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Goodman SG, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, Harrington RA, Jukema JW, White HD, Zeiher AM, Manvelian G, Pordy R, Poulouin Y, Stipek W, Garon G, Schwartz GG. Safety of the PCSK9 inhibitor alirocumab: insights from 47 296 patient-years of observation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:342-352. [PMID: 38658193 PMCID: PMC11249957 DOI: 10.1093/ehjcvp/pvae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/25/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024]
Abstract
The ODYSSEY OUTCOMES trial, comprising over 47 000 patient-years of placebo-controlled observation, demonstrated important reductions in the risk of recurrent ischaemic cardiovascular events with the monoclonal antibody to proprotein convertase subtilisin/kexin type 9 alirocumab, as well as lower all-cause death. These benefits were observed in the context of substantial and persistent lowering of low-density lipoprotein cholesterol with alirocumab compared with that achieved with placebo. The safety profile of alirocumab was indistinguishable from matching placebo except for a ∼1.7% absolute increase in local injection site reactions. Further, the safety of alirocumab compared with placebo was evident in vulnerable groups identified before randomization, such as the elderly and those with diabetes mellitus, previous ischaemic stroke, or chronic kidney disease. The frequency of adverse events and laboratory-based abnormalities was generally similar to that in placebo-treated patients. Thus, alirocumab appears to be a safe and effective lipid-modifying treatment over a duration of at least 5 years.
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Affiliation(s)
- Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), and INSERM U1148, F-75018 Paris, France
| | - Michael Szarek
- CPC Clinical Research and Division of Cardiology, University of Colorado School of Medicine, Aurora, 80045 CO, USA
- State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, S2000 Rosario, Argentina
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Harvey D White
- Green Lane Cardiovascular Research Unit, Te Whatu Ora—Health New Zealand, Te Toka Tumai, and University of Auckland, Auckland 1030, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, 60596 Frankfurt am Main, Germany
| | | | - Robert Pordy
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA
| | | | - Wanda Stipek
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA
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Wright RS, Ray KK, Landmesser U, Koenig W, Raal FJ, Leiter LA, Conde LG, Han J, Schwartz GG. Effects of Inclisiran in Patients With Atherosclerotic Cardiovascular Disease: A Pooled Analysis of the ORION-10 and ORION-11 Randomized Trials. Mayo Clin Proc 2024; 99:S0025-6196(24)00167-8. [PMID: 39093262 DOI: 10.1016/j.mayocp.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE To evaluate the efficacy, safety, and tolerability of inclisiran in participants with atherosclerotic cardiovascular disease (ASCVD) from ORION-10 and ORION-11 stratified by key patient characteristics. PATIENTS AND METHODS Participants were randomized 1:1 to receive 300 mg inclisiran sodium (284 mg inclisiran) or placebo on days 1, 90, 270, and 450, alongside background lipid-lowering therapy. This pooled, post hoc analysis stratified participants with ASCVD by sex, age, race, kidney function, body mass index, and glycemic status. Co-primary endpoints were percentage changes in low-density lipoprotein cholesterol (LDL-C) from baseline to day 510, and after day 90 and up to day 540 (time-adjusted). LDL-C goal attainment and safety were also assessed. RESULTS This analysis of 2975 participants included: female, n=827; Black, n=213; 75 years of age or older, n=458; obese, n=1474; diabetes, n=1182; and moderate-to-severe chronic kidney disease, n=538. Mean baseline LDL-C levels in the total ASCVD population were balanced between treatment arms (inclisiran, 103.4 mg/dL; placebo, 102.0 mg/dL). With inclisiran, mean placebo-corrected percentage changes in LDL-C from baseline were -51.5% (95% CI, -54.0% to -49.0%) and -52.1% (95% CI, -53.9% to -50.4%) to day 510 and day 540 (time-adjusted), respectively; this was consistent across subgroups. LDL-C less than 55 mg/dL at 1 or more visits was reached by 87.6% of participants receiving inclisiran. The inclisiran safety profile was consistent across subgroups. CONCLUSION Twice-yearly inclisiran (after initial and 3-month doses) was well-tolerated and provided significant, consistent LDL-C reductions for up to 18 months in participants with ASCVD independent of key patient characteristics (ORION-10 [Inclisiran for Participants With Atherosclerotic Cardiovascular Disease and Elevated Low-density Lipoprotein Cholesterol]; NCT03399370 and ORION-11 [Inclisiran for Subjects With ASCVD or ASCVD-Risk Equivalents and Elevated Low-density Lipoprotein Cholesterol]; NCT03400800).
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Affiliation(s)
- R Scott Wright
- Division of Preventive Cardiology and the Department of Cardiology, Mayo Clinic, Rochester, MN, USA.
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité; Charité Universitätsmedizin Berlin, Berlin Institute of Health, DZHK, Partner Site Berlin, Berlin, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany and Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Frederick J Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Jackie Han
- Novartis Pharmaceuticals Corp, East Hanover, NJ, USA
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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3
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Zhao J, Tong X, Peng J, Lyu C, Lu S. Efficacy and Safety of PSCK9 Inhibitors on Patients with Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Rev Cardiovasc Med 2024; 25:94. [PMID: 39076939 PMCID: PMC11263862 DOI: 10.31083/j.rcm2503094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 07/31/2024] Open
Abstract
Background PCSK9 MaB (Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor) may reduce the occurrence of major adverse cardiovascular events (MACEs) in patients diagnosed with acute coronary syndrome (ACS). In this meta-analysis, we conducted a thorough compilation of evidence from established clinical studies to evaluate PCSK9 MaB's capacity to control blood lipid levels and prevent MACEs in ACS patients. Methods We conducted searches on Pubmed, Embase, the Cochrane Library, and Web of Science to identify relevant articles. Data from ACS patients were extracted using a standardized format for aggregating data. We calculated the risk ratio (RR) for MACE and assessed changes in blood lipid parameters. All statistical analyses were performed using RevMan. Results 11 articles representing 5 trials were included in our systematic review and meta-analysis. When compared to a placebo, PCSK9 MaB significantly reduced the risk of MACEs ( I 2 = 0%, p = 0.63, RR [95% CI] = 0.88 [0.81, 0.97], p < 0.01) and the recurrence rate of ACS ( I 2 = 45%, p = 0.18, RR [95% CI] = 0.89 [0.83, 0.95], p < 0.01). Additionally, PCSK9 MaB notably reduced low-density lipoprotein cholesterol (LDL-C) levels (SMD [95% CI] = -2.12 [-2.32, -1.92], p < 0.01) and Apolipoprotein B (ApoB) levels (SMD [95% CI] = -1.83 [-2.48, -1.18], p < 0.01). Importantly, there were no significant differences in adverse reactions between the PCSK9 MaB group and the control group. Conclusions PCSK9 MaB, whether used as a standalone treatment or in combination with other therapies, can effectively inhibit PCSK9. It substantially lowers key blood lipid parameters, including low-density lipoprotein (LDL), ApoB, and triglycerides, all without giving rise to notable safety concerns.
