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Bell G, Thoma A, Hargreaves IP, Lightfoot AP. The Role of Mitochondria in Statin-Induced Myopathy. Drug Saf 2024; 47:643-653. [PMID: 38492173 DOI: 10.1007/s40264-024-01413-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
Statins represent the primary therapy for combatting hypercholesterolemia and reducing mortality from cardiovascular events. Despite their pleiotropic effects in lowering cholesterol synthesis, circulating cholesterol, as well as reducing the risk of other systemic diseases, statins have adverse events in a small, but significant, population of treated patients. The most prominent of these adverse effects is statin-induced myopathy, which lacks precise definition but is characterised by elevations in the muscle enzyme creatine kinase alongside musculoskeletal complaints, including pain, weakness and fatigue. The exact aetiology of statin-induced myopathy remains to be elucidated, although impaired mitochondrial function is thought to be an important underlying cause. This may result from or be the consequence of several factors including statin-induced inhibition of coenzyme Q10 (CoQ10) biosynthesis, impaired Ca2+ signalling and modified reactive oxygen species (ROS) generation. The purpose of this review article is to provide an update on the information available linking statin therapy with mitochondrial dysfunction and to outline any mechanistic insights, which may be beneficial in the future treatment of myopathic adverse events.
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Affiliation(s)
- Gavin Bell
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Anastasia Thoma
- Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus
| | - Iain P Hargreaves
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK.
| | - Adam P Lightfoot
- Department of Life Sciences, Manchester Metropolitan University, Manchester, UK.
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Fogacci F, Giovannini M, Tocci G, Imbalzano E, Borghi C, Cicero AFG. Effect of Coenzyme Q 10 on Physical Performance in Older Adults with Statin-Associated Asthenia: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Clin Med 2024; 13:3741. [PMID: 38999304 PMCID: PMC11242215 DOI: 10.3390/jcm13133741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/13/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Available evidence from randomized clinical trials is contrasting and definitely inconclusive in determining whether or not CoQ10 dietary supplementation is advisable in patients with statin intolerance or poor statin tolerability. Methods: This randomized, double-blind, placebo-controlled clinical study aimed at investigating the effect of chronic dietary supplementation with coenzyme Q10 (CoQ10) phytosome on physical performance in older adults with a ≥3-month history of statin-associated asthenia. The study's participants were randomized to either a placebo or 300 mg daily CoQ10 phytosome (equivalent to 60 mg CoQ10; Ubiqsome®, Indena SpA, Milan, Italy). Asthenia, handgrip strength (HGs), 2-min step test (2MST), and 1-min sit-to-stand (STS) repetitions were assessed at baseline and at 8-week follow-up. Results: After the first 4 weeks of dietary supplementation, individuals taking CoQ10 phytosome showed a greater improvement in asthenia compared to the placebo group (p < 0.05). Even more significantly, at 8-week follow-up, participants receiving CoQ10 showed substantial improvements in asthenia (-30.0 ± 20.0%), HGS (+29.8 ± 3.6%), 2MST (+11.1 ± 1.8%), and 1-min STS repetitions (+36.4 ± 3.9%) compared to both baseline and placebo (p < 0.05). Conclusions: According to our findings, chronic dietary supplementation with CoQ10 phytosome significantly enhances physical performance in older adults with statin-associated asthenia. This could have relevant implications for improving the compliance of older adults with statin treatment.
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Affiliation(s)
- Federica Fogacci
- Hypertension and Cardiovascular Risk Factors Research Centre, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (C.B.); (A.F.G.C.)
| | - Marina Giovannini
- Hypertension and Cardiovascular Risk Factors Research Centre, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (C.B.); (A.F.G.C.)
| | - Giuliano Tocci
- Cardiology Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome ‘La Sapienza’, Sant’Andrea Hospital, 00198 Rome, Italy;
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Factors Research Centre, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (C.B.); (A.F.G.C.)
- Cardiovascular Medicine Unit, IRCCS AOU BO, 40138 Bologna, Italy
| | - Arrigo F. G. Cicero
- Hypertension and Cardiovascular Risk Factors Research Centre, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (C.B.); (A.F.G.C.)
- Cardiovascular Medicine Unit, IRCCS AOU BO, 40138 Bologna, Italy
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Smolderen KG, Gillaspy S, Evers AW, Kovacs AH, Massa-Carroll I, Moons P, Mena-Hurtado C. The Role of the Clinical Psychologist in the Care of Adults With Cardiovascular Disease. JACC. ADVANCES 2024; 3:100910. [PMID: 38939655 PMCID: PMC11198723 DOI: 10.1016/j.jacadv.2024.100910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/12/2024] [Accepted: 02/05/2024] [Indexed: 06/29/2024]
Abstract
Cardiovascular disease (CVD) is on the rise globally and, along with mental health conditions, will represent the largest public health burden, especially in a world impacted by climate change. Behavior, psychological mechanisms, and CVD are closely correlated. Evidence-based psychological interventions targeting behavior and psychological mechanisms exist across the CVD spectrum. This statement proposes the development of a subspecialty "cardiovascular psychology" to develop integrated pathways of behavioral care delivered to CVD populations. Scope of practice is discussed as it relates to diagnosing and treating comorbid health disorders, behavioral change interventions, pain management, lifestyle and wellbeing, neuropsychological assessment, and cognitive rehabilitation. An agenda on reforms for financials, training pathways, and diversification of the workforce is presented. Finally, normalizing the integration of behavioral health as part of CVD treatment is a shared responsibility across professional organizations and the community to realize value-based CVD care.
