Statins for the Primary Prevention of Coronary Heart Disease

Simvastatin, Its Antimicrobial Activity and Its Prevention of Alzheimer's Disease

Simvastatin, a blockbuster drug for treating hypercholesterolemia, has multifactorial benefits as an antimicrobial agent and plays a preventative role in reducing the incidence of Alzheimer's Disease (AD). Although most of the beneficial effects of simvastatin have been attributed to its ability to reduce cholesterol levels, recent scientific studies have suggested that its benefits are largely due to its pleiotropic effects in targeting other pathways, e.g., by inhibiting protein lipidation. There are certain pleiotropic effects that can be predicted from the inhibition of the mevalonate pathway; however, some of the effects of simvastatin in proteostasis lead to reduced levels of amyloid beta, the key contributor to AD. This review discusses the use of simvastatin as an antimicrobial agent and anti-AD drug.

The Polypill: A New Alternative in the Prevention and Treatment of Cardiovascular Disease

Cardiovascular disease (CVD) is the primary cause of death and disability worldwide. Although age-standardized CVD mortality rates decreased globally by 14.5% between 2006 and 2016, the burden of CVD remains disproportionately higher in low- and middle-income countries compared to high-income countries. Even though proven, effective approaches based on multiple-drug intake aimed at the prevention and treatment of CVD are currently available, poor adherence, early discontinuation of treatment, and suboptimal daily execution of the prescribed therapeutic regimes give rise to shortfalls in drug exposure, leading to high variability in the responses to the prescribed medications. Wald and Law, in their landmark paper published in BMJ 2003, hypothesized that the use of a fixed-dose combination of statins, β-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and aspirin (classic Polypill composition) may increase adherence and decrease CVD by up to 80% when prescribed as primary prevention or in substitution of traditional protocols. Since then, many clinical trials have tested this hypothesis, with comparable results. This review aims to describe the available clinical trials performed to assess the impact of fixed-dose combinations on adherence, cost-effectiveness, and the risk factors critical to the onset of CVD.

Impact of CYP2C19 Gene Variants on Long-Term Treatment with Atorvastatin in Patients with Acute Coronary Syndromes

The effectiveness of lipid-lowering therapies may be insufficient in high-risk cardiovascular patients and depends on the genetic variability of drug-metabolizing enzymes. Customizing statin therapy, including treatment with atorvastatin, may improve clinical outcomes. Currently, there is a lack of guidelines allowing the prediction of the therapeutic efficacy of lipid-lowering statin therapy. This study aimed to determine the effects of clinically significant gene variants of CYP2C19 on atorvastatin therapy in patients with acute coronary syndromes. In total, 92 patients with a confirmed diagnosis of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) were sequenced for target regions within the CYP2C19 gene on the Illumina Miniseq system. The CYP2C19 poor metabolizer phenotype (carriers of CYP2C19*2, CYP2C19*4, and CYP2C19*8 alleles) was detected in 29% of patients. These patients had significantly lower responses to treatment with atorvastatin than patients with the normal metabolizer phenotype. CYP2C19-metabolizing phenotype, patient age, and smoking increased the odds of undertreatment in patients (∆LDL-C (mmol/L) < 1). These results revealed that the CYP2C19 phenotype may significantly impact atorvastatin therapy personalization in patients requiring LDL lipid-lowering therapy.

Impact of coronary CT angiography in selection of treatment modalities and subsequent cardiovascular events in Thai patients with stable CAD

BACKGROUND

Coronary computed tomography angiography (CCTA) enables improved diagnosis of subclinical, coronary artery disease (CAD). This retrospective cohort study investigated the association between different treatment modalities guided by CCTA and the prevention of major adverse cardiovascular events (MACEs) in patients with stable CAD.

METHODS

From 2005 to 2013, a total of 9338 patients, including both asymptomatic individuals with risk factors and symptomatic patients with suspected CAD, who underwent CCTA were analyzed. The patients were categorized into one of three groups based on results of CCTA: obstructive CAD (≥ 50% stenosis in at least one vessel), non-obstructive CAD (1-49% stenosis in at least one vessel), and no observed CAD (0% stenosis). They were subsequently followed up to assess the treatment they received and the occurrence of MACEs (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or late revascularization).

