C lowering were observed when baseline LDL-C was >100 mg/dl and in extremely high risk ASCVD patient groups. CONCLUSIONS Greater cardiovascular and mortality risk reduction benefits from intensifying LDL-C lowering therapy may be expected in those with LDL-C ≥100 mg/dl, or in extremely high risk patient groups. When baseline LDL-C <100 mg/dl, the log linear association between LDL-C and event rates suggests that treatment options other than further LDL-C lowering should also be considered for optimal risk reduction.
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Affiliation(s)
- Jennifer G. Robinson
- Division of Cardiology, Department of Epidemiology and Internal Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Manju Bengaluru Jayanna
- Division of Cardiovascular Disease, Department of Medicine, Lenkenau Medical Center & Lankenau Institute for Medical Research, Wynnewood, PA, United States of America
| | - C. Noel Bairey Merz
- Barbara Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Neil J. Stone
- Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
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Duprez DA, Handelsman Y, Koren M. Cardiovascular Outcomes and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: Current Data and Future Prospects. Vasc Health Risk Manag 2020; 16:403-418. [PMID: 33116551 PMCID: PMC7548340 DOI: 10.2147/vhrm.s261719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular (CV) disease remains the leading cause of morbidity and mortality worldwide and poses an ongoing challenge with the aging population. Elevated low-density lipoprotein cholesterol (LDL-C) is an established risk factor for atherosclerotic cardiovascular disease (ASCVD), and the expert consensus is the use of statin therapy (if tolerated) as first line for LDL-C reduction. However, patients with ASCVD may experience recurrent ischemic events despite receiving maximally tolerated statin therapy, including those whose on-treatment LDL-C remains ≥70 mg/dL, patients with familial hypercholesterolemia, high-risk subgroups with comorbidities such as diabetes mellitus, and those who have an intolerance to statin therapy. Optimal therapeutic strategies for this unmet need should deploy aggressive lipid lowering to minimize the contribution of dyslipidemia to their CV risk, particularly for very high-risk populations with additional risk factors beyond hypercholesterolemia and established ASCVD. To understand the current clinical climate and guidelines regarding ASCVD, we primarily searched PubMed for articles published in English regarding lipid-lowering therapies and CV risk reduction, including emerging therapies, and CV outcomes trials with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. This review discusses the findings of recent clinical trial evidence for CV risk reduction with cholesterol-lowering therapies, with a focus on CV outcomes trials with PCSK9 inhibitors, and considers the impact of the study results for secondary prevention and future strategies in patients with hypercholesterolemia and CV risk despite maximally tolerated statin therapy.
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Affiliation(s)
- Daniel A Duprez
- Cardiovascular Division, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
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Kaddoura R, Orabi B, Salam AM. Efficacy and safety of PCSK9 monoclonal antibodies: an evidence-based review and update. J Drug Assess 2020; 9:129-144. [PMID: 32939318 PMCID: PMC7470150 DOI: 10.1080/21556660.2020.1801452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Treatment of dyslipidemia lowers cardiovascular (CV) risk. Although statin use is a cornerstone therapy, many patients are not achieving their risk-specific low-density lipoprotein cholesterol (LDL-C) goals. The proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies have been extensively studied as lipid-lowering therapy (LLT). Herein, we present an updated evidence-based review of the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of familial and non-familial hypercholesterolemia. Methods PubMed database was searched to review Phase III studies on PCSK9 monoclonal antibodies. Then, the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform were searched to identify and present the ongoing research. Results PCSK9 monoclonal antibodies were investigated for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional LLT. They proved effective and safe in the treatment of familial and non-familial hypercholesterolemia, and in the prevention of adverse CV events. Conclusions The use of PCSK9 monoclonal antibodies in the treatment of dyslipidemia is currently recommended to achieve risk-specific LDL-C goal to reduce adverse CV events. Future results of the ongoing research might expand their clinical generalizability to broader patient populations.