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Affiliation(s)
- Kim G. Smolderen
- Section of Cardiology, Department of Internal Medicine, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA
- Department of Psychiatry, Yale University, New Haven, Connecticut, USA
| | - Stephen Gillaspy
- American Psychological Association, Office of Health & Health Care Financing, Washington, DC, USA
| | - Andrea W.M. Evers
- Department of Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
| | | | | | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Carlos Mena-Hurtado
- Section of Cardiology, Department of Internal Medicine, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA
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Ruscica M, Bertoletti A, Gobbi C, Sirtori CR, Carugo S, Corsini A. Lipid-lowering approaches to manage statin-intolerant patients. Eur Heart J Suppl 2024; 26:i56-i59. [PMID: 38867860 PMCID: PMC11167966 DOI: 10.1093/eurheartjsupp/suae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Statins have improved the potential to prevent cardiovascular disease events and to prolong the lives of patients. Statins, among the most widely used drugs worldwide, reduce the levels of low-density lipoprotein cholesterol (LDL-C) by an average of 30-50%. However, non-adherence to statin therapy, due to statin intolerance, might be as high as 60% after 24 months of treatment and is associated with a 70% increase in the risk of cardiovascular disease events. Statin intolerance can be classified as a complete inability to tolerate any dose of a statin or a partial intolerance with the inability to tolerate the dose necessary to achieve the patient-specific therapeutic objective. Reasons for discontinuation are many, with statin-associated muscle symptoms being cited as the most frequent reason for stopping therapy and the incidence of muscle symptoms increasing with treatment intensity. Considering the causal effect of LDL-C in the atherosclerotic process, clinicians should consider that regardless of the lipid-lowering drugs patients are willing to take, any reduction in LDL-C they achieve will afford them some benefit in reducing cardiovascular risk. Besides statins, the current therapeutic armamentarium offers different strategies to reach LDL-C targets in statin-intolerant patients (i.e. a fixed combination between a lower dose of statin plus ezetimibe, bempedoic acid, or proprotein convertase subtilisin/kexin type 9 inhibition).
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Affiliation(s)
- Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences ‘Rodolfo Paoletti’, Università degli Studi di Milano, Milan
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico
| | - Alessandra Bertoletti
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico
| | - Cecilia Gobbi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico
| | - Cesare R Sirtori
- Department of Pharmacological and Biomolecular Sciences ‘Rodolfo Paoletti’, Università degli Studi di Milano, Milan
| | - Stefano Carugo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences ‘Rodolfo Paoletti’, Università degli Studi di Milano, Milan
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Sun B, Yew PY, Chi CL, Song M, Loth M, Liang Y, Zhang R, Straka RJ. Development and Validation of the Pharmacological Statin-Associated Muscle Symptoms Risk Stratification Score Using Electronic Health Record Data. Clin Pharmacol Ther 2024; 115:839-846. [PMID: 38372189 DOI: 10.1002/cpt.3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/30/2024] [Indexed: 02/20/2024]
Abstract
Statin-associated muscle symptoms (SAMS) can lead to statin nonadherence. This paper aims to develop a pharmacological SAMS risk stratification (PSAMS-RS) score using a previously developed PSAMS phenotyping algorithm that distinguishes objective vs. nocebo SAMS using electronic health record (EHR) data. Using our PSAMS phenotyping algorithm, SAMS cases and controls were identified from Minnesota Fairview EHR, with the statin user cohort divided into derivation (January 1, 2010, to December 31, 2018) and validation (January 1, 2019, to December 31, 2020) cohorts. A Least Absolute Shrinkage and Selection Operator regression model was applied to identify significant features for PSAMS. PSAMS-RS scores were calculated and the clinical utility of stratifying PSAMS risk was assessed by comparing hazard ratios (HRs) between fourth vs. first score quartiles. PSAMS cases were identified in 1.9% (310/16,128) of the derivation and 1.5% (64/4,182) of the validation cohorts. Sixteen out of 38 clinical features were determined to be significant predictors for PSAMS risk. Patients within the fourth quartile of the PSAMS scores had an over sevenfold (HR: 7.1, 95% confidence interval (CI): 4.03-12.45, derivation cohort) or sixfold (HR: 6.1, 95% CI: 2.15-17.45, validation cohort) higher hazard of developing PSAMS vs. those in their respective first quartile. The PSAMS-RS score is a simple tool to stratify patients' risk of developing PSAMS after statin initiation which could inform clinician-guided pre-emptive measures to prevent PSAMS-related statin nonadherence.
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Affiliation(s)
- Boguang Sun
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Pui Ying Yew
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chih-Lin Chi
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Meijia Song
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Matt Loth
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yue Liang
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rui Zhang
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert J Straka
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
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Peyrel P, Mauriège P, Frenette J, Laflamme N, Greffard K, Dufresne SS, Huth C, Bergeron J, Joanisse DR. No benefit of vitamin D supplementation on muscle function and health-related quality of life in primary cardiovascular prevention patients with statin-associated muscle symptoms: A randomized controlled trial. J Clin Lipidol 2024; 18:e269-e284. [PMID: 38177036 DOI: 10.1016/j.jacl.2023.12.002] [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: 09/28/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Statins are the leading lipid-lowering drugs, reducing blood cholesterol by controlling its synthesis. Side effects are linked to the use of statins, in particular statin-associated muscle symptoms (SAMS). Some data suggest that vitamin D supplementation could reduce SAMS. OBJECTIVE The purpose of this study was to evaluate the potential benefits of vitamin D supplementation in a randomized controlled trial. METHODS Men (n = 23) and women (n = 15) (50.5 ± 7.7 years [mean ± SD]) in primary cardiovascular prevention, self-reporting or not SAMS, were recruited. Following 2 months of statin withdrawal, patients were randomized to supplementation (vitamin D or placebo). After 1 month of supplementation, statins were reintroduced. Before and 2 months after drug reintroduction, muscle damage (creatine kinase and myoglobin) was measured. Force (F), endurance (E) and power (P) of the leg extensors (ext) and flexors (fle) and handgrip strength (FHG) were also measured with isokinetic and handheld dynamometers, respectively. The Short Form 36 Health Survey (SF-36) questionnaire and a visual analog scale (VAS) were administrated to assess participants' self-reported health-related quality of life and SAMS intensity, respectively. Repeated-measures analysis was used to investigate the effects of time, supplementation, and their interaction, according to the presence of SAMS. RESULTS Despite no change for objective measures, subjective measures worsened after reintroduction of statins, independent of supplementation (VAS, SF-36 mental component score, all p < 0.05). However, no interaction between time and supplementation according to the presence of SAMS was observed for any variables. CONCLUSIONS Vitamin D supplementation does not appear to mitigate SAMS.