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Affiliation(s)
- Jiajing Zhao
- Graduate School, Nanjing University of Chinese Medicine, 210029 Nanjing, Jiangsu, China
| | - Xinyu Tong
- Graduate School, Nanjing University of Chinese Medicine, 210029 Nanjing, Jiangsu, China
| | - Jian Peng
- Department of Cardiovascular, Wuxi Traditional Chinese Medicine Hospital, 214071 Wuxi, Jiangsu, China
| | - Chuxin Lyu
- Graduate School, Nanjing University of Chinese Medicine, 210029 Nanjing, Jiangsu, China
| | - Shu Lu
- Graduate School, Nanjing University of Chinese Medicine, 210029 Nanjing, Jiangsu, China
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Ferri N, Ruscica M, Fazio S, Corsini A. Low-Density Lipoprotein Cholesterol-Lowering Drugs: A Narrative Review. J Clin Med 2024; 13:943. [PMID: 38398257 PMCID: PMC10889346 DOI: 10.3390/jcm13040943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/26/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
The modern history of cholesterol-lowering drugs started in 1972 when Dr. Akira Endo identified an active compound (compactin) that inhibited cholesterol biosynthesis from the culture broth of blue-green mold (Penicillium citrinum Pen-51). Since 1987, statins have represented the milestone for the treatment of atherosclerotic cardiovascular disease. A new therapy for the treatment of hypercholesterolemia since the discovery of statins is ezetimibe, the first and only agent inhibiting intestinal cholesterol absorption. Ezetimibe was approved by the FDA in October 2002. A year later, the association between gain-of-function PCSK9 genetic mutations and hypercholesterolemia was reported, and this discovery opened a new era in lipid-lowering therapies. Monoclonal antibodies and small-interfering RNA approaches to reduce PCSK9 were developed and approved for clinical use in 2015 and 2022, respectively. Finally, the newly approved bempedoic acid, an oral adenosine triphosphate citrate lyase inhibitor that lowers LDL-C, is able to reduce major adverse cardiovascular events in both primary and secondary prevention. In the present narrative review, we summarize the pharmacological properties and the clinical efficacy of all these agents currently used for a tailored therapy of hypercholesterolemia in patients with atherosclerotic cardiovascular disease.
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Affiliation(s)
- Nicola Ferri
- Department of Medicine (DIMED), University of Padova, 35122 Padova, Italy
- Veneto Institute of Molecular Medicine (VIMM), 35129 Padua, Italy
| | - Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, University of Milan, 20133 Milan, Italy;
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sergio Fazio
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA;
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, University of Milan, 20133 Milan, Italy;
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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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Abstract
OBJECTIVE To examine the evidence base for lifestyle and pharmacologic interventions to reduce the risk of cardiovascular events in patients with chronic kidney disease, with an emphasis on reporting available data in distinct subtypes. DATA SOURCES A PubMed search (origin to February 2023) was conducted and references for selected studies were reviewed to identify additional articles. Search terms included chronic kidney disease, major adverse cardiovascular events, and heart failure hospitalization. STUDY SELECTION AND DATA ANALYSIS English language studies reporting cardiovascular outcomes data in patients with chronic kidney disease were included. DATA SYNTHESIS Much of the data on interventions to prevent cardiovascular events in patients with chronic kidney disease are derived from observational studies or subgroup analyses of trials of broader populations. Some common recommendations, such as weight loss, may be harmful in certain patients. Others may only offer benefits in subgroups, such as those with albuminuria. Newer agents, such as SGLT2 inhibitors and finerenone, have clearer evidence of cardiovascular benefit, but these may also apply only to specific subgroups. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Given the prevalence of chronic kidney disease and its attendant cardiovascular risk, it is important to understand which interventions offer the greatest benefit. CONCLUSIONS Patients diagnosed with chronic kidney disease have markedly increased risk of cardiovascular events, including myocardial infarction, stroke, heart failure, and cardiovascular death. However, until recently, there were few cardiovascular outcome studies that targeted enrollment specifically to those patients. Certain drugs now have shown benefits to cardiovascular end points in this population.
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Affiliation(s)
- Chris M Terpening
- Department of Clinical Pharmacy, School of Pharmacy, West Virginia University, Charleston, WV, USA
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Wojtasińska A, Kućmierz J, Tokarek J, Dybiec J, Rodzeń A, Młynarska E, Rysz J, Franczyk B. New Insights into Cardiovascular Diseases Treatment Based on Molecular Targets. Int J Mol Sci 2023; 24:16735. [PMID: 38069058 PMCID: PMC10706703 DOI: 10.3390/ijms242316735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Cardiovascular diseases (CVDs) which consist of ischemic heart disease, stroke, heart failure, peripheral arterial disease, and several other cardiac and vascular conditions are one of the most common causes of death worldwide and often co-occur with diabetes mellitus and lipid disorders which worsens the prognosis and becomes a therapeutic challenge. Due to the increasing number of patients with CVDs, we need to search for new risk factors and pathophysiological changes to create new strategies for preventing, diagnosing, and treating not only CVDs but also comorbidities like diabetes mellitus and lipid disorders. As increasing amount of patients suffering from CVDs, there are many therapies which focus on new molecular targets like proprotein convertase subtilisin/kexin type 9 (PCSK9), angiopoietin-like protein 3, ATP-citrate lyase, or new technologies such as siRNA in treatment of dyslipidemia or sodium-glucose co-transporter-2 and glucagon-like peptide-1 in treatment of diabetes mellitus. Both SGLT-2 inhibitors and GLP-1 receptor agonists are used in the treatment of diabetes, however, they proved to have a beneficial effect in CVDs as well. Moreover, a significant amount of evidence has shown that exosomes seem to be associated with myocardial ischaemia and that exosome levels correlate with the severity of myocardial injury. In our work, we would like to focus on the above mechanisms. The knowledge of them allows for the appearance of new strategies of treatment among patients with CVDs.
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Affiliation(s)
- Armanda Wojtasińska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Kućmierz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Julita Tokarek
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jill Dybiec
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Anna Rodzeń
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Sarakpi T, Mesic A, Speer T. Leukocyte-endothelial interaction in CKD. Clin Kidney J 2023; 16:1845-1860. [PMID: 37915921 PMCID: PMC10616504 DOI: 10.1093/ckj/sfad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 11/03/2023] Open
Abstract
Chronic kidney disease (CKD) represents an independent risk factor for cardiovascular diseases (CVD). Accordingly, CKD patients show a substantial increased risk of cardiovascular mortality. Inflammation represents an important link between CKD and CVD. The interaction between endothelial cells and effector cells of the innate immune system plays a central role in the development and progression of inflammation. Vascular injury causes endothelial dysfunction, leading to augmented oxidative stress, increased expression of leukocyte adhesion molecules and chronic inflammation. CKD induces numerous metabolic changes, creating a uremic milieu resulting in the accumulation of various uremic toxins. These toxins lead to vascular injury, endothelial dysfunction and activation of the innate immune system. Recent studies describe CKD-dependent changes in monocytes that promote endothelial dysfunction and thus CKD progression and CKD-associated CVD. The NLR family pyrin domain containing 3-interleukin-1β-interleukin-6 (NLRP3-IL-1β-IL-6) signaling pathway plays a pivotal role in the development and progression of CVD and CKD alike. Several clinical trials are investigating targeted inhibition of this pathway indicating that anti-inflammatory therapeutic strategies may emerge as novel approaches in patients at high cardiovascular risk and nonresolving inflammation. CKD patients in particular would benefit from targeted anti-inflammatory therapy, since conventional therapeutic regimens have limited efficacy in this population.
