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Goyal A, Shah S, Dahal K, Changez MIK, Tariq MD, Zuhair V, Shamim U, Abbasi HQ, Shrestha AB, Sah R, Sohail AH. Efficacy and outcomes of bempedoic acid versus placebo in patients with hypercholesterolemia: an updated systematic review and meta-analysis of randomized controlled trials. Cardiovasc Endocrinol Metab 2024; 13:e0302. [PMID: 38911912 PMCID: PMC11191974 DOI: 10.1097/xce.0000000000000302] [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: 12/23/2023] [Accepted: 03/21/2024] [Indexed: 06/25/2024]
Abstract
Introduction Bempedoic acid (BA) has shown varied efficacy in managing hyperlipidemia. We conducted the most extensive up-to-date meta-analysis, the first to include recent studies by Nissen et al., which boast the largest sample size. Methods Literature search was done on Medline, EMBASE, and Cochrane Library. The primary endpoint was a change in low-density lipoprotein-cholesterol (LDL-C) levels, while secondary endpoints encompassed changes in lipid parameters, clinical endpoints, and safety endpoints. The least-square mean (LSM) percent change was utilized for lipid changes, with statistical significance set at P < 0.05. Results This analysis included 12 randomized control trials with 22,249 participants. BA exhibited a substantial reduction in LDL-C levels [LSM % change, -24.34; 95% confidence interval (CI), -27.80 to -20.88; P < 0.0001], total cholesterol levels (LSM % change, -16.62; 95% CI, -21.70 to -11.54; P < 0.00001) and high-density lipoprotein-cholesterol (HDL-C) levels (LSM % change, -4.22; 95% CI, -5.51 to -2.92; P < 0.00001) compared to the placebo. Conclusions BA significantly lowers LDL-C, total cholesterol, HDL-C, non-HDL-C, high sensitivity C reactive protein, and apolipoprotein levels.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sangam Shah
- Department of Internal Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Krishna Dahal
- Department of Internal Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | | | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad
| | - Varisha Zuhair
- Department of Medicine, Jinnah Sindh Medical University, Karachi
| | - Urooj Shamim
- Department of Internal Medicine, Aga Khan University Hospital, Karachi
| | | | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Ranjit Sah
- Department of Microbiology, Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Maxico, USA
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Bosco G, Mszar R, Piro S, Sabouret P, Gallo A. Cardiovascular Risk Estimation and Stratification Among Individuals with Hypercholesterolemia. Curr Atheroscler Rep 2024; 26:537-548. [PMID: 38965183 DOI: 10.1007/s11883-024-01225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE OF THE REVIEW This review aims to assess the variability in considering hypercholesterolemia for cardiovascular risk stratification in the general population. Recent literature on the integration of hypercholesterolemia into clinical risk scores and its interaction with other risk factors will be explored. RECENT FINDINGS The impact of hypercholesterolemia on risk estimation varies among different cardiovascular risk calculators. Elevated lipid levels during early life stages contribute to atherosclerotic plaque development, influencing disease severity despite later treatment initiation. The interplay between low-density lipoprotein cholesterol (LDLc), inflammatory markers and non-LDL lipid parameters enhances cardiovascular risk stratification. Studies have also examined the role of coronary artery calcium (CAC) score as a negative risk marker in populations with severe hypercholesterolemia. Furthermore, polygenic risk scores (PRS) may aid in diagnosing non-monogenic hypercholesterolemia, refining cardiovascular risk stratification and guiding lipid-lowering therapy strategies. Understanding the heterogeneity in risk estimation and the role of emerging biomarkers and imaging techniques is crucial for optimizing cardiovascular risk prediction and guiding personalized treatment strategies in individuals with hypercholesterolemia.
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Affiliation(s)
- Giosiana Bosco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Sorbonne Université, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpètriêre, 47/83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pierre Sabouret
- Heart Institute, Cardiology Department, Sorbonne University, 47-83 Boulevard de L'Hôpital, 75013, Paris, FR, France
- National College of French Cardiologists, 13 Rue Niepce, 75014, Paris, FR, France
| | - Antonio Gallo
- Sorbonne Université, INSERM UMR1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpètriêre, 47/83 Boulevard de L'Hôpital, 75013, Paris, France.
