Comparison of the efficacy and safety of intensive-dose and standard-dose statin treatment for stroke prevention: A meta-analysis

Lipid-Lowering Therapy and Hemorrhagic Stroke Risk: Comparative Meta-Analysis of Statins and PCSK9 Inhibitors

BACKGROUND AND PURPOSE

Statins were shown to increase hemorrhagic stroke (HS) in patients with a first cerebrovascular event in 2006 (SPARCL), likely due to off-target antithrombotic effects, but continued to sometimes be used in patients with elevated HS risk due to absence of alternative medications. Recently, the PCSK9Is (proprotein convertase subtilisin kexin 9 inhibitors) have become available as a potent lipid-lowering class with potentially less hemorrhagic propensity.

METHODS

We performed a systematic comparative meta-analysis assessing HS rates across all completed statin and PCSK9I randomized clinical trials with treatment >3 months, following PRISMA guidelines. In addition to HS rates across all trials, causal relation was probed by evaluating for dose-response relationships by medication (low versus high medication dose/potency) and by presence and type of preceding brain vascular events at inception (none versus ischemic stroke/transient ischemic attack versus HS).

RESULTS

The systematic review identified 36 statin randomized clinical trials (204 918 patients) and 5 PCSK9I randomized clinical trials (76 140 patients). Across all patient types and all medication doses/potencies, statins were associated with increased HS: relative risk 1.15, P=0.04; PCSK9Is were not (P=0.77). In the medication dose/potency analysis, higher dose/potency statins (7 trials, 62 204 patients) were associated with magnified HS risk: relative risk, 1.53; P=0.002; higher dose/potency PCSK9Is (1 trial, 27 564 patients) were not (P=0.99). In the type of index brain vascular injury analysis for statins (5 trials, 9772 patients), prior ischemic stroke/transient ischemic attack was associated with a magnified risk of HS: relative risk, 1.43; P=0.04; and index intracerebral hemorrhage was associated with an extremely high effect estimate of risk of recurrent HS: hazard ratio, 4.06. For PCSK9Is, prior ischemic stroke/transient ischemic attack (1 trial, 5337 patients) was not associated with increased HS risk (P=0.97).

CONCLUSIONS

Statins increase the risk of HS in a medication dose- and type of index brain vascular injury-dependent manner; PCSK9Is do not increase HS risk. PCSK9Is may be a preferred lipid-lowering medication class in patients with elevated HS risk, including patients with prior HS.

Level of Control of Dyslipidemia Among Patients Followed in Family Medicine Clinics in Riyadh, Saudi Arabia

Background Dyslipidemia is a well-established primary risk factor leading to atherosclerotic cardiovascular disease (ASCVD). Treatment with lifestyle modification and lipid-lowering agents has been shown to reduce ASCVD morbidity and mortality. Objectives To explore the level of dyslipidemia control among patients followed in family medicine (FM) clinics and describe the prescribing pattern of lipid-lowering agents. Materials and methods This is a chart review cross-sectional observational study conducted over 382 patients who were followed in FM clinics at King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia, from January 2016 to January 2019. The data were extracted from the electronic medical record system (BESTCare) and analyzed using Statistical Package for the Social Sciences (SPSS), version 23 (IBM Corp., Armonk, NY) to look for the association. Result All patients had a reduction in their lipid parameters over the three years follow-up period. The mean low-density lipoprotein cholesterol (LDL-C) for the total sample was (2.783 ± 0.850) mmol/L. 82.1% were using a statin alone, 6% were using statin plus fenofibrate, and 12.8% were switched from one statin to another. Those who had statin plus fenofibrate and those switched from one statin to another had the most reduction in their LDL, TC, and TG. Conclusion Most of the patients visiting the Ministry of National Guard - Health Affairs (MNG-HA), Riyadh, Saudi Arabia, showed a continuous reduction in their lipid profile over the follow-up period; with better control for high-risk patients. Many factors may have contributed to the reduction, like the number of clinic visits, dietician, and health educator visits, along with the type of medication used.

Impact of changing reimbursement criteria on statin treatment patterns among patients with atherosclerotic cardiovascular disease or cardiovascular risk factors

WHAT IS KNOWN AND OBJECTIVE

Starting 1 August 2013, the eligible cholesterol level for statin reimbursement in patients with atherosclerotic cardiovascular disease (ASCVD) or cardiovascular disease (CVD)-related risk factors changed from LDL-C ≥ 130 mg/dl (or TC ≥ 200 mg/dl) to LDL-C ≥ 100 mg/dl (or TC ≥ 160 mg/dl) in Taiwan, which may modify clinician prescribing behaviours. We aimed to evaluate the impact of changing reimbursement criteria on statin treatment patterns.

