Efficacy and safety of lowering LDL cholesterol in older patients: a systematic review and meta-analysis of randomised controlled trials

Lipids, lipid-lowering drugs and the risk of herpes zoster: a Mendelian randomization study

Observational studies have shown that the risk of developing herpes zoster (HZ) increases with the use of statins. However, there are many confounding factors in observational studies. Therefore, our Mendelian randomization (MR) study aimed to explore the causal role of lipids in HZ and to assess the causal impact of lipid-lowering drug targets on HZ risk. Our study used low-density lipoprotein (LDL) as a biomarker, and MR analysis was applied to study the effects of genetic inhibition of 3-hydroxy-3-methylglutaryl CoA reductase (HMGCR, targeted by statins), Niemann-Pick C1-like 1 (NPC1L1, targeted by ezetimibe), and proprotein convertase subtilisin/kexin type 9 (PCSK9, targeted by, e.g., alirocumab) on the risk of HZ. Second, we analyzed the overall effect of different lipid traits, including LDL, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs), on the HZ. Finally, we analyzed the causal association between cardiovascular disease (CVD) and HZ. The primary MR analysis employed the inverse variance weighted (IVW) approach, which MR supplemented‒Egger, weighted median and weighted mode methods. In addition, we performed sensitivity analysis to assess the robustness of the results and the presence of bias. Heterogeneity and pleiotropy analyses were performed to ensure the accuracy of the results. Genetically modified HMGCR inhibition was significantly associated with an increased risk of HZ (OR: 2.02, per standard deviation reduction in LDL; 95% CI 1.05-3.90; P = 0.035, P(BH) = 0.0525 < 0.1). Moreover, genetically proxied PCSK9 inhibition was associated with a reduced risk of HZ (OR: 0.58, per standard deviation reduction in LDL; 95% CI 0.42-0.80; P = 0.001, P(BH) = 0.003 < 0.1). Sensitivity analysis did not provide statistical evidence of bias from pleiotropy or genetic confounding. No robust association was found for NPC1L1 inhibition. No significant effect of lipid traits or CVD on HZ risk was found. Our findings did not support dyslipidemia and CVD as causal factors for HZ. Among the three lipid-lowering drug targets, HMGCR inhibition (targeted by statins) was associated with an increased risk of HZ, and PCSK9 is a promising candidate drug target in HZ. These findings have important implications for understanding the pathogenesis of HZ and for the development of new therapeutic strategies.

High-risk characteristics of recurrent ischemic stroke after intensive medical management for 6-month follow-up: a histogram study on vessel wall MRI

OBJECTIVE

Intensive medical management has been recommended for ischemic stroke of intracranial atherosclerosis (ICAS), but 9.4-15% probability of recurrent stroke remains an inevitable reality. The characteristics of high-risk intracranial plaque that contribute to stroke recurrence after intensive therapy are unclear.

METHODS

The patients of acute ischemic stroke due to ICAS from two centers were prospectively analyzed, who underwent the 3D high-resolution head and neck vessel wall magnetic resonance imaging (hr-VW-MRI) at baseline and received intensive medical management within 90 days. The morphological features, such as minimal lumen area (MLA), and histogram parameters including entropy were assessed based on hr-VW-MR images. The recurrence of ischemic events after 6 months was defined as hyperintensity on diffusion-weighted images in the ipsilateral vascular territory. Cox regression analysis was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for recurrent events.

RESULTS

A total of 222 patients (age 59.5 ± 12.1; males 153) were finally included, and 38 had recurrent stroke after 6 months. After adjusting the age and gender, Cox regression demonstrated that smoking (HR = 4.321; 95% CI, 1.838-10.161; p = 0.001), taking exercise (HR = 0.409; 95% CI, 0.198-0.843; p = 0.015), blood pressure management (HR = 0.180; 95% CI, 0.073-0.443; p = 0.001), MLA (HR = 0.771; 95% CI, 0.625-0.951; p = 0.015) and entropy (HR = 0.274; 95% CI, 0.130-0.576; p = 0.001) were significant predictors of recurrent ischemic stroke. However, the area under curve value of MRI parameters was significantly higher than that of traditional clinical factors (0.86 vs 0.79; p = 0.01).

CONCLUSIONS

The plaque characteristics based on hr-VW-MRI may provide complementary values over traditional clinical features in predicting ischemic recurrence for ICAS.

KEY POINTS

Question The study addresses recurrent ischemic stroke in intracranial atherosclerosis patients, identifying high-risk plaque features that contribute to recurrence despite intensive medical management. Findings Plaque features on high-resolution vessel wall magnetic resonance imaging (hr-VW-MRI), such as minimal lumen area and entropy, improve prediction of stroke recurrence over clinical factors. Clinical relevance This two-center prospective study improves patient care by using hr-VW-MRI and histogram factors like entropy to better predict stroke recurrence, allowing for more personalized treatment strategies and potentially reducing ischemic events in patients with intracranial atherosclerosis.

13. Older Adults: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Advances in statin adverse reactions and the potential mechanisms: A systematic review

BACKGROUND

Elevated low-density lipoprotein (LDL) cholesterol is a major risk factor for cardiovascular disease. Statins are the cornerstone of preventing and treating cardiovascular disease and can reduce LDL cholesterol by more than 60%. Although statins have high tolerability and safety, as the number of users increases, their adverse reactions in the liver, kidneys, skeletal muscles, and their potential to induce diabetes have also received widespread attention.

AIM OF REVIEW

How to maximize the lipid-lowering effect of statins, reduce the incidence of adverse reactions, promote the rational application of statins in the clinic, and improve the risk-benefit level, in order to benefit more cardiovascular patients and provide reference for the related basic research of statins. Key scientific concepts of review: This article provides a comprehensive review of the clinical manifestations of statin-related adverse reactions (associated myopathy, hepatotoxicity, nephrotoxicity, glycemic effects, central nervous system, hemorrhagic stroke, etc.), risk factors for triggering adverse reactions, statin interactions with other drugs (food), potential etiopathological mechanisms and common interventions in the clinic. Genetic diversity is strongly associated with statin adverse effects, and thus, in the future genetic testing may also be key to mitigating statin adverse effects.

Associations Between Gene Variants of Lipid-Lowering Drug Targets and Adverse Outcomes After Ischemic Stroke

BACKGROUND

The association of lipid-lowering drug targets and their gene variants with cardiovascular diseases has been previously clarified. However, the relationship between gene variants of lipid-lowering drug targets and the adverse prognosis of ischemic stroke patients remains unclear.

METHODS AND RESULTS

Multiple single-nucleotide polymorphisms associated with 6 lipid-lowering drug targets were genotyped for patients with ischemic stroke. The primary outcome was death or major disability within 2 years after ischemic stroke. Genetic risk score was constructed from significant single-nucleotide polymorphisms identified via additive models, which was calculated by multiplying the number of risk alleles at each locus by the corresponding beta coefficient and then summing the products. The rs2006760-C of the HMGCR, rs11206510-T of PCSK9, and rs1864163-G and rs9929488-G of CETP were associated with increased odds of adverse outcomes within 2 years after ischemic stroke. Each additional risk allele was associated with higher odds of adverse outcomes. Genetic risk score was positively associated with the odds of primary outcome (odds ratio [OR], 1.48 [95% CI, 1.15-1.90]; Ptrend = 0.001), major disability (OR, 1.56 [95% CI, 1.16-2.08]; Ptrend = 0.002), death (hazard ratio [HR], 1.58 [95% CI, 1.12-2.25]; Ptrend = 0.011), and the composite outcome of death or cardiovascular events (HR, 1.41 [95% CI, 1.08-1.85]; Ptrend = 0.010) when 2 extreme quartiles were compared.

CONCLUSIONS

rs2006760-C of HMGCR, rs11206510-T of PCSK9, and rs1864163-G and rs9929488-G of CETP were associated with increased odds of adverse outcomes within 2 years after ischemic stroke. Furthermore, higher GRS was positively related to the odds of poor outcomes in patients with ischemic stroke. Registration: URL: https://www.clinicaltrials.gov; Identifier: NCT01840072.

Added Value of Medical Subject Headings Terms in Search Strategies of Systematic Reviews: Comparative Study

BACKGROUND

The massive increase in the number of published scientific articles enhances knowledge but makes it more complicated to summarize results. The Medical Subject Headings (MeSH) thesaurus was created in the mid-20th century with the aim of systematizing article indexing and facilitating their retrieval. Despite the advent of search engines, few studies have questioned the relevance of the MeSH thesaurus, and none have done so systematically.

OBJECTIVE

The objective of this study was to estimate the added value of using MeSH terms in PubMed queries for systematic reviews (SRs).

METHODS

SRs published in 4 high-impact medical journals in general medicine over the past 10 years were selected. Only SRs for which a PubMed query was provided were included. Each query was transformed to obtain 3 versions: the original query (V1), the query with free-text terms only (V2), and the query with MeSH terms only (V3). These 3 queries were compared with each other based on their sensitivity and positive predictive values.