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Hamayal M, Shahid W, Akhtar CH, Shekiba F, Iftikhar I, Tahir MD, Awwab M, Hussain S, Naeem S, Hafeez M. Risk of cardiovascular outcomes with bempedoic acid in high-risk statin intolerant patients: a systematic review and meta analysis. Future Cardiol 2024:1-12. [PMID: 39140596 DOI: 10.1080/14796678.2024.2388478] [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: 06/02/2024] [Accepted: 08/01/2024] [Indexed: 08/15/2024] Open
Abstract
Aim: Statin intolerance and myopathy is a major issue with prolonged use of statins myopathy. Bempedoic acid can be a good alternative for those intolerant to statins. This systematic review aims to observe incidence of major adverse cardiovascular events (MACE) and other adverse events, in high-risk statin intolerant patients receiving bempedoic acid. Methods: Literature search was conducted via Google Scholar, Science Direct and PubMed, after which screening, selection and data extraction of articles was done. Meta-analysis was performed on RevMan 5.4. Subgroup analysis was also conducted and heterogeneity was evaluated. Risk of bias was performed using ROB2 assessment scale. (CRD42024536827). Results: Only six randomized controlled trials were used in final analysis consisting of 17,844 patients. Treatment with bempedoic acid was associated with a reduced risk of MACE compared with placebo (RR 0.86; 95% CI [0.79, 0.94] p = 0.0005), with myocardial infarction significantly reduced. Incidence of adverse effects was increased with bempedoic acid (RR: 1.02; 95% [1.00, 1.03] p = 0.01) but no significant difference was observed. Incidence of myalgia was reduced in bempedoic group as well. Conclusion: Bempedoic acid is a safe and effective alternative to statins in high-risk patients intolerant to statins, decreasing the risk of MACE.
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Affiliation(s)
- Muhammad Hamayal
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Warda Shahid
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Chaudhary Humayun Akhtar
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Fnu Shekiba
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Iqra Iftikhar
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Muhammad Danyal Tahir
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Muhammad Awwab
- Quaid-e-Azam Medical College, Circular Road, Bahawalpur, 63100, Pakistan
| | - Saima Hussain
- University of Regina Saskatoon, The Concourse, Innovation Place, Saskatoon, SK S7N 3R3, Canada
| | - Saman Naeem
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
| | - Momina Hafeez
- Federal Medical & Dental College (FMDC), Al-Farabi Center, Hanna Road, G-8/4, Islamabad, 44080, Pakistan
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Yasmin F, Najeeb H, Moeed A, Ali E, Umar M, Ullah I, Shah N, Alraies MC. Efficacy and Safety of Bempedoic Acid for Prevention of Adverse Cardiovascular Events and Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Ther 2024:00045391-990000000-00204. [PMID: 39121181 DOI: 10.1097/mjt.0000000000001715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Affiliation(s)
- Farah Yasmin
- Yale University School of Medicine, New Haven, CT
| | - Hala Najeeb
- Dow University of Health Sciences, Karachi, Pakistan
| | - Abdul Moeed
- Dow University of Health Sciences, Karachi, Pakistan
| | - Eman Ali
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | | | - M Chadi Alraies
- Detroit Medical Center, Cardiovascular Institute, Detroit, MI
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Mansfield BS, Mohamed F, Larouche M, Raal FJ. The Hurdle of Access to Emerging Therapies and Potential Solutions in the Management of Dyslipidemias. J Clin Med 2024; 13:4160. [PMID: 39064199 PMCID: PMC11277596 DOI: 10.3390/jcm13144160] [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: 06/12/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
This review explores the many barriers to accessing lipid-lowering therapies (LLTs) for the prevention and management of atherosclerotic cardiovascular disease (ASCVD). Geographical, knowledge, and regulatory barriers significantly impede access to LLTs, exacerbating disparities in healthcare infrastructure and affordability. We highlight the importance of policy reforms, including pricing regulations and reimbursement policies, for enhancing affordability and streamlining regulatory processes. Innovative funding models, such as value-based pricing and outcome-based payment arrangements, have been recommended to make novel LLTs more accessible. Public health interventions, including community-based programs and telemedicine, can be utilized to reach underserved populations and improve medication adherence. Education and advocacy initiatives led by patient advocacy groups and healthcare providers play a crucial role in raising awareness and empowering patients. Despite the barriers to access, novel LLTs present a big opportunity to reduce the burden of ASCVD, emphasizing the need for collaborative efforts among policymakers, healthcare providers, industry stakeholders, and patient advocacy groups to address these barriers to improve access to LLTs globally.
