Prevalence and Predictors of Out-of-Target LDL Cholesterol 1 to 3 Years After Myocardial Infarction. A Subanalysis From the EYESHOT Post-MI Registry

LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias

BACKGROUND AND AIMS

Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender.

METHODS AND RESULTS

Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001).

CONCLUSION

In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.

Prognostic significance of the SYNTAX score and SYNTAX score II in patients with myocardial infarction treated with percutaneous coronary intervention

OBJECTIVES

We aimed to evaluate the prognostic significance of the SYNTAX score (SS) and SYNTAX score II (SS-II) in a contemporary real-world cohort of myocardial infarction (MI) patients treated with percutaneous coronary intervention (PCI).

BACKGROUND

The role of SS and SS-II in the prognostic stratification of patients presenting with MI and undergoing PCI has been poorly investigated.

METHODS

This study included MI patients treated with PCI from January 2015 to April 2020 at the University Hospital of Salerno. Patients were divided into tertiles according to the baseline SS and SS-II values. The primary outcome measure was all-cause mortality at long-term follow-up; secondary outcome measures were cardiovascular (CV) death and MI.

RESULTS

Overall, 915 patients were included in this study. Mean SS and SS-II were 16.1 ± 10.0 and 31.6 ± 11.5, respectively. At propensity weighting adjusted Cox regression analysis, both SS (hazard ratio [HR]: 1.02; 95% confidence interval [CI]: 1.02-1.06; p = 0.017) and SS-II (HR: 1.08; 95% CI: 1.07-1.10; p < 0.001) were significantly associated with the risk of all-cause mortality at long-term follow-up; both SS (HR 1.04; CI 1.01-1.06; p < 0.001) and SS-II (HR 1.08; CI 1.06-1.10; p < 0.001) were significantly associated with the risk of CV death, but only SS-II showed a significant association with the risk of recurrent MI (HR 1.03; CI 1.01-1.05; p < 0.001). At 5 years, SS-II showed a significantly higher discriminative ability for all-cause mortality than SS (area under the curve: 0.82 vs. 0.64; p < 0.001). SS-II was able to reclassify the risk of long-term mortality beyond the SS (net reclassification index 0.88; 95% CI: 0.38-1.54; p = 0.033).

CONCLUSIONS

In a real-world cohort of MI patients treated with PCI, SS-II was a stronger prognostic predictor of long-term mortality than SS.

A Retrospective Study on the Adoption of Lipid Management Guidelines in Post-Myocardial Infarction Patients in a Tertiary Care Centre

BACKGROUND

Lipid management after acute myocardial infarction (AMI) is one of the important aspects of secondary prevention in the high cardiovascular (CV) risk group, and targeted reduction of low-density lipoprotein cholesterol (LDL-C) remains the primary target for lipid therapy after myocardial infarction (MI).

STUDY OBJECTIVE

To conduct a retrospective study of the adequacy of lipid management in post-MI patients admitted to a tertiary care centre as compared to the 2019 European Society of Cardiology (ESC) guidelines for the management of dyslipidaemia.

METHODOLOGY

The study was a retrospective review of medical records of patients admitted with MI under the Ubora Heart Service, Nairobi Hospital, from January 2020 to June 2022.

RESULTS

The study population included 79 patients, with a mean age of 59.3 (SD ±12), predominantly male (61 patients, 77.2%), and of African descent (60 patients, 75.9%). The majority of the study population presented with an ST-segment elevation myocardial infarction (STEMI) (62%), and the six most prevalent cardiovascular risk factors recorded amongst the patients were: systemic arterial hypertension in 50 (63.3%) patients; dyslipidaemia in 34 (43.0%); type II diabetes mellitus (T2DM) in 25 (31.6); history of smoking in 12 (15.2%); obesity or being overweight in 12 (15.1%); and family history of premature coronary artery disease or sudden cardiac death in four (5.1%) patients. Moreover, 88.6% of the patients had their lipid profile assessment done within 48 hours of admission, with a mean LDL-C level of 3.18 mmol/L (SD ±.18). All the patients recruited in the study were started on high-intensity statins with either 40 mg or 80 mg of atorvastatin or 20 mg or 40 mg of rosuvastatin. Thirty-nine (44%) patients recruited had repeat lipid profiles on follow-up, with a median lipid analysis time of five months (interquartile range (IQR): 2.0-10.0). Of those, only six (17.1%) achieved the LDL-C goal of <1.4 mmo/L while only 16 (45.7%) achieved a greater than 50% reduction from their baseline LDL-C level, with three (8.6%) patients having an increased LDL-C level from baseline. Overall, 14.7% of the patients studied achieved the guideline-recommended LDL-C goal of an LDL-C target of <1.4 mmo/L and a ≥ 50% reduction from baseline LDL-C. After five months of follow-up, 75 (94.9%) patients were on statin monotherapy, with 4 (5.1%) on high-intensity statin and ezetimibe combination therapy.