RESULTS

In total, 59 SRs were included. The suppression of MeSH terms had an impact on the number of relevant articles retrieved for 24 (41%) out of 59 SRs. The median (IQR) sensitivities of queries V1 and V2 were 77.8% (62.1%-95.2%) and 71.4% (42.6%-90%), respectively. V1 queries provided an average of 2.62 additional relevant papers per SR compared with V2 queries. However, an additional 820.29 papers had to be screened. The cost of screening an additional collected paper was therefore 313.09, which was slightly more than triple the mean reading cost associated with V2 queries (88.67).

CONCLUSIONS

Our results revealed that removing MeSH terms from a query decreases sensitivity while slightly increasing the positive predictive value. Queries containing both MeSH and free-text terms yielded more relevant articles but required screening many additional papers. Despite this additional workload, MeSH terms remain indispensable for SRs.

A Nation-Wide Evaluation of Suboptimal Lipid-Lowering Treatment Patterns Among Patients Undergoing Intervention for Acute Coronary Syndrome in Hungary

Background/Objectives: A significant gap exists between guideline recommendations and everyday practice. Stringent treatment is needed for vulnerable patients with acute coronary syndrome (ACS). Methods: Data on the lipid-lowering therapy (LLT), including the adherence, persistence, and mortality of patients undergoing percutaneous coronary intervention or bypass surgery in Hungary in 2018 were followed up and analyzed based on the National Health Insurance Fund database until the end of 2020. Results: A total of 12,997 patients underwent revascularization for ACS in 2018, whose discharge therapy included any LLT, a high- or moderate-intensity statin, or ezetimibe at a proportion of 91%, 75%, 12%, and 4%, respectively. By the end of the observation period, the frequency of ezetimibe administration increased to 11%. Persistence decreased, reaching 50% for all therapeutic regimens by month 16. Patients on moderate statin doses had a significantly higher mortality rate at the end of follow-up than those receiving high-intensity statin with (20% vs. 9%, p < 0.0001) or without (20% vs. 14%, p = 0.00029) ezetimibe. Those taking less potent statin doses had higher rates of comorbidities; for example, a minimum of three comorbidities were present in 39% of patients taking medium statin doses and 23% among those on high-intensity statin therapy (p < 0.0001). Conclusions: LLT persistence decreased during follow-up. The administration of a higher-intensity lipid-lowering regimen was associated with better persistence and adherence, along with more favorable mortality rates. Multimorbidity was associated with the use of lower statin doses. The results suggest that more attention is needed in terms of lipid control of females, elderly people, and individuals with several comorbidities, and emphasis should be placed on improving persistence and increasing the frequency of combined LLT prescriptions.

Development and Validation of Prognostic Models for Bleeding and Ischemia in Elderly Patients With Comorbid Acute Coronary Syndrome and Atrial Fibrillation

BACKGROUND

Acute coronary syndrome and atrial fibrillation are common cardiovascular diseases in elderly individuals. Patients with comorbidities face increased risks of bleeding and ischemia; however, there is a lack of prognostic models for quantifying these risks in this special population.

METHODS AND RESULTS

In this retrospective cohort study, 1851 patients (≥65 years old) with acute coronary syndrome and atrial fibrillation from 2 hospitals in China were included in the development cohort (1252 individuals) and 2 external validation cohorts (284 and 315 individuals). During 1-year follow-up, 96 Bleeding Academic Research Consortium type 3 or 5 bleeding events and 245 thromboembolic events were observed. In the development cohort, the concordance indexes for bleeding at 3, 6, and 12 mo ranged from 0.737 to 0.845 and for ischemia ranged from 0.723 to 0.777. The calibration curve and decision curve analysis indicated adequate calibration and clinical practicability. The concordance indexes varied from 0.679 to 0.809 in the validation cohorts. Subgroup analyses focusing on anticoagulant drugs and antithrombotic therapy were conducted, revealing similar discrimination and calibration. Kaplan-Meier curves demonstrated significant differences (log-rank P<0.001). Additionally, the models outperformed conventional models in concordance indexes, integrated discrimination improvement, and net reclassification improvement.

CONCLUSIONS

Our study provides 2 robust prognostic models with easily available clinical factors for predicting bleeding and ischemia in elderly patients with acute coronary syndrome and atrial fibrillation. Furthermore, we provide online calculators to facilitate individualized risk evaluation and clinical decision-making.

REGISTRATION

URL: www.chictr.org.cn/. Unique Identifier: ChiCTR2200067185.

Evaluating the Efficacy of a Pre-Established Lipid-Lowering Algorithm in Managing Hypercholesterolemia in Patients at Very High Cardiovascular Risk

BACKGROUND

Recent data from European studies (EUROASPIRE V, DA VINCI, SANTORINI) indicate that achieving the LDL cholesterol (LDL-C) target in patients at very high cardiovascular risk is uncommon. Additionally, using a combination therapy involving statins and ezetimibe remains infrequent.

METHODS

A single-center assessment of a pre-defined lipid lowering treatment algorithm's effectiveness at achieving the LDL-C target in patients at very high cardiovascular risk one month and one year after hospitalization.

RESULTS

81 patients were included, all in secondary prevention. The average age of the patient was 66.9 years, and the main cardiovascular risk factors included hypertension, diabetes mellitus, and smoking history. Following the predefined lipid-lowering algorithm specific to our study, which involves initiating high-intensity statin therapy or a combination of statin and ezetimibe depending on initial LDL-C levels and patient history; 30 (37%) patients initiated high-intensity statin therapy (Atorvastatin (40 mg, 80 mg) or Rosuvastatin (20 mg, 40 mg)), while 51 (63%) started combination therapy with high-intensity statin and ezetimibe 10 mg. After one year, 57 (70.4%) remained adherent to their initial treatment, achieving a mean LDL-C of 49.5 ± 16.9 mg/dL, with 36 (63.2%) of them reaching the LDL-C target of <55 mg/dL. A total of 13 patients discontinued treatment, and 9 were lost to follow-up, withdrew from the study, or died.

CONCLUSION

Initiating dual statin and ezetimibe therapy or high-intensity statin therapy early, based on the expected treatment efficacy, holds the potential to more rapidly and effectively achieve LDL-C targets in a larger proportion of very high-risk cardiovascular patients.

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Statin treatment for primary and secondary prevention in elderly patients-a cross-sectional study in Stockholm, Sweden

BACKGROUND

Age is a major risk factor for atherosclerotic cardiovascular disease (CVD) and death, but there has been a debate about benefit-risk of statin treatment in the elderly with limited evidence on benefits for primary prevention, while there is strong evidence for its use in secondary prevention.

AIM

The aim of this study was to provide an overview of statin utilization in primary and secondary prevention for patients 75-84 years and ≥ 85 years in the Swedish capital Region Stockholm in 2019.

METHODS

This is a cross-sectional study based on the regional healthcare database VAL containing all diagnoses and dispensed prescription drugs for all 174,950 inhabitants ≥ 75 years old in the Stockholm Region. Prevalence and incidence were analyzed by sex, age, cardiovascular risk, substance, and the intensity of treatment.

RESULTS

A total of 35% of all individuals above the age of 75 in the region were treated with statins in 2019. The overall incidence in this age group was 31 patients per 1000 inhabitants. Men, individuals 75-84 compared to ≥ 85 years of age, and those with higher cardiovascular risk were treated to a greater extent. Simvastatin was used primarily by prevalent users and atorvastatin by incident users. The majority was treated with moderate-intensity dosages and fewer women received high intensity treatment.

CONCLUSIONS

Statins are widely prescribed in the elderly. Physicians seem to consider individual cardiovascular risk when deciding to initiate statin treatment for elderly patients, but here may still be some undertreatment among high-risk patients (especially women and elderly 85 + years) and some overtreatment among patients with low-risk for CVD.

Prognostic significance of baseline low-density lipoprotein cholesterol in patients undergoing coronary revascularization; a report from the CREDO-Kyoto registry

BACKGROUND

The impact of very low baseline levels of low-density lipoprotein cholesterol (LDL-C) on patients with coronary artery disease remains unclear.

METHOD

We enrolled 39,439 patients of the pooled population from the CREDO-Kyoto registries Cohorts 1, 2, and 3. The study population consisted of 33,133 patients who had undergone their first coronary revascularization. We assessed the risk for mortality and cardiovascular events according to quintiles of the baseline LDL-C levels.