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Affiliation(s)
- Brett S. Mansfield
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg 2193, South Africa; (B.S.M.); (F.M.)
- Carbohydrate & Lipid Metabolism Research Unit, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Farzahna Mohamed
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg 2193, South Africa; (B.S.M.); (F.M.)
- Carbohydrate & Lipid Metabolism Research Unit, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Miriam Larouche
- Département de Médecine, Université de Montréal and ECOGENE-21, Montreal, QC H3T 1J4, Canada;
| | - Frederick J. Raal
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg 2193, South Africa; (B.S.M.); (F.M.)
- Carbohydrate & Lipid Metabolism Research Unit, University of the Witwatersrand, Johannesburg 2193, South Africa
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Faluk M, Wardhere A, Mohamoud A, Nor M, Bampastsias D, Oikonomou E, Almubaid Z, Al-Hemyari B. Evolution of LDL-C lowering medications and their cardiovascular benefits: Past, present, and future. Curr Probl Cardiol 2024; 49:102637. [PMID: 38735347 DOI: 10.1016/j.cpcardiol.2024.102637] [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: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/14/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Hyperlipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C) is one of the major risk factors for CVD. Major landmark cardiovascular outcome clinical trials demonstrated that LDL-C lowering medications reduce cardiovascular events, and the lower the LDL-C the better the outcome. This article discusses the evolution of LDL-C lowering medications starting from bile acid sequestrants (BAS), statin therapy, bempedoic acid, the proprotein convertase subtilisin kexin 9 (PCSK9) synthesis inhibitor, novel small interfering RNA-based therapy (inclisiran) to the most recent oral PCSK9 inhibitors (MK-0616) which is currently under phase 3 clinical trial studies.
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Affiliation(s)
- Mohammed Faluk
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Abdirahman Wardhere
- Division of Cardiovascular Medicine, University of Columbia Irving Medical Center, New York, NY, USA
| | - Abdilahi Mohamoud
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Mohammed Nor
- Department of Internal Medicine, Stamford Hospital, Stamford, CT, USA
| | - Dimitrios Bampastsias
- Division of Cardiovascular Medicine, University of Columbia Irving Medical Center, New York, NY, USA
| | - Ermioni Oikonomou
- School of Medicine, National and Kapodostrian University of Athens, Athens, Greece
| | - Zaid Almubaid
- John Sealy School of Medicine, University of Texas Medical branch Galveston, TX, USA
| | - Bashar Al-Hemyari
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
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7
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Chen C, Wei FF, Dong Y, Liu C. Early Management of Blood Lipid Levels with Non-Statin Lipid-Lowering Drugs in Acute Coronary Syndrome: A Mini Review. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07587-9. [PMID: 38951453 DOI: 10.1007/s10557-024-07587-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 07/03/2024]
Abstract
Acute coronary syndrome (ACS) remains a major cause of morbidity and mortality, despite many improvements in its prevention and management. Lipid management is an important aspect of secondary prevention after ACS. Previous studies indicate that the early use of intensive statin therapy in patients with ACS may alleviate the risk of recurrent cardiovascular events and mortality. However, many patients do not reach the target low-density lipoprotein cholesterol (LDL-C) level of < 55 mg/dL with statin monotherapy, and muscle-related adverse effects caused by statins hinder adherence to treatment. Novel non-statin agents are recommended for patients who cannot achieve the target LDL-C levels with high-intensity statin therapy and those with statin intolerance. The combination of statins and non-statins may synergistically affect intensively lowering LDL-C through different mechanisms, which could lead to better cardiovascular outcomes than statin monotherapy. However, it remains uncertain whether the early use of combination lipid-lowering therapy is more beneficial. The present review summarizes the benefits of intensive statin monotherapy and their early combination with non-statin medications including ezetimibe, PCSK9 inhibitors, inclisiran, and bempedoic acid (BDA) in the management of ACS.
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Affiliation(s)
- Chen Chen
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China
| | - Fang-Fei Wei
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, PR China.
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, PR China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, PR China.