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Affiliation(s)
- Paul Peyrel
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Pascale Mauriège
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Jérôme Frenette
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron); Department of Rehabilitation, Université Laval, Québec, QC G1V 0A6, Canada (Frenette)
| | - Nathalie Laflamme
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron)
| | - Karine Greffard
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron)
| | - Sébastien S Dufresne
- Department of Health Sciences, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada (Dufresne)
| | - Claire Huth
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse)
| | - Jean Bergeron
- CHU de Québec - Université Laval Research Center, Québec, QC G1V 4G2, Canada (Frenette, Laflamme, Greffard, and Bergeron); Departments of Laboratory Medicine and of Specialized Medicine, Université Laval, Québec, QC G1V 0A6, Canada (Bergeron)
| | - Denis R Joanisse
- Department of Kinesiology, Université Laval, Québec, QC G1V 0A6, Canada (Peyrel, Mauriège, Huth, and Joanisse); Research Center of the University Institute of Cardiology and Pulmonology of Quebec, Québec, QC G1V 4G5, Canada (Peyrel, Mauriège, Huth, and Joanisse).
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Patel R, Sharma JB, Rajput S. Statins Ticagrelor and Rhabdomyolysis: A Coincidence or a Drug Interaction? J Lipid Atheroscler 2024; 13:61-68. [PMID: 38299164 PMCID: PMC10825574 DOI: 10.12997/jla.2024.13.1.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/08/2023] [Accepted: 09/09/2023] [Indexed: 02/02/2024] Open
Abstract
Objective Statins play a key role in the management of atherosclerotic cardiovascular disease for both primary and secondary prevention. However, their increasing usage has correspondingly led to a higher incidence of adverse effects, with muscle symptoms being the most common. An intriguing drug interaction exists between ticagrelor and high-intensity statins, which may exacerbate the adverse effects of statin-induced rhabdomyolysis, leading to significant consequences. This study was conducted to examine the profile of patients who have experienced statin-induced rhabdomyolysis while undergoing percutaneous transluminal coronary angioplasty (PTCA). Methods This was an observational study that included 1,862 patients who underwent PTCA at our institute over the course of 1 year. Results Over a 1-year period, we encountered four patients who were being treated with high-intensity statin therapy following acute coronary syndrome. These patients presented with muscle weakness and kidney injury. A notable commonality among all patients was the co-prescription of ticagrelor. Two patients died, while the other 2 were successfully managed through hydration, electrolyte balance, dialysis, and alternative lipid management drugs. Conclusion The concomitant use of ticagrelor and high-intensity statins should be carefully considered due to the additional risk of rhabdomyolysis and kidney injury. Future pharmacokinetic studies are needed to establish a causal relationship and predict potential drug interactions, which, if not avoided, could be fatal.
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Affiliation(s)
- Ramesh Patel
- Department of Cardiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Jai Bharat Sharma
- Department of Cardiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Saraswati Rajput
- Department of Medicine, Geetanjali Medical College and Hospital, Udaipur, India
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Bays HE, Bloedon LT, Lin G, Powell HA, Louie MJ, Nicholls SJ, Lincoff AM, Nissen SE. Safety of bempedoic acid in patients at high cardiovascular risk and with statin intolerance. J Clin Lipidol 2024; 18:e59-e69. [PMID: 37951797 DOI: 10.1016/j.jacl.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Bempedoic acid is an oral adenosine triphosphate citrate lyase (ACL) inhibitor that lowers low-density lipoprotein cholesterol (LDL-C) blood levels. The Cholesterol Lowering via Bempedoic acid, an ACL-Inhibiting Regimen (CLEAR) Outcomes study demonstrated that bempedoic acid reduced cardiovascular (CV) risk in patients at high risk for CV events who were unwilling or unable to take guideline-recommended doses of statins. OBJECTIVE To describe detailed safety information from CLEAR Outcomes, including events in the United States (US) prescribing information based on previous phase 3 hyperlipidemia studies. METHODS CLEAR Outcomes was a double-blind trial conducted in 13,970 patients randomized to oral bempedoic acid 180 mg daily or placebo and followed for a median of 3.4 years. RESULTS In patients who received at least one dose (7,001 bempedoic acid, 6,964 placebo), treatment emergent adverse events (AE) occurred in 86.3 % and 85 % of patients, respectively. COVID-19 was the most frequently reported AE in both groups. Changes in serum creatinine, blood urea nitrogen, hemoglobin, aminotransaminases, and uric acid were consistent with the known safety profile of bempedoic acid. Gout or gouty arthritis occurred in 3.2 % of bempedoic acid and 2.2 % of placebo patients. AE associated with tendinopathies, including tendon rupture, occurred in 2 % of patients in both treatment groups. Cholelithiasis occurred in 2.2 % of bempedoic acid and 1.2 % of placebo patients; AE related to gallbladder disease were similar between treatment groups. CONCLUSIONS Bempedoic acid was well-tolerated compared with placebo. Safety data from the long-term CLEAR Outcomes study reinforce the positive benefit-risk profile of bempedoic acid.
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Affiliation(s)
- Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville, KY 40213, USA (Dr Bays).