RESULTS

Patients in the very low LDL-C quintile (<85 mg/dL) had more comorbidities than those in the other quintiles. Lower LDL-C levels were strongly associated with anemia, thrombocytopenia, and end-stage renal disease. The cumulative 4-year incidence of all-cause death increased as LDL-C levels decreased (very low: 19.4 %, low: 14.5 %, intermediate: 11.1 %, high: 10.0 %, and very high: 9.2 %; p < 0.001), which was driven by both the early and late events. After adjusting for baseline characteristics, the adjusted risks of the very low and low LDL-C quintiles relative to the intermediate LDL-C quintile remained significant for all-cause death (very low: HR 1.29, 95 % CI 1.16-1.44, p < 0.001; low: HR 1.15, 95 % CI 1.03-1.29, p = 0.01). The excess adjusted risks of the lowest LDL-C quintile relative to the intermediate LDL-C quintile were significant for clinical outcomes such as cardiovascular death (HR 1.17, 95 % CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95 % CI 1.15-1.60), sudden death (HR 1.44, 95 % CI 1.01-2.06), and heart failure admission (HR 1.11 95 % CI 1.01-1.22), while there was no excess risk for the lowest LDL-C quintile relative to the intermediate LDL-C quintile for myocardial infarction and stroke.

CONCLUSIONS

Lower baseline LDL-C levels were associated with more comorbidities and a significantly higher risk of death, regardless of cardiovascular or non-cardiovascular causes, in patients who underwent coronary revascularization.

Diagnostic accuracy of Cardiochek® PA point-of-care testing (POCT) analyser with a 3-in-1 lipid panel for epidemiological surveys

BACKGROUND

Point-of-care testing (POCT) is commonly used in epidemiological surveys due to its various advantages, such as portability and immediate test results. The CardioChek® PA analyser 3-in-1 lipid panel measures total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol. This study tested the reliability and diagnostic accuracy of the CardioChek® PA analyser using a 3-in-1 lipid panel.

METHODS

A cross-sectional study design with quota sampling was used. A total of 203 respondents aged 18 years and above from a research centre in the Ministry of Health, Malaysia, were recruited. Venous blood was sent to the laboratory and tested with Siemens Atellica CH, while a POCT analyser was used for capillary blood measurements. Intraclass coefficient correlation (ICC) analysis was employed to determine the agreement between capillary and venous blood parameters. The diagnostic performance of the evaluated tests was evaluated using STATA version 12.

RESULTS

The agreement between capillary and laboratory venous blood was moderate (0.64-0.67) for TC and HDL, good (0.75) for LDL and excellent (0.91) for TG). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were as follows: TC, 57.1%, 94.3%, 92.3% and 64.8%; TG, 76.0%, 100%, 100%, and 96.6%; HDL, 96.2%, 83.2%, 47.2% and 99.3%; and LDL, 81.0%, 100%, 100% and 68.3%, respectively.

CONCLUSIONS

The CardioChek® PA analyser showed acceptable diagnostic accuracy for screening high-risk individuals more often in places where laboratories are inaccessible. It could also be used in clinical settings where patients would benefit from swift treatment decisions.

Sex specific analysis of patients with and without reported statin intolerance referred to a specialized outpatient lipid clinic

BACKGROUND

Lowering LDL-cholesterol is a fundamental goal for both primary and secondary prevention of atherosclerotic cardiovascular diseases. Our study aims to analyse potential sex disparities regarding the tolerability and effectiveness of lipid-lowering therapy in patients with and without reported statin intolerance who are being treated at a lipid-outpatient clinic.

METHODS

From 2017 to 2022, n = 1062 patients (n = 612 men, n = 450 women) at high-risk were referred to our lipid-outpatient clinic because of difficulties in lipid control by primary healthcare providers. The main therapeutic objective was to optimize lipid-lowering therapy according to current treatment guidelines.

RESULTS

Patients presented with high LDL-C baseline levels (4.97 ± 1.81 mmol/l (192 ± 70 mg/dL) in men and 5.46 ± 2.04 mmol/l (211 ± 79 mg/dL) in women). Intolerance towards statins was reported more frequently by women (48.2%) than by men (38.9%, p = 0.004). LDL-C continuously decreased with individual treatment adjustments across follow-up visits. In total, treatment goals (LDL < 1.4 mmol/l (< 55 mg/dl) or < 1.8 mmol/l (< 70 mg/dl)) were accomplished in 75.8% of men and 55.5% of women after the last follow-up visit (p < 0.0001). In men, these data are almost identical in subjects with statin intolerance. In contrast, treatment goals were reached less frequently in women with statin intolerance compared to women tolerant to statin therapy.

CONCLUSION

Even if treated in a specialized lipid clinic, women are less likely to reach their target LDL-C than men, particularly when statin intolerant. Nevertheless, many patients with statin intolerance can be successfully treated using oral combination and PCSK9 inhibitor therapy. However, ongoing follow-up care to monitor progress and to adjust treatment plans is necessary to reach this goal.

Adverse Lipid Profiles Are Associated with Lower Dementia Risk in Older People

OBJECTIVE

Midlife dyslipidemia is associated with higher risk of dementia in late-life dementia, but the impact of late-life dyslipidemia on dementia risk is uncertain. This may be due to the large heterogeneity in cholesterol measures and study designs employed. We used detailed data from a large prospective cohort of older persons to comprehensively assess the relation between a broad range of cholesterol measures and incident dementia, addressing potential biases, confounders, and modifiers.

DESIGN

Post hoc observational analysis based on data from a dementia prevention trial (PreDIVA).

SETTING AND PARTICIPANTS

3392 community-dwelling individuals, without dementia, aged 70-78 years at baseline (recruited between June 2006 and March 2009).

METHODS

Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and apolipoprotein A1 and B were assessed. Over a median of 6.7 years' follow-up, dementia was established by clinical diagnosis confirmed by independent outcome adjudication. Hazard ratios (HRs) for dementia and mortality were calculated using Cox regression.

RESULTS

Dementia occurred in 231 (7%) participants. One-SD increase in LDL/HDL conveyed a 19% (P = .01) lower dementia risk and a 10% (P = .02) lower risk of dementia/mortality combined. This was independent of age, cardiovascular risk factors, cognitive function, apolipoprotein E genotype, and cholesterol-lowering drugs (CLD). This association was not influenced by the competing risk of mortality. Consistent and significant interactions suggested these associations were predominant in individuals with low body mass index (BMI) and higher education.

CONCLUSIONS AND IMPLICATIONS

Dyslipidemia in older individuals was associated with a lower risk of dementia. Low BMI and higher education level mitigate poor outcomes associated with dyslipidemia. These findings suggest that a different approach may be appropriate for interpreting lipid profiles that are conventionally considered adverse in older adults. Such an approach may aid predicting dementia risk and designing intervention studies aimed at reducing dementia risk in older populations.

Chinese expert consensus on blood lipid management in patients with diabetes (2024 edition)

Diabetes is a significant independent risk factor for atherosclerotic cardiovascular disease (ASCVD), with dyslipidemia playing a critical role in the initiation and progression of ASCVD in diabetic patients. In China, the current prevalence of dyslipidemia in diabetes is high, but the control rate remains low. Therefore, to enhance lipid management in patients with diabetes, the Endocrinology and Metabolism Physician Branch of the Chinese Medical Doctor Association, in collaboration with the Experts' Committee of the National Society of Cardiometabolic Medicine, has convened experts to develop a consensus on the management of dyslipidemia in patients with type 1 or type 2 diabetes. The development of this consensus is informed by existing practices in lipid management among Chinese diabetic patients, incorporating contemporary evidence-based findings and guidelines from national and international sources. The consensus encompasses lipid profile characteristics, the current epidemiological status of dyslipidemia, ASCVD risk stratification, and lipid management procedures in diabetic patients. For the first time, both low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol have been recommended as primary targets for lipid intervention in diabetic patients. The consensus also includes a summary and recommendations for lipid management strategies in special diabetic populations, including children and adolescents, individuals aged 75 years and older, patients with chronic kidney disease, metabolic-associated fatty liver disease, and those who are pregnant. This comprehensive consensus aims to improve cardiovascular outcomes in diabetic patients by contributing to the dissemination of key clinical advancements and guiding clinical practice.

Treating Hypercholesterolemia in Older Adults for Primary Prevention of Cardiovascular Events

As the population ages, the demographic of adults aged 75 years and older in the U.S. is projected to grow to 45 million by 2050. Hypercholesterolemia is directly linked to atherosclerotic cardiovascular disease (ASCVD), which remains the leading cause of death in older adults. However, primary prevention of ASCVD through lipid-lowering agents remains unclear among older adults owing to limited involvement of older adults in current trials, lack of dedicated trials, and evidence primarily derived from secondary and retrospective analyses. Therefore, this article aims to (1) review key updates from the latest guidelines on treatment of hypercholesterolemia in older adults, (2) highlight limitations of the current ASCVD risk scores in the geriatric population, (3) present outcomes from key studies on the use of lipid-lowering agents and associated side effects, including a brief review of novel agents such as bempedoic acid, although very few adults over age 75 were included in these trial, and (4) finally, highlight upcoming dedicated trials of statins in older adults for the primary prevention of important geriatric outcomes as well as ASCVD.

Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence?

PURPOSE OF REVIEW

Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies.

RECENT FINDINGS

The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.

Ezetimibe use and mortality after myocardial infarction: A nationwide cohort study

Background

The inhibition of intestinal cholesterol absorption by ezetimibe improves outcomes after myocardial infarction (MI), yet real-world data on ezetimibe is scarce. We studied the usage of ezetimibe and association with outcome after MI.

Methods

Consecutive MI patients in Finland (2010-2018) were retrospectively studied (N = 57,505; 65 % men; mean age 69 years). The study data were collected from national registries. The median follow-up was 4.5 (IQR 2.8-7.1) years. Between-group differences were adjusted for using multivariable regression. Ezetimibe use was studied with competing risk analyses.

Results

The cumulative incidence of ezetimibe use was 3.7 % at 90 days, 13.4 % at 5 years, and 19.8 % at 10 years. Younger age was one of the strongest predictors of ezetimibe use (adj.sHR 6.67; CI 5.88-7.69 for patients aged <60 vs ≥80 years). Women were more likely to use ezetimibe during follow-up than men. The average proportion of patients using ezetimibe during follow-up was 6.8 %. (11.7 % at 10 years). Ezetimibe was discontinued by 43.6 % of patients during follow-up. Patients with early ezetimibe therapy after MI had lower all-cause mortality during follow-up (33.6% vs 45.1 %; adj.HR 0.77; CI 0.69-0.86; P < 0.0001). Early ezetimibe use was associated with lower mortality irrespective of sex, age, atrial fibrillation, diabetes, heart failure, malignancy, revascularization, or statin use. Ongoing ezetimibe therapy during follow-up was associated with lower mortality in a time-dependent analysis (adj.HR 0.53; CI 0.48-0.59; P < 0.0001).

Conclusions

Ezetimibe is associated with a lower risk of death after MI, yet its therapeutic use is limited, and discontinuation is frequent.

Cholesterol-ferroptosis nexus: Unveiling novel cancer therapeutic avenues

Ferroptosis, a novel form of regulated cell death characterized by iron-mediated lipid peroxidation, holds immense potential in cancer therapeutics due to its role in tumor progression and resistance. This review predominantly explores the intricate relationship between ferroptosis and cholesterol metabolism pathways, mainly focusing on the cholesterol biosynthesis pathway. This review highlights the therapeutic implications of targeting cholesterol metabolism pathways for cancer treatment by delving into the mechanisms underlying ferroptosis regulation. Strategies such as inhibiting HMG-CoA reductase and suppressing squalene synthesis offer promising avenues for inducing ferroptosis in cancer cells. Moreover, insights into targeting the 7-dehydrocholesterol pathway provide novel perspectives on modulating ferroptosis susceptibility and managing ferroptosis-associated diseases. Understanding the interplay between ferroptosis and cholesterol metabolism pathways underscores the potential of lipid metabolism modulation as an innovative therapeutic approach in cancer treatment.

Genome-wide association study of therapeutic response to statin drugs in cardiovascular disease

Cardiovascular disease (CVD) is one of the main causes of death in the world. The increased level of blood cholesterol is significantly correlated to CVD incidents. Statins are a group of drugs that decrease the synthesis of cholesterol in the liver by inhibiting the final enzyme of the pathway named HMG-CoA reductase. Several investigations showed that different patients give different responses to the administration of statin drugs according to their genetic background. In this research study, using Genome-Wide Association Studies (GWAS) data analysis methods, such as the SimpleM statistical approach and genomic connection matrix, we tried to discover the novel candidate SNPs that were involved in response to statin drugs. The investigation was carried out using 3,221 cardiovascular patients' data about genotypes and phenotypes of two important parameters including total cholesterol, and LDL level, in response to statin administration. Functional annotation of nearest genes to candidate SNPs was also carried out by using comprehensive databases and tools such as BioMart-Ensembl, UCSC, NCBI, and WebGestalt software. Our results represented eight novel SNPs (rs10820084, rs4803750, rs10989887, rs1966503, rs17502794, rs10785232, rs484071, rs4785621) significantly associated with statin response in different individual cardiovascular patients for the first time. In addition, the groups of genes that are close to the SNPs were also represented and evaluated in detail. Our results illustrated that some of the genes such as BAAT, BCL3, and CMTM6 have a direct functional impact on cholesterol level or LDL biosynthesis which confirmed the effects of neighbor SNPs on the response to statin drugs. Today, finding the loci, genes, and molecular mechanisms involved in the response to drugs is of great importance in pharmacogenomics and personalized medicine.

Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations

Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.

Coronary risk factor profiles according to different age categories in premature coronary artery disease patients who have undergone percutaneous coronary intervention

Many studies have investigated the coronary risk factors (CRFs) among premature coronary artery disease (PCAD) patients. However, reports on the proportion and CRFs of PCAD according to different age cut-offs for PCAD is globally under-reported. This study aimed to determine the proportion of PCAD patients and analyse the significant CRFs according to different age cut-offs among percutaneous coronary intervention (PCI)-treated patients. Patients who underwent PCI between 2007 and 2018 in two cardiology centres were included (n = 29,241) and were grouped into four age cut-off groups that defines PCAD: (A) Males/females: < 45, (B) Males: < 50; Females: < 55, (C) Males: < 55; Females: < 60 and (D) Males: < 55; Females: < 65 years old. The average proportion of PCAD was 28%; 9.2% for group (A), 21.5% for group (B), 38.6% and 41.9% for group (C) and (D), respectively. The top three CRFs of PCAD were LDL-c level, TC level and hypertension (HTN). Malay ethnicity, smoking, obesity, family history of PCAD, TC level and history of MI were the independent predictors of PCAD across all age groups. The proportion of PCAD in Malaysia is higher compared to other studies. The most significant risk factors of PCAD are LDL-c, TC levels and HTN. Early prevention, detection and management of the modifiable risk factors are highly warranted to prevent PCAD.

Achievement of LDL-Cholesterol Goals in Patients Receiving LLT in Primary Care: TERESA-AP Study: LDL-Cholesterol Goals in Primary Care

Background and Aim: Since 2019, LDL-cholesterol (LDL-C) is the risk factor with the strictest goals and the most difficult to reach, due to its role in the development of atherosclerotic plaque and, therefore, cardiovascular risk. The objective of the TERESA-AP study is to analyze the degree of LDL-C control in patients followed up in primary care with lipid-lowering drug treatment (LLT). Methods: Observational, multicenter, cross-sectional, nationwide study was conducted, in which 50 PC physicians recruited 929 patients who were receiving LLT during at least the preceding 6 months. The variables required to estimate the patients' cardiovascular risk and LDL control were recorded. Results: Nearly half of sample was women (50.5%), and the mean age was 67.8 (10.4) years. High blood pressure (65.3%) and sedentary lifestyle (59.7%) were the most frequent risk factors. Recommended goals were reached in 26.0% (95% CI: 23.3%-29.0%) of patients, with a slightly higher percentage in patients with cardiovascular disease (CVD) (26.7%), diabetes mellitus (DM) (35.5%), and a lower one in patients with chronic kidney disease (CKD) (12.1%). The most frequent drug treatments were statin monotherapy (69.0%) and statin with ezetimibe combination (27.6%), with moderate-intensity statins being the most commonly used in both groups. Conclusions: On average, only a quarter of the patients followed up in PC and who receive drug treatment reach their therapeutic targets. This percentage is slightly higher if the patients have CVD and DM and lower if they have CKD. The most commonly used therapeutic strategy is moderate-intensity statins, both in monotherapy and in combination with ezetimibe.

Benefits and Risks of Antihyperlipidemic Medication in Adults with Different Low-Density Lipoprotein Cholesterol Based on the Number Needed to Treat

PURPOSE

The objective of this investigation is to examine the benefits and potential risks of these drugs in individuals by varying baseline low-density lipoprotein cholesterol (LDL-C) values, utilizing the concept of the number needed to treat (NNT).

METHODS

We extensively searched electronic databases, such as PubMed, EMBASE, Cochrane, and Web of Science, up to 6 August 2023. Baseline LDL-C values were stratified into four categories: < 100, 100-129, 130-159, and ≥ 160 mg/dL. Risk ratios (RRs) and NNT values were computed.

RESULTS

This analysis incorporated data from 46 randomized controlled trials (RCTs), encompassing a total of 237,870 participants. The meta-regression analysis demonstrated an incremental diminishing risk of major adverse cardiovascular events (MACE) with increasing baseline LDL-C values. Statins exhibited a significant reduction in MACE [number needed to treat to benefit (NNTB) 31, 95% confidence interval (CI) 25-37], but this effect was observed only in individuals with baseline LDL-C values of 100 mg/dL or higher. Ezetimibe and PCSK9 inhibitors also were effective in reducing MACE (NNTB 18, 95% CI 11-41, and NNTB 18, 95% CI 16-24). Notably, the safety outcomes of statins and ezetimibe did not reach statistical significance, while the incidence of injection-site reactions with PCSK9 inhibitors was statistically significant [number needed to treat to harm (NNTH) 41, 95% CI 80-26].

