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Yang J, Zhang R, Han B, Li H, Wang J, Xiao Y, Yu X, Guan S, Dai C, Yan H, Jiang T, Cui H, Yang S, Zheng Z, Dong Y, Wang A, Su G, Wang Y. Atherogenic lipid profile in patients with statin treatment after acute coronary syndrome: a real-world analysis from Chinese cardiovascular association database. Lipids Health Dis 2024; 23:271. [PMID: 39198852 PMCID: PMC11351259 DOI: 10.1186/s12944-024-02244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/07/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Adverse atherogenic lipid profile is associated with an increased risk of major adverse cardiac events in patients after acute coronary syndrome (ACS). Knowledge regarding the impact of statins on lipid profile remains limited. METHODS We retrospectively analysed multicenter, real-world data from the Chinese Cardiovascular Association Database-iHeart Project. Patients with a primary diagnosis of ACS from 2014 to 2021 during index hospitalisation and having at least one lipid panel record after discharge within 12 months were enrolled. We analysed target achievement of atherogenic lipid profile, including apolipoprotein B (< 80 mg/dL), low-density lipoprotein cholesterol (LDL-C) (< 1.8 mmol/L), lipoprotein(a) [Lp(a)] (< 30 mg/dL), triglycerides (< 1.7 mmol/L), remnant cholesterol (RC) (< 0.78 mmol/L), non-high-density lipoprotein cholesterol (< 2.6 mmol/L) at baseline and follow-up. Multivariate Cox regression models were employed to investigate the association between patient characteristics and target achievement. RESULTS Among 4861 patients, the mean age was 64.9 years. Only 7.8% of patients had all atherogenic lipids within the target range at follow-up. The proportion of target achievement was for LDL-C 42.7%, Lp(a) 73.3%, and RC 78.5%. Patients with female sex, younger age, myocardial infarction, hypertension, and hypercholesteremia were less likely to control LDL-C, Lp(a), and RC. An increase in the burden of comorbidities was negatively associated with LDL-C and Lp(a) achievements but not with RC. CONCLUSIONS A substantial gap exists between lipid control and the targets recommended by contemporary guidelines. Novel therapeutics targeting the whole atherogenic lipid profile will be warranted to improve cardiovascular outcomes.
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Affiliation(s)
- Jing Yang
- Department of Cardiology, Zhongshan-Xuhui Hospital, Shanghai Xuhui Central Hospital, Fudan University, Shanghai, 200237, China.
| | - Rui Zhang
- China Heart House, Suzhou, 215124, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical School of Southeast University, Xuzhou, Jiangsu, 221009, China
| | - Hui Li
- Department of Cardiology, the second affiliated hospital of Soochow University, Suzhou, 215004, China
| | - Jingfeng Wang
- Department of Cardiovascular Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Yihui Xiao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi' an Jiaotong University, Xi'an, 710061, China
| | - Xiaofan Yu
- Department of Cardiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Shaofeng Guan
- Department of Cardiology, Huadong Hospital, Fudan University, Shanghai, 200040, China
| | - Cuilian Dai
- School of Medicine, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, 361000, China
| | - Hua Yan
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, 430022, China
| | - Tingbo Jiang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Hanbin Cui
- Cardiology Center, The First Affiliated Hospital of Ningbo University, Ningbo, 315000, China
| | - Shuang Yang
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Zeqi Zheng
- Department of Cardiology, the first affiliated hospital of Nanchang University, Nanchang, 330006, China
| | - Yugang Dong
- Department of Cardiology, the first affiliated hospital of Sun Yat-sen University, Guangzhou, 510080, China
- NHC key Laboratory of assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China
| | - Annai Wang
- China Heart House, Suzhou, 215124, China
| | - Guohai Su
- Department of Cardiology, Jinan Central Hospital, Shandong First Medical University, Shandong, 250013, China.
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen University, Xiamen, 200080, China.
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Agewall S. Special focus on the new anti-diabetic drugs. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:265-266. [PMID: 39012214 DOI: 10.1093/ehjcvp/pvae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Institute of Clinical Sciences, Karolinska Institute of Danderyd, Stockholm, Sweden
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3
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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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4
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Woods RH. Postmarketing Reports of Incomplete Dosing-Related Complications with Self-Injected PCSK9 Inhibitors: A Descriptive Study and Disproportionality Analysis. BioDrugs 2024; 38:589-600. [PMID: 38874875 DOI: 10.1007/s40259-024-00664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Evolocumab and alirocumab are self-injected proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors indicated for low-density lipoprotein cholesterol reduction. Complications in the use or functionality of self-injection devices may precipitate incomplete dosing. OBJECTIVE This study sought to characterize postmarketing dosing failure reports involving self-injected PCSK9 inhibitors. METHODS US Food and Drug Administration Adverse Event Reporting System (FAERS) [2016-second quarter of 2023] data were utilized for a disproportionality analysis. Eight self-injected comparator medications served as referents. Medical Dictionary for Regulatory Activities preferred terms indicating explicit or probable failure to administer a complete dose classified cases. Proportional reporting ratios (PRRs) > 2.0 and lower 95% confidence intervals (CIs) > 1.0 indicated disproportionality signals. US FDA Manufacturer and User Facility Device Experience (MAUDE) [2013-2023] data underwent a narrative review. RESULTS During the study period, 194,781 (evolocumab, n = 152,831; alirocumab, n = 41,950) drug-event pairs and 43,725 (evolocumab, n = 38,489; alirocumab, n = 5236) cases reported to FAERS identified PCSK9 inhibitors. MAUDE contained six evolocumab reports, half describing dose omission, and no alirocumab reports. A potential dosing failure signal was detected for evolocumab (PRR 2.01; 95% CI 1.98-2.03), but not alirocumab (PRR 0.99; 95% CI 0.97-1.02), relative to pooled comparator reports. Across three case term subcategories, incomplete dosing disproportionality signals were further identified for evolocumab patient usage complication terms (PRR 3.44; 95% CI 3.38-3.50) and alirocumab device malfunction terms (PRR 2.09; 95% CI 1.98-2.22). CONCLUSIONS Proprotein convertase subtilisin kexin type 9 inhibitor incomplete dosing-related complications are frequently reported in the postmarketing setting. Systematic efforts to understand the incidence and mechanisms of dosing failure and associated patient burdens are needed.
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Affiliation(s)
- Richard H Woods
- Levin, Papantonio, Rafferty, Proctor, Buchanan, O'Brien, Barr and Mougey, P.A., 316 South Baylen Street, Pensacola, FL, 32502, USA.
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5
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Schelemei P, Wagner E, Picard FSR, Winkels H. Macrophage mediators and mechanisms in cardiovascular disease. FASEB J 2024; 38:e23424. [PMID: 38275140 DOI: 10.1096/fj.202302001r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/21/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
Macrophages are major players in myocardial infarction (MI) and atherosclerosis, two major cardiovascular diseases (CVD). Atherosclerosis is caused by the buildup of cholesterol-rich lipoproteins in blood vessels, causing inflammation, vascular injury, and plaque formation. Plaque rupture or erosion can cause thrombus formation resulting in inadequate blood flow to the heart muscle and MI. Inflammation, particularly driven by macrophages, plays a central role in both atherosclerosis and MI. Recent integrative approaches of single-cell analysis-based classifications in both murine and human atherosclerosis as well as experimental MI showed overlap in origin, diversity, and function of macrophages in the aorta and the heart. We here discuss differences and communalities between macrophages in the heart and aorta at steady state and in atherosclerosis or upon MI. We focus on markers, mediators, and functional states of macrophage subpopulations. Recent trials testing anti-inflammatory agents show a major benefit in reducing the inflammatory burden of CVD patients, but highlight a necessity for a broader understanding of immune cell ontogeny and heterogeneity in CVD. The novel insights into macrophage biology in CVD represent exciting opportunities for the development of novel treatment strategies against CVD.
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Affiliation(s)
- Patrik Schelemei
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Elena Wagner
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Felix Simon Ruben Picard
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Holger Winkels
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
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Fularski P, Hajdys J, Majchrowicz G, Stabrawa M, Młynarska E, Rysz J, Franczyk B. Unveiling Familial Hypercholesterolemia-Review, Cardiovascular Complications, Lipid-Lowering Treatment and Its Efficacy. Int J Mol Sci 2024; 25:1637. [PMID: 38338916 PMCID: PMC10855128 DOI: 10.3390/ijms25031637] [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] [Received: 12/30/2023] [Revised: 01/19/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Familial hypercholesterolemia (FH) is a genetic disorder primarily transmitted in an autosomal-dominant manner. We distinguish two main forms of FH, which differ in the severity of the disease, namely homozygous familial hypercholesterolemia (HoFH) and heterozygous familial hypercholesterolemia (HeFH). The characteristic feature of this disease is a high concentration of low-density lipoprotein cholesterol (LDL-C) in the blood. However, the level may significantly vary between the two mentioned types of FH, and it is decidedly higher in HoFH. A chronically elevated concentration of LDL-C in the plasma leads to the occurrence of certain abnormalities, such as xanthomas in the tendons and skin, as well as corneal arcus. Nevertheless, a significantly more severe phenomenon is leading to the premature onset of cardiovascular disease (CVD) and its clinical implications, such as cardiac events, stroke or vascular dementia, even at a relatively young age. Due to the danger posed by this medical condition, we have investigated how both non-pharmacological and selected pharmacological treatment impact the course of FH, thereby reducing or postponing the risk of clinical manifestations of CVD. The primary objective of this review is to provide a comprehensive summary of the current understanding of FH, the effectiveness of lipid-lowering therapy in FH and to explain the anatomopathological correlation between FH and premature CVD development, with its complications.
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Affiliation(s)
- Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Magdalena Stabrawa
- 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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Volkova A, Shulgin B, Helmlinger G, Peskov K, Sokolov V. Optimization of the MACE endpoint composition to increase power in studies of lipid-lowering therapies-a model-based meta-analysis. Front Cardiovasc Med 2024; 10:1242845. [PMID: 38304061 PMCID: PMC10832431 DOI: 10.3389/fcvm.2023.1242845] [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: 07/02/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
Aims To develop a model-informed methodology for the optimization of the Major Adverse Cardiac Events (MACE) composite endpoint, based on a model-based meta-analysis across anti-hypercholesterolemia trials of statin and anti-PCSK9 drugs. Methods and results Mixed-effects meta-regression modeling of stand-alone MACE outcomes was performed, with therapy type, population demographics, baseline and change over time in lipid biomarkers as predictors. Randomized clinical trials up to June 28, 2022, of either statins or anti-PCSK9 therapies were identified through a systematic review process in PubMed and ClinicalTrials.gov databases. In total, 54 studies (270,471 patients) were collected, reporting 15 different single cardiovascular events. Treatment-mediated decrease in low density lipoprotein cholesterol, baseline levels of remnant and high-density lipoprotein cholesterol as well as non-lipid population characteristics and type of therapy were identified as significant covariates for 10 of the 15 outcomes. The required sample size per composite 3- and 4-point MACE endpoint was calculated based on the estimated treatment effects in a population and frequencies of the incorporated events in the control group, trial duration, and uncertainty in model parameters. Conclusion A quantitative tool was developed and used to benchmark different compositions of 3- and 4-point MACE for statins and anti-PCSK9 therapies, based on the minimum population size required to achieve statistical significance in relative risk reduction, following meta-regression modeling of the single MACE components. The approach we developed may be applied towards the optimization of the design of future trials in dyslipidemia disorders as well as in other therapeutic areas.