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Park SY, Jun JE, Jeong IK, Ahn KJ, Chung HY, Hwang YC. Comparison of the Efficacy of Ezetimibe Combination Therapy and High-Intensity Statin Monotherapy in Type 2 Diabetes. J Clin Endocrinol Metab 2024; 109:1883-1890. [PMID: 38175670 DOI: 10.1210/clinem/dgad714] [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: 06/13/2023] [Indexed: 01/05/2024]
Abstract
CONTEXT Low-density lipoprotein cholesterol (LDL-C)-lowering therapy is considerably important in preventing cardiovascular disease (CVD) among patients with diabetes. Studies comparing CVD, stroke, and mortality outcomes of low- or moderate-intensity statins with ezetimibe combination therapy and high-intensity statin monotherapy in patients with diabetes remain lacking. OBJECTIVE This study compared the primary prevention effect of myocardial infarction (MI), stroke, and all-cause death between combination therapy of low- or moderate-intensity statins and ezetimibe and high-intensity statin monotherapy in patients with diabetes using the Korean National Health Insurance claims database. METHODS Patients aged ≥20 years with type 2 diabetes and dyslipidemia were enrolled. The combination therapy of low- or moderate-intensity statin and ezetimibe was compared with high-intensity statin monotherapy after a propensity score-matched analysis. The incidence of composite outcomes consisting of MI, stroke, and all-cause death and each component were analyzed. RESULTS In moderate-intensity statin therapy with ezetimibe combination therapy, LDL-C (74 ± 37.9 mg/dL vs 80.8 ± 38.8 mg/dL, P < .001) and the incidence of composite outcomes were lower (hazard ratio 0.85, 95% CI 0.74-0.98) than those in high-intensity statin monotherapy. Meanwhile, no significant difference was observed in the LDL-C levels and composite outcomes between low-intensity statins with ezetimibe combination therapy and high-intensity statin monotherapy. CONCLUSION Adding ezetimibe to a moderate-intensity statin in patients with type 2 diabetes has a greater LDL-C-lowering effect and greater primary prevention of composite outcomes than that of high-intensity statin monotherapy.
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Affiliation(s)
- So Young Park
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul 02447, Republic of Korea
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
| | - Ji Eun Jun
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - In-Kyung Jeong
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - Kyu Jeung Ahn
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - Ho Yeon Chung
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
| | - You-Cheol Hwang
- Department of Endocrinology & Metabolism, Kyung Hee University School of Medicine, Seoul 02453, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
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Sbrana F, Bigazzi F, Corciulo C, Dal Pino B. A therapeutic cooperation by bempedoic acid and proprotein convertase subtilisin/kexin type 9 inhibitors in statin intolerance inherited dyslipidemias. Intern Emerg Med 2024:10.1007/s11739-024-03674-9. [PMID: 38872064 DOI: 10.1007/s11739-024-03674-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Francesco Sbrana
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy.
| | - Federico Bigazzi
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Carmen Corciulo
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Beatrice Dal Pino
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy
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Ibrahim S, Nurmohamed NS, Nierman MC, de Goeij JN, Zuurbier L, van Rooij J, Schonck WAM, de Vries J, Hovingh GK, Reeskamp LF, Stroes ESG. Enhanced identification of familial hypercholesterolemia using central laboratory algorithms. Atherosclerosis 2024; 393:117548. [PMID: 38643673 DOI: 10.1016/j.atherosclerosis.2024.117548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is a highly prevalent genetic disorder resulting in markedly elevated LDL cholesterol levels and premature coronary artery disease. FH underdiagnosis and undertreatment require novel detection methods. This study evaluated the effectiveness of using an LDL cholesterol cut-off ≥99.5th percentile (sex- and age-adjusted) to identify clinical and genetic FH, and investigated underutilization of genetic testing and undertreatment in FH patients. METHODS Individuals with at least one prior LDL cholesterol level ≥99.5th percentile were selected from a laboratory database containing lipid profiles of 590,067 individuals. The study comprised three phases: biochemical validation of hypercholesterolemia, clinical identification of FH, and genetic determination of FH. RESULTS Of 5614 selected subjects, 2088 underwent lipid profile reassessment, of whom 1103 completed the questionnaire (mean age 64.2 ± 12.7 years, 48% male). In these 1103 subjects, mean LDL cholesterol was 4.0 ± 1.4 mmol/l and 722 (65%) received lipid-lowering therapy. FH clinical diagnostic criteria were met by 282 (26%) individuals, of whom 85% had not received guideline-recommended genetic testing and 97% failed to attain LDL cholesterol targets. Of 459 individuals consenting to genetic validation, 13% carried an FH-causing variant, which increased to 19% in clinically diagnosed FH patients. CONCLUSIONS The identification of a substantial number of previously undiagnosed and un(der)treated clinical and genetic FH patients within a central laboratory database highlights the feasibility and clinical potential of this targeted screening strategy; both in identifying new FH patients and in improving treatment in this high-risk population.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostic Centers, Amsterdam, the Netherlands