CONCLUSION

Statins, ezetimibe, and PCSK9 inhibitors demonstrated a substantial capacity to reduce MACE, particularly among individuals whose baseline LDL-C values were relatively higher. The NNT visually demonstrates the gradient between baseline LDL-C and cardiovascular disease (CVD) risk.

SYSTEMATIC REVIEW REGISTRATION

Registration: PROSPERO identifier number: CRD42023458630.

Low-Density Lipoprotein Cholesterol, Cardiovascular Disease Risk, and Mortality in China

Importance

Limited evidence supports the association between low-density lipoprotein cholesterol (LDL-C) and mortality across different atherosclerotic cardiovascular disease (ASCVD) risk stratifications.

Objective

To explore the associations between LDL-C levels and mortality and to identify the optimal ranges of LDL-C with the lowest risk of mortality in populations with diverse ASCVD risk profiles.

Design, Setting, and Participants

The ChinaHEART project is a prospective cohort study that recruited residents aged 35 to 75 years from 31 provinces in mainland China between November 2014 and December 2022. Participants were categorized into low-risk, primary prevention, and secondary prevention cohorts on the basis of their medical history and ASCVD risk. Data analysis was performed from December 2022 to October 2023.

Main Outcomes and Measures

The primary end point was all-cause mortality, and secondary end points included cause-specific mortality. Mortality data were collected from the National Mortality Surveillance System and Vital Registration. The association between LDL-C levels and mortality was assessed by using Cox proportional hazard regression models with various adjusted variables.

Results

A total of 4 379 252 individuals were recruited, and 3 789 025 (2 271 699 women [60.0%]; mean [SD] age, 56.1 [10.0] years) were included in the current study. The median (IQR) LDL-C concentration was 93.1 (70.9-117.3) mg/dL overall at baseline. During a median (IQR) follow-up of 4.6 (3.1-5.8) years, 92 888 deaths were recorded, including 38 627 cardiovascular deaths. The association between LDL-C concentration and all-cause or cardiovascular disease (CVD) mortality was U-shaped in both the low-risk cohort (2 838 354 participants) and the primary prevention cohort (829 567 participants), whereas it was J-shaped in the secondary prevention cohort (121 104 participants). The LDL-C levels corresponding to the lowest CVD mortality were 117.8 mg/dL in the low-risk group, 106.0 mg/dL in the primary prevention cohort, and 55.8 mg/dL in the secondary prevention cohort. The LDL-C concentration associated with the lowest all-cause mortality (90.9 mg/dL vs 117.0 mg/dL) and CVD mortality (87 mg/dL vs 114.6 mg/dL) were both lower in individuals with diabetes than in individuals without diabetes in the overall cohort.

Conclusions and Relevance

This study found that the association between LDL-C and mortality varied among different ASCVD risk cohorts, suggesting that stricter lipid control targets may be needed for individuals with higher ASCVD risk and those with diabetes.

Interventions for primary prevention of cardiovascular disease: umbrella review of systematic reviews

Background

Cardiovascular diseases are the leading cause of death globally. The aim of this overview of systematic reviews was to compare the effectiveness of different pharmacological and non-pharmacological interventions for the primary prevention of cardiovascular disease.

Methods

A structured search of the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and the Database of Abstracts of Reviews of Effects archive was conducted to find systematic reviews that reported the effect of various pharmacological and non-pharmacological interventions for the primary prevention of cardiovascular disease from inception to March 2021. References of included studies were also checked. The included systematic reviews' methodological quality was assessed using the Assessment of Multiple Systematic Reviews 2 instrument (range, 0-16). The outcomes of each included review's meta-analysis were extracted and described narratively.

Results

This study analysed 95 systematic reviews, including 41 on non-pharmacological interventions and 54 on pharmacological interventions for cardiovascular health. The majority of the reviews focused on lipid-lowering interventions (n = 25) and antiplatelet medications (n = 21), followed by nutritional supplements, dietary interventions, physical activity, health promotion and other interventions. Only 1 of the 10 reviews addressing cardiovascular mortality showed a potential benefit, while the others found no effect. Antiplatelets were found to have a beneficial effect on all-cause mortality in 2 out of 12 meta-analyses and on major cardiovascular disease events in 8 out of 17 reviews. Lipid-lowering interventions showed beneficial effects on cardiovascular disease mortality, all-cause mortality and major cardiovascular disease events in varying numbers of the reviews. Glucose-lowering medications demonstrated significant benefits for major cardiovascular events, coronary heart disease events and mortality. However, the combination of dietary interventions, physical activities, nutritional supplements and polypills showed little or no significant benefit for major cardiovascular outcomes or mortality.

Future work and limitations

More research is needed to determine whether the effect of treatment varies depending on population characteristics. The findings of this review should be interpreted with caution because the majority of studies of non-pharmacological interventions compare primary prevention with usual care, which may include recommended pharmacological treatment in higher-risk patients (e.g. statins and/or antihypertensive medications, etc.). In addition, randomised controlled trial evidence may be better suited to the study of pharmacological interventions than dietary and lifestyle interventions.

Conclusions

This umbrella review captured the variability in different interventions on randomised controlled trial evidence on interventions for primary prevention of cardiovascular disease and identified areas that may benefit from further research. Specifically, this review focused on randomised controlled trial evidence on interventions for primary prevention of cardiovascular disease. Researchers may use these findings as a resource to direct new intervention studies and network meta-analyses to compare the efficacy of various interventions based on these findings.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme as award number 17/148/05.

Implementation of risk-based lipid-lowering therapies in older (age ≥ 65 years) and very-old adults (age ≥ 75 years) with ischemic heart disease in the greater Salzburg region

Introduction: European guidelines recommend the implementation of lipid-lowering therapies (LLTs) in adults (≥ 65 years) with established atherosclerotic cardiovascular disease (ASCVD) and for risk-based primary prevention in older adults (≤ 75 years), yet their use in very-old adults (> 75 years) is controversial, discretionary, and oriented on the presence of risk factors. The aim of this retrospective study is to assess guideline-directed LLT implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in high-/very-high-risk older/very-old adults (65-74 and ≥ 75 years) at presentation for ST-segment elevation myocardial infarction (STEMI) and also to assess evidence-based care delivery to older adults in our region. Methods: All STEMI patients with available LDL-C and total cholesterol presenting for treatment at a large tertiary center in Salzburg, Austria, 2018-2020, were screened (n = 910). High-risk/very-high-risk patients (n = 369) were classified according to European guidelines criteria and divided into cohorts by age: < 65 years (n = 152), 65-74 years (n = 104), and ≥ 75 years (n = 113). Results: Despite being at high-/very-high-risk, prior LLT use was < 40% in the total cohort, with no significant difference by age. Statin monotherapy predominated; 20%-23% of older/very-old adults in the entire cohort were using low-/moderate-intensity stains, 11%-13% were using high-intensity statins, 4% were on ezetimibe therapy, and none were taking proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In the secondary prevention cohort, 53% of older/very-old patients used prior LLTs. Significantly higher percentages of older/oldest ASCVD patients (43% and 49%) met LDL-C targets < 70 mg/dL compared to patients < 65 years (29%; p = 0.033), although just 22% and 30% of these older groups attained stricter LDL-C targets of < 55 mg/dL. Low LLT uptake (16%) among older adults aged 64-74 years for primary prevention resulted in 17% and 10% attainment of risk-based LDL-C targets < 70 mg/dL and < 55 mg/dL, respectively. Oldest adults (≥ 75 years) in both primary and secondary prevention groups more often met risk-based targets than older and younger adults, despite predominantly receiving low-/moderate-intensity statin monotherapy. Conclusion: Secondary prevention was sub-optimal in our region. Less than half of older/very-old adults with established ASCVD met LDL-C targets at the time of STEMI, suggesting severe care-delivery deficits in LLT implementation. Shortcomings in initiation of risk-based LLTs were also observed among high-/very-high-risk primary prevention patients < 75 years, with the achievement of risk-based LDL-C targets in 10%-48% of these patients.

Statin utilization and cardiovascular outcomes in a real-world primary prevention cohort of older adults

Background

Statins are a cost-effective therapy for prevention of atherosclerotic cardiovascular disease (ASCVD). Guidelines on statins for primary prevention are unclear for older adults (>75 years).

Objective

Investigate statin utility in older adults without ASCVD events, by risk stratifying in a large healthcare network.