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Affiliation(s)
- Rasha Kaddoura
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Bassant Orabi
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Amar M Salam
- Department of Cardiology, Hamad Medical Corporation, Al-khor Hospital, Doha, Ad Dawhah, Qatar
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Patient Characteristics and Treatment Patterns among Medicare Beneficiaries Initiating PCSK9 Inhibitor Therapy. Cardiovasc Drugs Ther 2020; 35:965-973. [PMID: 32594283 DOI: 10.1007/s10557-020-07028-3] [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] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE There is limited real-world evidence around use of proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i) among US older adults. This study examined baseline characteristics of fee-for-service (FFS) Medicare beneficiaries newly initiating PCSK9i therapy during the period immediately following market availability. METHODS This cross-sectional study used Medicare claims (2013-2016) to identify 5051 FFS Medicare beneficiaries who filled ≥ 1 PCSK9i prescription between August 2015 and December 2016. We analyzed patient demographics, clinical characteristics, and baseline healthcare expenditures in the 12-month period prior to PCSK9i initiation, for these beneficiaries. RESULTS Most beneficiaries initiating PCSK9i were female (57%), < 75 years of age (61%), white (89%), and lived in metropolitan areas (83%). At baseline, these PCSK9i initiators had 6 chronic conditions on average, with conditions such as hyperlipidemia, hypertension, and ischemic heart disease being most prevalent. Approximately 88% had a diagnosis of atherosclerotic cardiovascular disease (ASCVD), and 14% experienced acute cardiovascular events during the 12-month baseline period. Use of any statin and/or ezetimibe ranged from 54 to 76% in the 6-month and 24-month baseline period. Their total annual Medicare expenditures averaged US$17,552, of which most were attributable to ambulatory care and prescription use, in the 12-month baseline period. CONCLUSION High burden of cardiovascular conditions and prescription expenditures at baseline were common among FFS beneficiaries initiating PCSK9i therapy. These findings suggest that physicians prescribe PCSK9i to elderly patients at high risk for adverse cardiovascular events. Considering the evolving treatment landscape, PCSK9i utilization might increase in Medicare.
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Ruiz García A, Guijarro Herráiz C. Cardiovascular prevention guidelines of the scientific societies and healthcare administrations: The need for convergence. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ruiz García A, Guijarro Herráiz C. Guías de prevención cardiovascular de sociedades científicas y administraciones sanitarias: la necesidad de convergencia. Rev Clin Esp 2020; 220:294-296. [DOI: 10.1016/j.rce.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
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Lipid-Lowering Efficacy of Ezetimibe in Patients with Atherosclerotic Cardiovascular Disease: A Systematic Review and Meta-Analyses. Am J Cardiovasc Drugs 2020; 20:239-248. [PMID: 31724105 PMCID: PMC7266788 DOI: 10.1007/s40256-019-00379-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Patients with atherosclerotic cardiovascular disease (ASCVD), especially those with recent (< 1 year) acute coronary syndrome (ACS), are at high risk for recurrent cardiovascular events. This risk can be reduced by lowering low-density lipoprotein cholesterol (LDL-C) levels. A comprehensive meta-analysis on the LDL-C-lowering efficacy of ezetimibe is lacking. This study attempts to address this gap. METHODS A systematic literature review of randomized controlled trials evaluating the LDL-C-lowering efficacy of ezetimibe in the ASCVD population was conducted. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for publications from database inception to August 2018 and for conference abstracts from 2015 to August 2018. Meta-analyses were conducted to evaluate the LDL-C-lowering efficacy of ezetimibe in the ASCVD population and the recent ACS subgroup. RESULTS In total, 12 studies were eligible for the meta-analyses. Treatment with combination ezetimibe plus statin therapy showed greater absolute LDL-C reduction than statin monotherapy (mean difference - 21.86 mg/dL; 95% confidence interval [CI] - 26.56 to - 17.17; p < 0.0001) after 6 months of treatment (or at a timepoint closest to 6 months). Similarly, in patients with recent ACS, combination ezetimibe plus statin therapy was favorable compared with statin monotherapy (mean treatment difference - 19.19 mg/dL; 95% CI - 25.22 to - 13.16; p < 0.0001). CONCLUSIONS Ezetimibe, when added to statin therapy, provided a modest additional reduction in LDL-C compared with statin monotherapy. However, this may not be sufficient for some patients with ASCVD who have especially high LDL-C levels despite optimal statin therapy.