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Affiliation(s)
- Alina Volkova
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
| | - Boris Shulgin
- Research Center of Model-Informed Drug Development, Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Kirill Peskov
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
- Research Center of Model-Informed Drug Development, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Victor Sokolov
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
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Gavina C, Seabra‐Carvalho D, Aguiar C, Anastassopoulou A, Teixeira C, Ruivo JA, Almeida É, Luz‐Duarte L, Corte‐Real A, Canelas‐Pais M, Taveira‐Gomes T. Characterization and LDL-C management in a cohort of high and very high cardiovascular risk patients: The PORTRAIT-DYS study. Clin Cardiol 2024; 47:e24183. [PMID: 37933175 PMCID: PMC10766132 DOI: 10.1002/clc.24183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023] Open
Abstract
AIM This study aims to characterize sociodemographic and clinical characteristics, use of lipid-lowering therapies (LLTs), and low-density lipoprotein cholesterol (LDL-C) control in a population with increased cardiovascular (CV) risk. METHODS A cross-sectional observational study that uses electronic health records of patients from one hospital and across 14 primary care health centers in the North of Portugal, spanning from 2000 to 2020 (index date). Patients presented at least (i) 1 year of clinical data before inclusion, (ii) one primary care appointment 3 years before the index date, and (iii) sufficient data for CV risk classification. Patients were divided into three cohorts: high CV risk; atherosclerotic cardiovascular disease (ASCVD) risk equivalents without established ASCVD; evidence of ASCVD. CV risk and LDL-C control were defined by the 2019 and 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidemia guidelines. RESULTS A total of 51 609 patients were included, with 23 457 patients classified as high CV risk, 19 864 with ASCVD equivalents, and 8288 with evidence of ASCVD. LDL-C control with 2016 ESC/EAS guidelines was 32%, 10%, and 18% for each group, respectively. Considering the ESC/EAS 2019 guidelines control level was even lower: 7%, 3%, and 7% for the same cohorts, respectively. Patients without any LLT prescribed ranged from 37% in the high CV risk group to 15% in patients with evidence of ASCVD. CONCLUSION We found that LDL-C control was very low in patients at higher risk of CV events. An alarming gap between guidelines on dyslipidemia management and clinical implementation persists, even in those at very high risk or with established ASCVD.
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Affiliation(s)
- Cristina Gavina
- Hospital Pedro Hispano ‐ Unidade Local de Saúde de MatosinhosPortugal
- Department of Medicine, Faculty of MedicinePorto UniversityPortoPortugal
- UnIC, Faculty of MedicinePorto UniversityPortoPortugal
| | | | - Carlos Aguiar
- Advanced Heart Failure Unit, Department of CardiologyHospital Santa Cruz, CHLOLisbonPortugal
| | | | - Carla Teixeira
- Medical AffairsDaiichi Sankyo PortugalPorto SalvoPortugal
| | - Jorge A. Ruivo
- Medical AffairsDaiichi Sankyo PortugalPorto SalvoPortugal
- Department of Medicine, Lisbon Medical SchoolLisbon UniversityPortugal
- Centro Cardiovascular Universidade LisboaLisbon UniversityPortugal
| | - Élia Almeida
- Value and AccessDaiichi Sankyo PortugalPorto SalvoPortugal
| | - Leonor Luz‐Duarte
- UCSP CinfãesACeS BaixoPortugal
- MTG Research and Development LabPortoPortugal
| | - Ana Corte‐Real
- MTG Research and Development LabPortoPortugal
- UCSP BarroselasUnidade Local de Saúde do Alto MinhoPortugal
| | - Mariana Canelas‐Pais
- MTG Research and Development LabPortoPortugal
- Department of Community Medicine, Health Information and Decision, Faculty of MedicineUniversity of PortoPortoPortugal
| | - Tiago Taveira‐Gomes
- MTG Research and Development LabPortoPortugal
- Department of Community Medicine, Health Information and Decision, Faculty of MedicineUniversity of PortoPortoPortugal
- Faculty of Health SciencesFernando Pessoa UniversityPortugal
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9
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Cherepianskii MS, Ponomareva GM, Skiba IB, Abakarov RM, Dudayte VV, Cherepianskaia AA. [Inclisiran in patients with acute ischemic stroke: first data]. KARDIOLOGIIA 2023; 63:39-46. [PMID: 37970854 DOI: 10.18087/cardio.2023.10.n2560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/02/2023] [Indexed: 11/19/2023]
Abstract
AIM To evaluate the effect of inclisiran therapy on parameters of lipid metabolism in hospitalized patients with acute ischemic stroke. MATERIAL AND METHODS A prospective, observational, non-randomized study was performed. The study included 12 patients with acute ischemic stroke prescribed with a combination lipid-lowering therapy with inclisiran (284 mg as a single dose). At 15 days after the start of therapy, changes in blood lipid composition were assessed. For quantitative variables, median, maximum and minimum values were determined. The significance of differences between related samples in quantitative variables was assessed using the Mann-Whitney test. RESULTS Before the start of combination lipid-lowering therapy, total cholesterol (TC) was 7.33 mmol/l and low-density lipoprotein C (LDL-C) was 5.23 mmol/l. At 15 days after the start of inclisiran therapy, TC significantly decreased by 52.1 % and LDL-C decreased by 71.1 %. The proportion of patients who reached the LDL-C goal was 66.7 %. There were no adverse events considered by the investigators to be related with the therapy. CONCLUSION The strategy of early administration of inclisiran (or its combination with a statin) in patients with ischemic stroke allows safe achievement of a significant reduction in LDL-C already in 15 days after the start of therapy.
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Affiliation(s)
| | | | - I B Skiba
- Pavlov First Saint-Petersburg State Medical University
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10
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Li J, Zhu P, Tang X, Jiang L, Li Y, Yan K, Yang W, Qiao S, Yang Y, Gao R, Xu B, Yuan J, Zhao X. Combined effect of D-dimer, hs-CRP, and Lp(a) on 5-year clinical outcomes after percutaneous coronary intervention: A large real-world study in China. iScience 2023; 26:107030. [PMID: 37485360 PMCID: PMC10362257 DOI: 10.1016/j.isci.2023.107030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/01/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023] Open
Abstract
To reduce cardiovascular risk in patients with established coronary heart disease, the present study investigated the combined effect of D-dimer, high-sensitivity C-reactive protein (hs-CRP), and lipoprotein(a) [Lp(a)] on long-term cardiovascular outcomes from the perspectives of thrombosis, inflammation, and lipid risk simultaneously. Consecutive 10,724 patients with percutaneous coronary intervention (PCI) were enrolled throughout 2013. Over a median follow-up of 5.1 years, each individual elevation of D-dimer, hs-CRP, and Lp(a) was associated with poor ischemic outcomes but not bleeding. Concurrent high D-dimer, hs-CRP, and Lp(a) had even greater risks of all-cause death (hazard ratio [HR] 2.714, 95% confidence interval [CI] 1.742-4.231) and cardiac death (HR 4.152, 95% CI 2.207-7.812) and had incremental value beyond the traditional risk factors model. Concurrent high D-dimer, hs-CRP, and Lp(a) levels had a synergistic effect on adverse 5-year ischemic outcomes, highlighting that the potential utility of simultaneous assessment of multiple cardiovascular risk biomarkers may help to identify high-risk patients after PCI.
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Affiliation(s)
- Jiawen Li
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Pei Zhu
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xiaofang Tang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lin Jiang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yulong Li
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Kailun Yan
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Weixian Yang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shubin Qiao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yuejin Yang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Runlin Gao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bo Xu
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jinqing Yuan
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xueyan Zhao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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11
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Zuo Y, Zhang C, Zhou Y, Li H, Xiao W, Herzog RW, Xu J, Zhang J, Chen YE, Han R. Liver-specific in vivo base editing of Angptl3 via AAV delivery efficiently lowers blood lipid levels in mice. Cell Biosci 2023; 13:109. [PMID: 37322547 PMCID: PMC10273718 DOI: 10.1186/s13578-023-01036-0] [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: 02/17/2023] [Accepted: 04/18/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Gene editing has emerged as an exciting therapeutic development platform for numerous genetic and nongenetic diseases. Targeting lipid-modulating genes such as angiopoietin-related protein 3 (ANGPTL3) with gene editing offers hope for a permanent solution to lower cardiovascular disease risks associated with hypercholesterolemia. RESULTS In this study, we developed a hepatocyte-specific base editing therapeutic approach delivered by dual adeno-associated virus (AAV) to enable hepatocyte-specific targeting of Angptl3 to lower blood lipid levels. Systemic AAV9-mediated delivery of AncBE4max, a cytosine base editor (CBE), targeting mouse Angptl3 resulted in the installation of a premature stop codon in Angptl3 with an average efficiency of 63.3 ± 2.3% in the bulk liver tissue. A near-complete knockout of the ANGPTL3 protein in the circulation were observed within 2-4 weeks following AAV administration. Furthermore, the serum levels of triglyceride (TG) and total cholesterol (TC) were decreased by approximately 58% and 61%, respectively, at 4 weeks after treatment. CONCLUSIONS These results highlight the promise of liver-targeted Angptl3 base editing for blood lipid control.
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Affiliation(s)
- Yuanbojiao Zuo
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Department of Surgery, The Ohio State University, Columbus, OH, 43210, USA
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, P.R. China
| | - Chen Zhang
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Department of Surgery, The Ohio State University, Columbus, OH, 43210, USA
| | - Yuan Zhou
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Department of Surgery, The Ohio State University, Columbus, OH, 43210, USA
| | - Haiwen Li
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Department of Surgery, The Ohio State University, Columbus, OH, 43210, USA
| | - Weidong Xiao
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Roland W Herzog
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jie Xu
- Center for Advanced Models for Translational Sciences and Therapeutics, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Jifeng Zhang
- Center for Advanced Models for Translational Sciences and Therapeutics, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Y Eugene Chen
- Center for Advanced Models for Translational Sciences and Therapeutics, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Renzhi Han
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- Department of Surgery, The Ohio State University, Columbus, OH, 43210, USA.
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12
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Kim OM, Givens TK, Tang EG, Schimmer JJ, Ramsey T, Boyd K, Delate T. Real-World Outcomes of Proprotein Convertase Subtilisin Kexin-9 Inhibitor Use. J Cardiovasc Pharmacol 2023; 81:339-347. [PMID: 36795508 DOI: 10.1097/fjc.0000000000001404] [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] [Received: 09/29/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023]
Abstract
ABSTRACT Although the proprotein convertase subtilisin kexin-9 inhibitors (PCSK9i) were shown to significantly lower low-density lipoprotein and reduce atherosclerotic cardiovascular disease events in clinical trials, there is a dearth of use data on these agents in real-world settings. This study compares PCSK9i use in a population of real-world patients with atherosclerotic cardiovascular disease or familial hypercholesterolemia. This was a matched cohort study of adult patients who were dispensed a PCSK9i along with adult patients who did not receive a PCSK9i. PCSK9i patients were matched on a propensity to have received a PCSK9i score up to 1:10 to non-PCSK9i patients. The primary outcomes were changes in cholesterol levels. Secondary outcomes included a composite outcome of all-cause mortality, major cardiovascular events, and ischemic strokes along with health care utilization during follow-up. Adjusted conditional, multivariate Cox proportional hazards, and negative binomial modeling were performed. Ninety-one PCSK9i patients were matched to 840 non-PCSK9i patients. Seventy-one percent of PCSK9i patients either discontinued or switched PCSK9i therapy. PCSK9i patients had greater median reductions in low-density lipoprotein (-73.0 mg/dL vs. -30.0 mg/dL) and total (-77.0 vs. -31.0) cholesterol (both P < 0.001). No adjusted between-group differences in the composite outcome or individual components of the composite outcome were identified (all P > 0.05). PCSK9i patients had a lower rate of medical office visits during follow-up (adjusted incidence rate ratio = 0.61, P = 0.019). These findings support the effectiveness of PCSK9i therapy in real-world settings but suggest that use may be limited by PCSK9i adverse reactions and patient cost barriers.