Methods

We included 8,114 older adults, without CAD, PVD or ischemic stroke. Statin utilization based on ACC/AHA 10-year ASCVD risk calculation, was evaluated in intermediate (7.5%-19.9%) and high-risk patients (≥ 20%); and categorized using low and 'moderate or high' intensity statins with a follow up period of ∼7 years. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. Data was adjusted for competing risk using Elixhauser Comorbidity Index.

Results

Compared with those on moderate or high intensity statins, high-risk older patients not on any statin had a significantly increased risk of MI [HR 1.51 (1.17-1.95); p<0.01], stroke [HR 1.47 (1.14-1.90); p<0.01] and all-cause mortality [HR 1.37 (1.19-1.58); p<0.001] in models adjusted for Elixhauser Comorbidity Index. When comparing the no statin group versus the moderate or high intensity statin group in the intermediate risk cohort, although a trend for increased risk was seen, it did not meet statistical significance thresholds for MI, stroke or all-cause mortality.

Conclusion

Lack of statin use was associated with increased cardiovascular events and mortality in high-risk older adults. Given the benefits appreciated, statin use may need to be strongly considered for primary ASCVD prevention among high-risk older adults. Future studies will assess the risk-benefit ratio of statin intervention in older adults.

Evolving Concepts of the SCORE System: Subtracting Cholesterol from Risk Estimation: A Way for a Healthy Longevity?

The role of cholesterol, mainly low-density lipoproteins (LDL-C), as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) is now established and accepted by the international scientific community. Based on this evidence, the European and American guidelines recommend early risk stratification and "rapid" achievement of the suggested target according to the risk estimation to reduce the number of major cardiovascular events. Prolonged exposure over the years to high levels of LDL-C is one of the determining factors in the development and progression of atherosclerotic plaque, on which the action of conventional risk factors (cigarette smoking, excess weight, sedentary lifestyle, arterial hypertension, diabetes mellitus) as well as non-conventional risk factors (gut microbiota, hyperuricemia, inflammation), alone or in combination, favors the destabilization of the atherosclerotic lesion with rupture/fissuration/ulceration and consequent formation of intravascular thrombosis, which leads to the acute clinical manifestations of acute coronary syndromes. In the current clinical practice, there is a growing number of cases that, although extremely common, are emblematic of the concept of long-term exposure to the risk factor (LDL hypercholesterolemia), which, not adequately controlled and in combination with other risk factors, has favored the onset of major cardiovascular events. The triple concept of "go lower, start earlier and keep longer!" should be applied in current clinical practice at any level of prevention. In the present manuscript, we will review the current evidence and documents supporting the causal role of LDL-C in determining ASCVD and whether it is time to remove it from any score.

The effect of lipid-lowering therapy on lipid-related residual risk factors: a prospective study

BACKGROUND

Remnant cholesterol (RC) and nonhigh-density lipoprotein cholesterol (nonHDL-C) are key risk factors for atherosclerotic cardiovascular disease (ASCVD), with apolipoprotein B (apoB) and lipoprotein(a) [Lp(a)] also contributing to its residual risk. However, real-world population-based evidence regarding the impact of current clinical LDL-C-centric lipid-lowering therapy (LLT) on achieving RC and nonHDL-C goals, as well as on modifying residual CVD risk factors is limited.

METHODS

This prospective observational study enrolled 897 CVD patients from September, 2020 to July, 2021. All participants had previously received low-/moderate-intensity LLT and were discharged with either low-/moderate-intensity LLT or high-intensity LLT. After a median follow-up of 3 months, changes in RC, nonHDL-C, and other biomarkers were assessed. Multivariate logistic regression was performed to analyze the impact of the LLT on goal attainment.

RESULTS

Among all patients, 83.50% transitioned to high-intensity LLT from low or moderate. After follow-up, the high-intensity group saw significantly greater reductions in RC (-20.51% vs. -3.90%, P = 0.025), nonHDL-C (-25.12% vs. 0.00%, P < 0.001), apoB (-19.35% vs. -3.17%, P < 0.001), triglycerides (-17.82% vs. -6.62%, P < 0.001), and LDL-C and total cholesterol. Spearman correlation analysis revealed that LDL-C reduction from current LLT was strongly correlated with nonHDL-C reduction (r = 0.87, P < 0.001). Patients who received high-intensity LLT had significant improvements in attainment of RC (from 44.2% to 60.7%, χ² = 39.23, P < 0.001) and nonHDL-C (from 19.4% to 56.9%, χ² = 226.06, P < 0.001) goals. Furthermore, multivariate logistic regression showed that high-intensity LLT was a protective factor for RC [odds ratio (OR) = 0.66; 95% confidence intervals (CI), 0.45-0.97; P = 0.033] and nonHDL-C goal attainment (OR = 0.51; 95% CI, 0.34-0.75; P < 0.001), without a significant increase of adverse reactions.

CONCLUSION

Current levels of clinically prescribed LDL-C-centric treatment can reduce RC and other lipid-related residual risk factors, but high-intensity LLT is better at achieving nonHDL-C and RC goals than low-/moderate-intensity LLT, with a good safety profile. More targeted RC treatments are still needed to reduce residual lipid risk further.

Evaluating different low-density lipoprotein cholesterol thresholds to initiate statin for prevention of cardiovascular diseases in patients with type 2 diabetes mellitus: A target trial emulation study

AIM

The present study aimed to evaluate the effect of statin therapy for primary prevention of cardiovascular diseases (CVDs) when initiating therapy at different baseline low-density lipoprotein cholesterol (LDL-C) levels in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Using territory-wide public electronic medical records in Hong Kong, we emulated a sequence of trials on patients with T2DM with elevated LDL-C levels in every calendar month from January 2008 to December 2014. Pooled logistic regression was applied to obtain the hazard ratios for the major CVDs (stroke, myocardial infarction, heart failure), all-cause mortality and major adverse events (myopathies and liver dysfunction) of statin therapy.

RESULTS

The estimated hazard ratios (95% confidence intervals) of CVD incidence for statin initiation were 0.78 (0.72, 0.84) in patients with baseline LDL-C of 1.8-2.5 mmol/L (i.e., 70-99 mg/dL) and 0.90 (0.88, 0.92) in patients with baseline LDL-C ≥2.6 mmol/L (i.e., ≥100 mg/dL) in intention-to-treat analysis, which was 0.59 (0.51, 0.68) and 0.77 (0.74, 0.81) in per-protocol analysis, respectively. No significant increased risks were observed for the major adverse events. The absolute 10-year risk difference of overall CVD in per-protocol analysis was -7.1% (-10.7%, -3.6%) and -3.9% (-5.1%, -2.7%) in patients with baseline LDL-C 1.8-2.5 and ≥2.6 mmol/L, respectively. The effectiveness and safety were consistently observed in patients aged >75 years initiating statin at both LDL-C thresholds.

CONCLUSIONS

Compared with the threshold of 2.6 mmol/L, initiating statin in patients with a lower baseline LDL-C level at 1.8-2.5 mmol/L can further reduce the risks of CVD and all-cause mortality without significantly increasing the risk of major adverse events in patients with T2DM, including patients aged >75 years.

Chronic Coronary Disease in Older Adults

The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.

Management of lipid variables in primary cardiovascular prevention: A position paper from the Heart, Vessels and Metabolism Group of the French Society of Cardiology

Low-density lipoprotein cholesterol has been established as a powerful cardiovascular risk factor; its reduction provides a clinical benefit in primary cardiovascular prevention, irrespective of the characteristics of the patients treated. It is useful to tailor low-density lipoprotein cholesterol targets according to the magnitude of cardiovascular risk (low, high or very high) in order to reduce the cardiovascular risk as fully as possible. In order to provide a uniform approach, it is necessary to propose recommendations for good practice, defining strategies for reducing low-density lipoprotein cholesterol. It is also necessary to know their merits, to analyse their practical limits and to propose adaptations, taking into account limitations and national specifics. This position paper aims to analyse the contribution and limits, as well as the adaptation to French practice, of 2019 and 2021 European Society of Cardiology recommendations for the management of lipid variables and cardiovascular prevention.

Association of Use and Dose of Lipid-Lowering Therapy Post Acute Myocardial Infarction With 5-Year Survival in Older Adults

BACKGROUND

Older people are underrepresented in randomized trials. The association between lipid-lowering therapy (LLT) and its intensity after acute myocardial infarction and long-term mortality in this population deserves to be assessed.

METHODS

The FAST-MI (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) program consists of nationwide French surveys including all patients admitted for acute myocardial infarction ≤48 hours from onset over a 1- to 2-month period in 2005, 2010, and 2015, with long-term follow-up. Numerous data were collected and a centralized 10-year follow-up was organized. The present analysis focused on the association between prescription of LLT (atorvastatin ≥40 mg or equivalent, or any combination of statin and ezetimibe) and 5-year mortality in patients aged ≥80 years discharged alive. Cox multivariable analysis and propensity score matching were used to adjust for baseline differences.