| | - Jim N de Goeij
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Linda Zuurbier
- Department of Human Genetics, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeroen van Rooij
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Willemijn A M Schonck
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jard de Vries
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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11
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Natale F, Franzese R, Marotta L, Mollo N, Solimene A, Luisi E, Gentile C, Loffredo FS, Golino P, Cimmino G. Evolving Concepts of the SCORE System: Subtracting Cholesterol from Risk Estimation: A Way for a Healthy Longevity? Life (Basel) 2024; 14:679. [PMID: 38929662 PMCID: PMC11204887 DOI: 10.3390/life14060679] [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: 04/29/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
The role of cholesterol, mainly low-density lipoproteins (LDL-C), as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) is now established and accepted by the international scientific community. Based on this evidence, the European and American guidelines recommend early risk stratification and "rapid" achievement of the suggested target according to the risk estimation to reduce the number of major cardiovascular events. Prolonged exposure over the years to high levels of LDL-C is one of the determining factors in the development and progression of atherosclerotic plaque, on which the action of conventional risk factors (cigarette smoking, excess weight, sedentary lifestyle, arterial hypertension, diabetes mellitus) as well as non-conventional risk factors (gut microbiota, hyperuricemia, inflammation), alone or in combination, favors the destabilization of the atherosclerotic lesion with rupture/fissuration/ulceration and consequent formation of intravascular thrombosis, which leads to the acute clinical manifestations of acute coronary syndromes. In the current clinical practice, there is a growing number of cases that, although extremely common, are emblematic of the concept of long-term exposure to the risk factor (LDL hypercholesterolemia), which, not adequately controlled and in combination with other risk factors, has favored the onset of major cardiovascular events. The triple concept of "go lower, start earlier and keep longer!" should be applied in current clinical practice at any level of prevention. In the present manuscript, we will review the current evidence and documents supporting the causal role of LDL-C in determining ASCVD and whether it is time to remove it from any score.
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Affiliation(s)
- Francesco Natale
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
| | - Rosa Franzese
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Luigi Marotta
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Noemi Mollo
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Achille Solimene
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Ettore Luisi
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Carmine Gentile
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Francesco S. Loffredo
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Paolo Golino
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (F.N.); (R.F.); (L.M.); (N.M.); (A.S.); (E.L.); (C.G.); (F.S.L.); (P.G.)
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Giovanni Cimmino
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
- Cardiology Unit, AOU Luigi Vanvitelli, 80138 Naples, Italy
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12
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Ibrahim S, Reeskamp LF, de Goeij JN, Hovingh GK, Planken RN, Bax WA, Min JK, Earls JP, Knaapen P, Wiegman A, Stroes ESG, Nurmohamed NS. Beyond early LDL cholesterol lowering to prevent coronary atherosclerosis in familial hypercholesterolaemia. Eur J Prev Cardiol 2024; 31:892-900. [PMID: 38243822 DOI: 10.1093/eurjpc/zwae028] [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: 10/30/2023] [Revised: 12/16/2023] [Accepted: 01/15/2024] [Indexed: 01/22/2024]
Abstract