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Affiliation(s)
- Olivia M Kim
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Tatyana K Givens
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
- Pharmacy Department, VillageMD, Atlanta, GA; and
| | - Emily G Tang
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
- Pharmacy Department, Yale New Haven Hospital, New Haven, CT
| | | | - Tanya Ramsey
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Kayla Boyd
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy Services, Aurora, CO
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13
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Pradhan A, Bhandari M, Vishwakarma P, Singh A, Perrone MA, Sethi R. Bempedoic Acid: An Emerging Therapy for Uncontrolled Low-Density Lipoprotein (LDL) Cholesterol. J Cardiovasc Dev Dis 2023; 10:jcdd10050195. [PMID: 37233162 DOI: 10.3390/jcdd10050195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is a silent epidemic, which is progressing relentlessly across the globe. Developing countries such as India have a high prevalence of dyslipidemia and consequently a huge burden of coronary artery disease (CAD) and ASCVD. Low-density lipoprotein is regarded as the primary culprit in the genesis of ASCVD, and statins are the first line therapy for LDL-C lowering. Statin therapy has unequivocally demonstrated the benefit of lowering LDL-C in patients across the spectrum of CAD and ASCVD. Muscle symptoms and worsening of glycemic homeostasis could be challenges with statin therapy, especially with the use of high doses. A large fraction of patients are also unable to achieve their LDL goals with statins alone in clinical practice. Moreover, LDL-C goals have become aggressive over years, necessitating a combination of lipid lowering therapies. PCSK-9 inhibitors and Inclisiran have emerged as robust and safe lipid-lowering agents, but parenteral administration and high cost precludes their widespread use. Bempedoic acid is a novel lipid-lowering agent working upstream of statins by inhibiting the enzyme ATP citrate lyase (ACL). The drug produces an average LDL lowering of 22-28% in statin-naïve patients and 17-18% when given to preexisting statin users. Because skeletal muscles lack the ACL enzyme, there is minimal risk of muscle-related symptoms. In combination with ezetimibe, the drug synergistically reduced LDL-C by 39%. Moreover, the drug has no adverse effect on glycemic parameters and lowers hsCRP (inflammation) like statin. The series of four randomized CLEAR trials, involving >4000 patients, have shown consistent LDL lowering across the spectrum of ASCVD patients with or without background therapy. The large and only cardiovascular outcome trial of the drug (CLEAR Outcomes) has recently demonstrated a 13% reduction of MACE at 40 months. Rise in levels of uric acid (four times) and acute gout (three times) are more common compared to placebo with the drug, owing to competitive renal transportation by OAT 2. In a nutshell, Bempedoic acid represents a value addition to the inventory of dyslipidemia management.
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Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
| | - Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
| | - Pravesh Vishwakarma
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
| | - Abhishek Singh
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
| | - Marco Alfonso Perrone
- Department of Cardiology and CardioLab, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
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14
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Albert SL, Massar RE, Correa L, Kwok L, Joshi S, Shah S, Boas R, Alcalá HE, McMacken M. Change in cardiometabolic risk factors in a pilot safety-net plant-based lifestyle medicine program. Front Nutr 2023; 10:1155817. [PMID: 37153909 PMCID: PMC10157493 DOI: 10.3389/fnut.2023.1155817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/10/2023] Open
Abstract
Introduction Interventions emphasizing healthful lifestyle behaviors are proliferating in traditional health care settings, yet there is a paucity of published clinical outcomes, outside of pay-out-of-pocket or employee health programs. Methods We assessed weight, hemoglobin A1c (HbA1c), blood pressure, and cholesterol for 173 patients of the Plant-Based Lifestyle Medicine Program piloted in a New York City safety-net hospital. We used Wilcoxon signed-rank tests to assess changes in means, from baseline to six-months, for the full sample and within baseline diagnoses (i.e., overweight or obesity, type 2 diabetes, prediabetes, hypertension, hyperlipidemia). We calculated the percentage of patients with clinically meaningful changes in outcomes for the full sample and within diagnoses. Findings The full sample had statistically significant improvements in weight, HbA1c, and diastolic blood pressure. Patients with prediabetes or overweight or obesity experienced significant improvements in weight and those with type 2 diabetes had significant improvements in weight and HbA1c. Patients with hypertension had significant reductions in diastolic blood pressure and weight. Data did not show differences in non-high-density lipoprotein cholesterol (non-HDL-C), but differences in low-density lipoprotein cholesterol (LDL-C) were approaching significance for the full sample and those with hyperlipidemia. The majority of patients achieved clinically meaningful improvements on all outcomes besides systolic blood pressure. Conclusion Our study demonstrates that a lifestyle medicine intervention within a traditional, safety-net clinical setting improved biomarkers of cardiometabolic disease. Our findings are limited by small sample sizes. Additional large-scale, rigorous studies are needed to further establish the effectiveness of lifestyle medicine interventions in similar settings.
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Affiliation(s)
| | | | | | - Lorraine Kwok
- NYU Grossman School of Medicine, New York, NY, United States
| | - Shivam Joshi
- NYU Grossman School of Medicine, New York, NY, United States
- Veterans Affairs, Orlando, FL, United States
| | - Sapana Shah
- NYU Grossman School of Medicine, New York, NY, United States
- NYC Health + Hospitals, New York, NY, United States
| | - Rebecca Boas
- NYU Grossman School of Medicine, New York, NY, United States
- NYC Health + Hospitals, New York, NY, United States
| | - Héctor E. Alcalá
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD, United States
- Program in Oncology, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, United States
| | - Michelle McMacken
- NYU Grossman School of Medicine, New York, NY, United States
- NYC Health + Hospitals, New York, NY, United States
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15
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Patti G, Spinoni EG, Grisafi L, Mehran R, Mennuni M. Safety and efficacy of very low LDL-cholesterol intensive lowering: a meta-analysis and meta-regression of randomized trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:138-147. [PMID: 36102667 DOI: 10.1093/ehjcvp/pvac049] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/22/2022] [Accepted: 09/12/2022] [Indexed: 02/04/2023]
Abstract
AIMS We performed a study-level meta-analysis to provide more robust evidence on safety of very low LDL-cholesterol (LDL-C) levels. BACKGROUND Concerns on the safety of LDL-C values achieved with potent lipid-lowering therapies have been raised. METHODS AND RESULTS We searched randomized trials reporting clinical outcomes with intensive lipid-lowering treatments leading to very low (<40 mg/dL) LDL-C levels vs. a control group with higher LDL-C levels. Only studies with follow-up duration ≥ 3 months were considered. Primary endpoint was the incidence of various safety measures. A total of 10 randomized trials were overall included, with 38 427 patients being in the very low LDL-C group vs. 70 668 in the control group. Median follow-up duration was 28.8 months. The incidence of all safety outcomes was similar in the two groups: non-cardiovascular death: OR 1.13, 95% CI 0.87-1.45; P = 0.36; any adverse events: OR 1.00, 0.90-1.11, P = 0.94; adverse events leading to drug discontinuation: OR 1.00, 0.87-1.15, P = 0.99; cancer: OR 1.02, 0.95-1.10, P = 0.57; haemorrhagic stroke OR 0.89, 0.66-1.20, P = 0.44; new-onset diabetes: OR 1.16, 0.91-1.47, P = 0.23; neurocognitive disorders: OR 0.97, 0.91-1.04, P = 0.41; haepatobiliary disorders: OR 0.99, 0.83-1.18, P = 0.93; muscle disorders: OR 0.94, 0.77-1.13, P = 0.49; cataract: OR 1.28, 0.78-2.10, P = 0.34. The rates of major adverse cardiovascular events were significantly lower in the very low LDL-C group: OR 0.82, 0.72-0.94, P = 0.005. CONCLUSION This meta-analysis indicates that very low LDL-C levels on intensive lipid-lowering treatments are not associated with any adverse event and maintain a persistent reduction of cardiovascular events.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Novara 28100, Italy.,Division of Cardiology, Maggiore della Carità Hospital, Novara 28100, Italy
| | - Enrico Guido Spinoni
- Department of Translational Medicine, University of Eastern Piedmont, Novara 28100, Italy
| | - Leonardo Grisafi
- Department of Translational Medicine, University of Eastern Piedmont, Novara 28100, Italy
| | - Roxana Mehran
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York NY 10029, USA
| | - Marco Mennuni
- Division of Cardiology, Maggiore della Carità Hospital, Novara 28100, Italy
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16
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Zubielienė K, Valterytė G, Jonaitienė N, Žaliaduonytė D, Zabiela V. Familial Hypercholesterolemia and Its Current Diagnostics and Treatment Possibilities: A Literature Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1665. [PMID: 36422206 PMCID: PMC9692978 DOI: 10.3390/medicina58111665] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/30/2022] [Accepted: 11/13/2022] [Indexed: 09/30/2023]
Abstract
Familial hypercholesterolemia (FH) is a common, inherited disorder of cholesterol metabolism. This pathology is usually an autosomal dominant disorder and is caused by inherited mutations in the APOB, LDLR, and PCSK9 genes. Patients can have a homozygous or a heterozygous genotype, which determines the severity of the disease and the onset age of cardiovascular disease (CVD) manifestations. The incidence of heterozygous FH is 1: 200-250, whereas that of homozygous FH is 1: 100.000-160.000. Unfortunately, FH is often diagnosed too late and after the occurrence of a major coronary event. FH may be suspected in patients with elevated blood low-density lipoprotein cholesterol (LDL-C) levels. Moreover, there are other criteria that help to diagnose FH. For instance, the Dutch Lipid Clinical Criteria are a helpful diagnostic tool that is used to diagnose FH. FH often leads to the development of early cardiovascular disease and increases the risk of sudden cardiac death. Therefore, early diagnosis and treatment of this disease is very important. Statins, ezetimibe, bile acid sequestrants, niacin, PCSK9 inhibitors (evolocumab and alirocumab), small-interfering-RNA-based therapeutics (inclisiran), lomitapide, mipomersen, and LDL apheresis are several of the available treatment possibilities that lower LDL-C levels. It is important to say that the timeous lowering of LDL-C levels can reduce the risk of cardiovascular events and mortality in patients with FH. Therefore, it is essential to increase awareness of FH in order to reduce the burden of acute coronary syndrome (ACS).
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Affiliation(s)
- Kristina Zubielienė
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Clinics, LT-50161 Kaunas, Lithuania
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Hospital, LT-45130 Kaunas, Lithuania
- Kaunas Region Society of Cardiology, LT-44307, Kaunas, Lithuania
| | - Gintarė Valterytė
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Clinics, LT-50161 Kaunas, Lithuania
| | - Neda Jonaitienė
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Clinics, LT-50161 Kaunas, Lithuania
| | - Diana Žaliaduonytė
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Clinics, LT-50161 Kaunas, Lithuania
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Hospital, LT-45130 Kaunas, Lithuania
- Kaunas Region Society of Cardiology, LT-44307, Kaunas, Lithuania
| | - Vytautas Zabiela
- Department of Cardiology, Lithuanian University of Health Sciences Kaunas Clinics, LT-50161 Kaunas, Lithuania
- Kaunas Region Society of Cardiology, LT-44307, Kaunas, Lithuania
- Institute of Cardiology Kaunas, Cardiology Research Automation Laboratory, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania
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17
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Duan Y, Gong K, Xu S, Zhang F, Meng X, Han J. Regulation of cholesterol homeostasis in health and diseases: from mechanisms to targeted therapeutics. Signal Transduct Target Ther 2022; 7:265. [PMID: 35918332 PMCID: PMC9344793 DOI: 10.1038/s41392-022-01125-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 12/13/2022] Open
Abstract
Disturbed cholesterol homeostasis plays critical roles in the development of multiple diseases, such as cardiovascular diseases (CVD), neurodegenerative diseases and cancers, particularly the CVD in which the accumulation of lipids (mainly the cholesteryl esters) within macrophage/foam cells underneath the endothelial layer drives the formation of atherosclerotic lesions eventually. More and more studies have shown that lowering cholesterol level, especially low-density lipoprotein cholesterol level, protects cardiovascular system and prevents cardiovascular events effectively. Maintaining cholesterol homeostasis is determined by cholesterol biosynthesis, uptake, efflux, transport, storage, utilization, and/or excretion. All the processes should be precisely controlled by the multiple regulatory pathways. Based on the regulation of cholesterol homeostasis, many interventions have been developed to lower cholesterol by inhibiting cholesterol biosynthesis and uptake or enhancing cholesterol utilization and excretion. Herein, we summarize the historical review and research events, the current understandings of the molecular pathways playing key roles in regulating cholesterol homeostasis, and the cholesterol-lowering interventions in clinics or in preclinical studies as well as new cholesterol-lowering targets and their clinical advances. More importantly, we review and discuss the benefits of those interventions for the treatment of multiple diseases including atherosclerotic cardiovascular diseases, obesity, diabetes, nonalcoholic fatty liver disease, cancer, neurodegenerative diseases, osteoporosis and virus infection.