| | - LeAnne T Bloedon
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Grace Lin
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Heather A Powell
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Michael J Louie
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, 631 Blackburn Rd, Clayton VIC 3168, Australia (Dr Nicholls)
| | - A Michael Lincoff
- Cleveland Clinic, 9500 Euclid Avenue, Rm JB-820, Cleveland, OH 44195, USA (Drs Lincoff and Nissen)
| | - Steven E Nissen
- Cleveland Clinic, 9500 Euclid Avenue, Rm JB-820, Cleveland, OH 44195, USA (Drs Lincoff and Nissen)
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Karalis DG. Strategies of improving adherence to lipid-lowering therapy in patients with atherosclerotic cardiovascular disease. Curr Opin Lipidol 2023; 34:252-258. [PMID: 37594008 DOI: 10.1097/mol.0000000000000896] [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: 08/19/2023]
Abstract
PURPOSE OF REVIEW Lowering LDL-C has been shown to reduce ASCVD events, yet many ASCVD patients do not achieve their guideline-directed LDL-C goals leaving patients at increased risk of another ASCVD event. This review discusses implementation strategies to improve guideline-directed lipid management in patients with ASCVD focusing on the provider, patient, and system level. RECENT FINDINGS At a provider level, under-prescribing of statin intensity due most often to statin intolerance, clinical inertia, insufficient monitoring of LDL-C levels, and the difficulty and cost of prescribing other lipid-lowering therapies such as the PCSK9 inhibitors leads to suboptimal cholesterol management in ASCVD patients. Patients concerns about medication side effects and lack of understanding of their ASCVD risk are causes of poor adherence to their lipid-lowering therapy as are barriers at a system level. SUMMARY To improve cholesterol management in ASCVD patients will require an integrated approach targeting the provider, the patient and the system. There is a need for further education of clinicians on the importance of intensive LDL-C lowering in ASCVD patients and greater use of nonstatin LDL-C-lowering therapies for those patients on a maximally tolerated statin who have not achieved their guideline-directed LDL-C goal. This will require shared decision-making with a focus on patient education and patient-clinician communication so that the clinician's goals and aims align with that of the patient.
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Affiliation(s)
- Dean G Karalis
- From the Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Sun B, Yew PY, Chi CL, Song M, Loth M, Zhang R, Straka RJ. Development and application of pharmacological statin-associated muscle symptoms phenotyping algorithms using structured and unstructured electronic health records data. JAMIA Open 2023; 6:ooad087. [PMID: 37881784 PMCID: PMC10597587 DOI: 10.1093/jamiaopen/ooad087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/03/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
Importance Statins are widely prescribed cholesterol-lowering medications in the United States, but their clinical benefits can be diminished by statin-associated muscle symptoms (SAMS), leading to discontinuation. Objectives In this study, we aimed to develop and validate a pharmacological SAMS clinical phenotyping algorithm using electronic health records (EHRs) data from Minnesota Fairview. Materials and Methods We retrieved structured and unstructured EHR data of statin users and manually ascertained a gold standard set of SAMS cases and controls using the published SAMS-Clinical Index tool from clinical notes in 200 patients. We developed machine learning algorithms and rule-based algorithms that incorporated various criteria, including ICD codes, statin allergy, creatine kinase elevation, and keyword mentions in clinical notes. We applied the best-performing algorithm to the statin cohort to identify SAMS. Results We identified 16 889 patients who started statins in the Fairview EHR system from 2010 to 2020. The combined rule-based (CRB) algorithm, which utilized both clinical notes and structured data criteria, achieved similar performance compared to machine learning algorithms with a precision of 0.85, recall of 0.71, and F1 score of 0.77 against the gold standard set. Applying the CRB algorithm to the statin cohort, we identified the pharmacological SAMS prevalence to be 1.9% and selective risk factors which included female gender, coronary artery disease, hypothyroidism, and use of immunosuppressants or fibrates. Discussion and Conclusion Our study developed and validated a simple pharmacological SAMS phenotyping algorithm that can be used to create SAMS case/control cohort to enable further analysis which can lead to the development of a SAMS risk prediction model.
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Affiliation(s)
- Boguang Sun
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, United States
| | - Pui Ying Yew
- Institute for Health Informatics, Office of Academic Clinical Affairs, University of Minnesota, Minneapolis, MN 55455, United States
| | - Chih-Lin Chi
- Institute for Health Informatics, Office of Academic Clinical Affairs, University of Minnesota, Minneapolis, MN 55455, United States
- School of Nursing, University of Minnesota, Minneapolis, MN 55455, United States
| | - Meijia Song
- School of Nursing, University of Minnesota, Minneapolis, MN 55455, United States
| | - Matt Loth
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Rui Zhang
- Institute for Health Informatics, Office of Academic Clinical Affairs, University of Minnesota, Minneapolis, MN 55455, United States
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Robert J Straka
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, United States
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Mulder JWCM, Galema-Boers AMH, Roeters van Lennep JE. First clinical experiences with inclisiran in a real-world setting. J Clin Lipidol 2023; 17:818-827. [PMID: 37775462 DOI: 10.1016/j.jacl.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Inclisiran is the first-in-class small interfering RNA (siRNA) proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor. In clinical trials inclisiran showed effective and sustained low-density lipoprotein cholesterol (LDL-C) reduction of ± 50 %. As data in clinical setting are scarce, we aim to investigate the efficacy and safety in clinical practice. METHODS We describe a registry of consecutive patients who started with inclisiran at a lipid clinic of a university hospital. Patients were eligible if they fulfilled the reimbursement criteria in the Netherlands. Patients were included if they started with inclisiran as first line (group 1) or switched from PCSK9 monoclonal antibody (mAbs) to inclisiran (group 2). LDL-C levels were measured at 3 and 9 months after initiation of inclisiran. Median change of LDL-C levels was calculated on an individual and group level. RESULTS We analysed 65 patients (36 women), median [25th percentile; 75th percentile] age of 63 [54; 68] years. Of these, 44 patients had both a 3 month and 9 month visit. At 3 months, patients who newly started inclisiran (group 1, n = 45) showed a LDL-C decrease of 38 [-49;-33] %. Patients who used statins as co-medication (n = 15) had a higher median LDL-C decrease compared to those without statin use (n=30; 45 % vs 38 %). However, patients who switched from mAbs to inclisiran (group 2, n = 20) had an increase in LDL-C of 38 [+4; +97] %. Adverse effects associated with inclisiran were mild and consisted of mild injection site reactions. Efficacy was slightly less whereas safety results were similar at 9 months. CONCLUSION Our initial experience of inclisiran in a clinical setting showed less reduction in LDL-C levels compared to clinical trials but a similar safety profile. Moreover, patients who switched from PCSK9 mAbs to inclisiran generally showed an increase in LDL-C levels implying that inclisiran is less potent in LDL-C reduction compared to PCSK9 mAbs.