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Affiliation(s)
- Tamim Sarakpi
- Department of Internal Medicine 4 – Nephrology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Else Kröner-Fresenius-Zentrum for Nephrological Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Armir Mesic
- Department of Internal Medicine 4 – Nephrology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Else Kröner-Fresenius-Zentrum for Nephrological Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Thimoteus Speer
- Department of Internal Medicine 4 – Nephrology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Else Kröner-Fresenius-Zentrum for Nephrological Research, Goethe University Frankfurt, Frankfurt am Main, Germany
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García-Agudo R, Rojas-Fernández MÁ, Canllavi-Fiel E, Proy-Vega B, Tejera-Muñoz A. Safe and Successful Treatment With Pcsk9 Inhibitors in Hypercholesterolemia and Renal Transplantation: A Case Report. Transplant Proc 2023; 55:1921-1923. [PMID: 37612152 DOI: 10.1016/j.transproceed.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are more prone to cardiovascular disease (CVD) risks, including CVD-derived sudden death. Additionally, patients with CKD also develop lipid metabolism abnormalities. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (PCSK9i) are drugs capable of reducing CVD risk in patients with CKD, but their efficacy is scarcely assessed in transplant patients. CASE PRESENTATION Here, we report a case of a 74-year-old man undergoing nephrology follow-up for a cadaver donor kidney transplant. The patient described an atorvastatin allergic reaction after an acute coronary syndrome. Because the patient had a very high risk for CVD, alirocumab was substituted for atorvastatin. The patient showed a well-tolerated and effective response and stable everolimus levels. CONCLUSION PCSK9i may be considered a pharmacologic option for treating lipid metabolism disorder and reducing low-density lipoprotein cholesterol in transplant recipients.
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Affiliation(s)
- Rebeca García-Agudo
- Nephrology Department, Hospital La Mancha-Centro, Alcázar de San Juan (Ciudad Real), Spain; Instituto de Investigación Sanitaria de Castilla La-Mancha (IDISCAM), Toledo, Spain
| | - Miguel Ángel Rojas-Fernández
- Nephrology Department, Hospital La Mancha-Centro, Alcázar de San Juan (Ciudad Real), Spain; Instituto de Investigación Sanitaria de Castilla La-Mancha (IDISCAM), Toledo, Spain
| | | | - Beatriz Proy-Vega
- Instituto de Investigación Sanitaria de Castilla La-Mancha (IDISCAM), Toledo, Spain; Hospital Pharmacy, Hospital La Mancha-Centro, Alcázar de San Juan (Ciudad Real), Spain
| | - Antonio Tejera-Muñoz
- Instituto de Investigación Sanitaria de Castilla La-Mancha (IDISCAM), Toledo, Spain; Research Support Unit, Hospital La Mancha-Centro, Alcázar de San Juan (Ciudad Real), Spain.
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10
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Park S, Kim SG, Lee S, Kim Y, Cho S, Kim K, Kim YC, Han SS, Lee H, Lee JP, Joo KW, Lim CS, Kim YS, Kim DK. Genetic variations in HMGCR and PCSK9 and kidney function: a Mendelian randomization study. Kidney Res Clin Pract 2023; 42:460-472. [PMID: 37448291 PMCID: PMC10407636 DOI: 10.23876/j.krcp.22.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/27/2023] [Accepted: 02/08/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The genetically predicted lipid-lowering effect of HMGCR or PCSK9 variant can be used to assess drug proxy effects on kidney function. METHODS Mendelian randomization (MR) analysis-identified HMGCR and PCSK9 genetic variants were used to predict the low-density lipoprotein (LDL) cholesterol-lowering effects of medications targeting related molecules. Primary summary-level outcome data for log-estimated glomerular filtration rate (eGFR; creatinine) were provided by the CKDGen Consortium (n = 1,004,040 European) from a meta-analysis of CKDGen and UK Biobank data. We also conducted a separate investigation of summary-level data from CKDGen (n = 567,460, log-eGFR [creatinine]) and UK Biobank (n = 436,581, log-eGFR [cystatin C]) samples. Summary-level MRs using an inverse variance weighted method and pleiotropy-robust methods were performed. RESULTS Summary-level MR analysis indicated that the LDL-lowering effect predicted genetically by HMGCR variants (50-mg/dL decrease) was significantly associated with a decrease in eGFR (-1.67%; 95% confidence interval [CI], -2.20% to -1.13%). Similar significance was found in results from the pleiotropy-robust MR methods when the CKDGen and UK Biobank data were analyzed separately. However, the LDL-lowering effect predicted genetically by PCSK9 variants was significantly associated with an increase in eGFR (+1.17%; 95% CI, 0.10%-2.25%). The results were similarly supported by the weighted median method and in each CKDGen and UK Biobank dataset, but the significance obtained by MR-Egger regression was attenuated. CONCLUSION Genetically predicted HMG-CoA reductase inhibition was associated with low eGFR, while genetically predicted PCSK9 inhibition was associated with high eGFR. Clinicians should consider that the direct effect of different types of lipid-lowering medication on kidney function can vary.
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Affiliation(s)
- Sehoon Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seong Geun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soojin Lee
- Department of Internal Medicine, Uijeongbu Eulji University Medical Center, Uijeongbu, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Semin Cho
- Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Yon Su Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
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11
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Wang D, Zhang D. Safety Issues Associated With the Clinical Application of PCSK9 Inhibitors: Current Findings. Cardiol Rev 2023; 31:155-161. [PMID: 35175957 DOI: 10.1097/crd.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Reduction in low-density lipoprotein cholesterol levels is the cornerstone of treatment and prevention of atherosclerotic cardiovascular diseases. Currently, high-intensity statins are being used as the first-line therapy to lower low-density lipoprotein cholesterol levels, as they improve the prognosis of patients with atherosclerotic cardiovascular disease and those in high-risk groups. However, in some patients, the expected reduction in cholesterol is not achieved despite aggressive treatment with statins. Moreover, some patients cannot tolerate the dosage or show poor response or compliance to statins. Therefore, combination therapies with statins and other medications should be considered. Recently, several clinical trials have shown that the use of proprotein convertase subtilisin/kexin type 9 inhibitors with or without statins and/or other lipid-lowering drugs can significantly reduce low-density lipoprotein cholesterol levels, sometimes to extremely low levels. Therefore, to facilitate appropriate prescription of these new lipid-lowering drugs, we systemically evaluated the safety issues associated with these inhibitors and extremely low low-density lipoprotein cholesterol levels.
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Affiliation(s)
- Dan Wang
- From the Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
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12
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Abstract
Patients with chronic kidney disease (CKD) are at high risk to develop cardiovascular disease with its manifestations coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. In addition, the presence of CKD has a major impact on the prognosis of patients with cardiovascular disease, leading to an increased morbidity and mortality if both comorbidities are present. Therapeutic options including medical therapy and interventional treatment are often limited in patients with advanced CKD, and in most cardiovascular outcome trials, patients with advanced CKD have been excluded. Thus, in many patients, treatment strategies for cardiovascular disease need to be extrapolated from trials conducted in patients without CKD. The current article summarizes the epidemiology, clinical presentation, and treatment options for the most prevalent manifestations of cardiovascular disease in CKD and discusses the currently available treatment options to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Katharina Schuett
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Michael Lehrke
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
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13
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AlRahimi J, AlSaif S, Alasnag M, Awan Z, Almutairi F, Al Mudaiheem H, Gencer B, Catapano AL, Mach F, Tash A. 2022 Saudi Guidelines for the Management of Dyslipidemia. Heart Views 2023; 24:67-92. [PMID: 37305331 PMCID: PMC10249637 DOI: 10.4103/heartviews.heartviews_102_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/16/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
- Jamilah AlRahimi
- Department of Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Dammam, Saudi Arabia
| | - Shukri AlSaif
- Department of Cardiology, Saud AlBabtain Cardiac Center, Dammam, Saudi Arabia
| | - Mirvat Alasnag
- Department of Cardiology, Catheterization Laboratory, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Zuhier Awan
- Medicine, Biochemistry and Molecular Genetics, Clinical Biochemistry Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fawaz Almutairi
- Department of Cardiology, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hajer Al Mudaiheem
- Therapeutic Affairs Department, Ministry of Health, Riyadh, Saudi Arabia
| | - Baris Gencer
- Department of Cardiology, Geneva University Hospital, Geneva
- Institute of Primary Healthcare (BIHAM), Bern University, Bern, Switzerland
| | - Alberico L. Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva
| | - Adel Tash
- Cardiac Services Development, Ministry of Health, Riyadh, Saudi Arabia
- National Heart Center, Saudi Health Council, Riyadh, Saudi Arabia
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14
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Korneva VA, Kuznetsova TY, Scopets IS, Vezikova NN. Efficacy and safety of the use of alirocumab in real clinical practice. TERAPEVT ARKH 2023; 94:1401-1406. [PMID: 37167185 DOI: 10.26442/00403660.2022.12.201991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
Aim. To evaluate the results of two-year use of alirokumab in Karelia Republic.