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Affiliation(s)
- Yajun Duan
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.,Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Ke Gong
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Suowen Xu
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Feng Zhang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Xianshe Meng
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Jihong Han
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China. .,College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China.
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18
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Liu HH, Guo YL, Zhu CG, Wu NQ, Gao Y, Xu RX, Dong Q, Qian J, Dou KF, Li JJ. Synergistic effect of the commonest residual risk factors, remnant cholesterol, lipoprotein(a), and inflammation, on prognosis of statin-treated patients with chronic coronary syndrome. J Transl Med 2022; 20:243. [PMID: 35619146 PMCID: PMC9134647 DOI: 10.1186/s12967-022-03448-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/18/2022] [Indexed: 12/24/2022] Open
Abstract
Background Currently, remnant cholesterol (RC), lipoprotein(a) [Lp(a)], and inflammation are considered the principal residual cardiovascular risk (RCVR) factors. This study sought to evaluate the combined impact of RC, Lp(a), and inflammation on prognosis of statin-treated patients with chronic coronary syndrome (CCS), which has not been investigated. Methods A total of 6839 patients with CCS were consecutively enrolled. Baseline RC, Lp(a), and high-sensitivity C-reactive protein (hsCRP) concentrations were measured and their medians were used for categorizations. All patients were followed for the major adverse cardiovascular events (MACEs), including cardiovascular death, non-fatal myocardial infarction, and stroke. The individual and combined effects of RC, Lp(a), and hsCRP on MACEs were examined and stratification analysis according to low-density lipoprotein cholesterol (LDL-C) was performed. Results Over an average of 54.93 ± 18.59 months follow-up, 462 MACEs were recorded. Multivariate Cox analysis showed that elevated RC and Lp(a) levels were significantly associated with an increased risk of MACEs, while high hsCRP levels were related to a slightly but non-significantly increased MACEs risk. Moreover, when participants were subgrouped according to RC, Lp(a), and hsCRP levels together, only High RC-High Lp(a)-High hsCRP group had significantly higher risk of MACEs [hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.15–3.47] compared with the reference group (Low RC-Low Lp(a)-Low hsCRP), especially in patients with LDL-C < 2.6 mmol/L. Conclusions The combination of elevated levels of RC, Lp(a), and hsCRP potentiated the adverse effect on MACEs among statin-treated patients with CCS, suggesting that multiple RCVR factors assessment may be a better strategy to improve stratification in very-high risk population. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03448-x.
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Affiliation(s)
- Hui-Hui Liu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Yuan-Lin Guo
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Cheng-Gang Zhu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Na-Qiong Wu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ying Gao
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Rui-Xia Xu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Qian Dong
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jie Qian
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ke-Fei Dou
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jian-Jun Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
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19
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Bi L, Yi J, Wu C, Hu S, Zhang X, Lu J, Liu J, Zhang H, Yang Y, Cui J, Xu W, Song L, Guo Y, Li X, Zheng X. Atherosclerotic Cardiovascular Disease Risk and Lipid-Lowering Therapy Requirement in China. Front Cardiovasc Med 2022; 9:839571. [PMID: 35419429 PMCID: PMC8996051 DOI: 10.3389/fcvm.2022.839571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundLipid-lowering therapy (LLT) is one of the key strategies for reducing the atherosclerotic cardiovascular disease (ASCVD) burden. However, little is known about the percentage of people in need of different LLT regimens to achieve optimal targets of low-density lipoprotein cholesterol (LDL-C), and the corresponding cost and benefit.MethodsWe conducted a simulation study based on the data from the nationwide China PEACE MPP population cohort (2015–2020), from which we included 2,904,914 participants aged 35–75 years from all the 31 provinces in mainland China. Participants were grouped based on their 10-year ASCVD risks, then entered into a Monte Carlo model which was used to perform LLT intensification simulation scenarios to achieve corresponding LDL-C goals in each risk stratification.ResultsAfter standardizing age and sex, the proportions of participants included at low, moderate, high, and very-high risk were 70.8%, 15.6%, 11.5%, and 2.1%, respectively. People who failed to achieve the corresponding LDL-C goals −8.1% at low risk, 19.6% at moderate risk, 53.2% at high risk, and 93.6% at very-high risk (either not achieving the goal or not receiving LLT)—would be in need of the LLT intensification simulation. After the use of atorvastatin 20 mg was simulated, over 99% of the population at low or moderate risk could achieve the LDL-C goals; while 11.3% at high and 24.5% at very-high risk would still require additional non-statin therapy. After the additional use of ezetimibe, there were still 4.8% at high risk and 11.3% at very-high risk in need of evolocumab; and 99% of these two groups could achieve the LDL-C goals after the use of evolocumab. Such LLT intensification with statin, ezetimibe, and evolocumab would annually cost $2.4 billion, $4.2 billion, and $24.5 billion, respectively, and prevent 264,170, 18,390, and 17,045 cardiovascular events, respectively.ConclusionsModerate-intensity statin therapy is pivotal for the attainment of optimal LDL-C goals in China, and around 10–25% of high- or very-high-risk patients would require additional non-statin agents. There is an opportunity to reduce the rising ASCVD burden in China by optimizing LLT.
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Affiliation(s)
- Lei Bi
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jiayi Yi
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Chaoqun Wu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Shuang Hu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Xingyi Zhang
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jiapeng Lu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jiamin Liu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Haibo Zhang
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Yang Yang
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jianlan Cui
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Wei Xu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Lijuan Song
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuanlin Guo
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
- Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, China
- *Correspondence: Xin Zheng
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Shenzhen, Coronary Artery Disease Center, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
- Xi Li
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20
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Tokgözoğlu L, Libby P. The dawn of a new era of targeted lipid-lowering therapies. Eur Heart J 2022; 43:3198-3208. [PMID: 35051271 PMCID: PMC9448630 DOI: 10.1093/eurheartj/ehab841] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/26/2021] [Accepted: 11/25/2021] [Indexed: 01/22/2023] Open
Abstract
Lipid risk factors for cardiovascular disease depend in part on lifestyle, but optimum control of lipids often demands additional measures. Low-density lipoprotein (LDL) doubtless contributes causally to atherosclerosis. Recent human genetic findings have substantiated a number of novel targets for lipid-lowering therapy including apolipoprotein C-III, angiopoietin-like protein 3 and 4, apolipoprotein V, and ATP citrate lyase. These discoveries coupled with advances in biotechnology development afford new avenues for management of LDL and other aspects of lipid risk. Beyond LDL, new treatments targeting triglyceride-rich lipoproteins and lipoprotein(a) have become available and have entered clinical development. Biological and RNA-directed agents have joined traditional small-molecule approaches, which themselves have undergone considerable refinement. Innovative targeting strategies have increased efficacy of some of these novel interventions and markedly improved their tolerability. Gene-editing approaches have appeared on the horizon of lipid management. This article reviews this progress offering insight into novel biological and therapeutic discoveries, and places them into a practical patient care perspective.
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Affiliation(s)
- Lale Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey
| | - Peter Libby
- Corresponding author. Tel: +1 617 525 4383, Fax: +1 617 525 4400,
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21
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Ginsberg HN, Rosenson RS, Hovingh GK, Letierce A, Samuel R, Poulouin Y, Cannon CP. LDL-C calculated by Friedewald, Martin-Hopkins, or NIH equation 2 versus beta-quantification: pooled alirocumab trials. J Lipid Res 2022; 63:100148. [PMID: 34774485 PMCID: PMC8953656 DOI: 10.1016/j.jlr.2021.100148] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 12/31/2022] Open
Abstract
Accurate assessment of LDL-C levels is important, as they are often used for treatment recommendations. For many years, plasma LDL-C levels were calculated using the Friedewald equation, but there are limitations to this method compared with direct measurement via beta-quantification (BQ). Here, we assessed differences between the Friedewald, Martin-Hopkins, and NIH equation 2 methods of calculating LDL-C and the "gold standard" BQ method using pooled phase 3 data with alirocumab. All randomized patients were included irrespective of the treatment arm (n = 6,122). We compared pairs of LDL-C values (n = 17,077) determined by each equation and BQ. We found that BQ-derived LDL-C values ranged from 1 to 397 mg/dl (mean 90.68 mg/dl). There were strong correlations between Friedewald-calculated, Martin-Hopkins-calculated, and NIH equation 2-calculated LDL-C with BQ-determined LDL-C values (Pearson's correlation coefficient = 0.985, 0.981, and 0.985, respectively). Importantly, for BQ-derived LDL-C values ≥70 mg/dl, only 3.2%, 1.4%, and 1.8% of Friedewald-calculated, Martin-Hopkins-calculated, and NIH equation 2-calculated values were <70 mg/dl, respectively. When triglyceride (TG) levels were <150 mg/dl, differences between calculated and BQ-derived LDL-C values were minimal, regardless of the LDL-C level (<40, <55, or <70 mg/dl). However, when TG levels were >150 mg/dl, NIH equation 2 provided greater accuracy than Friedewald or Martin-Hopkins. When TGs were >250 mg/dl, inaccuracies were seen with all three methods, although NIH equation 2 remained the most accurate. In conclusion, LDL-C calculated by any of the three methods can guide treatment decisions for most patients, including those treated with proprotein convertase subtilisin/kexin type 9 inhibitors.
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Affiliation(s)
| | | | - G Kees Hovingh
- Academic Medical Center, Amsterdam, The Netherlands; Novo Nordisk AS, Copenhagen, Denmark
| | | | - Rita Samuel
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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22
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Nakamura M, Ako J, Arai H, Hirayama A, Nohara A, Murakami Y, Ozaki A, Harada-Shiba M. Lipid Management and 2-Year Clinical Outcomes in Japanese Patients with Acute Coronary Syndrome: EXPLORE-J. J Atheroscler Thromb 2021; 28:1307-1322. [PMID: 33612707 PMCID: PMC8629700 DOI: 10.5551/jat.59543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/23/2020] [Indexed: 12/05/2022] Open
Abstract
AIM The prevalence of atherosclerotic cardiovascular (CV) disease has risen in Japan due to increasing metabolic risk factors, including dyslipidemia. A positive linear correlation between low-density lipoprotein cholesterol (LDL-C) levels, incidence of CV events, and preventive effects of lipid-lowering therapy (LLT) is well established; however, data in Japan are limited. This analysis evaluated current lipid management practices and risk of recurrent CV events in Japanese post-acute coronary syndrome (ACS) patients. METHODS EXPLORE-J is a multicenter, 2-year observational study of hospitalized ACS patients in Japan. RESULTS At 2-year follow-up (n=1944, mean age 66 years, 80.3% male), the cumulative incidence of major adverse cardiovascular events (MACE; death associated with myocardial infarction/cerebrovascular accident [CVA] and other CV death, non-fatal ACS, and non-fatal CVA requiring hospitalization during the observation period) was 6.2%; respective incidences of CV death, non-fatal ACS, and CVA were 0.7%, 4.5%, and 1.7%. Statin, intensive statin, and ezetimibe were prescribed for 93.6%, 8.2%, and 3.9% at visit (V)1 (Day[D]1+14), and 92.3%, 10.5%, and 11.6% of patients at V5 (D730±30 days), respectively. Mean LDL-C was reduced from first post-ACS measurement (121.3 mg/dL) to V5 (79.8 mg/dL). A limited number of patients achieved LDL-C <70 mg/dL from V1-V5 (14.4%-34.6%); those with a greater LDL-C reduction by V1 had a lower probability of MACE, indicating the benefits of early LDL-C reduction post ACS. CONCLUSIONS Guideline-recommended LDL-C target achievement post ACS in Japan is suboptimal, suggesting the need for LLT intensification. Additional analyses by risk stratification of the study population and the benefits of lipid management are planned.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, Kanagawa, Japan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | | | - Atsushi Nohara
- Department of Clinical Genetics, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | | | | | - Mariko Harada-Shiba
- Department of Molecular Innovation in Lipidology, National Cerebral & Cardiovascular Center Research Institute, Osaka, Japan
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23
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Pulipati VP, Alenghat FJ. The impact of lipid-lowering medications on coronary artery plaque characteristics. Am J Prev Cardiol 2021; 8:100294. [PMID: 34877559 PMCID: PMC8627965 DOI: 10.1016/j.ajpc.2021.100294] [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: 09/09/2021] [Revised: 10/29/2021] [Accepted: 11/06/2021] [Indexed: 11/28/2022] Open
Abstract
Atherosclerosis is the predominant cause of coronary artery disease. The last several decades have witnessed significant advances in lipid-lowering therapies, which comprise a central component of atherosclerotic cardiovascular disease prevention. In addition to cardiovascular risk reduction with dyslipidemia management, some lipid-based therapies show promise at the level of the atherosclerotic plaque itself through mechanisms governing lipid accumulation, plaque stability, local inflammation, endothelial dysfunction, and thrombogenicity. The capacity of lipid-lowering therapies to modify atherosclerotic plaque burden, size, composition, and vulnerability should correlate with their ability to reduce disease progression. This review discusses plaque characteristics, diagnostic modalities to evaluate these characteristics, and how they are altered by current and emerging lipid-lowering therapies, all in human coronary artery disease.