RESULTS

During an average follow-up period of 9.9 ± 2.4 years, patients with obstructive CAD had the highest incidence of MACEs (19.8%), followed by those with non-obstructive CAD and no coronary artery stenosis (10.3 and 5.5%, respectively). After adjusting for confounding variables, it was found that patients treated with statins alone were the least likely to develop MACEs in all three groups, compared to those receiving no treatment, with hazard ratios (95% CI) of 0.43 (0.32, 0.58), 0.47 (0.34, 0.64), and 0.46 (0.31, 0.69), respectively. In patients with obstructive CAD, treatment with a combination of statin and aspirin, or early revascularization was associated with a lower likelihood of experiencing MACEs compared to no treatment with hazard ratios of 0.43 (0.33, 0.58) and 0.64 (0.43, 0.97), respectively.

CONCLUSION

CCTA offers useful guidance for the treatment of patients with stable CAD and shows potential for prevention of CV events. However, the full validation of a given strategy utilizing CCTA will require a prospective longitudinal study, utilizing a randomized clinical trial design.

Networks of C-reactive protein and depression symptoms in patients with stable coronary heart disease: Findings from the Heart and Soul Study

OBJECTIVE

Research addressing the associations between C-reactive protein (CRP) and depression among patients with stable coronary heart disease (CHD) has produced inconsistent results. This might be attributable to varying associations of CRP with specific depression symptom profiles. We responded to this challenge using various network analysis techniques.

METHODS

A total of 967 outpatients with documented CHD were drawn from the baseline cross-sectional data of the Heart and Soul Study. We first estimated mixed graphical models that included CRP and individual depression symptoms, before and after adjusting for relevant covariates, to explore whether CRP is correlated with specific facets of depression. We also investigated whether CRP levels moderated the associations between specific depression symptoms using moderated network models. Finally, we performed a network comparison test and compared the symptom network properties between non-elevated and elevated CRP groups.

RESULTS

In the network model without covariates, CRP was positively associated with fatigue, appetite changes, and psychomotor problems. CRP maintained its negative association with concentration difficulty regardless of covariate adjustment. Few symptom-symptom associations, especially those involving appetite changes, were moderated by CRP. Further, the elevated CRP group showed greater overall symptom connectivity as compared to the non-elevated group.

CONCLUSION

This study segues into CRP-depression relationship with sophisticated methodology.

Lipid-lowering therapies for cardiovascular disease prevention and management in primary care: PEER umbrella systematic review of systematic reviews

OBJECTIVE

To assess the benefits and harms of lipid-lowering therapies used to prevent or manage cardiovascular disease including bile acid sequestrants (BAS), ezetimibe, fibrates, niacin, omega-3 supplements, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, and statins.

DATA SOURCES

MEDLINE, the Cochrane Database of Systematic Reviews, and a grey literature search.

STUDY SELECTION

Systematic reviews of randomized controlled trials published between January 2017 and March 2022 looking at statins, ezetimibe, PCSK9 inhibitors, fibrates, BAS, niacin, and omega-3 supplements for preventing cardiovascular outcomes were selected. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, and adverse events.

SYNTHESIS

A total of 76 systematic reviews were included. Four randomized controlled trials were also included for BAS because no efficacy systematic review was identified. Statins significantly reduced MACE (6 systematic reviews; median risk ratio [RR]=0.74; interquartile range [IQR]=0.71 to 0.76), cardiovascular mortality (7 systematic reviews; median RR=0.85, IQR=0.83 to 0.86), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.88 to 0.92). Major adverse cardiovascular events were also significantly reduced by ezetimibe (3 systematic reviews; median RR=0.93, IQR=0.93 to 0.94), PCSK9 inhibitors (14 systematic reviews; median RR=0.84, IQR=0.83 to 0.87), and fibrates (2 systematic reviews; mean RR=0.86), but these interventions had no effect on cardiovascular or all-cause mortality. Fibrates had no effect on any cardiovascular outcomes when added to a statin. Omega-3 combination supplements had no effect on MACE or all-cause mortality but significantly reduced cardiovascular mortality (5 systematic reviews; median RR=0.93, IQR=0.93 to 0.94). Eicosapentaenoic acid ethyl ester alone significantly reduced MACE (1 systematic review, RR=0.78) and cardiovascular mortality (2 systematic reviews; RRs of 0.82 and 0.82). In primary cardiovascular prevention, only statins showed consistent benefits on MACE (6 systematic reviews; median RR=0.75, IQR=0.73 to 0.78), cardiovascularall-cause mortality (7 systematic reviews, median RR=0.83, IQR=0.81 to 0.90), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.87 to 0.91).

CONCLUSION

Statins have the most consistent evidence for the prevention of cardiovascular complications with a relative risk reduction of about 25% for MACE and 10% to 15% for mortality. The addition of ezetimibe, a PCSK9 inhibitor, or eicosapentaenoic acid ethyl ester to a statin provides additional MACE risk reduction but has no effect on all-cause mortality.