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Affiliation(s)
- Janneke W C M Mulder
- Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, the Netherlands
| | - Annette M H Galema-Boers
- Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, the Netherlands
| | - Jeanine E Roeters van Lennep
- Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, the Netherlands.
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12
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Gavilán-Carrera B, Soriano-Maldonado A, Mediavilla-García JD, Lavie CJ, Vargas-Hitos JA. Prescribing statin therapy in physically (in)active individuals vs prescribing physical activity in statin-treated patients: A four-scenario practical approach. Pharmacol Res 2023; 197:106962. [PMID: 37866703 DOI: 10.1016/j.phrs.2023.106962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023]
Abstract
Statins are among the most commonly prescribed medications worldwide. Statin-associated muscle symptoms (SAMS) represent a frequent statin-related adverse effect associated with statin discontinuation and increased cardiovascular disease (CVD) events. Emerging evidence indicate that the majority of SAMS might not be actually caused by statins, and the nocebo/drucebo effect (i.e. adverse effects caused by negative expectations) might also explain SAMS. Physical activity (PA) is a cornerstone in the management of CVD risk. However, evidence of increased creatine-kinase levels in statin-treated athletes exposed to a marathon has been generalized, at least to some extent, to the general population and other types of PA. This generalization is likely inappropriate and might induce fear around PA in statin users. In addition, the guidelines for lipid management focus on aerobic PA while the potential of reducing sedentary behavior and undertaking resistance training have been overlooked. The aim of this report is to provide a novel proposal for the concurrent prescription of statin therapy and PA addressing the most common and clinically relevant scenarios by simultaneously considering the different stages of statin therapy and the history of PA. These scenarios include i) statin therapy initiation in physically inactive patients, ii) PA/exercise initiation in statin-treated patients, iii) statin therapy initiation in physically active patients, and iv) statin therapy in athletes and very active individuals performing SAMS-risky activities.
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Affiliation(s)
- Blanca Gavilán-Carrera
- Department of Internal Medicine, Virgen de las Nieves University Hospital, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; PA-HELP "Physical Activity for HEaLth Promotion" Research Group, University of Granada, Granada, Spain; Sport and Health University Research Institute (iMUDS), University of Granada, Granada, Spain
| | - Alberto Soriano-Maldonado
- Department of Education, Faculty of Education Sciences, University of Almería, Almería, Spain; SPORT Research Group (CTS-1024), CIBIS (Centro de Investigación para el Bienestar y la Inclusión Social) Research Center, University of Almería, Almería, Spain.
| | | | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, USA
| | - José Antonio Vargas-Hitos
- Department of Internal Medicine, Virgen de las Nieves University Hospital, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
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13
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Affiliation(s)
- Francisco I Farias
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Samuel M Kim
- Cardiology, New York-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Michael D Shapiro
- Cardiovascular Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
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14
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Cordero A, Fernández Olmo R, Badimon L, Santos-Gallego CG, Castellano JM, Fácila L, Rodriguez-Manero M, Bonanad C, Vilahur G, Escribano D, Badimon JJ, González-Juanatey JR. The efficacy of intensive lipid-lowering therapies on the reduction of LDLc and of major cardiovascular events. J Clin Lipidol 2023; 17:602-611. [PMID: 37775463 DOI: 10.1016/j.jacl.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Statins are the cornerstone of lipid-lowering therapy (LLT) for reduction of low-density lipoprotein cholesterol (LDLc) levels and high percentage of patients require LLT combinations or alternative treatments for adequate LDLc control. METHODS We performed an intention-to-treat meta-analysis of published data of phase III trials evaluating LLT efficacy on major adverse cardiovascular events (MACE). The primary endpoint was MACE incidence, as reported in each trial, and secondary analyses included myocardial infarction, stroke and mortality. RESULTS Eleven clinical trials and 135,688 patients were included; seven trials tested high intensity LLT and 4 LLT combinations. Intensive LLT reduced MACE risk by 15% (12.03% vs. 13.79%, HR: 0.85 95% CI 0.80-0.90; p<0.001). The number needed to treat was 56 patients. Meta-regression analyses showed a linear correlation between absolute LDLc reductions and the risk of MACE. Significant reductions in myocardial infarction (HR: 0.83, 95% CI 0.80-0.86) and stroke (HR: 0.81, 95% CI 0.75-0.87) were observed. Cardiovascular death rate was 3.32% in LLT treatment arm vs. 3.56% in controls, resulting in a HR: 0.94 (95% CI 0.88-0.99; p = 0.03); no effect on all-cause mortality was observed (HR: 0.97 95% CI 0.93-1.01; p = 0.09). The sensitivity analyses verified the lack of heterogeneity, except for MACE that was mainly driven by the divergent results of the 2 trials. Small study effect was detected for the assessment of mortality. CONCLUSIONS Current evidence consistently supports the efficacy of available intensity LLT for LDLc decrease on MACE and cardiovascular mortality reduction.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department. Hospital IMED. Elche, Spain (Dr Cordero); Grupo de Investigación Cardiovascular (GRINCAVA). Universidad Miguel Hernández. Elche, Spain (Dr Cordero); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey).