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Affiliation(s)
- Vishnu Priya Pulipati
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, United States
| | - Francis J. Alenghat
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, United States
- Pritzker School of Medicine, University of Chicago, Chicago, United States
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24
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Wong ND, Puri R, Mehta V, Duell PB. When is it Appropriate to Lower Low Density Lipoprotein-Cholesterol Levels to <30 mg/dL? Am J Cardiol 2021; 157:142-144. [PMID: 34344510 DOI: 10.1016/j.amjcard.2021.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022]
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25
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Karagiannis AD, Mehta A, Dhindsa DS, Virani SS, Orringer CE, Blumenthal RS, Stone NJ, Sperling LS. How low is safe? The frontier of very low (<30 mg/dL) LDL cholesterol. Eur Heart J 2021; 42:2154-2169. [PMID: 33463677 DOI: 10.1093/eurheartj/ehaa1080] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/16/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023] Open
Abstract
Low-density lipoprotein cholesterol (LDL-C) is a proven causative factor for developing atherosclerotic cardiovascular disease. Individuals with genetic conditions associated with lifelong very low LDL-C levels can be healthy. We now possess the pharmacological armamentarium (statins, ezetimibe, PCSK9 inhibitors) to reduce LDL-C to an unprecedented extent. Increasing numbers of patients are expected to achieve very low (<30 mg/dL) LDL-C. Cardiovascular event reduction increases log linearly in association with lowering LDL-C, without reaching any clear plateau even when very low LDL-C levels are achieved. It is still controversial whether lower LDL-C levels are associated with significant clinical adverse effects (e.g. new-onset diabetes mellitus or possibly haemorrhagic stroke) and long-term data are needed to address safety concerns. This review presents the familial conditions characterized by very low LDL-C, analyses trials with lipid-lowering agents where patients attained very low LDL-C, and summarizes the benefits and potential adverse effects associated with achieving very low LDL-C. Given the potential for cardiovascular benefit and short-term safe profile of very low LDL-C, it may be advantageous to attain such low levels in specific high-risk populations. Further studies are needed to compare the net clinical benefit of non-LDL-C-lowering interventions with very low LDL-C approaches, in addition to comparing the efficacy and safety of very low LDL-C levels vs. current recommended targets.
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Affiliation(s)
- Angelos D Karagiannis
- Department of Internal Medicine, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, USA
| | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Way NE, Atlanta, GA 30322, USA
| | - Devinder S Dhindsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Way NE, Atlanta, GA 30322, USA
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA
| | - Carl E Orringer
- University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, 601 North Caroline Street Suite 7200, Baltimore, MD 21287, USA
| | - Neil J Stone
- Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, USA
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Way NE, Atlanta, GA 30322, USA
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26
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Langlois MR, Nordestgaard BG, Langsted A, Chapman MJ, Aakre KM, Baum H, Borén J, Bruckert E, Catapano A, Cobbaert C, Collinson P, Descamps OS, Duff CJ, von Eckardstein A, Hammerer-Lercher A, Kamstrup PR, Kolovou G, Kronenberg F, Mora S, Pulkki K, Remaley AT, Rifai N, Ros E, Stankovic S, Stavljenic-Rukavina A, Sypniewska G, Watts GF, Wiklund O, Laitinen P. Quantifying atherogenic lipoproteins for lipid-lowering strategies: consensus-based recommendations from EAS and EFLM. Clin Chem Lab Med 2021; 58:496-517. [PMID: 31855562 DOI: 10.1515/cclm-2019-1253] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Indexed: 12/15/2022]
Abstract
The joint consensus panel of the European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) recently addressed present and future challenges in the laboratory diagnostics of atherogenic lipoproteins. Total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDLC), LDL cholesterol (LDLC), and calculated non-HDLC (=total - HDLC) constitute the primary lipid panel for estimating risk of atherosclerotic cardiovascular disease (ASCVD) and can be measured in the nonfasting state. LDLC is the primary target of lipid-lowering therapies. For on-treatment follow-up, LDLC shall be measured or calculated by the same method to attenuate errors in treatment decisions due to marked between-method variations. Lipoprotein(a) [Lp(a)]-cholesterol is part of measured or calculated LDLC and should be estimated at least once in all patients at risk of ASCVD, especially in those whose LDLC declines poorly upon statin treatment. Residual risk of ASCVD even under optimal LDL-lowering treatment should be also assessed by non-HDLC or apolipoprotein B (apoB), especially in patients with mild-to-moderate hypertriglyceridemia (2-10 mmol/L). Non-HDLC includes the assessment of remnant lipoprotein cholesterol and shall be reported in all standard lipid panels. Additional apoB measurement can detect elevated LDL particle (LDLP) numbers often unidentified on the basis of LDLC alone. Reference intervals of lipids, lipoproteins, and apolipoproteins are reported for European men and women aged 20-100 years. However, laboratories shall flag abnormal lipid values with reference to therapeutic decision thresholds.
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Affiliation(s)
- Michel R Langlois
- Department of Laboratory Medicine, AZ St-Jan, Ruddershove 10, 8000 Brugge, Belgium.,University of Ghent, Ghent, Belgium
| | - Børge G Nordestgaard
- Herlev and Gentofte Hospital, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anne Langsted
- Herlev and Gentofte Hospital, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M John Chapman
- National Institute for Health and Medical Research (INSERM), Paris, France.,Endocrinology-Metabolism Service, Pitié-Salpetriere University Hospital, Paris, France
| | - Kristin M Aakre
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | - Hannsjörg Baum
- Institute for Laboratory Medicine, Mikrobiologie und Blutdepot, Regionale Kliniken Holding RKH GmbH, Ludwigsburg, Germany
| | - Jan Borén
- Institute of Medicine, Sahlgrenska Academy at Göteborg University, Gothenburg, Sweden.,Wallenberg Laboratory for Cardiovascular and Metabolic Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eric Bruckert
- Department of Endocrinology and Prevention of Cardiovascular Disease, Pitié-Salpetriere University Hospital, Paris, France
| | - Alberico Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.,IRCCS Multimedica, Milan, Italy
| | - Christa Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Collinson
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK.,Department of Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Olivier S Descamps
- Department of Internal Medicine, Centres Hospitaliers Jolimont, Haine-Saint-Paul, Belgium.,Department of Cardiology, UCL Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Christopher J Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | | | | | - Pia R Kamstrup
- Herlev and Gentofte Hospital, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Florian Kronenberg
- Department of Medical Genetics, Molecular and Clinical Pharmacology, Division of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Samia Mora
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Turku and Turku University Hospital, Turku, Finland
| | - Alan T Remaley
- Lipoprotein Metabolism Section, Cardiovascular-Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nader Rifai
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emilio Ros
- Lipid Clinic, Department of Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi Sunyer, Hospital Clínic, Barcelona, Spain.,Ciber Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Sanja Stankovic
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Grazyna Sypniewska
- Department of Laboratory Medicine, Collegium Medicum, NC University, Bydgoszcz, Poland
| | - Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Olov Wiklund
- Institute of Medicine, Sahlgrenska Academy at Göteborg University, Gothenburg, Sweden.,Wallenberg Laboratory for Cardiovascular and Metabolic Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Päivi Laitinen
- Department of Clinical Chemistry, HUSLAB, Helsinki University Hospital, Helsinki, Finland
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28
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Allahyari A, Jernberg T, Hagström E, Leosdottir M, Lundman P, Ueda P. Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study. Eur Heart J 2021; 41:3900-3909. [PMID: 32072178 PMCID: PMC7654933 DOI: 10.1093/eurheartj/ehaa034] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/28/2019] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
AIMS To estimate the proportion of patients with a recent myocardial infarction (MI) who would be eligible for additional lipid-lowering therapy according to the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias, and to simulate the effects of expanded lipid-lowering therapy on attainment of the low-density lipoprotein cholesterol (LDL-C) target as recommended by the guidelines. METHODS AND RESULTS Using the nationwide SWEDEHEART register, we included 25 466 patients who had attended a follow-up visit 6-10 weeks after an MI event, 2013-17. While most patients (86.6%) were receiving high-intensity statins, 82.9% of the patients would be eligible for expanded lipid-lowering therapy, as they had not attained the target of an LDL-C level of <1.4 mmol and a ≥50% LDL-C level reduction. When maximized use of high-intensity statins followed by add-on therapy with ezetimibe was simulated using a Monte Carlo model, the LDL-C target was reached in 19.9% using high-intensity statin monotherapy and in another 28.5% with high-intensity statins and ezetimibe, while 50.7% would still be eligible for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. When use of alirocumab or evolocumab was simulated in those who were eligible for PCSK9 inhibitors, around 90% of all patients attained the LDL-C target. CONCLUSION Our study suggests that, even with maximized use of high-intensity statins and ezetimibe, around half of patients with MI would be eligible for treatment with PCSK9 inhibitors according to the 2019 ESC/EAS guidelines. Considering the current cost of PCSK9 inhibitors, the financial implications of the new guidelines may be substantial.
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Affiliation(s)
- Ali Allahyari
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288 Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288 Stockholm, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden.,Uppsala Clinical Research Center, 75185 Uppsala, Sweden
| | - Margrét Leosdottir
- Department of Cardiology, Skane University Hospital, 20502 Malmo, Sweden.,Department of Clinical Sciences Malmo, Lund University, 20502 Malmo, Sweden
| | - Pia Lundman
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288 Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, 17176 Stockholm, Sweden
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2773] [Impact Index Per Article: 924.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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XIE YY, LIU SM, ZHANG Q, JIA Y, DING JP. Associations between low-density lipoprotein cholesterol and haemorrhagic stroke. J Geriatr Cardiol 2021; 18:204-209. [PMID: 33907550 PMCID: PMC8047185 DOI: 10.11909/j.issn.1671-5411.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE To investigate the associations between the blood concentrations of low-density lipoprotein cholesterol (LDL-C) and the clinical features of haemorrhagic stroke. METHODS This study analysed the data from patients with acute haemorrhagic stroke at a comprehensive stroke centre from 2013 to 2018. Patients were stratified into three groups according to their baseline LDL-C levels: < 70, 70 to < 100 and ≥ 100 mg/dL. We used multivariate logistic regression models to analyse the associations between LDL-C and the risks of having severe neurological deficits (National Institute Health Stroke Scale [NIHSS] scores ≥ 15) and unfavourable outcomes (modified Rankin Scale [mRS] scores>2) at discharge. RESULTS Six-hundred and six patients were analysed. Their median age was 58 years. Among the patients, 75 (12%) patients had LDL-C levels < 70 mg/dL, 194 (32%) patients had LDL-C levels between 70 to < 100 mg/dL and the other 337 (56%) patients had LDL-C levels ≥ 100 mg/dL. Patients with higher LDL-C levels were less likely to suffer severe neurological deficits (LDL-C: 70 to < 100 vs. < 70 mg/dL, adjusted odds ratio [OR]: 0.29, 95% CI: 0.15-0.57; LDL-C: ≥ 100 vs. < 70 mg/dL, adjusted OR = 0.27, 95% CI: 0.15-0.51) and to have unfavourable outcomes at discharge (LDL-C: 70 to < 100 vs. < 70 mg/dL, adjusted OR = 0.50, 95% CI: 0.29-0.87 and LDL-C: ≥ 100 vs. < 70 mg/dL, adjusted OR = 0.46, 95% CI: 0.28-0.78). CONCLUSIONS An LDL-C level < 70 mg/dL was independently associated with severe neurological deficits of haemorrhagic stroke and may increase the risks of unfavourable outcomes at discharge.