RESULTS

Among the 2258 patients aged ≥80 years (mean age, 85±4 years; 51% women; 39% ST-segment elevation myocardial infarction; 58% with percutaneous coronary intervention), 415 were discharged without LLT (18%), 866 with conventional doses (38%), and 977 with high-dose LLT (43%). Five-year survival was 36%, 47.5%, and 58%, respectively. Compared with patients without LLT, high-dose LLT was significantly associated with lower 5-year mortality (adjusted hazard ratio, 0.78 [95% CI, 0.66-0.92]), whereas conventional-intensity LLT was not (adjusted hazard ratio, 0.93 [95% CI, 0.80-1.09]). In propensity score-matched cohorts (n=278 receiving high-intensity LLT and n=278 receiving no statins), 5-year survival was 52% with high-intensity LLT at discharge and 42% without statins (hazard ratio, 0.78 [95% CI, 0.62-0.98]).

CONCLUSIONS

In these observational cohorts, high-intensity LLT at discharge after acute myocardial infarction was associated with reduced all-cause mortality at 5 years in an older adult population. These results suggest that high-intensity LLT should not be denied to patients on the basis of old age.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.

Association between atorvastatin and erectile dysfunction: a comprehensive analysis incorporating real-world pharmacovigilance and Mendelian randomization

Background

Atorvastatin is a commonly prescribed medication for the prevention of cardiovascular diseases. Recent observational studies have suggested a potential association between atorvastatin use and the occurrence of Erectile Dysfunction (ED). In this study, we aimed to explore the relationship between atorvastatin and ED using real-world data from the FAERS database and employed Mendelian randomization to assess causality.

Methods

To evaluate the disproportionality of atorvastatin in relation to ED, we conducted several pharmacovigilance analyses, including odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence propagation neural network (BCPNN), and gamma-Poisson contractile apparatus (GPS). Additionally, we employed Mendelian randomization to investigate the causal relationship between atorvastatin and ED.

Results

Pharmacovigilance disproportionality analysis revealed a significant association between atorvastatin and ED, as indicated by the following results: ROR [3.707078559, 95% CI (3.33250349, 4.123756054)], PRR [3.702969038, χ2 (669.2853829)], IC [1.870490139, IC025 (1.702813857)], and EBGM [3.656567867, EBGM05 (3.28709656)]. Furthermore, the two-sample Mendelian randomization analysis provided evidence supporting a causal relationship between atorvastatin use and ED, with an inverse variance weighted estimate of β = 3.17 (OR = 23.91, p = 0.02 < 0.05).

Conclusion

Based on comprehensive analyses incorporating pharmacovigilance and Mendelian randomization, our findings suggest that atorvastatin use is associated with an increased risk of ED and indicate a causal relationship. These results emphasize the importance of considering potential adverse effects, such as ED, when prescribing atorvastatin for cardiovascular disease prevention. Further research and clinical monitoring are warranted to better understand the underlying mechanisms and develop appropriate strategies to mitigate this side effect.

Lipotoxicity as a therapeutic target in obesity and diabetic cardiomyopathy

Unhealthy sources of fats, ultra-processed foods with added sugars, and a sedentary lifestyle make humans more susceptible to developing overweight and obesity. While lipids constitute an integral component of the organism, excessive and abnormal lipid accumulation that exceeds the storage capacity of lipid droplets disrupts the intracellular composition of fatty acids and results in the release of deleterious lipid species, thereby giving rise to a pathological state termed lipotoxicity. This condition induces endoplasmic reticulum stress, mitochondrial dysfunction, inflammatory responses, and cell death. Recent advances in omics technologies and analytical methodologies and clinical research have provided novel insights into the mechanisms of lipotoxicity, including gut dysbiosis, epigenetic and epitranscriptomic modifications, dysfunction of lipid droplets, post-translational modifications, and altered membrane lipid composition. In this review, we discuss the recent knowledge on the mechanisms underlying the development of lipotoxicity and lipotoxic cardiometabolic disease in obesity, with a particular focus on lipotoxic and diabetic cardiomyopathy.

The anti-hyperlipidemia effect of Atractylodes macrocephala Rhizome increased HDL via reverse cholesterol transfer

Aim

Atractylodes macrocephala Rhizome (AM) has been used to treat hyperlipidemia for centuries, but its functional components and mechanisms are not clear. This research aimed to investigate the active components in AM and the mechanisms that underlie its anti-hyperlipidemia effect.

Methods

SD rats were fed a high-sucrose high-fat diet in conjunction with alcohol (HSHFDAC) along with different AM extracts (AMW, AMO, AME, and AMP) for 4 weeks. AM's active components were analyzed using multiple databases, and their mechanisms were explored through network pharmacology. The relationship between AM's effect of enhancing serum HDL-c and regulating the expression of reverse cholesterol transport (RCT)-related proteins (Apo-A1, LCAT, and SR-BI) was further validated in the HSHFDAC-induced hyperlipidemic rats. The kidney and liver functions of the rats were measured to evaluate the safety of AM.

Results

AMO, mainly comprised of volatile and liposoluble components, contributed the most significant anti-hyperlipidemia effect among the four extracts obtained from AM, significantly improving the blood lipid profile. Network pharmacology analysis also suggested that volatile and liposoluble components, comprise AM's main active components and they might act on signaling pathways associated with elevated HDL-c. Validation experiments found that AMO substantially and dose-dependently increased HDL-c levels, upregulated the expression of Apo-A1, SR-BI, and LCAT, improved the pathological changes in the kidney and liver, and significantly reduced the serum creatinine levels in rats with hyperlipidemia.

Conclusion

The main anti-hyperlipidemia active components of AM are its volatile and liposoluble components, which may enhance serum HDL-c by increasing the expression of the RCT-related proteins Apo-A1, LCAT, and SR-BI.

The Effects of Pharmacological Urate-Lowering Therapy on Cardiovascular Disease in Older Adults with Gout

Cardiovascular disease is an important cause of mortality in older patients. In addition to the traditional risk factors for cardiovascular disease, hyperuricemia has been increasingly associated with an elevated risk of cardiovascular disease. Uric acid itself has several unfavorable effects on the cardiovascular system, and hyperuricemia can lead to the development of gout. Gout is the most prevalent inflammatory rheumatic disease. Older patients with gout have an increased risk of cardiovascular morbidity and mortality due to an increased prevalence of traditional risk factors, as well as the inflammatory burden of gout activity. As the prevalence of traditional risk factors and the prevalence of both hyperuricemia and gout are increasing in older adults, cardiovascular risk management in these patients is very important. This risk management consists of, on the one hand, treatment of individual traditional risk factors and, on the other hand, of urate lowering, thereby decreasing inflammatory burden of gout. However, there is insufficient evidence to conclude that urate-lowering therapy reduces the risk of cardiovascular events. Moreover, from a cardiovascular point of view, there is no preference for one urate lowering drug over another in patients with gout, nor is there enough evidence to support a preference in patients with gout with increased cardiovascular risk. Personalized treatment in older patients with gout should be aimed at optimizing serum uric acid levels, as well as targeting traditional cardiovascular risk factors. Further prospective randomized trials are needed to support the hypothesis that urate lowering reduces cardiovascular risk in older patients with gout.

Treatment of Ezetimibe lowers total and low-density lipoprotein cholesterol in hypercholesterolemic dogs with hyperadorenocorticism

Ezetimibe is a cholesterol absorption inhibitor that blocks the intestinal absorption of both biliary and dietary cholesterol, thereby lowering primarily low density lipoprotein-cholesterol (LDL-chol) in human studies. This study aimed to investigate the effects of ezetimibe on dyslipidemia control in nine dogs with hypercholesterolemia. Changes in total cholesterol (T-chol) and each lipoprotein fractions were evaluated at 0, 2, and 4 months following initiation of ezetimibe treatment. A significant decrease in T-chol was observed, and a mean T-chol concentration below 400 mg/dL was achieved at 2 and 4 months. Furthermore, a significant decrease in LDL-chol was observed (-53.3% and -64.3% at 2 and 4 months, respectively). Taken together, treatment of ezetimibe could lower LDL-chol levels in dogs with hypercholesterolemia.

Updates on Non-Statin LDL-Lowering Therapy

PURPOSE OF REVIEW

There is ample evidence of the benefits and safety of low-density lipoprotein (LDL)-lowering therapies in the prevention of atherosclerotic cardiovascular disease. While statins remain the first-line agent for LDL reduction, several new therapies are now available. This narrative review provides an overview of currently available non-statin LDL-lowering agents, specifically mechanisms of action and data on efficacy and safety. It also discusses recommendations on their use in clinical practice.

RECENT FINDINGS

Ezetimibe, PCSK9 inhibitors, and bempedoic acid have proven safe and efficacious in reducing cardiovascular events in large randomized controlled trials. Inclisiran is a promising agent that suppresses PCSK9 mRNA translation and is currently under investigation in a large clinical outcomes randomized controlled trial assessing its effect on clinical outcomes. Expert consensus advocates for lower LDL targets in higher risk patients and escalation to or a combination of non-statin therapies as needed to achieve these goals.