Materials and methods. The observation group consisted of 27 patients (17 patients with familial hypercholesterolemia, 10 patients with the history of myocardial infarction), mean age 53.44.3 years, 70.3% men, follow-up duration from one year to 2.5 years, 18 (66.6%) patients received therapy for more than 2 years. 19 patients received alirocumab at a dose of 75 mg/ml once every 2 weeks, eight at a dose of 150 mg/ml once every 2 weeks. Before the start of therapy, the majority received maximally tolerated statin therapy, 10 patients received statin therapy in combination with ezetemibe, 3 patients received ezetemibe monotherapy due to statin intolerance. The target levels of LDL cholesterol were considered for very high risk patients less than 1.4 mmol/L, high risk less than 1.8 mmol/L, extreme risk less than 1 mmol/L.
Results. The reduction of LDL on therapy with alirocumab was 58%; target levels of LDL were achieved in 77.8%. The level of decrease in LDL cholesterol less than 50% was noted only in 7.4% of cases. Patients requiring a large dose of the drug were classified as very high risk, had higher cholesterol and LDL-C levels. The level of Lp(a) decrease on 29.7% by 612 months. No destabilization of coronary heart disease, new cases of stroke were registered.
Conclusion. The inclusion of alirocumab in the treatment regimen contributed to the stable course of atherosclerosis-associated diseases, the achievement of LDL cholesterol targets in 77.8% of patients, was not accompanied by side effects during 2.5 years therapy.
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15
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Liao G, Wang X, Li Y, Chen X, Huang K, Bai L, Ye Y, Peng Y. Antidyslipidemia Pharmacotherapy in Chronic Kidney Disease: A Systematic Review and Bayesian Network Meta-Analysis. Pharmaceutics 2022; 15:pharmaceutics15010006. [PMID: 36678635 PMCID: PMC9862001 DOI: 10.3390/pharmaceutics15010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIMS The benefits and safety of antidyslipidemia pharmacotherapy in patients with chronic kidney disease were not well defined so the latest evidence was summarized by this work. METHODS This systematic review and Bayesian network meta-analysis (NMA) included searches of PubMed, Embase, and Cochrane Library from inception to 28 February 2022, for randomized controlled trials of any antilipidaemic medications administered to adults with chronic kidney disease [CKD: defined as estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m2 not undergoing transplantation], using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool to assess the certainty of the evidence. RESULTS 55 trials and 30 works of them were included in our systematic review and NMA, respectively. In comparisons with no antidyslipidemia therapy or placebo, proprotein convertase subtilisin/Kexin type 9 inhibitors plus statin (PS) was the most effective drug regimen for reducing all-cause mortality (OR 0.62, 95% CI [0.40, 0.93]; GRADE: moderate), followed by moderate-high intensity statin (HS, OR 0.76, 95% CI [0.60, 0.93]; I2 = 66.9%; GRADE: moderate). PS, HS, low-moderate statin (LS), ezetimibe plus statin (ES), and fibrates (F) significantly decreased the composite cardiovascular events. The subgroup analysis revealed the null effect of statins on death (OR 0.92, 95% CI [0.81, 1.04]) and composite cardiovascular events (OR 0.94, 95% CI [0.82, 1.07]) in dialysis patients. CONCLUSION In nondialysis CKD patients, statin-based therapies could significantly and safely reduce all-cause death and major composite cardiovascular events despite the presence of arteriosclerotic cardiovascular disease and LDL-c levels. Aggressive medication regimens, PS and HS, appeared to be more effective, especially in patients with established CAD.
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Affiliation(s)
- Guangzhi Liao
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Xiangpeng Wang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yiming Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Xuefeng Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Ke Huang
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Lin Bai
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Yuyang Ye
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, China
- Correspondence: ; Tel.: +86-28-85423362; Fax: +86-28-85423169
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16
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Ridker PM, Tuttle KR, Perkovic V, Libby P, MacFadyen JG. Inflammation drives residual risk in chronic kidney disease: a CANTOS substudy. Eur Heart J 2022; 43:4832-4844. [PMID: 35943897 DOI: 10.1093/eurheartj/ehac444] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/09/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Hyperlipidaemia and inflammation jointly contribute to atherosclerotic disease. Yet, after the initiation of statin therapy, the relative contributions of these processes may differ in patient groups, such as those with and without impaired kidney function. METHODS AND RESULTS Among 9151 stable statin-treated post-myocardial infarction patients participating in the CANTOS trial, the contributions of residual cholesterol risk and residual inflammatory risk were evaluated as determinants of recurrent major adverse cardiovascular events (MACE) and total mortality, stratified by baseline estimated glomerular filtration rate (eGFR) above or below 60 mL/min/1.73 m2 using the race agnostic CKD-EPI 2021 formula (all participants had eGFR > 30 mL/min/1.73 m2). Analyses of residual inflammatory risk focused on high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) while analyses of residual cholesterol risk focused on LDL-cholesterol (LDL-C) and non-HDL-cholesterol (non-HDL-C). Participants were followed for a period of up to 5 years (median 3.7 years). Median baseline levels of LDL-C and hsCRP were 81 mg/dL and 4.2 mg/L. Among participants with eGFR ≥ 60 mL/min/1.73 m2, increasing quartiles of plasma hsCRP, IL-6, LDL-C, and non-HDL-C all positively associated with risks of recurrent MACE [hazard ratios (HR) comparing the top to bottom quartile for hsCRP 1.45; for IL-6 2.48; for LDL-C 1.64; and for non-HDL-C 1.68] (all P < 0.0001). By contrast, among those with eGFR < 60 mL/min/1.73 m2, increasing quartiles of hsCRP and IL-6 significantly predicted recurrent MACE [HR comparing the top to bottom quartile for hsCRP 1.50 (P = 0.021); for IL-6 1.84 (P = 0.048)], whereas increasing quartiles of LDL-C and non-HDL-C did not [HR comparing the top to bottom quartile for LDL-C 1.04 (P = 0.80); for non-HDL-C 0.98 (P = 0.88)]. The predictive utility of hsCRP and IL-6 in the setting of eGFR < 60 mL/min/1.73 m2 remained significant after adjustment for a wide range of potential confounding factors including age, sex, smoking status, blood pressure, body mass index, and diabetes. For the endpoint of total mortality, both hsCRP (HR 1.77, P = 0.0021) and IL-6 (HR 2.15, P = 0.015) were significant predictors among those with eGFR < 60 mL/min/1.73 m2, whereas LDL-C (HR 0.91, P = 0.56) and non-HDL-C (HR 0.85, P = 0.31) were not. Similar effects were observed in analyses stratified by the albumin to creatinine ratio rather than eGFR. CONCLUSION Among atherosclerosis patients with impaired kidney function already aggressively treated with statin therapy, residual inflammatory risk plays a substantial role in determining the risk of recurrent cardiovascular events. These data have implications for risk stratification of individuals with chronic kidney disease and for the development of novel agents that target inflammatory processes in this high-risk group of patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT01327846.