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Affiliation(s)
- Yun-Yan XIE
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shi-Meng LIU
- Department of Neurology, University of California, Irvine, Irvine, California, USA
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qian ZHANG
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu JIA
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian-Ping DING
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Sud M, Han L, Koh M, Abdel-Qadir H, Austin PC, Farkouh ME, Godoy LC, Lawler PR, Udell JA, Wijeysundera HC, Ko DT. Low-Density Lipoprotein Cholesterol and Adverse Cardiovascular Events After Percutaneous Coronary Intervention. J Am Coll Cardiol 2021; 76:1440-1450. [PMID: 32943162 DOI: 10.1016/j.jacc.2020.07.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND After percutaneous coronary interventions (PCIs), patients remain at high risk of developing late cardiovascular events. Although controlling low-density lipoprotein cholesterol (LDL-C) may improve outcomes after PCI, practice guidelines do not have specific recommendations on LDL-C management for this subgroup. OBJECTIVES The purpose of this study was to evaluate LDL-C testing and levels after PCIs, and to assess the association between LDL-C and longer-term cardiovascular events after PCIs. METHODS All patients who received their first PCI from October 1, 2011, to September 30, 2014, in Ontario, Canada, were considered for inclusion. Patients who had LDL-C measurement within 6 months after PCI were categorized as: <70 mg/dl, 70 to <100 mg/dl, and ≥100 mg/dl. The primary composite outcome was cardiovascular death, myocardial infarction, coronary revascularization, and stroke through December 31, 2016. RESULTS Among 47,884 included patients, 52% had LDL-C measured within 6 months of PCI and 57% had LDL-C <70 mg/dl. After a median 3.2 years, the rates of cardiovascular events were 55.2/1,000 person-years for the LDL-C <70 mg/dl group, 60.3/1,000 person-years for 70 to <100 mg/dl, and 94.0/1,000 person-years for ≥100 mg/dl. The adjusted subdistribution hazard ratios for cardiovascular events were 1.17 (95% confidence interval: 1.09 to 1.26) for LDL-C of 70 to <100 mg/dl, and 1.78 (95% confidence interval: 1.64 to 1.94) for LDL-C ≥100 mg/dl when compared with LDL-C <70 mg/dl. CONCLUSIONS One in 2 patients had LDL-C measured within 6 months after PCI, and only 57% had LDL-C <70 mg/dl. Higher levels of LDL-C were associated with an increased incidence of late cardiovascular events. Improved cholesterol management after PCI should be considered to improve the outcomes of these patients.
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Affiliation(s)
- Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | - Husam Abdel-Qadir
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Ted Roger's Centre for Heart Research, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Ted Roger's Centre for Heart Research, Toronto, Ontario, Canada
| | - Lucas C Godoy
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Patrick R Lawler
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Ted Roger's Centre for Heart Research, Toronto, Ontario, Canada
| | - Jacob A Udell
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Ted Roger's Centre for Heart Research, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Wang D, Li C, Xu X, Xu H, Guo C, Wang J, Guo J, Huang L. Effect of Yugengtongyu Granules in Patients with Stable Coronary Artery Disease on Reducing Adverse Cardiovascular Events: A Double-Blind Controlled Trial. J Altern Complement Med 2020; 27:142-149. [PMID: 33259734 DOI: 10.1089/acm.2020.0361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To evaluate the effect of Yugengtongyu granules on reducing the incidence of adverse cardiovascular events and improving quality of life (QOL) in patients with stable coronary artery disease (SCAD). Methods: A double-blind randomized controlled trial was conducted among SCAD population. One hundred fourteen patients were randomly assigned to experimental group (n = 57) and control group (n = 57) following randomized block design. Combined with the basis of standard treatment of SCAD, the experimental group and control group received Yugengtongyu granules or placebo, respectively, twice daily for 6 months and were followed for another 1 year (18 months in total from enrollment). Major outcomes (any occurrence of cardiovascular death, nonfatal myocardial infarction, or coronary revascularization), minor outcomes (any occurrence of all-cause death, ischemic stroke, readmission due to unstable angina, heart failure, or malignant arrhythmia), and composite outcomes (union of major and minor outcomes) were used to evaluate prognosis; Seattle Angina Questionnaire (SAQ) was applied to evaluate QOL, and levels of low density lipoprotein-cholesterol (LDL-C) and high sensitive C reacting protein (HS-CRP) in serum were tested. Results: The incidence of composite outcomes in the experimental group was significantly lower than that in the control group (3 [5.2%] vs. 11 [19.2%], hazard ratio: 0.273, 95% confidence interval: 0.080-0.926, p = 0.022); major outcomes, minor outcomes, and independent events such as nonfatal myocardial infarction showed lowering trend in experimental group. Experimental group scored significantly higher than control group in four dimensions of SAQ: physical limitation, angina frequency, treatment satisfaction, and disease perception at the third- and sixth-month follow-up; there was no significant difference in serum level of LDL or HS-CRP at all scheduled timepoints. Conclusion: The addition of Yugengtongyu granules based on current standard treatment reduced the incidence of composite outcomes and improved QOL in patients with SCAD. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-13004370).
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Affiliation(s)
- Dayang Wang
- Cardiovascular Institute, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Chunyan Li
- China-Japan Friendship Hospital, Beijing, China
| | - Xiaoqing Xu
- Cardiovascular Institute, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Hui Xu
- Department of Cardiology, Jiangxi Province Hospital of Integrated Chinese and Western Medicine, Nanchang, China
| | - Congcong Guo
- Shandong University of Chinese Medicine Affiliated Hospital, Jinan, China
| | | | - Jingyin Guo
- Department of Cardiology, Shunyi Branch of Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Li Huang
- China-Japan Friendship Hospital, Beijing, China
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Duprez DA, Handelsman Y, Koren M. Cardiovascular Outcomes and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: Current Data and Future Prospects. Vasc Health Risk Manag 2020; 16:403-418. [PMID: 33116551 PMCID: PMC7548340 DOI: 10.2147/vhrm.s261719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular (CV) disease remains the leading cause of morbidity and mortality worldwide and poses an ongoing challenge with the aging population. Elevated low-density lipoprotein cholesterol (LDL-C) is an established risk factor for atherosclerotic cardiovascular disease (ASCVD), and the expert consensus is the use of statin therapy (if tolerated) as first line for LDL-C reduction. However, patients with ASCVD may experience recurrent ischemic events despite receiving maximally tolerated statin therapy, including those whose on-treatment LDL-C remains ≥70 mg/dL, patients with familial hypercholesterolemia, high-risk subgroups with comorbidities such as diabetes mellitus, and those who have an intolerance to statin therapy. Optimal therapeutic strategies for this unmet need should deploy aggressive lipid lowering to minimize the contribution of dyslipidemia to their CV risk, particularly for very high-risk populations with additional risk factors beyond hypercholesterolemia and established ASCVD. To understand the current clinical climate and guidelines regarding ASCVD, we primarily searched PubMed for articles published in English regarding lipid-lowering therapies and CV risk reduction, including emerging therapies, and CV outcomes trials with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. This review discusses the findings of recent clinical trial evidence for CV risk reduction with cholesterol-lowering therapies, with a focus on CV outcomes trials with PCSK9 inhibitors, and considers the impact of the study results for secondary prevention and future strategies in patients with hypercholesterolemia and CV risk despite maximally tolerated statin therapy.
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Affiliation(s)
- Daniel A Duprez
- Cardiovascular Division, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael Koren
- Jacksonville Center for Clinical Research, Jacksonville, FL, USA
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Panagiotopoulou O, Chiesa ST, Tousoulis D, Charakida M. Dyslipidaemias and Cardiovascular Disease: Focus on the Role of PCSK9 Inhibitors. Curr Med Chem 2020; 27:4494-4521. [PMID: 31453780 DOI: 10.2174/0929867326666190827151012] [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: 10/08/2017] [Revised: 12/23/2018] [Accepted: 01/15/2019] [Indexed: 12/19/2022]
Abstract
Genetic, experimental and clinical studies have consistently confirmed that inhibition of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) can result in significant lowering of LDL-C and two fully human PCSK9 monoclonal antibodies have received regulatory approval for use in highrisk patients. Co-administration of PCSK9 with statins has resulted in extremely low LDL-C levels with excellent short-term safety profiles. While results from Phase III clinical trials provided significant evidence about the role of PCSK9 inhibitors in reducing cardiovascular event rates, their impact on mortality remains less clear. PCSK9 inhibitor therapy can be considered for high-risk patients who are likely to experience significant cardiovascular risk reduction.
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Affiliation(s)
- Olga Panagiotopoulou
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing St. Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Scott T Chiesa
- UCL Institute of Cardiovascular Sciences, London, United Kingdom
| | | | - Marietta Charakida
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing St. Thomas' Hospital, London SE1 7EH, United Kingdom
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Kaddoura R, Orabi B, Salam AM. Efficacy and safety of PCSK9 monoclonal antibodies: an evidence-based review and update. J Drug Assess 2020; 9:129-144. [PMID: 32939318 PMCID: PMC7470150 DOI: 10.1080/21556660.2020.1801452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Treatment of dyslipidemia lowers cardiovascular (CV) risk. Although statin use is a cornerstone therapy, many patients are not achieving their risk-specific low-density lipoprotein cholesterol (LDL-C) goals. The proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies have been extensively studied as lipid-lowering therapy (LLT). Herein, we present an updated evidence-based review of the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of familial and non-familial hypercholesterolemia. Methods PubMed database was searched to review Phase III studies on PCSK9 monoclonal antibodies. Then, the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform were searched to identify and present the ongoing research. Results PCSK9 monoclonal antibodies were investigated for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional LLT. They proved effective and safe in the treatment of familial and non-familial hypercholesterolemia, and in the prevention of adverse CV events. Conclusions The use of PCSK9 monoclonal antibodies in the treatment of dyslipidemia is currently recommended to achieve risk-specific LDL-C goal to reduce adverse CV events. Future results of the ongoing research might expand their clinical generalizability to broader patient populations.
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Affiliation(s)
- Rasha Kaddoura
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Bassant Orabi
- Hamad Medical Corporation, Heart Hospital Pharmacy, Doha, Ad Dawhah, Qatar
| | - Amar M Salam
- Department of Cardiology, Hamad Medical Corporation, Al-khor Hospital, Doha, Ad Dawhah, Qatar
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Tomlinson B, Chan P, Zhang Y, Lam CWK. Efficacy and safety of add on therapies in patients with hypercholesterolemia undergoing statin therapy. Expert Opin Pharmacother 2020; 21:2137-2151. [PMID: 32772741 DOI: 10.1080/14656566.2020.1801638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Statins are the first-line treatment to reduce cardiovascular (CV) events, mainly by reducing low-density-lipoprotein cholesterol (LDL-C), but many patients need additional treatments to reach the current lipid goals. AREAS COVERED Herein, the authors review the published literature on the efficacy and safety of the therapies that are most often added to statins to achieve lipid targets. EXPERT OPINION Ezetimibe is usually the first additional treatment to achieve LDL-C targets. It reduces LDL-C by about a further 20% and has an excellent safety and tolerability profile. The monoclonal antibody proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab, and alirocumab, can reduce LDL-C by ≥50% when added to statins and they also have a well-established safety and tolerability record. The recently approved bempedoic acid is well tolerated and appears to be free of skeletal muscle-related problems, but the CV outcome study with this drug has not been completed. Inclisiran, a small-interfering RNA targeting PCSK9 is at an advanced stage of development and the available data indicate a satisfactory safety profile and LDL-C lowering efficacy similar to the PCSK9 monoclonal antibodies with the advantage of less frequent administration.