AIMS Familial hypercholesterolaemia (FH) patients are subjected to a high lifetime exposure to low density lipoprotein cholesterol (LDL-C), despite use of lipid-lowering therapy (LLT). This study aimed to quantify the extent of subclinical atherosclerosis and to evaluate the association between lifetime cumulative LDL-C exposure and coronary atherosclerosis in young FH patients. METHODS AND RESULTS Familial hypercholesterolaemia patients, divided into a subgroup of early treated (LLT initiated <25 years) and late treated (LLT initiated ≥25 years) patients, and an age- and sex-matched unaffected control group, underwent coronary CT angiography (CCTA) with artificial intelligence-guided analysis. Ninety genetically diagnosed FH patients and 45 unaffected volunteers (mean age 41 ± 3 years, 51 (38%) female) were included. Familial hypercholesterolaemia patients had higher cumulative LDL-C exposure (181 ± 54 vs. 105 ± 33 mmol/L ∗ years) and higher prevalence of coronary plaque compared with controls (46 [51%] vs. 10 [22%], OR 3.66 [95%CI 1.62-8.27]). Every 75 mmol/L ∗ years cumulative exposure to LDL-C was associated with a doubling in per cent atheroma volume (total plaque volume divided by total vessel volume). Early treated patients had a modestly lower cumulative LDL-C exposure compared with late treated FH patients (167 ± 41 vs. 194 ± 61 mmol/L ∗ years; P = 0.045), without significant difference in coronary atherosclerosis. Familial hypercholesterolaemia patients with above-median cumulative LDL-C exposure had significantly higher plaque prevalence (OR 3.62 [95%CI 1.62-8.27]; P = 0.001), compared with patients with below-median exposure. CONCLUSION Lifetime exposure to LDL-C determines coronary plaque burden in FH, underlining the need of early as well as potent treatment initiation. Periodic CCTA may offer a unique opportunity to monitor coronary atherosclerosis and personalize treatment in FH.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jim N de Goeij
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Willem A Bax
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | | | - James P Earls
- Cleerly Inc., Denver, CO, USA
- The George Washington University School of Medicine, 2150 Pennsylvania Avenue NW, Washington, 0037 DC, USA
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - Albert Wiegman
- Department of Paediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
- The George Washington University School of Medicine, 2150 Pennsylvania Avenue NW, Washington, 0037 DC, USA
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
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13
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Abrahams T, Nicholls SJ, Nelson AJ. Optimal Medical Therapy for Stable Ischemic Heart Disease in 2024: Focus on Blood Pressure and Lipids. Med Clin North Am 2024; 108:441-453. [PMID: 38548456 DOI: 10.1016/j.mcna.2023.12.005] [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] [Indexed: 04/02/2024]
Abstract
Hypertension and dyslipidemia are 2 highly prevalent and modifiable risk factors in patients with stable ischemic heart disease. Multiple lines of evidence demonstrate that lowering blood pressure and low-density lipoprotein cholesterol improves clinical outcomes in patients with ischemic heart disease. Accordingly, clinical guidelines recommend intensive treatment targets for these high-risk patients. This article summarizes the pathophysiology, supporting evidence, and treatment recommendations for management of hypertension and dyslipidemia among patients with manifest ischemic heart disease and points to future research and unmet clinical needs.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia.
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14
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Nicholls SJ, Nelson AJ. New targets and mechanisms of action for lipid-lowering and anti-inflammatory therapies in atherosclerosis: where does the field stand? Expert Opin Ther Targets 2024; 28:375-384. [PMID: 38815057 DOI: 10.1080/14728222.2024.2362644] [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: 12/20/2023] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality worldwide, despite widespread use of statins. There is a need to develop additional therapeutic strategies that will complement statins to achieve more effective reductions in cardiovascular risk. AREAS COVERED This review provides a comprehensive summary of current areas of therapeutic development targeting both lipid and inflammatory factors implicated in the pathogenesis of atherosclerosis. In addition to develop of novel approaches that will produce more effective lowering of low-density lipoprotein cholesterol, clinical trials are currently evaluating the potential to target other atherogenic lipid parameters such as triglyceride-rich lipoproteins and Lp(a), in addition to promoting the biological properties of high-density lipoproteins. Targeting inflammation within the vascular wall has emerged as a new frontier in cardiovascular prevention, with early evidence that use of anti-inflammatory agents have the potential to reduce cardiovascular risk. EXPERT OPINION Clinical practice has an increasing array of therapeutic tools to achieve more effective lowering of low-density lipoprotein cholesterol for high-risk patients. In addition, clinical trials have the potential to deliver a range of additional agents to the clinic, that target alternative lipid and inflammatory mediators. This will permit the potential to personalize cardiovascular prevention.