Cost-effectiveness analysis of implementing polygenic risk score in a workplace cardiovascular disease prevention program

Background

Polygenic risk score for coronary artery disease (CAD-PRS) improves precision in assessing the risk of cardiovascular diseases and is cost-effective in preventing cardiovascular diseases in a health system and may be cost-effective in other settings and prevention programs such as workplace cardiovascular prevention programs. Workplaces provide a conducitve environment for cardiovascular prevention interventions, but the cost-effectiveness of CAD-PRS in a workplace setting remains unknown. This study examined the cost-effectiveness of integrating CAD-PRS in a workplace cardiovascular disease prevention program compared to the standard cardiovascular workplace program without CAD-PRS and no-workplace prevention program.

Methods

We developed a cohort simulation model to project health benefits (quality-adjusted life years gained) and costs over a period of 5 years in a cohort of employees with a mean age of 50 years. The model health states reflected the risk of disease (coronary artery disease and ischemic stroke) and statin prevention therapy side effects (diabetes, hemorrhagic stroke, and myopathy). We considered medical and lost productivity costs. Data were obtained from the literature, and the analysis was performed from a self-insured employer perspective with future costs and quality-adjusted life years discounted at 3% annually. Uncertainty in model parameter inputs was assessed using deterministic and probabilistic sensitivity analyses. Three programs were compared: (1) a workplace cardiovascular program that integrated CAD-PRS with the pooled cohort equation-a standard of care for assessing the risk of cardiovascular diseases (CardioriskSCORE); (2) a workplace cardiovascular prevention program without CAD-PRS (Standard-WHP); and (3) no-workplace health program (No-WHP). The main outcomes were total costs (US $2019), incremental costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratio.

Results

CardioriskSCORE lowered employer costs ($53 and $575) and improved employee quality-adjusted life years (0.001 and 0.005) per employee screened compared to Standard-WHP and No-WHP, respectively. The effectiveness of statin prevention therapy, employees' baseline cardiovascular risk, the proportion of employees that enrolled in the program, and statin adherence had the largest effect size on the incremental net monetary benefit. However, despite the variation in parameter input values, base case results remained robust.

Conclusion

Polygenic testing in a workplace cardiovascular prevention program improves employees' quality of life and simultaneously lowers health costs and productivity monetary loss for employers.

Causal Relationship of Coronary Artery Calcium on Myocardial Infarction and Preventive Effect of Antiplatelet Therapy

Background

The role of coronary artery calcium score (CACS) to guide antiplatelet therapy in order to prevent myocardial infarction (MI) is still uncertain. This study aimed to find the causal relationship of CACS on MI and preventive effect of antiplatelet therapy.

Methods

From 2005 to 2013, all patients with cardiovascular risk factors or symptoms of suspected CAD underwent coronary computed tomography. CACSs were measured using Agatston method and stratified into 4 groups: 0, 1–99, 100–399, and ≥ 400. Antiplatelet therapy was prescribed following physician discretion. Outcomes of interest were MI and bleeding. A mediation analysis was applied to find association pathways. CACS was considered as an independent variable, whereas antiplatelet therapy was considered as a mediator and MI considered the outcome of interest.

Results

A total of 7,849 subjects were enrolled. During an average of 9.9 ± 2.4 years follow-up, MI and bleeding events occurred in 2.24% (n = 176) and 2.82% (n = 221) of subjects, respectively. CACSs 100–399 and CAC ≥ 400 were significantly associated with the development of MI [OR 3.14 (1.72, 5.72), and OR 3.22 (1.66, 6.25), respectively, p < 0.001]. Antiplatelet therapy reduced the risk of MI of these corresponding CAC groups with ORs of 0.60 (0.41, 0.78) and 0.56 (0.34, 0.77), p < 0.001]. A risk of bleeding was associated with antiplatelet therapy (only aspirin), anticoagulant, hypertension, male gender and old age.

Conclusion

CACS was associated with the development of future MI. The preventive effect of antiplatelet therapy was clearly demonstrated in subjects with CACSs equal to or above 100, but this benefit was partially offset by an increased risk of bleeding.