CONCLUSION

This retrospective study highlights the need for early sensitisation and the adoption of secondary prevention strategies in acute coronary syndrome (ACS), as recommended by the 2019 ESC guidelines.

ANMCO position paper on the management of hypercholesterolaemia in patients with acute coronary syndrome

Patients suffering from acute coronary syndrome (ACS) present a high risk of recurrence and new adverse cardiovascular events after hospital discharge. Elevated plasma LDL-cholesterol (LDL-C) levels have been shown to be a causal factor for the development of coronary heart disease, and robust clinical evidence has documented that LDL-C levels decrease linearly correlates with a reduction in cardiovascular events. Recent studies have also demonstrated the safety and efficacy of an early and significant reduction in LDL-C levels in patients with ACS. In this position paper, Italian Association of Hospital Cardiologists proposes a decision algorithm on early adoption of lipid-lowering strategies at hospital discharge and short-term follow-up of patients with ACS, in the light of the multiple evidence generated in recent years on the treatment of hypercholesterolaemia and the available therapeutic options, considering current reimbursement criteria.

Soluble PCSK9 Inhibition: Indications, Clinical Impact, New Molecular Insights and Practical Approach-Where Do We Stand?

Current research on cardiovascular prevention predominantly focuses on risk-stratification and management of patients with coronary artery disease (CAD) to optimize their prognosis. Several basic, translational and clinical research efforts aim to determine the etiological mechanisms underlying CAD pathogenesis and to identify lifestyle-dependent metabolic risk factors or genetic and epigenetic parameters responsible for CAD occurrence and/or progression. A log-linear association between the absolute exposure of LDL cholesterol (LDL-C) and the risk of atherosclerotic cardio-vascular disease (ASCVD) was well documented over the year. LDL-C was identified as the principal enemy to fight against, and soluble proprotein convertase subtilisin kexin type 9 (PCSK9) was attributed the role of a powerful regulator of blood LDL-C levels. The two currently available antibodies (alirocumab and evolocumab) against PCSK9 are fully human engineered IgG that bind to soluble PCSK9 and avoid its interaction with the LDLR. As documented by modern and dedicated "game-changer" trials, antibodies against soluble PCSK9 reduce LDL-C levels by at least 60 percent when used alone and up to 85 percent when used in combination with high-intensity statins and/or other hypolipidemic therapies, including ezetimibe. Their clinical indications are well established, but new areas of use are advocated. Several clues suggest that regulation of PCSK9 represents a cornerstone of cardiovascular prevention, partly because of some pleiotropic effects attributed to these newly developed drugs. New mechanisms of PCSK9 regulation are being explored, and further efforts need to be put in place to reach patients with these new therapies. The aim of this manuscript is to perform a narrative review of the literature on soluble PCSK9 inhibitor drugs, with a focus on their indications and clinical impact.

Secondary Cardiovascular Prevention after Acute Coronary Syndrome: Emerging Risk Factors and Novel Therapeutic Targets