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Affiliation(s)
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Australia
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15
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Velidakis N, Stachteas P, Gkougkoudi E, Papadopoulos C, Kadoglou NPE. Classical and Novel Lipid-Lowering Therapies for Diabetic Patients with Established Coronary Artery Disease or High Risk of Coronary Artery Disease-A Narrative Clinical Review. Pharmaceuticals (Basel) 2024; 17:568. [PMID: 38794138 PMCID: PMC11124492 DOI: 10.3390/ph17050568] [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: 03/19/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
Diabetic atherosclerosis is a complex process that is characterized by diffuse and unstable lesions increasing 2-4-fold the risk of adverse cardiovascular (CV) events. Diabetic dyslipidemia has a predominant role in coronary artery disease (CAD) and has been the target of classical and emerging pharmaceutical agents with established or promising CV benefits. The aim of the present narrative review was to summarize the effects of classical and novel lipid-lowering pharmaceutical agents on lipid profile and CV outcomes in diabetic patients with established CAD or high risk of CAD. Statins remain the first-line treatment for all diabetic patients since they considerably ameliorate lipid parameters and non-lipid CV risk factors, leading to reduced CV morbidity and mortality. Complementary to statins, ezetimibe exerts lipid-lowering properties with modest but significant reductions in major adverse cardiovascular events (MACEs) and CV mortality. PCSK9 inhibitors considerably reduce LDL-C levels and lower MACEs in diabetic patients. On the other hand, fibrates may confer a very modest decline in MACE incidence, while the CV impact of omega-3 fatty acids is promising but remains questionable. Bempedoic acid and inclisiran have a potential therapeutic role in the management of diabetic dyslipidemia, but this is still not adequately documented. Given the heightened CV risk among individuals with diabetes, more decisive results would be of great importance in the utility of all these drugs.
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Affiliation(s)
- Nikolaos Velidakis
- Medical School, University of Cyprus, 2029 Nicosia, Cyprus; (N.V.); (E.G.)
| | - Panagiotis Stachteas
- Third Department of Cardiology, Aristotle University of Thessaloniki, General Hospital “Hippokration”, 541 24 Thessaloniki, Greece; (P.S.); (C.P.)
| | | | - Christodoulos Papadopoulos
- Third Department of Cardiology, Aristotle University of Thessaloniki, General Hospital “Hippokration”, 541 24 Thessaloniki, Greece; (P.S.); (C.P.)
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16
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Lucà F, Pavan D, Gulizia MM, Manes MT, Abrignani MG, Benedetto FA, Bisceglia I, Brigido S, Caldarola P, Calvanese R, Canale ML, Caretta G, Ceravolo R, Chieffo A, Chimenti C, Cornara S, Cutolo A, Di Fusco SA, Di Matteo I, Di Nora C, Fattirolli F, Favilli S, Francese GM, Gelsomino S, Geraci G, Giubilato S, Ingianni N, Iorio A, Lanni F, Montalto A, Nardi F, Navazio A, Nesti M, Parrini I, Pilleri A, Pozzi A, Rao CM, Riccio C, Rossini R, Scicchitano P, Valente S, Zuccalà G, Gabrielli D, Grimaldi M, Colivicchi F, Oliva F. Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'. Eur Heart J Suppl 2024; 26:ii264-ii293. [PMID: 38784671 PMCID: PMC11110461 DOI: 10.1093/eurheartjsupp/suae034] [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] [Indexed: 05/25/2024]
Abstract
It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Daniela Pavan
- Cardio-Cerebro-Rehabilitation Department, Azienda Sanitaria Friuli Occidentale, (AS FO) Via della Vecchia Ceramica, 1, Pordenone 33170, Italy
| | - Michele Massimo Gulizia
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | - Maria Teresa Manes
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | | | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Irma Bisceglia
- Cardio-Thoraco-Vascular Department, San Camillo Forlanini Hospital, 00152 Roma, Italy
| | - Silvana Brigido
- Cardiology Clinics, ‘F.’ Hospital Jaia’, 70014 Conversano, BA, Italy
| | | | | | | | - Giorgio Caretta
- Cardiology Unit, Sant’Andrea Hospital, 19100 La Spezia, SP, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospial, 88046 Lamezia Terme, CZ, Italy
| | - Alaide Chieffo
- Interventional Cardiology, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, 00161 Roma, Italy
| | - Stefano Cornara
- Levante Cardiology, San Paolo Hospital, Savona, 17100 Savona, SV, Italy
| | - Ada Cutolo
- Cardiolog Unit, Ospedale dell’Angelo, 30172 Mestre, Italy
| | | | - Irene Di Matteo
- Cardiology Unit, Cariovascular Department, ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Concetta Di Nora