Enhancement of the Solubility and Bioavailability of Pitavastatin through a Self-Nanoemulsifying Drug Delivery System (SNEDDS)

The purpose of the study was to develop an SNEDDS to improve the solubility and bioavailability of pitavastatin. The solubility of pitavastatin in different oils, surfactants, and co-surfactants was determined and a pseudo-ternary phase diagram was constructed. The SNEDDS was characterized by zeta-sizer, zeta-potential, FTIR, DSC, and TGA. Release and permeation of pitavastatin from the SNEDDS was studied for 12 and 24 h, respectively. The lipolysis test, RBC lysis, effect on lipid profile, and pharmacokinetics were studied. The SPC3 formulation showed a 104 ± 1.50 nm particle size, a 0.198 polydispersity index (PDI), and a –29 zeta potential. FTIR, DSC, and TGA showed the chemical compatibility and thermal stability. The release and permeation of pitavastatin from SPC3 was 88.5 ± 2.5% and 96%, respectively. In the lipolysis test, the digestion of SPC3 yielded a high amount of pitavastatin and showed little RBC lysis. The lipid profile suggested that after 35 days of administration of the SNEDDS, there was a marked decrease in TC, LDL, and triglyceride levels. The SNEDDS of SPC3 showed an 86% viability of Caco-2 cells. Pharmacokinetics of SPC3 showed improved values of C_max, T_max, half-life, MRT, AUC, and AUMC compared to the reference formulation. Our study demonstrated that the SNEDDS effectively enhanced the solubility and bioavailability of a BCS class II drug.

Gut Metabolite Trimethylamine-N-Oxide in Atherosclerosis: From Mechanism to Therapy

Atherosclerosis is associated with various pathological manifestations, such as ischemic heart disease, ischemic stroke, and peripheral arterial disease, and remains a leading cause of public health concern. Atherosclerosis is an inflammatory disease characterized by endothelial dysfunction; vascular inflammation; and the deposition of lipids, cholesterol, calcium, and cellular debris within the vessel wall intima. In-depth studies of gut flora in recent years have shown that bacterial translocation and the existence of bacterial active products in blood circulation can affect the inflammatory state of the whole blood vessel. The gut flora is considered to be a large “secretory organ,” which produces trimethylamine-N-oxide (TMAO), short-chain fatty acids and secondary bile acids by breaking down the ingested food. Studies have shown that TMAO is an independent risk factor for the occurrence of malignant adverse cardiovascular events, but whether it is harmful or beneficial to patients with cardiovascular diseases with mild or no clinical manifestations remains controversial. We review the relationship between TMAO and its precursor (L-carnitine) and coronary atherosclerosis and summarize the potential molecular mechanism and therapeutic measures of TMAO on coronary atherosclerosis.

Toward a Best-in-Class Inhibitor of Cholesteryl Ester Transfer Protein (CETP)

Inhibitors of cholesteryl ester transfer protein (CETP) elevate HDL levels human clinical trials. However, the first CETP inhibitors proved toxic in pivotal trials or showed minimal therapeutic benefit. Anacetrapib showed some clinical benefit but is high lipophilic. This Viewpoint highlights efforts to optimize anacetrapib to a best-in-class CETP inhibitor.

Endometriosis Is Associated with an Increased Risk of Coronary Artery Disease in Asian Women

Endometriosis is a common systemic chronic inflammatory disease. Inflammation is the key mechanism responsible for the development of endothelial dysfunction and atherosclerosis. We aimed to investigate the risk of coronary artery disease (CAD) among Asian women with endometriosis. This retrospective population-based cohort study included patients with endometriosis diagnosed from 2000 to 2012 and registered in the Longitudinal Health Insurance Database, Taiwan. The comparison cohort (those without endometriosis) were selected (1:4) by matching the age frequency and the index year. We followed up the patients until the diagnosis of CAD (ICD-9-CM codes: 410-414, A270, and A279), withdrawal from the National Health Insurance system, death, or the end of the study. We used a multivariable-adjusted Cox proportional hazard model for evaluating the risk of CAD. We included 19,454 patients with endometriosis and 77,816 women as a comparison group. The mean age of the women at the diagnosis of endometriosis was 37.4 years. A total of 3245 women developed CAD in both groups during a median follow-up of 7 years. The incidence of CAD was higher in women with endometriosis than in those without (5.96 vs. 4.38 per 10,000 person-years; adjusted hazard ratio [95% confidence interval], 1.34 [1.22-1.47]). In conclusion, Asian women with endometriosis had a significantly higher risk of CAD. Further large-scale studies are needed to elucidate the cause-effect relationship between endometriosis and CAD.

Immunity in Atherosclerosis: Focusing on T and B Cells

Atherosclerosis is the major cause of the development of cardiovascular disease, which, in turn, is one of the leading causes of mortality worldwide. From the point of view of pathogenesis, atherosclerosis is an extremely complex disease. A huge variety of processes, such as violation of mitophagy, oxidative stress, damage to the endothelium, and others, are involved in atherogenesis; however, the main components of atherogenesis are considered to be inflammation and alterations of lipid metabolism. In this review, we want to focus on inflammation, and more specifically on the cellular elements of adaptive immunity, T and B cells. It is known that various T cells are widely represented directly in atherosclerotic plaques, while B cells can be found, for example, in the adventitia layer. Of course, such widespread and well-studied cells have attracted attention as potential therapeutic targets for the treatment of atherosclerosis. Various approaches have been developed and tested for their efficacy.