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Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology , Macau, China
| | - Paul Chan
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University , Taipei City, Taiwan
| | - Yuzhen Zhang
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine , Shanghai, China
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Brandts J, Ray KK. Small interfering RNA to proprotein convertase subtilisin/kexin type 9: transforming LDL-cholesterol-lowering strategies. Curr Opin Lipidol 2020; 31:182-186. [PMID: 32487819 DOI: 10.1097/mol.0000000000000691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition is a new strategy to reduce LDL cholesterol (LDL-C), that is currently pursued by mAbs. A promising novel approach to target PCSK9 is using small interfering RNAs to inhibit hepatic PCSK9 synthesis. The first small interfering RNA developed for this purpose is inclisiran. Here, we review its clinical trial data and potential impact on patient management. RECENT FINDINGS Inclisiran achieves sustained, additional 50% LDL-C reduction in patients receiving background statin therapy. Resulting LDL-C changes can be maintained by an infrequent dosing regimen with twice per year injections, that appear safe and well tolerated. Thus far, inclisiran has been studied in patients with established cardiovascular disease, high-risk primary prevention and in patients with familial hypercholesterolemia. SUMMARY High and very high-risk individuals may benefit from the additional LDL-C-lowering effect of inclisiran when added to current lipid-lowering therapies. Furthermore, the simple dosing regimen may improve the convenience for users and facilitate patient adherence to therapy. The safety and convenience of inclisiran may offer new opportunities for population health.
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Affiliation(s)
- Julia Brandts
- Department of Medicine I, University Hospital RWTH Aachen, Aachen, Germany
- Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, School of Public Health, Imperial College London, London, UK
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Langlois MR, Sniderman AD. Non-HDL Cholesterol or apoB: Which to Prefer as a Target for the Prevention of Atherosclerotic Cardiovascular Disease? Curr Cardiol Rep 2020; 22:67. [PMID: 32562186 DOI: 10.1007/s11886-020-01323-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Guidelines propose using non-HDL cholesterol or apolipoprotein (apo) B as a secondary treatment target to reduce residual cardiovascular risk of LDL-targeted therapies. This review summarizes the strengths, weaknesses, opportunities, and threats (SWOT) of using apoB compared with non-HDL cholesterol. RECENT FINDINGS Non-HDL cholesterol, calculated as total-HDL cholesterol, includes the assessment of remnant lipoprotein cholesterol, an additional risk factor independent of LDL cholesterol. ApoB is a direct measure of circulating numbers of atherogenic lipoproteins, and its measurement can be standardized across laboratories worldwide. Discordance analysis of non-HDL cholesterol versus apoB demonstrates that apoB is the more accurate marker of cardiovascular risk. Baseline and on-treatment apoB can identify elevated numbers of small cholesterol-depleted LDL particles that are not reflected by LDL and non-HDL cholesterol. ApoB is superior to non-HDL cholesterol as a secondary target in patients with mild-to-moderate hypertriglyceridemia (175-880 mg/dL), diabetes, obesity or metabolic syndrome, or very low LDL cholesterol < 70 mg/dL. When apoB is not available, non-HDL cholesterol should be used to supplement LDLC.
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Affiliation(s)
- Michel R Langlois
- Department of Laboratory Medicine, AZ St-Jan Hospital, Ruddershove 10, B-8000, Bruges, Belgium. .,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. .,Working Group on Guidelines, European Federation of Clinical Chemistry and Laboratory Medicine (EFLM), Brussels, Belgium.
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Division of Cardiology, Royal Victoria Hospital-McGill University Health Centre, Montreal, Quebec, Canada
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Krempf M, Hopkins PN, Bruckert E, Lee S, Donahue S. Efficacy and Safety of Alirocumab in Patients With Autosomal Dominant Hypercholesterolemia Associated With Proprotein Convertase Subtilisin/Kexin Type 9 Gain-of-Function or Apolipoprotein B Loss-of-Function Mutations. Am J Cardiol 2020; 125:880-886. [PMID: 31932084 DOI: 10.1016/j.amjcard.2019.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 11/19/2022]
Abstract
Autosomal dominant hypercholesterolemia results from mutations affecting the low-density lipoprotein receptor pathway, including proprotein convertase subtilisin/kexin type 9 (PCSK9) gain-of-function mutations (GoFm) and apolipoprotein B (APOB) loss-of-function mutations (LoFm). This study examined the long-term efficacy and safety of alirocumab in patients with PCSK9 GoFm and APOB LoFm who participated in the open-label extension to a Phase 2 double-blind study (NCT01604824). Of the 23 patients who completed the 14-week double-blind period and 8-week follow-up, 21 opted to continue in the open-label extension (PCSK9 GoFm, n = 15; APOB LoFm, n = 6). Patients received alirocumab 150 mg every 2 weeks from week 32 up to 3 years for PCSK9 GoFm and 2 years for APOB LoFm. Mean duration of alirocumab exposure was 129 weeks (median: 144 weeks). After initiation of alirocumab treatment, low-density lipoprotein cholesterol (LDL-C) decreased in both groups. At week 80, mean percent reduction in LDL-C from baseline was 58.0% and 47.1% for PCSK9 GoFm and APOB LoFm groups, respectively. Treatment-emergent adverse events were reported in 19 patients (90.5%); no patients discontinued treatment due to treatment-emergent adverse events. In patients with autosomal dominant hypercholesterolemia and elevated LDL-C levels despite receiving maximally tolerated lipid-lowering therapies, alirocumab 150 mg every 2 weeks resulted in clinically meaningful reductions in LDL-C, sustained through to 3 years and 2 years for patients with PCSK9 GoFm and APOB LoFm, respectively. Alirocumab was generally well tolerated with no unexpected safety concerns.
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Affiliation(s)
| | - Paul N Hopkins
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Shane Lee
- Regeneron Pharmaceuticals, Inc., Basking Ridge, New Jersey
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Mattiuzzi C, Sanchis-Gomar F, Lippi G. Worldwide burden of LDL cholesterol: Implications in cardiovascular disease. Nutr Metab Cardiovasc Dis 2020; 30:241-244. [PMID: 31748177 DOI: 10.1016/j.numecd.2019.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/09/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIM an increased value of low-density lipoprotein cholesterol (LDL-C) is now universally considered a major cardiovascular disease (CVD) risk factor. LDL-C is included in the vast majority of worldwide cardiovascular risk prediction algorithms, as well as in the guidelines for cardiovascular risk prevention. We aimed to provide an overview of the worldwide adverse healthcare impact of low-density lipoprotein cholesterol (LDL-C). METHODS AND RESULTS Data on the epidemiologic burden of LDL-C >1.3 mmol/L were retrieved from Global Health Data Exchange (GHDx) registry. The current burden is 94.92 million disability-adjusted life years (DALYs), with an exponential increase occurred during the past 25 years. 4.32 million deaths can be attributed to LDL cholesterol values > 1.3 mmol/L. DALYs and deaths due to LDL-C have significantly increased in all countries except those with high socio-demographic index. CONCLUSION More effective structural healthcare policies shall be planned at a worldwide scale for contrasting the epidemics of LDL-C attributable heath loss.
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Affiliation(s)
- Camilla Mattiuzzi
- Service of Clinical Governance, Provincial Agency for Social and Sanitary Services, Trento, Italy
| | - Fabian Sanchis-Gomar
- Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM. Atherosclerosis 2020; 294:46-61. [DOI: 10.1016/j.atherosclerosis.2019.12.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022]
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3935] [Impact Index Per Article: 983.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Penson PE, Long DL, Howard G, Toth PP, Muntner P, Howard VJ, Safford MM, Jones SR, Martin SS, Mazidi M, Catapano AL, Banach M. Associations between very low concentrations of low density lipoprotein cholesterol, high sensitivity C-reactive protein, and health outcomes in the Reasons for Geographical and Racial Differences in Stroke (REGARDS) study. Eur Heart J 2019; 39:3641-3653. [PMID: 30165636 PMCID: PMC6195947 DOI: 10.1093/eurheartj/ehy533] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/09/2018] [Indexed: 01/30/2023] Open
Abstract
Aims Recent findings have demonstrated the important contribution of inflammation to the risk of cardiovascular disease (CVD) in individuals with optimally managed low density lipoprotein cholesterol (LDL-C). We explored relationships between LDL-C, high sensitivity C-reactive protein (hs-CRP), and clinical outcomes in a free-living US population. Methods and results We used data from the REasons for Geographical And Racial Differences in Stroke (REGARDS), and selected individuals at 'high risk' for coronary events with a Framingham Coronary Risk Score of ≥10% or atherosclerotic cardiovascular disease (ASCVD) risk ≥7.5% in order to explore relationships between low LDL-C [<70 mg/dL (1.8 mmol/L) in comparison to ≥70 mg/dL (1.8 mmol/L)]; hs-CRP <2 compared with ≥2 mg/L and clinical outcomes [all-cause mortality, incident coronary heart disease (CHD), and incident stroke]. To assess the association between the LDL-C and hs-CRP categories and each outcome, a series of incremental Cox proportional hazards models were employed on complete cases. To account for missing observations, the most adjusted model was used to interrogate the data using multiple imputation with chained equations (MICE). In this analysis, 6136 REGARDS high-risk participants were included. In the MICE analysis, participants with high LDL-C (≥70 mg/dL) and low hs-CRP (<2 mg/L) had a lower risk of incident stroke [hazard ratio (HR) 0.69, 0.47-0.997], incident CHD (HR 0.71, 0.53-0.95), and CHD death (HR 0.70, 0.50-0.99) than those in the same LDL-C category high hs-CRP (≥2 mg/L). In participants with high hs-CRP (≥2 mg/dL), low LDL-C [<70 mg/dL (1.8 mmol/L)] was not associated with additional risk reduction of any investigated outcome, but with the significant increase of all-cause mortality (HR 1.37, 1.07-1.74). Conclusions In this high-risk population, we found that low hs-CRP (<2 mg/L) appeared to be associated with reduced risk of incident stroke, incident CHD, and CHD death, whereas low LDL-C (<70 mg/dL) was not associated with protective effects. Thus, our results support other data with respect to the importance of inflammatory processes in the pathogenesis of CVD.
