Achievement of low-density lipoprotein cholesterol goals: new strategies to address new guidelines

Clinical Effectiveness of the Cardiovascular Polypill in a Real-Life Setting in Patients with Cardiovascular Risk: The SORS Study

BACKGROUND

The cardiovascular disease pandemic has promoted the cardiovascular polypill as one of the most scalable public health strategies to improve cardiovascular risk by increasing accessibility and adherence to treatments. Data from randomized clinical trials has shown that the polypill strategy significantly improves adherence as well as risk factor control (cholesterol and blood pressure), however, to date, no information from phase IV registries has been available.

METHODS

We conducted a multicentre, observational and prospective registry of a polypill-based treatment strategy. A total of 1193 patients in Mexico were included. Patient demographics, clinical history, blood pressure, analysis of blood lipids and the Framingham risk score were measured at baseline and after 12 months of treatment with the CNIC-Ferrer polypill.

RESULTS

At one year with the polypill, systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels changed from mean 146.9 mmHg to 128 mmHg (p <0.001), and from 89.1 mmHg to 80.4 mmHg (p <0.001) respectively. LDLc levels were significantly reduced 132.5-107.6 mg/dL (p <0.001). The 10 year Framingham cardiovascular disease risk was also reduced in the high-risk group (33.7 + 22.0 vs. 21.2 + 14.8; p <0.001) and in the intermediate risk group (23.7 + 14.8 vs. 12.7 + 11.4; p <0.001).

CONCLUSIONS

To our knowledge, the results of the current study constitute the first real life data on the impact of a polypill therapy on cardiovascular risk factor control. The results show major improvements on the primary outcome, above and beyond those presented previously in the setting of randomized clinical trials.

[Elevated HDL is the main negative risk factor for coronary artery disease in the elderly patient with calcific aortic valve disease]

In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD).

OBJECTIVE

To evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile.

METHODS

This was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a).

RESULTS

With the exception of male gender, diabetes and HDL, the other factors studied - smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) - did not show significant differences between groups A and B; LDL was 116 +/- 40mg/dl in group A vs. 123 +/- 38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p < 0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49 +/- 14mg/dl in group A vs. 59 +/- 16mg/dl in group B (p < 0.001); HDL in group A was 49 +/- 14 mg/dl in men vs. 49 +/- 13 mg/dl in women (NS) and 45 +/- 13 mg/dl in diabetic patients vs. 52 +/- 14 mg/dl in non-diabetics (p <0.02); HDL in group B diabetic patients was 54 +/- 17 mg/dl in men vs. 56 +/- 18 mg/dl in women (NS), and HDL in group B non-diabetic patients was 55 +/- 13mg/dl in men vs. 63 +/- 17 mg/dl in women (p < 0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels.

CONCLUSIONS

Elevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.

Effectiveness of inhibition of cholesteryl ester transfer protein by JTT-705 in combination with pravastatin in type II dyslipidemia

The inhibition of cholesteryl ester transfer protein (CETP) has recently been shown to effectively increase high-density lipoprotein (HDL) cholesterol. This study examined the use of the CETP inhibitor JTT-705 combined with pravastatin. In a randomized, double-blind, placebo-controlled trial, 155 patients with type II dyslipidemia using pravastatin 40 mg were treated with placebo or JTT-705 300 or 600 mg. Four weeks of treatment with JTT-705 600 mg led to a 30% decrease in CETP activity (p <0.001), a 28% increase in HDL cholesterol (p <0.001), and a 5% decrease in low-density lipoprotein cholesterol (p <0.03). Combination therapy using JTT-705 and pravastatin effectively increases HDL cholesterol levels and is safe and well tolerated up to 4 weeks of administration.

Ezetimibe/Simvastatin: a review of its use in the management of hypercholesterolemia

Ezetimibe/simvastatin (Inegy, Vytorin) therapy combines two lipid-lowering compounds with complementary mechanisms of action, thereby blocking the two sources of plasma cholesterol and improving lipid profiles. Thus, intestinal absorption of dietary cholesterol and related phytosterols is blocked by ezetimibe, with the biosynthesis of cholesterol in the liver inhibited by simvastatin. Developing management trends for primary hypercholesterolemia include the aggressive reduction of low-density lipoprotein cholesterol (LDL-C) to goals lower than previously considered appropriate, the targeting of lipid subfractions and atherogenic indices other than LDL-C alone, and the broader use of combination lipid-lowering therapy. In line with these trends, ezetimibe/simvastatin is an effective and generally well tolerated adjunct to dietary therapy for markedly reducing LDL-C levels, providing a 52% reduction with the recommended starting dosage. Furthermore, ezetimibe/simvastatin is formulated with variable doses of simvastatin (i.e. 10/10 mg, 10/20 mg, 10/40 mg, and 10/80 mg) and hence, the dosage may be adjusted to suit the individual patient's needs. As longer-term efficacy, tolerability, economic and outcome data accrue, ezetimibe/simvastatin will be positioned more definitively relative to existing and emerging lipid-lowering treatments. Currently, ezetimibe/simvastatin therapy represents a valuable novel option for the management of primary hypercholesterolemia across diverse patient populations and as an adjunct to other lipid-lowering treatments in those with homozygous familial hypercholesterolemia.