Determinants of Statin Initiation Among Adult Diabetic Patients in Bonga, Ethiopia

BACKGROUND

Diabetes mellitus (DM) is a chronic degenerative disease associated with a high risk of chronic complications and comorbidities. According t the World Health Organization, 16.7 million people worldwide die of cardiovascular diseases each year.

AIM OF THE STUDY

The aim of this study is to evaluate determinants of statin initiation among diabetic patients.

METHODS

A hospital-based cross-sectional study was conducted to evaluate statin initiation and determinants in Gebre Tsadik Shewa General Hospital, Bonga, Ethiopia. This hospital covers a catchment population of about 1.4 million and offers diagnosis and treatment in outpatient and inpatient settings in different departments. Epi data 4.0.2.49 and STATA 14.2 were used for data entry and analysis. Before analysis, presence of co-linearity and model fitness were checked. Chi-square statistics were used to check adequacy of cells for binary logistic regression. Bivariate analysis was done and p <0.25 was included in a multivariate model. Finally p-value less than 0.05 was considered a significant predictor.

RESULTS

A total of 120 patients were included in this study, of which 77 (64.17%) were males. The mean age and standard deviation was 47.04 ± 12.13 years with 75% of patients ≥40 years. The mean duration of illness was 10.26 ± 0.6 years. Ninety-eight (81.67%) patients had varying comorbidities. Sixty-four (53.33%) patients developed complications. The majority of patients were evaluated by a general practitioner (GP). Fifty-one (42.5%) patients started statins. Of them, 31 (60.78%) started for secondary prevention. The majority of patients had atorvastatin with moderate dosage. Government insurance (p=0.029), polypharmacy (0.008), physician level of training (0.023) and previous counseling of patients about the importance of statins (p<001) were significantly associated with initiation of statins.

CONCLUSION

Only near to 40% of patients started statins. Physician reluctance and unavailability of drugs were the most common reasons not to initiate statins. The hospital tries to provide medication. Physicians should evaluate patients in need of cardio-protective drugs.

Role of Statins in the Primary Prevention of Atherosclerotic Cardiovascular Disease and Mortality in the Population with Mean Cholesterol in the Near-Optimal to Borderline High Range: A Systematic Review and Meta-Analysis

Objective

The objective of this meta-analysis was to analyze the benefits and harms of treating the population with statins in those having mean low-density lipoprotein cholesterol (LDL-C) in the near-optimal (100 to 129 mg/dl) to borderline high (130 to 159 mg/dl) range and free of cardiovascular disease (CVD).

Methods

We searched PubMed, PubMed Central, Cochrane Library, and Google Scholar databases for randomized controlled trials (RCTs) published between 1994 and July 2020. We included RCTs with greater than 90% of participants free of CVD. Two reviewers independently screened the articles using the Covidence software, assessed the methodological quality using the risk of bias 2 tool, and analyzed the data using the RevMan 5.4 software.

Results

Eleven trials were included. Statin therapy was associated with a decreased risk of myocardial infarction (RR = 0.56, 95% CI: 0.47 to 0.67), major cerebrovascular events (RR = 0.78, 95% CI: 0.63 to 0.96), major coronary events (RR = 0.67, 95% CI: 0.57 to 0.80), composite cardiovascular outcome (RR = 0.71, 95% CI: 0.62 to 0.82), revascularizations (RR = 0.65, 95% CI: 0.57 to 0.74), angina (RR = 0.76, 95% CI: 0.63 to 0.92), and hospitalization for cardiovascular causes (RR = 0.74, 95% CI: 0.64 to 0.86). There was no benefit associated with statin therapy for cardiovascular mortality and coronary heart disease mortality. All-cause mortality benefit with statin therapy was seen in the population with diabetes and increased risk of CVD. Statin therapy was associated with no significant increased risk of myalgia, creatine kinase elevation, rhabdomyolysis, myopathy, incidence of any cancer, incidence of diabetes, withdrawal of the drug due to adverse events, serious adverse events, fatal cancer, and liver enzyme abnormalities.

Conclusion

Statin therapy was associated with a reduced risk of cardiovascular disease and procedures without increased risk of harm in populations with mean LDL-C in the near-optimal to the borderline high range and without prior atherosclerotic cardiovascular disease.