Atteinte des cibles thérapeutiques recommandées en prévention secondaire après infarctus du myocarde dans un centre tertiaire nord-africain

INTRODUCTION

Despite the demonstrated efficacy of cardiovascular (CV) preventive measures, data from international literature indicate that control of CV risk factors (RF) remains insufficient in very high-risk patients.

AIM

This study aimed to assess prevalence of achievement of recommended therapeutic targets for the major and modifiable CVRF 12 months after myocardial infarction (MI).

METHODS

From 1st January to 30th April 2023, we collected consecutive patients with type 1 MI who had completed 12 months follow-up. Primary endpoint was prevalence of achievement of all recommended therapeutic targets of low-density lipoprotein cholesterol (LDL-C), diabetes mellitus (DM), arterial hypertension (HTN), and smoking. Targets and treatment goals were defined according to the 2021 European Society of Cardiology guidelines on CV disease prevention.

RESULTS

107 patients, mean age 58.8 ± 8.8 years, 74.8% male, were included. 42 (39.3%) patients had HTN, 50 (46.7%) were diabetics, 77 (72.0%) were smokers and eight (7.5%) had hypercholesterolemia. At 12 months, primary endpoint was achieved in 20 (18.7%) patients. 55 (71.4%) of 77 smoker patients were weaned. Blood pressure was at target in 26 (61.9%) among hypertensive patients. In DM patients, HbA1c target was achieved in 23 (46.0%) of them. 32 patients (29.9%) achieved the goal of LDL-C < 0.55 g/L.

CONCLUSIONS

Secondary prevention of CV disease was suboptimal. Less than a fifth of patients achieved treatment target for most major and modifiable risk factors. Improvement in follow-up care and treatment after MI is needed.

The associations between peripheral inflammatory and lipid parameters, white matter hyperintensity, and cognitive function in patients with non-disabling ischemic cerebrovascular events

BACKGROUND

The global prevalence of VCI has increased steadily in recent years, but diagnostic biomarkers for VCI in patients with non-disabling ischemic cerebrovascular incidents (NICE) remain indefinite. The primary objective of this research was to investigate the relationship between peripheral serological markers, white matter damage, and cognitive function in individuals with NICE.

METHODS

We collected clinical data, demographic information, and medical history from 257 patients with NICE. Using the MoCA upon admission, patients were categorized into either normal cognitive function (NCF) or VCI groups. Furthermore, they were classified as having mild white matter hyperintensity (mWMH) or severe WMH based on Fazekas scores. We then compared the levels of serological markers between the cognitive function groups and the WMH groups.

RESULTS

Among 257 patients with NICE, 165 were male and 92 were female. Lymphocyte count (OR = 0.448, P < 0.001) and LDL-C/HDL-C (OR = 0.725, P = 0.028) were protective factors for cognitive function in patients with NICE. The sWMH group had a higher age and inflammation markers but a lower MoCA score, and lymphocyte count than the mWMH group. In the mWMH group, lymphocyte count (AUC = 0.765, P < 0.001) and LDL-C/HDL-C (AUC = 0.740, P < 0.001) had an acceptable diagnostic value for the diagnosis of VCI. In the sWMH group, no significant differences were found in serological markers between the NCF and VCI groups.

CONCLUSION

Lymphocyte count, LDL-C/HDL-C were independent protective factors for cognitive function in patients with NICE; they can be used as potential biological markers to distinguish VCI in patients with NICE and are applicable to subgroups of patients with mWMH.

An Update on Dyslipidemia Management and Medications: A Review

Dyslipidemia, characterized by abnormal lipid levels in the bloodstream, is a very common and underappreciated chronic disease associated with a significant cardiovascular disease burden. The management landscape for dyslipidemia has historically been static, with a sparse selection of therapeutic options. This article presents a comprehensive review of contemporary approaches to dyslipidemia management, focusing on therapeutic strategies and emerging interventions. We delineate the most current American Heart Association/American College of Cardiology & Canadian Cardiovascular Society guidelines and examine pivotal clinical trials that are shaping the contemporary approach to dyslipidemia management.

Dyslipidaemia in elderly and stroke patients

Lowering of cholesterol containing atherogenic particles through lipid lowering therapies is of outmost important in both in the elderly age group and younger age group in reducing the cardiovascular risk. This chapter summarizes the current existing knowledge regarding the factors which affects the key decision-making process in patients with older age, and also in special circumstance where the direct evidence of benefit for cholesterol lowering is lacking. Effort has been made to briefly summarize the recommendations to the patient and his/her family based on risk stratification of atherosclerotic versus non-atherosclerotic cardiovascular disease, comorbidity burden, quality of life, survival prognosis, lifestyle/socioeconomic status and presence of frailty. Here in this chapter, we have collated and presented the available robust clinical trial evidence which is very much necessary for the assessment of risk versus benefit for hypolipidemic drugs in the elderly age group. While plethora of pharmacological interventions has evolved including statins, ezetimibe, bempedoic acid, PCSK9 inhibitors, Inclisiran etc., but it is essential to establish lipid-lowering therapy goals based on the stroke subtype and the presence of comorbidities. Here in this section we have reviewed the collated clinical evidences for optimal drug regimen recommendation for elderly stroke patients for both primary and secondary prevention.

Lipid-Lowering Therapy and Risk of Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

There is debate over whether statins increase risk of hemorrhagic stroke, so we assessed current evidence, including data from new statin trials and trials of nonstatin low-density lipoprotein-cholesterol (LDL-C)- and triglyceride-lowering therapies.

METHODS AND RESULTS

We performed a systematic review of large randomized clinical trials (≥1000 patients with ≥2 years follow-up) of LDL-C-lowering therapy (statin, ezetimibe, and PCSK-9 [proprotein convertase subtilisin/kexin type 9] inhibitor) and triglyceride-lowering therapy (omega-3 supplements and fibrate) that reported hemorrhagic stroke as an outcome. We searched MEDLINE, Embase, and Cochrane Library up to July 2, 2021 and updated a meta-analysis of cardiovascular statin trials published in 2012. Among our several subgroup analyses, we looked at difference depending on stroke status and also depending on age. We identified 37 trials for LDL-C lowering (284 301 participants) and 11 for triglyceride lowering (120 984 participants). Overall, we found a higher risk of hemorrhagic stroke for LDL-C lowering, risk ratio (RR) 1.16 (95% CI, 1.01-1.32, P=0.03). For statins (33 trials, 216 258 participants), RR=1.17 (95% CI, 1.01-1.36); for PCSK-9 inhibitors (2 trials, 46 488 participants), RR=0.86 (95% CI, 0.43-1.74); and for ezetimibe (2 trials, 21 555 participants), RR=1.14 (95% CI, 0.64-2.03). In statin trials of patients with previous stroke/transient ischemic attack, RR was 1.46 (95% CI, 1.05-2.04), and in trials with mean age ≥65 years old, RR=1.34 (95% CI, 1.04-1.73) (Pint=0.14 and Pint=0.23 respectively); for triglyceride lowering (11 trials, 120 984 participants), RR=1.05 (95% CI, 0.86-1.30).

CONCLUSIONS

We found evidence for a small increased risk of hemorrhagic stroke events with LDL-C-lowering therapies but no clear evidence for triglyceride-lowering therapies.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42021275363.

Medical Therapy After CABG: the Known Knowns, the Known Unknowns, and the Unknown Unknowns

PURPOSE

Medical therapies play a central role in secondary prevention after surgical revascularization. While coronary artery bypass grafting is the most definitive treatment for ischemic heart disease, progression of atherosclerotic disease in native coronary arteries and bypass grafts result in recurrent adverse ischemic events. The aim of this review is to summarize the recent evidence regarding current therapies in secondary prevention of adverse cardiovascular outcomes after CABG and review the existing recommendations as they pertain to the CABG subpopulations.

RECENT FINDINGS

There are many pharmacologic interventions recommended for secondary prevention in patients after coronary artery bypass grafting. Most of these recommendations are based on secondary outcomes from trials which include but did not focus on surgical patients as a cohort. Even those designed with CABG in mind lack the technical and demographic scope to provide universal recommendations for all CABG patients.

CONCLUSION

Recommendations for medical therapy after surgical revascularization are chiefly based on large-scale randomized controlled trials and meta-analyses. Much of what is known about medical management after surgical revascularization results from trials comparing surgical to non-surgical approaches and important characteristics of the operative patients are omitted. These omissions create a group of patients who are relatively heterogenous making solid recommendations elusive. While advances in pharmacologic therapies are clearly adding to the armamentarium of options for secondary prevention, knowing what patients benefit most from each therapeutic option remains challenging and a personalized approach is still required.