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Board C, Kelly MS, Shapiro MD, Dixon DL. PCSK9 Inhibitors in Secondary Prevention-An Opportunity for Personalized Therapy. J Cardiovasc Pharmacol 2020; 75:410-420. [PMID: 32379108 DOI: 10.1097/fjc.0000000000000809] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide. Low-density lipoprotein cholesterol (LDL-C) is the primary cause of ASCVD and reducing LDL-C levels with statin therapy significantly reduces ASCVD risk; however, significant residual risk remains. Two monoclonal antibodies (mAbs), alirocumab and evolocumab, that target proprotein convertase subtilisin/kexin-type 9 (PCSK9), reduce LDL-C levels by up to 60% when used in combination with statins and significantly reduce the risk of recurrent ASCVD events in both stable secondary prevention and acute coronary syndrome populations. Prespecified analyses of recent randomized controlled trials have shed light on how best to prioritize these therapies to maximize their value in select high-risk groups. These data have also informed recent clinical practice guidelines and scientific statements resulting in an expanded role for PCSK9-mAbs compared with previous guidelines, albeit there are notable differences between these recommendations. Ongoing research is exploring the long-term safety of PCSK9-mAbs and their role in the acute setting and patients without prior myocardial infarction or stroke. Novel therapies that inhibit PCSK9 synthesis via small interfering RNA, such as inclisiran, are also in development and may reduce LDL-C levels similar to PCSK9-mAbs, but with less frequent administration. Nonetheless, the PCSK9-mAbs are a breakthrough therapy and warrant consideration in very high-risk patients who are most likely to benefit. Such a personalized approach can help to ensure cost-effectiveness and maximize their value.
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Affiliation(s)
- Chase Board
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - Michael S Kelly
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA; and
| | - Michael D Shapiro
- Section on Cardiovascular Medicine, Center for the Prevention of Cardiovascular Disease, Wake Forest Baptist Health, Winston-Salem, NC
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
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Buckley LF, Ting C, Fatani N, Fanikos J. Changes in nationwide Medicare and Medicaid expenditures on lipid-lowering therapies after proprotein convertase/subtilisin type 9 inhibitor availability. J Clin Lipidol 2020; 14:315-321.e4. [DOI: 10.1016/j.jacl.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022]
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Gallego-Colon E, Daum A, Yosefy C. Statins and PCSK9 inhibitors: A new lipid-lowering therapy. Eur J Pharmacol 2020; 878:173114. [PMID: 32302598 DOI: 10.1016/j.ejphar.2020.173114] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/17/2020] [Accepted: 04/09/2020] [Indexed: 11/28/2022]
Abstract
The clinical benefit of lipid-lowering therapies is to reduce circulating levels of atherogenic particles and to ameliorate the risk of atherosclerotic cardiovascular disease (ASCVD). The completion of two major clinical trials on PCSK9 inhibitors (PCSK9i), the FOURIER and the ODYSSEY outcome trials, has marked the beginning of a new era of lipid-lowering drugs. PCSK9i, evolocumab and alirocumab, are monoclonal antibodies that inactivate the liver proprotein convertase subtilisin kexin 9 (PCSK9). Inhibition of PCSK9 increases the number of low-density lipoprotein (LDL) receptors available leading to a profound reduction in circulating LDL particles. By preventing LDL receptor destruction, PCSK9i as adjunct to statin therapy can reduce LDL-C by 50-60% above that achieved by statin therapy alone. In addition, PCSK9i in combination with high-dose statins may reduce cardiovascular events and all-cause mortality in patients with clinical ASCVD. Based on evidence from clinical trials, the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidemias now include the use of PCSK9i to very high-risk ASCVD patients who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe. However, the cost-effectiveness of PCSK9i therapy is limited to secondary prevention in high-risk patients. This review outlines the main clinical trials leading to a change in the guidelines, clinical practice as well as the future challenges of PCSK9i therapy.
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Affiliation(s)
- Enrique Gallego-Colon
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel.