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Affiliation(s)
- Paul M Ridker
- Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Avenue, Boston, MA 02215, USA.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Vlado Perkovic
- Royal North Shore Hospital, University of New South Wales, Sydney, NSW 2052, Australia
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean G MacFadyen
- Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Avenue, Boston, MA 02215, USA
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17
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Shaik A, Kosiborod M, de Lemos JA, Gao Q, Mues KE, Alam S, Bhatt DL, Cannon CP, Ballantyne CM, Rosenson RS. Use of lipid-lowering therapies in patients with chronic kidney disease and atherosclerotic cardiovascular disease: 2-year results from Getting to an imprOved Understanding of Low-Density lipoprotein cholesterol and dyslipidemia management (GOULD). Clin Cardiol 2022; 45:1303-1310. [PMID: 36124341 DOI: 10.1002/clc.23923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/19/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a known risk factor of atherosclerotic cardiovascular disease (ASCVD). Per the 2018 American Heart Association/American College of Cardiology cholesterol guidelines, high-risk ASCVD patients with CKD and low-density lipoprotein cholesterol (LDL-C) levels ≥ $\ge $ 70 mg/dL should take a high-intensity statin with ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). OBJECTIVE/METHODS We examined the changes in use of lipid lowering therapies (LLT) over two years in 3304 patients with ASCVD and CKD in the Getting to an imprOved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) observational cohort study. RESULTS Of those with eGFR <60 ml/min/1.73 m2 , 21.6% (171/791) had intensification of LLT while 10.4% (82/791) had de-escalation of LLT. Notably, 61.6% (487/791) had no change in LLT regimen over 2 years. Statin use was 83.2% (785/944) at baseline and 80.1% (634/791) at 2 years. Statin/ezetimibe use increased from 2.9% (27/944) to 4.9% (39/791). Statin discontinuation at 2 years was greater with lower eGFR levels across all cohorts. CONCLUSION Despite the recommendations of multiscociety guidelines, statin use, while high, is not ubiquitous and rates of high-intensity statin and ezetimibe use remain low in patients with CKD. There remains a significant opportunity to optimize LLT and achieve atheroprotective cholesterol levels in the CKD population.
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Affiliation(s)
- Aleesha Shaik
- The Cardiometabolic Disorders Unit, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Qi Gao
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | - Robert S Rosenson
- The Cardiometabolic Disorders Unit, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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18
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Zhu X, Zhang P, Xiong J, Wang N, Yang S, Zhu R, Zhang L, Liu W, Wu L. Effect of glomerular filtration rate in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31498. [PMID: 36343078 PMCID: PMC9646511 DOI: 10.1097/md.0000000000031498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Through meta-analysis of the relationship between glomerular filtration rate and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), we studied the impact of glomerular filtration rate on the prognosis of PCI. METHODS We collected literature on the incidence of MACE in patients with chronic kidney disease (CKD; estimated glomerular filtration rate < 60 mL/minute/1.73 m2) and patients with nonchronic kidney disease undergoing PCI. The search period was from January 1, 2000, to November 1, 2021. The searched databases included CNKI, Chinese Wanfang Data, China Biology Medicine disc, Web of Science, PubMed, and Cochrane Library. We used subgroup analysis and meta-regression to assess heterogeneity. RESULTS Twenty-one eligible studies were included, with 46,255 samples included, 4903 cases of MACE (10.6%), and patients with CKD had a higher risk of MACE after PCI (Risk ratios = 1.67; 95% confidence interval: 1.51-1.85). Multivariate meta regression results show that heterogeneity is related to region. The risk of MACEs in patients with CKD is different in different regions, and North America has the lowest risk, with an risk ratios value of 1.21 (95% confidence interval: 1.08-1.35). CONCLUSION Chronic kidney disease will increase the probability of MACE in patients with myocardial infarction after PCI and affect the prognosis of PCI. Therefore, clinical attention should be given to assessing glomerular filtration rate effects while treating patients with myocardial infarction with the PCI procedure.
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Affiliation(s)
- Xiang Zhu
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, People's Republic of China
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19
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Xiao Y, Ba Z, Pang S, Liu D, Wang H, Liang H, Wang Y, Yuan J. PCSK9 Inhibitor: Safe Alternative to Fill the Treatment Gap in Statin-Limited Conditions? Rev Cardiovasc Med 2022; 23:380. [PMID: 39076187 PMCID: PMC11269069 DOI: 10.31083/j.rcm2311380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/28/2022] [Accepted: 10/08/2022] [Indexed: 07/31/2024] Open
Abstract
Lipid-lowering therapy is of great importance in reducing the burden of atherosclerotic cardiovascular disease. Statins act as first-line therapy in the current lipid management guidelines. However, statin use is limited in (1) statin-induced adverse events, including statin-associated muscle symptoms, new-onset diabetes mellitus, drug-induced liver injuries, acute kidney injuries, cognitive effects, hemorrhagic strokes, and cataracts; (2) special populations, including pregnant and lactating patients, patients with decompensated cirrhosis, and patients on dialysis; (3) coadministration with statin-interactive drugs, such as anti-human immunodeficiency virus drugs, anti-hepatitis C virus drugs, and immunosuppressive drugs. These considerable statin-limited groups are in urgent need of safer alternative lipid-lowering options. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are attracting widespread attention for their documented safety in general populations and superior lipid-lowering properties. Therefore, questions have been raised whether PCSK9 inhibitors could be a safe alternative in patients who are intolerant to statin therapy. In this review, we discuss the safety of PCSK9 inhibitors in statin-limited conditions. We conclude that PCSK9 inhibitors are a safe alternative lipid-lowering therapy in various statin-limited conditions. Furthermore, we identify several limitations in the current literature and suggest future directions, for the refinement of lipid management regimens.
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Affiliation(s)
- Ying Xiao
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
| | - Zhengqing Ba
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
| | - Shurui Pang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences
& Peking Union Medical College, 100730 Beijing, China
| | - Dong Liu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
| | - Hao Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences
& Peking Union Medical College, 100730 Beijing, China
| | - Hanyang Liang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
| | - Yong Wang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
| | - Jiansong Yuan
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences & Peking Union Medical College, 100037 Beijing,
China
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20
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Zuzda K, Grycuk W, Małyszko J, Małyszko J. Kidney and lipids: novel potential therapeutic targets for dyslipidemia in kidney disease? Expert Opin Ther Targets 2022; 26:995-1009. [PMID: 36548906 DOI: 10.1080/14728222.2022.2161887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Altered lipid distribution and metabolism may lead to the development and/or progression of chronic kidney disease (CKD). Dyslipidemia is a major risk factor for CKD and increases the risk of cardiovascular events and mortality. Therefore, lipid-lowering treatments may decrease cardiovascular risk and prevent death. AREAS COVERED Key players involved in regulating lipid accumulation in the kidney; contribution of lipids to CKD progression, lipotoxicity, and mitochondrial dysfunction in kidney disease; recent therapeutic approaches for dyslipidemia. EXPERT OPINION The precise mechanisms for regulating lipid metabolism, particularly in kidney disease, are poorly understood. Guidelines for lipid-lowering therapy for CKD are controversial. Several hypolipemic therapies are available, but compared to others, statin therapy is the most common. No clinical trial has evaluated the efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in preventing cardiovascular events or improving kidney function among patients with CKD or kidney transplant recipients. Attractive alternatives, such as PCSK9-small interfering RNA (siRNA) molecules or evinacumab are available. Additionally, several promising agents, such as cyclodextrins and the FXR/TGR5 dual agonist, INT-767, can improve renal lipid metabolism disorders and delay CKD progression. Drugs targeting mitochondrial dysfunction could be an option for the treatment of dyslipidemia and lipotoxicity, particularly in renal diseases.