| | | | - Lina Badimon
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey); Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona, Spain (Dr Badimon and Vilahur); Cardiovascular Research Chair, Autonomous University of Barcelona, Spain (Dr Badimon)
| | - Carlos G Santos-Gallego
- Mount Sinai School of Medicine, New York, USA (Drs Santos-Gallego and Badimon); Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, USA (Drs Santos-Gallego and Badimon)
| | - José M Castellano
- Centro Integral de Enfermedades Cardiovasculares (CIEC), Hospital Universitario HM Monteprincipe, Grupo HM Hospitales, Madrid, Spain (Dr Castellano)
| | - Lorenzo Fácila
- Cardiology Department, Consorcio Hospital General de Valencia, Valencia, Spain (Dr Fácila)
| | - Moisés Rodriguez-Manero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey); Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain (Drs Rodriguez-Manero and González-Juanatey)
| | - Clara Bonanad
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey); Cardiology Department, Hospital Clínico, Valencia, Spain (Dr Bonanad)
| | - Gemma Vilahur
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey); Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona, Spain (Dr Badimon and Vilahur)
| | - David Escribano
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain (Dr Escribano)
| | - Juan J Badimon
- Mount Sinai School of Medicine, New York, USA (Drs Santos-Gallego and Badimon); Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, USA (Drs Santos-Gallego and Badimon)
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain (Drs Cordero, Badimon, Rodriguez-Manero, Bonanad, Vilahur and González-Juanatey); Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain (Drs Rodriguez-Manero and González-Juanatey)
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Sun B, Yew PY, Chi CL, Song M, Loth M, Liang Y, Zhang R, Straka RJ. Development and validation of the pharmacological statin-associated muscle symptoms risk stratification (PSAMS-RS) score using real-world electronic health record data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.10.23293939. [PMID: 37645885 PMCID: PMC10462208 DOI: 10.1101/2023.08.10.23293939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Introduction Statin-associated muscle symptoms (SAMS) contribute to the nonadherence to statin therapy. In a previous study, we successfully developed a pharmacological SAMS (PSAMS) phenotyping algorithm that distinguishes objective versus nocebo SAMS using structured and unstructured electronic health records (EHRs) data. Our aim in this paper was to develop a pharmacological SAMS risk stratification (PSAMS-RS) score using these same EHR data. Method Using our PSAMS phenotyping algorithm, SAMS cases and controls were identified using University of Minnesota (UMN) Fairview EHR data. The statin user cohort was temporally divided into derivation (1/1/2010 to 12/31/2018) and validation (1/1/2019 to 12/31/2020) cohorts. First, from a feature set of 38 variables, a Least Absolute Shrinkage and Selection Operator (LASSO) regression model was fitted to identify important features for PSAMS cases and their coefficients. A PSAMS-RS score was calculated by multiplying these coefficients by 100 and then adding together for individual integer scores. The clinical utility of PSAMS-RS in stratifying PSAMS risk was assessed by comparing the hazard ratio (HR) between 4th vs 1st score quartile. Results PSAMS cases were identified in 1.9% (310/16128) of the derivation and 1.5% (64/4182) of the validation cohort. After fitting LASSO regression, 16 out of 38 clinical features were determined to be significant predictors for PSAMS risk. These factors are male gender, chronic pulmonary disease, neurological disease, tobacco use, renal disease, alcohol use, ACE inhibitors, polypharmacy, cerebrovascular disease, hypothyroidism, lymphoma, peripheral vascular disease, coronary artery disease and concurrent uses of fibrates, beta blockers or ezetimibe. After adjusting for statin intensity, patients in the PSAMS score 4th quartile had an over seven-fold (derivation) (HR, 7.1; 95% CI, 4.03-12.45) and six-fold (validation) (HR, 6.1; 95% CI, 2.15-17.45) higher hazard of developing PSAMS versus those in 1st score quartile. Conclusion The PSAMS-RS score can be a simple tool to stratify patients' risk of developing PSAMS after statin initiation which can facilitate clinician-guided preemptive measures that may prevent potential PSAMS-related statin non-adherence.
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Cheeley MK, Clegg K, Lockridge C, Schubert TJ, Jones LK. Statin Intolerance: an Overview of US and International Guidance. Curr Atheroscler Rep 2023; 25:517-526. [PMID: 37410332 PMCID: PMC10412662 DOI: 10.1007/s11883-023-01124-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW To review recent international and domestic definitions, considerations, and treatment algorithms for statin intolerance, and specifically, statin-associated muscle symptoms (SAMS). RECENT FINDINGS Multiple organizations around the world have produced guidance documents to aid clinicians on managing statin intolerance. A common theme resides among all the guidance documents that most patients can tolerate statins. For those patients who cannot, healthcare teams need to evaluate, rechallenge, educate, and ensure adequate reduction of atherogenic lipoproteins. Statin therapy remains the cornerstone of lipid-lowering therapies to reduce atherosclerotic cardiovascular disease (ASCVD) and reduce mortality and morbidity. The common theme throughout all these guidance documents is the importance of statin therapy to reduce ASCVD and continual adherence to treatment. Because adverse events occur and inhibit patients from achieving adequate lowering of their atherogenic lipoproteins, trial and rechallenge of statin therapy, as well as addition of non-statin therapies, especially in high-risk patients, is also undisputed. The main differences stem from laboratory monitoring and the classification of the severity of the adverse effect. Future research should focus on consistently diagnosing SAMS so that these patients can be easily identified in the electronic health records.
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Affiliation(s)
| | - Katarina Clegg
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510 USA
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
| | | | - Tyler J. Schubert
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510 USA
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
| | - Laney K. Jones
- Department of Genomic Medicine, Geisinger, Danville, PA 17822 USA
- Heart and Vascular Institute, Geisinger, Danville, PA 17822 USA
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17
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Louro R, Gouveia E Melo R, Ruivo J, Almeida AG, Pinto FJ, Caldeira D. Incidence of muscle symptoms in placebo arm among statin-intolerant patients: a systematic review with meta-analysis. Expert Rev Cardiovasc Ther 2023; 21:887-894. [PMID: 37916684 DOI: 10.1080/14779072.2023.2274502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Statins are highly used in cardiovascular prevention. Statin intolerance is the most significant cause of decreased adherence, translating into a higher cardiovascular risk. This systematic review aims to estimate the incidence of muscle adverse events in patients with a history of statin intolerance receiving placebo. METHODS Database search was performed in CENTRAL, MEDLINE, and EMBASE until March 2023. This systematic review included blinded randomized control trials enrolling patients with a history of statin intolerance who received a placebo. A random-effects meta-analysis was performed. Results were presented in percentages, with 95% confidence intervals (95% CI). RESULTS Overall, eight studies with 8095 patients with a history of statin intolerance receiving placebo were included. The muscle adverse events incidence rate was 21.34% (95% CI 13.26-30.63%, 8 studies), and discontinuation due to adverse muscle events was 6.12% (95% CI 1.22-13.70%, 3 studies). The incidence was higher in subcutaneous placebo/sham (41.67%, 1 study) compared to oral placebo studies (22.95%, 6 studies). CONCLUSION In patients previously labeled as statin-intolerant, about a fifth of the patients exhibited muscle symptoms when receiving a placebo. This highlights the importance of ruling out non-statin-related symptoms to further optimize statin therapy for cardiovascular risk improvement.
