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Jamil YA, Cohen R, Alameddine DK, Deo SV, Kumar M, Orkaby AR. Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence? Curr Atheroscler Rep 2024; 26:521-536. [PMID: 38958924 DOI: 10.1007/s11883-024-01224-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies. RECENT FINDINGS The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.
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Affiliation(s)
- Yasser A Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Dana K Alameddine
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Salil V Deo
- Cleveland VA Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Manish Kumar
- Albert Einstien College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, 150 S Huntington St, Boston, MA, 02130, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Park DY, Jamil Y, Frampton J, Damluji AA, Nanna MG. Trend of Controlled Low-Density Lipoprotein Cholesterol in Older Adults With a History of Myocardial Infarction or Stroke. JACC. ADVANCES 2024; 3:101091. [PMID: 39099776 PMCID: PMC11294686 DOI: 10.1016/j.jacadv.2024.101091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Affiliation(s)
| | - Yasser Jamil
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Abdulla Al Damluji
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Inova Center of Outcomes Research, Falls Church, Virginia, USA
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Kopp K, Motloch LJ, Wernly B, Berezin AE, Maringgele V, Dieplinger A, Hoppe UC, Lichtenauer M. Implementation of risk-based lipid-lowering therapies in older (age ≥ 65 years) and very-old adults (age ≥ 75 years) with ischemic heart disease in the greater Salzburg region. Front Pharmacol 2024; 15:1357334. [PMID: 38966548 PMCID: PMC11223559 DOI: 10.3389/fphar.2024.1357334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/17/2024] [Indexed: 07/06/2024] Open
Abstract
Introduction: European guidelines recommend the implementation of lipid-lowering therapies (LLTs) in adults (≥ 65 years) with established atherosclerotic cardiovascular disease (ASCVD) and for risk-based primary prevention in older adults (≤ 75 years), yet their use in very-old adults (> 75 years) is controversial, discretionary, and oriented on the presence of risk factors. The aim of this retrospective study is to assess guideline-directed LLT implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in high-/very-high-risk older/very-old adults (65-74 and ≥ 75 years) at presentation for ST-segment elevation myocardial infarction (STEMI) and also to assess evidence-based care delivery to older adults in our region. Methods: All STEMI patients with available LDL-C and total cholesterol presenting for treatment at a large tertiary center in Salzburg, Austria, 2018-2020, were screened (n = 910). High-risk/very-high-risk patients (n = 369) were classified according to European guidelines criteria and divided into cohorts by age: < 65 years (n = 152), 65-74 years (n = 104), and ≥ 75 years (n = 113). Results: Despite being at high-/very-high-risk, prior LLT use was < 40% in the total cohort, with no significant difference by age. Statin monotherapy predominated; 20%-23% of older/very-old adults in the entire cohort were using low-/moderate-intensity stains, 11%-13% were using high-intensity statins, 4% were on ezetimibe therapy, and none were taking proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In the secondary prevention cohort, 53% of older/very-old patients used prior LLTs. Significantly higher percentages of older/oldest ASCVD patients (43% and 49%) met LDL-C targets < 70 mg/dL compared to patients < 65 years (29%; p = 0.033), although just 22% and 30% of these older groups attained stricter LDL-C targets of < 55 mg/dL. Low LLT uptake (16%) among older adults aged 64-74 years for primary prevention resulted in 17% and 10% attainment of risk-based LDL-C targets < 70 mg/dL and < 55 mg/dL, respectively. Oldest adults (≥ 75 years) in both primary and secondary prevention groups more often met risk-based targets than older and younger adults, despite predominantly receiving low-/moderate-intensity statin monotherapy. Conclusion: Secondary prevention was sub-optimal in our region. Less than half of older/very-old adults with established ASCVD met LDL-C targets at the time of STEMI, suggesting severe care-delivery deficits in LLT implementation. Shortcomings in initiation of risk-based LLTs were also observed among high-/very-high-risk primary prevention patients < 75 years, with the achievement of risk-based LDL-C targets in 10%-48% of these patients.
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Affiliation(s)
- Kristen Kopp
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Lukas J. Motloch
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
- Department of Internal Medicine II, Salzkammergut Klinikum, OOEG, Voecklabruck, Austria
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Bernhard Wernly
- Institute for General-, Family- and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alexander E. Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Victoria Maringgele
- Department of Psychiatry, Psychotherapy and Psychosomatics, Paracelsus Medical University, Salzburg, Austria
| | - Anna Dieplinger
- Institute for Nursing and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
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Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
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Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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Zhao J, Chen R, Luo M, Gong H, Li K, Zhao Q. Lipid-lowering drugs and inflammatory bowel disease's risk: a drug-target Mendelian randomization study. Diabetol Metab Syndr 2024; 16:12. [PMID: 38191425 PMCID: PMC10775535 DOI: 10.1186/s13098-023-01252-1] [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: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) has been associated with lipid-lowering drugs in observational studies. Drug-target Mendelian randomization (MR) was utilized in this study to examine the causal relationship between lipid-lowering drugs and incidence of IBD, aiming to identify new preventive uses for the drugs. METHODS We identified instrumental variables for three classes of lipid-lowering drugs: HMGCR inhibitors, PCSK9 inhibitors, and NPC1L1 inhibitors, using data from the Global Lipids Genetics Consortium. Summary statistics of IBD were obtained from UK Inflammatory Bowel Disease Genetics. The summary-data-based MR (SMR) and the inverse-variance weighted (IVW) MR were used for analysis. Sensitivity analyses were performed by conventional MR methods. RESULTS The SMR analysis showed no significant genetic association between increased gene expression of HMGCR, PCSK9, and NPC1L1 and IBD, Crohn's disease (CD) and ulcerative colitis (UC). According to IVW-MR analysis, increased HMGCR expression is associated with a reduced risk of IBD (OR = 0.73, 95% confidence interval (CI) 0.59-0.90, P = 0.003) and CD (OR = 0.75, 95% CI 0.57-0.97, P = 0.03), but not with UC. Additionally, increased NPC1L1 gene expression was associated with elevated risk of IBD (OR = 1.60, 95% CI 1.07-2.40, P = 0.023), but not with CD and UC. However, no significant causal relationships were found between PCSK9 gene expression and IBD, CD, and UC. The sensitivity analysis demonstrated no evidence of heterogeneity or pleiotropy among the reported results. CONCLUSIONS The heightened expression of genetic variations in HMGCR inhibitor targets could potentially reduce the risk of IBD and CD, while genetic variation in the expression of NPC1L1 targets was positively associated with IBD.