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Affiliation(s)
- Konrad Zuzda
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Bialystok, Poland
| | - Wiktoria Grycuk
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Bialystok, Poland
| | - Jacek Małyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, Bialystok, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Bialystok, Poland
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21
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Liu C, Chan KH, Lv J, Lam H, Newell K, Meng X, Liu Y, Chen R, Kartsonaki C, Wright N, Du H, Yang L, Chen Y, Guo Y, Pei P, Yu C, Shen H, Wu T, Kan H, Chen Z, Li L. Long-Term Exposure to Ambient Fine Particulate Matter and Incidence of Major Cardiovascular Diseases: A Prospective Study of 0.5 Million Adults in China. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2022; 56:13200-13211. [PMID: 36044001 PMCID: PMC9494741 DOI: 10.1021/acs.est.2c03084] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Few cohort studies explored the long-term effects of ambient fine particulate matter (PM2.5) on incidence of cardiovascular diseases (CVDs), especially in countries with higher levels of air pollution. We aimed to evaluate the association between long-term exposure to PM2.5 and incidence of CVD in China. We performed a prospective cohort study in ten regions that recruited 512,689 adults during 2004-2008, with follow-up until 2017. Annual PM2.5 concentrations were estimated using a satellite-based model with national coverage and 1 x 1 km spatial resolution. Time-varying Cox proportional hazard regression models were used to estimate hazard ratios (HRs) for all-cause and cause-specific CVDs associated with PM2.5, adjusting for conventional covariates. During 5.08 million person-years of follow-up, 148,030 incident cases of CVD were identified. Long-term exposure to PM2.5 showed positive and linear association with incidence of CVD, without a threshold below any concentration. The adjusted HRs per 10 μg/m3 increase in PM2.5 was 1.04 (95%CI: 1.02, 1.07) for total CVD. The risk estimates differed between certain population subgroups, with greater HRs in men, in household with higher income, and in people using unclean heating fuels. This prospective study of large Chinese population provided essential epidemiological evidence for CVD incident risk associated with PM2.5.
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Affiliation(s)
- Cong Liu
- School
of Public Health, Key Lab of Public Health Safety of the Ministry
of Education, NHC Key Lab of Health Technology Assessment, IRDR ICoE
on Risk Interconnectivity and Governance on Weather/Climate Extremes
Impact and Public Health, Fudan University, Shanghai 200032, China
| | - Ka Hung Chan
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
- Oxford
British Heart Foundation Center of Research Excellence, University of Oxford, Oxford OX3 7LF, UK
| | - Jun Lv
- Department
of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China
- Peking
University Center for Public Health and Epidemic Preparedness &
Response, Beijing 100191, China
- Key Laboratory
of Molecular Cardiovascular Sciences (Peking University), Ministry
of Education, Beijing 100191, China
| | - Hubert Lam
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Katherine Newell
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Xia Meng
- School
of Public Health, Key Lab of Public Health Safety of the Ministry
of Education, NHC Key Lab of Health Technology Assessment, IRDR ICoE
on Risk Interconnectivity and Governance on Weather/Climate Extremes
Impact and Public Health, Fudan University, Shanghai 200032, China
| | - Yang Liu
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Renjie Chen
- School
of Public Health, Key Lab of Public Health Safety of the Ministry
of Education, NHC Key Lab of Health Technology Assessment, IRDR ICoE
on Risk Interconnectivity and Governance on Weather/Climate Extremes
Impact and Public Health, Fudan University, Shanghai 200032, China
| | - Christiana Kartsonaki
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Neil Wright
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Huaidong Du
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Ling Yang
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Yiping Chen
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Yu Guo
- Fuwai
Hospital Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Pei Pei
- Fuwai
Hospital Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Canqing Yu
- Department
of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China
- Peking
University Center for Public Health and Epidemic Preparedness &
Response, Beijing 100191, China
| | - Hongbing Shen
- Department
of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing 211166, China
| | - Tangchun Wu
- School
of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Haidong Kan
- School
of Public Health, Key Lab of Public Health Safety of the Ministry
of Education, NHC Key Lab of Health Technology Assessment, IRDR ICoE
on Risk Interconnectivity and Governance on Weather/Climate Extremes
Impact and Public Health, Fudan University, Shanghai 200032, China
| | - Zhengming Chen
- Clinical
Trial Service Unit & Epidemiological Studies Unit, Nuffield Department
of Population Health, University of Oxford, Oxford OX3 7LF, UK
- MRC
Population Health Research Unit, Nuffield Department of Population
Health, University of Oxford, Oxford OX3 7LF, United Kingdom
| | - Liming Li
- Department
of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China
- Peking
University Center for Public Health and Epidemic Preparedness &
Response, Beijing 100191, China
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22
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Schwartz GG, Giugliano RP. Proprotein convertase subtilisin/kexin type 9 inhibition after acute coronary syndrome or prior myocardial infarction. Curr Opin Lipidol 2022; 33:147-159. [PMID: 35695614 DOI: 10.1097/mol.0000000000000830] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Lowering low-density lipoprotein cholesterol (LDL-C) with statins or ezetimibe reduces major adverse cardiovascular events (MACE) in patients with coronary heart disease. Additional treatment with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may lower LDL-C to levels not achievable with conventional lipid-lowering agents. This review summarizes findings from two large, placebo-controlled trials that evaluated the cardiovascular efficacy of monoclonal antibodies directed against PCSK9, added to background statin therapy, in patients with established atherosclerotic cardiovascular disease (ASCVD) or recent acute coronary syndrome (ACS) and persistent elevation of atherogenic lipoproteins despite statin treatment. RECENT FINDINGS The FOURIER trial with evolocumab and the ODYSSEY OUTCOMES trial with alirocumab demonstrated 15% overall reductions in MACE compared to placebo, associated with average achieved LDL-C levels as low as 30-40 mg/dl. Alirocumab treatment was associated with fewer deaths after ACS. Subgroups with large absolute treatment benefit included those with baseline LDL-C ≥100 mg/dl, diabetes, polyvascular or peripheral artery disease, prior coronary bypass surgery, statin intolerance, or elevated lipoprotein(a) levels. No safety concerns arose with use of PCSK9 monoclonal antibodies, even in patients who achieved LDL-C levels below 20 mg/dl. SUMMARY In selected patients with established ASCVD or recent ACS, PCSK9 inhibitors can play an important role in reducing the risk of MACE, and may also reduce the risk of death after ACS.