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Affiliation(s)
- Rita Louro
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ryan Gouveia E Melo
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Vascular Surgery, Heart and Vessels Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jorge Ruivo
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana G Almeida
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHLN), Centro Académico de Medicina de Lisboa (CAML), Lisbon, Portugal
| | - Fausto J Pinto
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHLN), Centro Académico de Medicina de Lisboa (CAML), Lisbon, Portugal
| | - Daniel Caldeira
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHLN), Centro Académico de Medicina de Lisboa (CAML), Lisbon, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Somers T, Allard NAE, Siddiqi S, Janssen MCM, Hopman MTE, Morshuis WJ, Russel FGM, Timmers S, Schirris TJJ. Mitochondrial complex III activity: from invasive muscle biopsies to patient-friendly buccal swab analysis. Sci Rep 2023; 13:9638. [PMID: 37316639 DOI: 10.1038/s41598-023-36741-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/08/2023] [Indexed: 06/16/2023] Open
Abstract
Drug-induced mitochondrial dysfunction is a common adverse effect, particularly in case of statins-the most prescribed drugs worldwide. These drugs have been shown to inhibit complex III (CIII) of the mitochondrial oxidative phosphorylation process, which is related to muscle pain. As muscle pain is the most common complaint of statin users, it is crucial to distinguish it from other causes of myalgia to prevent unnecessary cessation of drug therapy. However, diagnosing CIII inhibition currently requires muscle biopsies, which are invasive and not practical for routine testing. Less invasive alternatives for measurement of mitochondrial complex activities are only available yet for complex I and IV. Here, we describe a non-invasive spectrophotometric method to determine CIII catalytic activities using buccal swabs, which we validated in a cohort of statin and non-statin users. Our data indicate that CIII can be reliably measured in buccal swabs, as evidenced by reproducible results above the detection limit. Further validation on a large-scale clinical setting is recommended.
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Affiliation(s)
- Tim Somers
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.
| | - Neeltje A E Allard
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sailay Siddiqi
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Margit C M Janssen
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Maria T E Hopman
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J Morshuis
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Silvie Timmers
- Department of Human and Animal Physiology, Wageningen University, Wageningen, The Netherlands
| | - Tom J J Schirris
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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Cicero AFG, Fogacci F, Stoian AP, Toth PP. Red Yeast Rice for the Improvement of Lipid Profiles in Mild-to-Moderate Hypercholesterolemia: A Narrative Review. Nutrients 2023; 15:nu15102288. [PMID: 37242171 DOI: 10.3390/nu15102288] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Reducing low-density lipoprotein cholesterol (LDL-C) levels is a key target for lowering cardiovascular risk and preventing atherosclerotic cardiovascular disease (ASCVD). Red yeast rice (RYR) is a nutraceutical widely used as a lipid-lowering dietary supplement. The main cholesterol-lowering components of RYR are monacolins, particularly monacolin K, which is structurally identical to lovastatin and targets the same key enzyme of cholesterol biosynthesis. RYR supplementation reduces LDL-C levels by approximately 15-34% versus placebo, with a similar effect to low-dose, first-generation statins in subjects with mild-to-moderate dyslipidemia. RYR has also demonstrated beneficial reductions of up to 45% versus placebo in the risk of ASCVD events in secondary prevention studies. RYR at a dose that provides about 3 mg/d of monacolin K is well tolerated, with an adverse event profile similar to that of low-dose statins. RYR is therefore a treatment option for lowering LDL-C levels and ASCVD risk for people with mild-to-moderate hypercholesterolemia who are ineligible for statin therapy, particularly those who are unable to implement lifestyle modifications, and also for people who are eligible for statin therapy but who are unwilling to take a pharmacologic therapy.
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Affiliation(s)
- Arrigo F G Cicero
- Center for the Study of Hypertension and Related Cardiovascular Risk Factors, Medical and Surgery Sciences Department (DIMEC), University of Bologna, 40126 Bologna, Italy
- IRCCS AOU S. Orsola di Bologna, 40138 Bologna, Italy
| | - Federica Fogacci
- Center for the Study of Hypertension and Related Cardiovascular Risk Factors, Medical and Surgery Sciences Department (DIMEC), University of Bologna, 40126 Bologna, Italy
- Department of Medicine and Surgery Sciences, University of Bologna, 40126 Bologna, Italy
| | - Anca Pantea Stoian
- Department of Diabetes, Faculty of Medicine, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Peter P Toth
- CGH Medical Center, Sterling, IL 61081, USA
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Cheung B, Sikand G, Dineen EH, Malik S, Barseghian El-Farra A. Lipid-Lowering Nutraceuticals for an Integrative Approach to Dyslipidemia. J Clin Med 2023; 12:jcm12103414. [PMID: 37240523 DOI: 10.3390/jcm12103414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 05/28/2023] Open
Abstract
Dyslipidemia is a treatable risk factor for atherosclerotic cardiovascular disease that can be addressed through lifestyle changes and/or lipid-lowering therapies. Adherence to statins can be a clinical challenge in some patients due to statin-associated muscle symptoms and other side effects. There is a growing interest in integrative cardiology and nutraceuticals in the management of dyslipidemia, as some patients desire or are actively seeking a more natural approach. These agents have been used in patients with and without established atherosclerotic cardiovascular disease. We provide an updated review of the evidence on many new and emerging nutraceuticals. We describe the mechanism of action, lipid-lowering effects, and side effects of many nutraceuticals, including red yeast rice, bergamot and others.