| | - Aner Daum
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel
| | - Chaim Yosefy
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel
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Familial hypercholesterolaemia: evolving knowledge for designing adaptive models of care. Nat Rev Cardiol 2020; 17:360-377. [DOI: 10.1038/s41569-019-0325-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 01/05/2023]
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Brown TM, Bittner V, Colantonio LD, Deng L, Farkouh ME, Limdi N, Monda KL, Rosenson RS, Serban MC, Somaratne RM, Zhao H, Woodward M, Muntner P. Residual risk for coronary heart disease events and mortality despite intensive medical management after myocardial infarction. J Clin Lipidol 2020; 14:260-270. [PMID: 32115398 DOI: 10.1016/j.jacl.2020.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 11/17/2019] [Accepted: 01/12/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND High-intensity statins, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and antiplatelet agents (ie, intensive medical management) reduce coronary heart disease (CHD) risk after myocardial infarction (MI). OBJECTIVE The objective of the study was to determine the risk of CHD events or death despite receiving intensive medical management after MI. METHODS We studied 16,853 United States adults with health insurance in the MarketScan and Medicare databases who underwent percutaneous coronary intervention while hospitalized for MI between January 1, 2014 and June 30, 2015 and received intensive medical management within 30 days after hospital discharge. MI, CHD, and all-cause mortality rates from 30 days after hospital discharge through December 31, 2015 were compared with 67,412 individuals in each of three groups: (1) the general MarketScan and Medicare populations, (2) with diabetes, and (3) with a CHD history. RESULTS Among beneficiaries intensively medically managed after their MI, recurrent MI, CHD events, and all-cause mortality rates were 47.1, 72.0, and 57.5 per 1000 person-years, respectively. The multivariable-adjusted hazard ratio (95% CI) comparing intensively medically managed beneficiaries after MI to the general population, those with diabetes, and those with a history of CHD were 8.54 (7.52-9.70), 7.40 (6.61-8.28), and 5.45 (4.92-6.05), respectively, for recurrent MI; 7.82 (7.07-8.64), 6.27 (5.74-6.86), and 4.45 (4.10-4.82), respectively, for CHD events; and 1.15 (1.05-1.25), 1.05 (0.97-1.14), and 1.06 (0.97-1.15), respectively, for all-cause mortality. CONCLUSION Substantial residual risk for MI and CHD events remains despite intensive medical management after MI.
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Affiliation(s)
- Todd M Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Vera Bittner
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lisandro D Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luqin Deng
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
| | - Nita Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keri L Monda
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Maria-Corina Serban
- Department of Functional Sciences, University of Medicine and Pharmacy "Victor Babes" Timisoara, Romania
| | | | - Hong Zhao
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, United Kingdom; The George Institute for Global Health, University of New South Wales, Sydney, Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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From the editor: The “roaring Twenties” revisited? J Clin Lipidol 2020; 14:1-2. [DOI: 10.1016/j.jacl.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Robinson JG. The next treatment paradigm in cardiovascular prevention? Lancet 2019; 394:2129-2131. [PMID: 31810608 DOI: 10.1016/s0140-6736(19)32949-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer G Robinson
- Departments of Epidemiology and Internal Medicine, Division of Cardiology, University of Iowa, Iowa City, IA 52242, USA.
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Wong ND, Toth PP, Amsterdam EA. Most important advances in preventive cardiology during this past decade: Viewpoint from the American Society for Preventive Cardiology. Trends Cardiovasc Med 2019; 31:49-56. [PMID: 31882264 DOI: 10.1016/j.tcm.2019.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/21/2019] [Accepted: 11/27/2019] [Indexed: 12/25/2022]
Abstract
The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol mangement focusing on the identification of "statin eligible groups" and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare. The availability of the sodium glucose transport protein-2 (SGLT2) inhibitors and glucagon-like peptide -1 receptor antagonists (GLP1-RA) for managing diabetes have shifted our focus in diabetes care beyond glucose lowering to addressing cardiovascular risk reduction. While many prior trials of fish oil therapy have failed to show benefit, the recent Reduction of Cardiovascular Events With EPA - Intervention Trial (REDUCE-IT) testing the efficacy of icosapent ethyl has shown dramatic benefit in further addressing residual atherosclerotic cardiovascular disease (ASCVD) risk beyond statin therapy not only in those with known ASCVD, but also in diabetic patients with multiple risk factors. The past decade also ushered in confirmation of the inflammation hypothesis of atherosclerosis with the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) using canakinumab, despite the fact the therapy was not approved by the Food and Drug Administration (FDA) for cardiovascular risk reduction. Also, to improve our understanding of heart disease in women, the emergence of novel concepts of ischemia or myocardial infarction in those with normal or nonobstructive atherosclerotic disease has been a major advance. Moreover, the past decade brought the emergence of proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy and the cardiovascular risk reduction benefits seen in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trials, providing further evidence-based therapy for additional reduction of ASCVD risk beyond statin therapy. The PCSK9 monoclonal antibodies have facilitated the attainment of LDL-C levels never previously thought possible. Finally with the mRNA interference therapy inclisiran in development, we may soon have a "vaccine-like" approach for addressing dyslipidemia and atherosclerosis.
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Affiliation(s)
- Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, C240 Medical Sciences, University of California, Irvine, CA 92697-4079, United States.
| | - Peter P Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, University of California, Davis, United States
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Implications of cost-effectiveness analyses of lipid-lowering therapies: From the policy-maker's desk to the patient's bedside. Prog Cardiovasc Dis 2019; 62:406-413. [DOI: 10.1016/j.pcad.2019.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 12/19/2022]
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