The control of cardiovascular risk factors, the promotion of a healthy lifestyle, and antithrombotic therapy are the cornerstones of secondary prevention after acute coronary syndrome (ACS). However, many patients have recurrent ischemic events despite the optimal control of traditional modifiable risk factors and the use of tailored pharmacological therapy, including new-generation antiplatelet and lipid-lowering agents. This evidence emphasizes the importance of identifying novel risk factors and targets to optimize secondary preventive strategies. Lipoprotein(a) (Lp(a)) has emerged as an independent predictor of adverse events after ACS. New molecules such as anti-PCSK9 monoclonal antibodies, small interfering RNAs, and antisense oligonucleotides can reduce plasma Lp(a) levels and are associated with a long-term outcome benefit after the index event. The inflammatory stimulus and the inflammasome, pivotal elements in the development and progression of atherosclerosis, have been widely investigated in patients with coronary artery disease. More recently, randomized clinical trials including post-ACS patients treated with colchicine and monoclonal antibodies targeting cytokines yielded promising results in the reduction in major cardiovascular events after an ACS. Gut dysbiosis has also raised great interest for its potential pathophysiological role in cardiovascular disease. This evidence, albeit preliminary and needing confirmation by larger population-based studies, suggests the possibility of targeting the gut microbiome in particularly high-risk populations. The risk of recurrent ischemic events after ACS is related to the complex interaction between intrinsic predisposing factors and environmental triggers. The identification of novel risk factors and targets is fundamental to customizing patient clinical management with a precision medicine perspective.

Incidence, Characteristics, and Management of Patients with Recurrent Myocardial Infarctions: Insights from the EYESHOT POST-MI

Background. It is unknown whether patients who survived two or multiple episodes of myocardial infarction (MI) present different clinical characteristics and management than patients at their first MI. Methods. The EYESHOT post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients presenting to cardiologists 1 to 3 years from the last MI event. In 3 months of enrolment, 165 Italian cardiology centers included 1633 consecutive post-MI patients. In the present analysis, we stratified the study cohort according to the number of prior MI episodes (i.e., 1, 2 or ≥3). Results. Among the 1618 patients enrolled with complete data on MI history, 1335 (82.5%) were at their first MI episode, 209 (12.9%) had a history of 2 MIs, and the remaining 74 (4.6%) had ≥ 3 prior MIs. Patients with a history of multiple MIs were increasingly older and presented a significantly higher rate of risk factors compared to those at their first MI. During the year prior to enrolment, patients with 2 or ≥3 MI episodes more frequently underwent coronary angiography compared to the other group ( $p<0.0001$ ). In addition, several lifesaving and antianginal drugs were more frequently prescribed in patients presenting with a history of multiple MIs compared to those at their first MI. Conclusions. Our data suggest that patients with multiple MIs managed by cardiologists in routine clinical practice present an incremental clinical risk, more frequently undergo coronary angiography, and are more intensively managed with pharmacological therapies compared to patients at their first MI episode.

Predictors of Recurrent Ischemic Events in Patients With ST-Segment Elevation Myocardial Infarction

Little is known about the predictors recurrent ischemic events in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed at investigating the predictors of recurrent myocardial infarction (MI) at long-term follow-up in a real-world STEMI cohort. All consecutive STEMI patients who underwent emergent coronary angiography and primary percutaneous coronary intervention between February 2013 and June 2019 at our institution were included. The primary outcome was recurrent MI; secondary outcomes were all-cause death, target vessel revascularization (TVR), in-stent restenosis, definite stent thrombosis (ST) and non-TVR. The study population included 724 STEMI patients; at median follow-up of 803 (324 to 1,394) days, the primary outcome was reported in 70 patients (10.1%). All-cause death occurred in 6.8%, TVR in 4.2%, in-stent restenosis in 2.5%, and ST in 1.9% of cases. At multivariable analysis, diabetes (hazard ratio [HR] = 1.18), serum level of lipoprotein(a) [Lp(a), HR = 1.01], and angiographic evidence of restenotic lesion (HR = 2.98) resulted independent predictors of recurrent MI. Kaplan-Meier analysis confirmed that diabetes, restenotic lesion, and differential Lp(a) risk range values, identified patients with lower long-term survival free from recurrent MI. Lp(a) level ≥ 30 mg/dL had an incremental prognostic stratification capability in patients with diabetes (HR = 5.34), and in patients with both diabetes and restenotic lesion (HR = 17.07). In conclusion, in this contemporary cohort of STEMI patients, diabetes, Lp(a) serum levels and restenotic lesions were independently associated with recurrent MI at long term. The coexistence of Lp(a) level ≥ 30 mg/dL showed an incremental risk stratification capability, supporting its implementation for long-term prognostic assessment in this high-risk clinical setting.