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Affiliation(s)
- Gregory G Schwartz
- Cardiology Section, Rocky Mountain Regional VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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23
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Ostadal P, Steg PG, Poulouin Y, Bhatt DL, Bittner VA, Chua T, Diaz R, Goodman SG, Huo Y, Jukema JW, Karpov Y, Pordy R, Scemama M, Szarek M, White HD, Schwartz GG. Metabolic risk factors and effect of alirocumab on cardiovascular events after acute coronary syndrome: a post-hoc analysis of the ODYSSEY OUTCOMES randomised controlled trial. Lancet Diabetes Endocrinol 2022; 10:330-340. [PMID: 35378068 DOI: 10.1016/s2213-8587(22)00043-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/14/2022] [Accepted: 02/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many patients with acute coronary syndrome have concurrent metabolic risk factors that affect risk of major adverse cardiovascular events (MACE). We aimed to assess the effects of the PCSK9 inhibitor alirocumab compared with placebo on MACE according to baseline metabolic risk factors. METHODS We performed a post-hoc analysis of the ODYSSEY OUTCOMES trial, which was a multicentre, double-blind, randomised controlled trial done in 1315 hospitals and outpatient clinics in 57 countries. Patients aged 40 years or older with recent acute coronary syndrome (ie, in the past 1-12 months) and elevated concentrations of atherogenic lipoproteins, despite high-intensity or maximum-tolerated statin treatment, were eligible for enrolment. Between Nov 2, 2012, and Feb 9, 2017, patients were randomly assigned (1:1) to 75 mg alirocumab by subcutaneous injection every 2 weeks or matching placebo, beginning 1-12 months after acute coronary syndrome and were followed up for a median of 2·8 years (IQR 2·3-3·4). Patients and investigators were masked to group assignment and treatment dose adjustment. The primary outcome was a composite of death from coronary artery disease, non-fatal myocardial infarction, fatal or non-fatal ischaemic stroke, or unstable angina requiring hospital admission. Analysis of MACE according to an ordinal number of metabolic risk factors was done post hoc. Metabolic risk factors were defined as blood pressure of at least 130/85 mm Hg or treatment with antihypertensive medication, triglyceride concentration of at least 150 mg/dL, HDL cholesterol concentration less than 40 mg/dL for men and 50 mg/dL women, fasting plasma glucose concentration of at least 100 mg/dL or treatment with glucose-lowering medication, and BMI of at least 30 kg/m2. Risk of MACE and effect of alirocumab were assessed according to the number of metabolic risk factors. ODYSSEY OUTCOMES is registered with ClinicalTrials.gov, number NCT01663402. FINDINGS Of 18 924 patients, 3882 (41%) of 9462 in the alirocumab group and 3859 (41%) of 9462 in the placebo group had three or more metabolic risk factors. In the placebo group, MACE incidence increased monotonically with each metabolic risk factor from 7·8% (no risk factors) to 19·6% (five risk factors; HR 1·18, 95% CI 1·13-1·24 per metabolic risk factor). Alirocumab decreased relative risk of MACE consistently across categories defined by the number of metabolic risk factors (pinteraction=0·77), but absolute risk reduction (aRR) increased with the number of metabolic risk factors (no risk factors aRR 0·7%, -1·81 to 3·29 vs five risk factors aRR 3·9%, -1·45 to 9·25; pinteraction<0·001). Similarly, when patients with diabetes were excluded, the incidence of MACE in the placebo group increased from 7·7% in patients with no metabolic risk factors to 14·6% in those with five metabolic risk factors and aRR with alirocumab increased from 0·91% in patients with no metabolic risk factors to 3·82% in those with five factors. Alirocumab was well tolerated in all subgroups defined by the presence of metabolic risk factors. INTERPRETATION Accumulation of metabolic risk factors was associated with higher risk of MACE in patients with recent acute coronary syndrome. Alirocumab reduced MACE consistently, but aRR increased with number of metabolic risk factors. FUNDING Sanofi and Regeneron Pharmaceuticals.
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Affiliation(s)
| | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials, Université de Paris, Assistance Publique-Hôpitaux de Paris, and INSERM U1148, Hôpital Bichat, Paris, France; Imperial College, Royal Brompton Hospital, London, UK
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Terrence Chua
- National Heart Centre, Singapore General Hospital, Singapore
| | - Rafael Diaz
- Estudios Cardiológicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada; St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yong Huo
- Peking University First Hospital, Beijing, China
| | - Johan Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands; Netherlands Heart Institute, Utrecht, Netherlands
| | - Yuri Karpov
- National Medical Research Centre of Cardiology, Moscow, Russia
| | | | | | - Michael Szarek
- State University of New York, Downstate School of Public Health, Brooklyn, NY, USA; CPC Clinical Research and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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24
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Theofilis P, Vordoni A, Koukoulaki M, Vlachopanos G, Kalaitzidis RG. Dyslipidemia in Chronic Kidney Disease: Contemporary Concepts and Future Therapeutic Perspectives. Am J Nephrol 2021; 52:693-701. [PMID: 34569479 DOI: 10.1159/000518456] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an increasingly prevalent disease state met with great morbidity and mortality primarily resulting from the high incidence of adverse cardiovascular outcomes. Therapeutic strategies in this patient population aim at controlling modifiable cardiovascular risk factors, including dyslipidemia. SUMMARY In this review article, we first provide the latest pathophysiologic evidence regarding the altered dyslipidemia pattern in CKD, followed by its contemporary management according to the latest guidelines. Moreover, we present the current progress regarding the emerging therapeutic strategies. Key Messages: The presence of renal impairment leads to alterations in cholesterol structure, metabolism, and reverse transport paired with increased oxidative stress. Statins remain the cornerstone of dyslipidemia management in patients with kidney dysfunction who are at risk for cardiovascular events. However, their efficacy is debatable in end-stage renal disease under renal replacement therapy. Therefore, novel treatment approaches aiming at hypertriglyceridemia, proprotein convertase subtilisin/kexin type 9, and lipoprotein(a) are under rigorous investigation while the research of gut microbiome might provide additional mechanistic and therapeutic insight.
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Affiliation(s)
| | - Aikaterini Vordoni
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
| | - Maria Koukoulaki
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
| | | | - Rigas G Kalaitzidis
- Department of Nephrology, General Hospital of Nikaia-Piraeus, Athens, Greece
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25
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Is a treat-to-target approach to lipid-lowering therapy appropriate in patients with chronic kidney disease? A prospective French cohort study. J Nephrol 2021; 34:1467-1477. [PMID: 34117621 DOI: 10.1007/s40620-021-01086-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Whereas European guidelines recommend adjusting lipid-lowering therapy (LLT) to meet prespecified targets ('treat-to-target') for low-density lipoprotein cholesterol (LDL-C), other guidelines do not ('fire and forget'). In a large observational prospective cohort, we sought to evaluate which strategy could be associated with better cardiovascular outcomes in chronic kidney disease (CKD). METHODS In CKD-REIN, patients (CKD stages 3 and 4) on LLT were categorized according to achievement of LDL-C targets for high and very high cardiovascular risk (< 2.6 and < 1.8 mmol/L, respectively) at baseline. Primary outcome was fatal/non-fatal atheromatous cardiovascular disease (CVD). Secondary outcomes were non-atheromatous CVD, atheromatous or non-atheromatous CVD, and major adverse cardiovascular events. RESULTS The population comprised 1521 patients (68 ± 12 years, 31% women, mean estimated glomerular filtration rate [eGFR] 35 mL/min/1.73 m2). Overall, 523 (34%) met their LDL-C targets at baseline. Median follow-up was 2.9 years (interquartile range 2.2-3.0). Incidence rates per 100 patient-years were 6.2% (95% confidence interval [CI] 5.5-7.0) for atheromatous CVD, 9.2% (8.3-10.1) for non-atheromatous CVD, 15.2% (14.0-16.4) for atheromatous/non-atheromatous CVD, and 6.3% (5.5-7.1) for major adverse cardiovascular events. Corresponding rates in patients who achieved targets were 6.6%, 9.8%, 16.1%, and 6.3%, respectively. Target achievement was not associated with risk of fatal/non-fatal atheromatous CVD (adjusted hazard ratio 1.04, 95% CI 0.76-1.44, p = 0.77) or fatal/non-fatal atheromatous or non-atheromatous CVD (0.98, 0.78-1.23, p = 0.91). CONCLUSIONS These findings do not appear to support a treat-to-target approach in CKD patients on LLT, and may favor the hypothesis of an advantage of fire-and-forget. Randomized trials are needed to confirm this theory.