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Affiliation(s)
- Jiaxi Zhao
- General Practice Ward/International Medical Center Ward General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Rong Chen
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Mengqi Luo
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongping Gong
- General Practice Ward/International Medical Center Ward General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Kaixin Li
- Department of Nephrology, Huadong Hospital, Shanghai, China
| | - Qian Zhao
- General Practice Ward/International Medical Center Ward General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Mosher CL, Osazuwa-Peters OL, Nanna MG, MacIntyre NR, Que LG, Jones WS, Palmer SM, O’Brien EC. Risk of Atherosclerotic Cardiovascular Disease Hospitalizations after COPD Hospitalization among Older Adults. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.19.23300254. [PMID: 38196600 PMCID: PMC10775335 DOI: 10.1101/2023.12.19.23300254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Meta-analyses have suggested the risk of atherosclerotic cardiovascular disease (ASCVD) events is significantly higher after a chronic obstructive pulmonary disease (COPD) exacerbation. However, these studies have been limited to highly selected patient populations potentially not generalizable to the broader population of COPD. METHODS We assessed the risk of ASCVD hospitalizations after COPD hospitalization compared to before COPD hospitalization and identified patient factors associated with ASCVD hospitalizations after COPD hospitalization. This retrospective cohort study used claims data from 920,550 Medicare beneficiaries hospitalized for COPD from 2016-2019 in the US. The primary outcome was risk of a ASCVD hospitalization composite outcome (myocardial infarction, percutaneous coronary intervention, coronary artery by-pass graft surgery, stroke, or transient ischemic attack) in the 1 year after-COPD hospitalization relative to the 1 year before-COPD hospitalization. Time from discharge to a composite ASCVD hospitalization outcome was modeled using an extension of the Cox Proportional-Hazards model, the Anderson-Gill model with adjustment for patient characteristics. Additional analyses evaluated for interactions in subgroups and risk factors associated with the composite ASCVD hospitalization outcome. RESULTS Among 920,550 patients (mean age, 73 years) the hazard ratio estimate (HR; 95% CI) for the composite ASCVD hospitalization outcome after-COPD hospitalization vs before-COPD hospitalization was 0.99 (0.97, 1.02; p = 0.53) following adjustment. We observed 3 subgroups that were significantly associated with higher risk for ASCVD hospitalizations after COPD hospitalization: 76+ years old, women, COPD hospitalization severity. Among the 19 characteristics evaluated, 10 were significantly associated with higher risk of CVD events 1 year after COPD hospitalization with hyperlipidemia (2.78; 2.67, 2.90) and history of cardiovascular disease (1.77; 1.72 1.83) associated with the greatest risk. CONCLUSION Among Medicare beneficiaries hospitalized for COPD, the risk of ASCVD hospitalizations was not significantly increased after COPD-hospitalization relative to before-COPD hospitalization. Although, we identified age 76+ years old, female sex, and COPD hospitalization severity as high risk subgroups and 10 risk factors associated with increased risk of ASCVD events after-COPD hospitalization. Further research is needed to characterize the COPD exacerbation populations at highest ASCVD hospitalization risk.
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Affiliation(s)
- Christopher L. Mosher
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Neil R. MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
| | - Loretta G. Que
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Division of Cardiovascular Disease, Duke University School of Medicine, Durham, NC
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Emily C. O’Brien
- Duke Clinical Research Institute, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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PCSK9 Inhibitors in Cancer Patients Treated with Immune-Checkpoint Inhibitors to Reduce Cardiovascular Events: New Frontiers in Cardioncology. Cancers (Basel) 2023; 15:cancers15051397. [PMID: 36900189 PMCID: PMC10000232 DOI: 10.3390/cancers15051397] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Cancer patients treated with immune checkpoint inhibitors (ICIs) are exposed to a high risk of atherosclerosis and cardiometabolic diseases due to systemic inflammatory conditions and immune-related atheroma destabilization. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key protein involved in metabolism of low-density lipoprotein (LDL) cholesterol. PCSK9 blocking agents are clinically available and involve monoclonal antibodies, and SiRNA reduces LDL levels in high-risk patients and atherosclerotic cardiovascular disease events in multiple patient cohorts. Moreover, PCSK9 induces peripheral immune tolerance (inhibition of cancer cell- immune recognition), reduces cardiac mitochondrial metabolism, and enhances cancer cell survival. The present review summarizes the potential benefits of PCSK9 inhibition through selective blocking antibodies and siRNA in patients with cancer, especially in those treated with ICIs therapies, in order to reduce atherosclerotic cardiovascular events and potentially improve ICIs-related anticancer functions.
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