METHODS

A before-after cohort design was conducted using Taiwan's National Health Insurance Research Database. Differences in statin treatment patterns between the pre- and postregulation periods were compared. Two prespecified study cohorts were identified to examine the impacts of this change on those who need statins for "secondary prevention" (patients newly diagnosed with ASCVD) and those who need statins for "primary prevention" (patients newly diagnosed with CVD-related risk factors, such as diabetes mellitus [DM]). Treatment patterns measured in this study included initiation, discontinuation, switching, dose increase, dose decrease and dose maximization.

RESULTS

The proportion of patients who initiated statins during the postregulation period was higher than that of patients who initiated statins during the preregulation period (eg coronary heart disease (CHD) patients, pre- vs. postregulation: 41.23% vs. 48.25%). Notably, only 30%-40% of patients initiated statin use in the postregulation period across different conditions. In addition, the proportion of patients who discontinued statins remained very high. Even in the postregulation period, more than half of CHD patients discontinued statins during the 1-year follow-up period (eg CHD patients, pre- vs. postregulation: 59.07% vs. 52.75%).

WHAT IS NEW AND CONCLUSION

The new reimbursement criteria started on 1 August 2013 seemed to lower the barriers of access to the first statin prescription among patients with CHD, cerebrovascular disease (CBVD) and DM. Nevertheless, the proportion of patients who initiated statin use was suboptimal, and the proportion of patients who discontinued statins was very high in the postregulation period.

Association of Apolipoprotein E Gene Polymorphism with Ischemic Stroke in Coronary Heart Disease Patients Treated with Medium-intensity Statins

OBJECTIVE

To study the association of apolipoprotein E(APOE) gene polymorphism with ischemic stroke (IS) in coronary heart disease (CHD) patients treated with medium-intensity statins.

METHODS

The retrospective study was performed on 662 samples including 169 CHD subjects complicated with IS, 296 subjects with CHD, and 197 control subjects. The APOE gene was obtained from case files. Univariable and multivariable logistic regression analyses were utilized to recognize the possible risks of CHD and IS.

RESULTS

The frequency of ε3-ε4 genotype was increased in the CHD group (p=0.013) and CHD-IS group (p=0.001), the frequency of ε4 allele was also increased in the CHD group (p=0.047) and the CHD-IS group (p=0.009) compared with control group. ε3-ε4 genotype was the independent risk for CHD and CHD-IS after adjusting for traditional risk factors with adjusted odds ratio (AOR) 2.210, 95%CI: 1.263-3.867, p=0.005) and (AOR 2.794, 95%CI: 1.539-5.072, p=0.002). The ε4 allele was also significantly associated with CHD (AOR 2.126, 95%CI: 1.265-3.575,=0.004) and CHD-IS (AOR 2.740, 95%CI: 1.569-4.784, p=0.001).

CONCLUSION

These results demonstrated that ε4 allele influenced the development of CHD with or without IS, especially for the genotype of ε3-ε4. CHD patients carrying the ε3-ε4 genotype and the ε4 allele were significantly associated with the incidence of IS, even if medium-intensity statins had been used.

Treatment Strategy for Dyslipidemia in Cardiovascular Disease Prevention: Focus on Old and New Drugs

Prevention and treatment of dyslipidemia should be considered as an integral part of individual cardiovascular prevention interventions, which should be addressed primarily to those at higher risk who benefit most. To date, statins remain the first-choice therapy, as they have been shown to reduce the risk of major vascular events by lowering low-density lipoprotein cholesterol (LDL-C). However, due to adherence to statin therapy or statin resistance, many patients do not reach LDL-C target levels. Ezetimibe, fibrates, and nicotinic acid represent the second-choice drugs to be used in combination with statins if lipid targets cannot be reached. In addition, anti-PCSK9 drugs (evolocumab and alirocumab) provide an effective solution for patients with familial hypercholesterolemia (FH) and statin intolerance at very high cardiovascular risk. Recently, studies demonstrated the effects of two novel lipid-lowering agents (lomitapide and mipomersen) for the management of homozygous FH by decreasing LDL-C values and reducing cardiovascular events. However, the costs for these new therapies made the cost–effectiveness debate more complicated.