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26
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Shrestha P, Adepu S, Vivès RR, Masri RE, Klooster A, Kaptein F, Dam W, Bakker SJL, van Goor H, van de Sluis B, van den Born J. Hypercholesterolemia in Progressive Renal Failure Is Associated with Changes in Hepatic Heparan Sulfate - PCSK9 Interaction. J Am Soc Nephrol 2021; 32:1371-1388. [PMID: 33758009 PMCID: PMC8259657 DOI: 10.1681/asn.2020091376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/04/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Dyslipidemia is an important risk factor in CKD. The liver clears triglyceride-rich lipoproteins (TRL) via LDL receptor (LDLR), LDLR-related protein-1 (LRP-1), and heparan sulfate proteoglycans (HSPGs), mostly syndecan-1. HSPGs also facilitate LDLR degradation by proprotein convertase subtilisin/kexin type 9 (PCSK9). Progressive renal failure affects the structure and activity of hepatic lipoprotein receptors, PCSK9, and plasma cholesterol. METHODS Uninephrectomy- and aging-induced CKD in normotensive Wistar rats and hypertensive Munich-Wistar-Frömter (MWF) rats. RESULTS Compared with 22-week-old sex- and strain-matched rats, 48-week-old uninephrectomized Wistar-CKD and MWF-CKD rats showed proteinuria, increased plasma creatinine, and hypercholesterolemia (all P<0.05), which were most apparent in hypertensive MWF-CKD rats. Hepatic PCSK9 expression increased in both CKD groups (P<0.05), with unusual sinusoidal localization, which was not seen in 22-week-old rats. Heparan sulfate (HS) disaccharide analysis, staining with anti-HS mAbs, and mRNA expression of HS polymerase exostosin-1 (Ext-1), revealed elongated HS chains in both CKD groups. Solid-phase competition assays showed that the PCSK9 interaction with heparin-albumin (HS-proteoglycan analogue) was critically dependent on polysaccharide chain length. VLDL binding to HS from CKD livers was reduced (P<0.05). Proteinuria and plasma creatinine strongly associated with plasma cholesterol, PCSK9, and HS changes. CONCLUSIONS Progressive CKD induces hepatic HS elongation, leading to increased interaction with PCSK9. This might reduce hepatic lipoprotein uptake and thereby induce dyslipidemia in CKD. Therefore, PCSK9/HS may be a novel target to control dyslipidemia.
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Affiliation(s)
- Pragyi Shrestha
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Saritha Adepu
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Romain R. Vivès
- University Grenoble Alpes, Centre National de la Recherche Scientifique (CNRS), Commissariat à l’Energie Atomique (CEA), Institute of Structural Biology, Grenoble, France
| | - Rana El Masri
- University Grenoble Alpes, Centre National de la Recherche Scientifique (CNRS), Commissariat à l’Energie Atomique (CEA), Institute of Structural Biology, Grenoble, France
| | - Astrid Klooster
- Department of Pathology, Pathology Friesland, Leeuwarden, The Netherlands
| | - Fleur Kaptein
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wendy Dam
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J. L. Bakker
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart van de Sluis
- Department Pediatrics, Section of Molecular Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacob van den Born
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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27
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Zheng PP, Yao SM, Guo D, Cui LL, Miao GB, Dong W, Wang H, Yang JF. Prevalence and Prognostic Value of Heart Failure Stages: An Elderly Inpatient Based Cohort Study. Front Med (Lausanne) 2021; 8:639453. [PMID: 33968953 PMCID: PMC8100028 DOI: 10.3389/fmed.2021.639453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/26/2021] [Indexed: 11/27/2022] Open
Abstract
Background: The prevalence and prognostic value of heart failure (HF) stages among elderly hospitalized patients is unclear. Methods: We conducted a prospective, observational, multi-center, cohort study, including hospitalized patients with the sample size of 1,068; patients were age 65 years or more, able to cooperate with the assessment and to complete the echocardiogram. Two cardiologists classified all participants in various HF stages according to 2013 ACC/AHA HF staging guidelines. The outcome was rate of 1-year major adverse cardiovascular events (MACE). The Kaplan–Meier method and Cox proportional hazards models were used for survival analyses. Survival classification and regression tree analysis were used to determine the optimal cutoff of N-terminal pro-brain natriuretic peptide (NT-proBNP) to predict MACE. Results: Participants' mean age was 75.3 ± 6.88 years. Of them, 4.7% were healthy and without HF risk factors, 21.0% were stage A, 58.7% were stage B, and 15.6% were stage C/D. HF stages were associated with worsening 1-year survival without MACE (log-rank χ2 = 69.62, P < 0.001). Deterioration from stage B to C/D was related to significant increases in HR (3.636, 95% CI, 2.174–6.098, P < 0.001). Patients with NT-proBNP levels over 280.45 pg/mL in stage B (HR 2; 95% CI 1.112–3.597; P = 0.021) and 11,111.5 pg/ml in stage C/D (HR 2.603, 95% CI 1.014–6.682; P = 0.047) experienced a high incidence of MACE adjusted for age, sex, and glomerular filtration rate. Conclusions : HF stage B, rather than stage A, was most common in elderly inpatients. NT-proBNP may help predict MACE in stage B. Trial Registration: ChiCTR1800017204; 07/18/2018.
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Affiliation(s)
- Pei-Pei Zheng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Si-Min Yao
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Di Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ling-Ling Cui
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Guo-Bin Miao
- Department of Cardiology, Tsinghua University Affiliated Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Wei Dong
- Department of Cardiology, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Hua Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jie-Fu Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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28
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Abstract
Purpose of review Based on the recent data of the DA VINCI study, it is clear that, besides utilization of statins, there is a need to increase non-statin lipid lowering approaches to reduce the cardiovascular burden in patients at highest risk. Recent findings For hypercholesterolemia, the small synthetic molecule bempedoic acid has the added benefit of selective liver activation, whereas inclisiran, a hepatic inhibitor of the PCSK9 synthesis, has comparable effects with PCSK9 monoclonal antibodies. For hypertriglyceridemia, cardiovascular benefit has been achieved by the use of icosapent ethyl, whereas results with pemafibrate, a selective agonist of PPAR-α, are eagerly awaited. In the era of RNA-based therapies, new options are offered to dramatically reduce levels of lipoprotein(a) (APO(a)LRX) and of triglycerides (ANGPTL3LRX and APOCIII-LRx). Summary Despite the demonstrated benefits of statins, a large number of patients still remain at significant risk because of inadequate LDL-C reduction or elevated blood triglyceride-rich lipoproteins or lipoprotein(a). The area of lipid modulating agents is still ripe with ideas and major novelties are to be awaited in the next few years.
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29
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Crea F. New challenges in the management of acute coronary syndromes: residual risk and sex-related inequalities. Eur Heart J 2020; 41:4075-4078. [DOI: 10.1093/eurheartj/ehaa900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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