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Affiliation(s)
- Brian Cheung
- Susan Samueli Integrative Health Institute, 856 Health Sciences Road, Irvine, CA 92617, USA
- Division of Cardiology, University of California, Irvine, CA 92521, USA
| | - Geeta Sikand
- Division of Cardiology, University of California, Irvine, CA 92521, USA
| | - Elizabeth H Dineen
- Susan Samueli Integrative Health Institute, 856 Health Sciences Road, Irvine, CA 92617, USA
- Division of Cardiology, University of California, Irvine, CA 92521, USA
| | - Shaista Malik
- Susan Samueli Integrative Health Institute, 856 Health Sciences Road, Irvine, CA 92617, USA
- Division of Cardiology, University of California, Irvine, CA 92521, USA
| | - Ailin Barseghian El-Farra
- Susan Samueli Integrative Health Institute, 856 Health Sciences Road, Irvine, CA 92617, USA
- Division of Cardiology, University of California, Irvine, CA 92521, USA
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Sun B, Yew PY, Chi CL, Song M, Loth M, Zhang R, Straka RJ. Development and Application of Pharmacological Statin-Associated Muscle Symptoms Phenotyping Algorithms Using Structured and Unstructured Electronic Health Records Data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.04.23289523. [PMID: 37215024 PMCID: PMC10197715 DOI: 10.1101/2023.05.04.23289523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Background Statins are widely prescribed cholesterol-lowering medications in the US, but their clinical benefits can be diminished by statin-associated muscle symptoms (SAMS), leading to discontinuation. In this study, we aimed to develop and validate a pharmacological SAMS clinical phenotyping algorithm using electronic health records (EHRs) data from Minnesota Fairview. Methods We retrieved structured and unstructured EHR data of statin users and manually ascertained a gold standard set of SAMS cases and controls using the SAMS-CI tool from clinical notes in 200 patients. We developed machine learning algorithms and rule-based algorithms that incorporated various criteria, including ICD codes, statin allergy, creatine kinase elevation, and keyword mentions in clinical notes. We applied the best performing algorithm to the statin cohort to identify SAMS. Results We identified 16,889 patients who started statins in the Fairview EHR system from 2010-2020. The combined rule-based (CRB) algorithm, which utilized both clinical notes and structured data criteria, achieved similar performance compared to machine learning algorithms with a precision of 0.85, recall of 0.71, and F1 score of 0.77 against the gold standard set. Applying the CRB algorithm to the statin cohort, we identified the pharmacological SAMS prevalence to be 1.9% and selective risk factors which included female gender, coronary artery disease, hypothyroidism, use of immunosuppressants or fibrates. Conclusion Our study developed and validated a simple pharmacological SAMS phenotyping algorithm that can be used to create SAMS case/control cohort for further analysis such as developing SAMS risk prediction model.
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Affiliation(s)
- Boguang Sun
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, Minneapolis, Minnesota
| | - Pui Ying Yew
- Institute for Health Informatics, Minneapolis, Minnesota
| | - Chih-Lin Chi
- Institute for Health Informatics, Minneapolis, Minnesota
- School of Nursing, Minneapolis, Minnesota
| | - Meijia Song
- Institute for Health Informatics, Minneapolis, Minnesota
| | - Matt Loth
- Center for Learning Health System Sciences, Minneapolis, Minnesota
| | - Rui Zhang
- Institute for Health Informatics, Minneapolis, Minnesota
- Center for Learning Health System Sciences, Minneapolis, Minnesota
| | - Robert J. Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, Minneapolis, Minnesota
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Effects of Bempedoic Acid in Acute Myocardial Infarction in Rats: No Cardioprotection and No Hidden Cardiotoxicity. Int J Mol Sci 2023; 24:ijms24021585. [PMID: 36675100 PMCID: PMC9860765 DOI: 10.3390/ijms24021585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/22/2022] [Accepted: 12/30/2022] [Indexed: 01/15/2023] Open
Abstract
Lipid-lowering drugs have been shown to have cardioprotective effects but may have hidden cardiotoxic properties. Therefore, here we aimed to investigate if chronic treatment with the novel lipid-lowering drug bempedoic acid (BA) exerts hidden cardiotoxic and/or cardioprotective effects in a rat model of acute myocardial infarction (AMI). Wistar rats were orally treated with BA or its vehicle for 28 days, anesthetized and randomized to three different groups (vehicle + ischemia/reperfusion (I/R), BA + I/R, and positive control vehicle + ischemic preconditioning (IPC)) and subjected to cardiac 30 min ischemia and 120 min reperfusion. IPC was performed by 3 × 5 min I/R cycles before ischemia. Myocardial function, area at risk, infarct size and arrhythmias were analyzed. Chronic BA pretreatment did not influence cardiac function or infarct size as compared to the vehicle group, while the positive control IPC significantly reduced the infarct size. The incidence of reperfusion-induced arrhythmias was significantly reduced by BA and IPC. This is the first demonstration that BA treatment does not show cardioprotective effect although moderately reduces the incidence of reperfusion-induced arrhythmias. Furthermore, BA does not show hidden cardiotoxic effect in rats with AMI, showing its safety in the ischemic/reperfused heart.
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Dicken W, Mehta A, Karagiannis A, Jain V, Vavuranakis M, Sperling L, Cassimatis D. Statin associated muscle symptoms: An update and review. Prog Cardiovasc Dis 2022; 75:40-48. [PMID: 36400232 DOI: 10.1016/j.pcad.2022.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022]
Abstract
Statin therapy has been shown to have a significant effect on lowering of low-density lipoprotien cholesterol (LDL-C) levels. This subsequently results in cardiovascular (CV) benefit through reduction in major adverse CV disease (CVD) events and overall mortality. Although there is well proven clinical benefit, statin therapy may be discontinued in some patients, and the most common cause for discontinuation is concern for statin-associated muscle symptoms. However, the data on the true prevalence of these symptoms is mixed and continued studies are showing that the symptoms may be less prevalent than previously believed. With statin-associated muscle symptoms being the most common reason for a patient to not be on statin therapy, it is important for physicians to understand how to evaluate for and manage these symptoms. This manuscript provides an overview of statin associated muscle symptoms so that physicians may be able to better manage patients on statin therapy and continue to use these medications when indicated to best reduce future risk of CVD for patients.
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Affiliation(s)
- Weston Dicken
- Emory University, Atlanta, GA, United States of America
| | - Anurag Mehta
- Virginia Commonwealth University, Richmond, VA, United States of America
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