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Affiliation(s)
- Peter E Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool, UK
| | - D Leann Long
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, 1665 University Boulevard, Birmingham, AL, USA
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, 1665 University Boulevard, Birmingham, AL, USA
| | - Peter P Toth
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, 600 N. Wolfe St, Carnegie 565-G, Baltimore, MD, USA.,Preventive Cardiology, CGH Medical Center, 01 East Miller Road, Sterling, IL, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, 700 University Boulevard, Suite LHL 450, Birmingham, AL, USA
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, 700 University Boulevard, Suite LHL 450, Birmingham, AL, USA
| | - Monica M Safford
- Department of Medicine, Weill Cornell Medicine, 1320 York Avenue, HT-621 New York, NY, USA
| | - Steven R Jones
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, 600 N. Wolfe St, Carnegie 565-G, Baltimore, MD, USA
| | - Seth S Martin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, 600 N. Wolfe St, Carnegie 565-G, Baltimore, MD, USA
| | - Mohsen Mazidi
- Department of Biology and Biological Engineering, Food and Nutrition Science, Chalmers University of Technology, Kemigarden 4, SE-412 96 Gothenburg, Sweden
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan and IRCCS Multimedica, Via Balzaretti 9, Milan, Italy
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, Lodz, Poland.,Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/288; Lodz, Poland.,Cardiovascular Research Centre, University of Zielona Gora, Zyty 28; Zielona Gora, Poland
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Abstract
PURPOSE OF REVIEW To review randomized interventional clinical and imaging trials that support lower targeted atherogenic lipoprotein cholesterol goals in "extreme" and "very high" atherosclerotic cardiovascular disease (ASCVD) risk settings. Major atherosclerotic cardiovascular event (MACE) prevention among the highest risk patients with ASCVD requires aggressive management of global risks, including lowering of the fundamental atherogenic apolipoprotein B-associated lipoprotein cholesterol particles [i.e., triglyceride-rich lipoprotein remnant cholesterol, low-density lipoprotein cholesterol (LDL-C), and lipoprotein(a)]. LDL-C has been the long-time focus of imaging studies and randomized clinical trials (RCTs). The 2004 adult treatment panel (ATP-III) update recognized that the long-standing targeted LDL-C goal of < 100 mg/dL potentially fostered substantial undertreatment of the very highest coronary heart disease (CHD) risk individuals and was lowered to < 70 mg/dL as an "optional" goal for "very high" 10-year CHD [CHD death + myocardial infarction (MI)] risk exceeding 20%. This evidence-based guideline change was supported by the observed benefits demonstrated in the high-risk primary and secondary prevention populations in the Heart Protection Study (HPS), the acute coronary syndrome (ACS) population in the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 trial (PROVE-IT), and the secondary prevention population in the Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) intravascular ultrasound (IVUS) study. Subsequent national and international guidelines maintained a targeted LDL-C goal < 70 mg/dL, or a threshold for management of > 70 mg/dL for patients with CHD, CHD risk equivalency, or ASCVD. RECENT FINDINGS Subgroup or meta-analyses of several RCTs, IVUS imaging studies, and the ACS population in IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) supported the evidence-based 2017 American Association Clinical Endocrinologist (AACE) guideline change establishing a targeted LDL-C goal < 55 mg/dL, non-HDL-C < 80 mg/dl, and apolipoprotein B (apo B) < 70 mg/dL for patients at "Extreme" ASCVD risk, i.e., 10-year 3-point-MACE-composite (CV death, non-fatal MI, or ischemic stroke) risk exceeding 30%. Moreover, with no recognized lower-limit-associated intolerance or safety issues, even more intensive lowering of atherogenic cholesterol levels is supported by the following evidence base: (1) analysis of eight high-intensity statin-based prospective secondary prevention IVUS atheroma volume regression trials; (2) a distribution analysis of on-treatment, ezetimibe and background-statin, of the very low LDL-C levels reached and CVD event risk in the IMPROVE-IT ACS population; (3) the secondary prevention Global Assessment of Pl\aque Regression With a PCSK9 Antibody as Measured by Intravascular Ultrasound (GLAGOV) on background-statin; and (4) the secondary prevention population of Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER). By example, in FOURIER, the population on background-statin at a baseline median 92 mg/dL achieved median LDL-C level of 30 mg/dL and non-HDL-C to < 65 mg/dl, and apo B to < 50 mg/dL, and subgroup and post hoc analyses all demonstrated additional ASCVD event reduction benefits as LDL-C was further reduced. The level of ASCVD risk determines the degree, urgency, and persistence in global risk management, including fundamental atherogenic lipoprotein cholesterol particle lowering. "Extreme" risk patients may require extremely low targeted LDL-C, non-HDL-C and apo B goals; such efforts, implied by more recent interventional trials and analyses, are aimed at maximal atheroma plaque regression, stabilization, and MACE event reduction with the aspiration of improved quality lifespan.
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Affiliation(s)
- Paul D Rosenblit
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, University California, Irvine (UCI), School of Medicine, Irvine, CA, 92697, USA.
- Diabetes Out-Patient Clinic, UCI Medical Center, Orange, CA, 92868, USA.
- Diabetes/Lipid Management & Research Center, 18821 Delaware St., Suite 202, Huntington Beach, CA, 92648, USA.
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Vallejo-Vaz AJ, Ginsberg HN, Davidson MH, Eckel RH, Cannon CP, Lee LV, Bessac L, Pordy R, Letierce A, Ray KK. Lower On-Treatment Low-Density Lipoprotein Cholesterol and Major Adverse Cardiovascular Events in Women and Men: Pooled Analysis of 10 ODYSSEY Phase 3 Alirocumab Trials. J Am Heart Assoc 2019; 7:e009221. [PMID: 30371190 PMCID: PMC6222947 DOI: 10.1161/jaha.118.009221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background In statin trials, men and women derived similar relative risk reductions in cardiovascular events per 39 mg/dL low‐density lipoprotein cholesterol (LDL‐C) reduction. We explored whether lower LDL‐C levels and greater LDL‐C percentage reductions than those achieved with statins are associated with reduced major adverse cardiovascular event (MACE) rates in women as well as men. Methods and Results Data pooled from 10 phase 3 ODYSSEY randomized trials (n=4983) comparing alirocumab with control (placebo/ezetimibe) were assessed for association between 39 mg/dL lower on‐treatment LDL‐C and percentage LDL‐C change from baseline, and MACE risk by sex, using multivariable Cox regression. Mean baseline LDL‐C was 135 mg/dL (women) and 121 mg/dL (men). Average on‐treatment LDL‐C levels with alirocumab, ezetimibe, and placebo were 71, 114, and 134 mg/dL, respectively, in women (n=1882) and 52, 93, and 122 mg/dL, respectively, in men (n=3090). Overall, 36.5% and 58.7% of women and men, respectively, achieved on‐treatment LDL‐C <50 mg/dL. Each 39 mg/dL lower LDL‐C was associated with a 33% and 22% lower risk of MACE in women (P=0.0209) and men (P=0.0307), respectively, with no significant between‐sex difference (P for heterogeneity=0.4597). Results were similar when analyzed per 50% LDL‐C reduction, 24% (P=0.1094) and 29% (P=0.0125) lower MACE risk in women and men, respectively (P for heterogeneity=0.7499). Alirocumab was generally well tolerated in both sexes. Conclusions The present analysis reinforces the notion that both sexes derive a similar cardiovascular benefit from LDL‐C lowering. Although women had slightly higher on‐treatment LDL‐C than men, both sexes showed a similar lower MACE risk with lower LDL‐C.
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Affiliation(s)
- Antonio J Vallejo-Vaz
- 1 Imperial Centre for Cardiovascular Disease Prevention Department of Primary Care and Public Health Imperial College London United Kingdom
| | | | | | - Robert H Eckel
- 4 University of Colorado Anschutz Medical Campus Aurora CO
| | | | | | | | | | | | - Kausik K Ray
- 1 Imperial Centre for Cardiovascular Disease Prevention Department of Primary Care and Public Health Imperial College London United Kingdom
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Nishikido T, Ray KK. Targeting the peptidase PCSK9 to reduce cardiovascular risk: Implications for basic science and upcoming challenges. Br J Pharmacol 2019; 178:2168-2185. [PMID: 31465540 DOI: 10.1111/bph.14851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/30/2019] [Accepted: 08/16/2019] [Indexed: 02/06/2023] Open
Abstract
LDL cholesterol (LDL-C) plays a central role in the progression of atherosclerosis. Statin therapy for lowering LDL-C reduces the risk of atherosclerotic cardiovascular disease and is the recommended first-line treatment for patients with high LDL-C levels. However, some patients are unable to achieve an adequate reduction in LDL-C with statins or are statin-intolerant; thus, PCSK9 inhibitors were developed to reduce LDL-C levels, instead of statin therapy. PCSK9 monoclonal antibodies dramatically reduce LDL-C levels and cardiovascular risk, and promising new PCSK9 inhibitors using different mechanisms are currently being developed. The absolute benefit of LDL-C reduction depends on the individual absolute risk and the achieved absolute reduction in LDL-C. Therefore, PCSK9 inhibitors may provide the greatest benefits from further LDL-C reduction for the highest risk patients. Here, we focus on PCSK9-targeted therapies and discuss the challenges of LDL-C reduction for prevention of atherosclerotic cardiovascular disease.
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Affiliation(s)
- Toshiyuki Nishikido
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.,Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Müller-Wieland D, Rader DJ, Moriarty PM, Bergeron J, Langslet G, Ray KK, Manvelian G, Thompson D, Bujas-Bobanovic M, Roth EM. Efficacy and Safety of Alirocumab 300 mg Every 4 Weeks in Individuals With Type 2 Diabetes on Maximally Tolerated Statin. J Clin Endocrinol Metab 2019; 104:5253-5262. [PMID: 31166599 PMCID: PMC6763278 DOI: 10.1210/jc.2018-02703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/30/2019] [Indexed: 01/14/2023]
Abstract
CONTEXT In the ODYSSEY CHOICE I trial, alirocumab 300 mg every 4 weeks (Q4W) was assessed in patients with hypercholesterolemia. Alirocumab efficacy and safety were evaluated in a patient subgroup with type 2 diabetes mellitus (T2DM) and who were receiving maximally tolerated statins with or without other lipid-lowering therapies. METHODS Participants received either alirocumab 300 mg Q4W (n = 458, including 96 with T2DM) or placebo (n = 230, including 50 with T2DM) for 48 weeks, with alirocumab dose adjustment to 150 mg every 2 weeks at Week (W) 12 if W8 low-density lipoprotein cholesterol (LDL-C) levels were ≥70 mg/dL or ≥ 100 mg/dL, depending on cardiovascular risk, or if LDL-C reduction was <30% from baseline. Efficacy end points included percentage change from baseline to W24 for lipids, and time-averaged LDL-C over W21 to W24. RESULTS In individuals with T2DM, LDL-C reductions from baseline to W24 and the average of W21 to W24 were significantly greater with alirocumab (-61.6% and -68.8%, respectively) vs placebo. At W24, alirocumab significantly reduced levels of non-high-density lipoprotein cholesterol (HDL-C) and other lipids. At W24, 85.9% and 12.5% of individuals in the alirocumab and placebo groups, respectively, reached both non-HDL-C <100 mg/dL and LDL-C <70 mg/dL. At W12, In total, 18% of alirocumab-treated participants received dose adjustment. The most common treatment-emergent adverse events were upper respiratory tract infection and injection-site reaction. No clinically significant changes in fasting plasma glucose and glycated hemoglobin were observed. CONCLUSION In individuals with T2DM, alirocumab 300 mg Q4W was generally well tolerated and efficacious in reducing atherogenic lipoproteins.
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Affiliation(s)
- Dirk Müller-Wieland
- Department of Medicine I, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Daniel J Rader
- Department of Medicine and Genetics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennysylvania
| | - Patrick M Moriarty
- Department of Internal Medicine, Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jean Bergeron
- Clinique des Maladies Lipidiques, Department of Medicine, Centre Hospitalier Universitaire de Québec – Université Laval, Québec, Canada
| | | | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | | | | | | | - Eli M Roth
- The Sterling Research Group and University of Cincinnati, Cincinnati, Ohio
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Scherer DJ, Nelson AJ, O’Brien R, Kostner KM, Hare DL, Colquhoun DM, Barter PJ, Aylward P, Nicholls SJ, Watts GF. Status of PCSK9 Monoclonal Antibodies in Australia. Heart Lung Circ 2019; 28:1571-1579. [DOI: 10.1016/j.hlc.2019.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/27/2019] [Indexed: 12/18/2022]
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Affiliation(s)
- Kyoung Im Cho
- Department of Cardiology, Kosin University Gospel Hospital
| | - Jongwook Yu
- Department of Cardiovascular Medicine, Heart Center, Gachon University Gil Medical Center
| | - Toshio Hayashi
- School of Health Sciences, Nagoya University Graduate School of Medicine
| | - Seung Hwan Han
- Department of Cardiovascular Medicine, Heart Center, Gachon University Gil Medical Center
- Gachon Cardiovascular Research Institute
| | - Kwang Kon Koh
- Department of Cardiovascular Medicine, Heart Center, Gachon University Gil Medical Center
- Gachon Cardiovascular Research Institute
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Rivaroxaban With or Without Aspirin for the Secondary Prevention of Cardiovascular Disease: Clinical Implications of the COMPASS Trial. Am J Cardiovasc Drugs 2019; 19:343-348. [PMID: 30680652 DOI: 10.1007/s40256-018-00322-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The COMPASS trial compared the impact of the selective direct factor Xa inhibitor, rivaroxaban, as monotherapy or in combination with aspirin on major adverse cardiovascular events (MACE) in patients with stable atherosclerotic disease. Patients treated with rivaroxaban 2.5 mg twice daily in combination with aspirin experienced fewer cardiovascular events but more bleeding complications than those who received aspirin monotherapy. In contrast, a higher dose of rivaroxaban (5 mg twice daily) and aspirin produced no clinical benefit and continued to be associated with greater bleeding rates than aspirin. Examining this study in the context of other trials of anticoagulant therapy in atherosclerotic vascular disease, this review attempts to place the role of very low-dose rivaroxaban in clinical context and highlights areas for future research.
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