- Cardiac Surgery Unit, Santa Maria della Misericordia Hospital, 33100 Udine, UD, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, Florence University, 50121 Firenze, Italy
| | - Silvia Favilli
- Pediatric and Transition Cardiology Unit, Meyer University Hospital, 50139 Florence, Italy
| | - Giuseppina Maura Francese
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | - Sandro Gelsomino
- Pediatric and Transition Cardiology Unit, Meyer University Hospital, 50139 Florence, Italy
| | - Giovanna Geraci
- Cardiology Unit, Sant'Antonio Abate di Erice, 91016 Erice, Trapani, Italy
| | | | | | - Annamaria Iorio
- Cardiology Unity 1, Cardiology 1, Cardiovascular Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Francesca Lanni
- Cardiology Unity, San Giuseppe Moscati Hospital, 83100 Avellino, Italy
| | - Andrea Montalto
- Cardiac Surgery Unit, San Camillo Forlanini Hospital, 00152 Roma, Italy
| | - Federico Nardi
- Dipartimento di Cardiologia, Ospedale Santo Spirito, Casale Monferrato, Italy
| | | | - Martina Nesti
- Cardiology Unity, San Donato Hospital, 52100 Arezzo, Italy
| | - Iris Parrini
- Cardiology Unity, Umberto I Di Torino Hospital, 10128 Torino, Italy
| | - Annarita Pilleri
- Federico Nardi, Cardiology Unit, Casale Monferrato Hospital, 15033 Casale Monferrato (AL), Italy
| | - Andrea Pozzi
- Cardiology Unity 1, Cardiology 1, Cardiovascular Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Carmine Riccio
- Post-Acute Patient Follow-up Unit, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | | | | | - Serafina Valente
- Clinical-Surgical Cardiology, A.O.U. Siena, Santa Maria alle Scotte Hospital, 53100 Siena, Italy
| | - Giuseppe Zuccalà
- Department of Geriatrics, Center for Aging Medicine, Catholic University of the Sacred Heart and IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
- Fondazione per il Tuo cuore—Heart Care Foundation, 50121 Firenze, Italy
| | - Massimo Grimaldi
- Cardiology Division, Coronary Intensive Care Unit, Miulli Hospital, 70021 Acquaviva delle Fonti, Italy
| | | | - Fabrizio Oliva
- Cardiology Unit, Cariovascular Department, ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
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17
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De Luca L, Di Fusco SA, Iannopollo G, Mistrulli R, Rizzello V, Aimo A, Navazio A, Bilato C, Corda M, Di Marco M, Geraci G, Iacovoni A, Milli M, Pascale V, Riccio C, Scicchitano P, Tizzani E, Gabrielli D, Grimaldi M, Colivicchi F, Oliva F. Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention. Eur Heart J Suppl 2024; 26:ii236-ii251. [PMID: 38784670 PMCID: PMC11110452 DOI: 10.1093/eurheartjsupp/suae032] [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] [Indexed: 05/25/2024]
Abstract
The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Stefania Angela Di Fusco
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | | | - Raffaella Mistrulli
- Dipartimento di Medicina Clinica e Molecolare, Università degli studi di Roma La Sapienza, Rome, Italy
| | | | - Alberto Aimo
- UOC Cardiologia, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alessandro Navazio
- SOC Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Reggio Emilia, Italy
| | - Claudio Bilato
- UOC Cardiologia, Ospedali dell'Ovest Vicentino, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Marco Corda
- SC Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | | | - Giovanna Geraci
- UOC Cardiologia, Ospedale Sant'Antonio Abate, Trapani, Italy
| | - Attilio Iacovoni
- SSD Chirurgia dei Trapianti e del Trattamento Chirurgico dello Scompenso, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Milli
- Cardiologia Firenze 1 (Ospedali S. Maria Nuova e Nuovo San Giovanni di Dio), Azienda USL Toscana Centro, Firenze, Italy
| | - Vittorio Pascale
- UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro, Italy
| | - Carmine Riccio
- U.O.S.D. Follow-up del Paziente Post-Acuto, Dipartimento Cardio-Vascolare, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | | | - Emanuele Tizzani
- Dipartimento di Cardiologia, Ospedale degli Infermi, Rivoli, TO, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Grimaldi
- U.O.C. Cardiologia-UTIC, Ospedale Miulli, Acquaviva delle Fonti, BA, Italy
| | - Furio Colivicchi
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
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18
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Fernandez-Vazquez D, Weideman S, Banerjee S. Assessing the Role of Bempedoic Acid in Lipid-Lowering Therapy. Am J Cardiol 2024; 216:93-94. [PMID: 38369175 DOI: 10.1016/j.amjcard.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/02/2024] [Indexed: 02/20/2024]
Affiliation(s)
| | - Sarah Weideman
- Baylor Scott & White Research Institute, Cardiology, Dallas, Texas
| | - Subhash Banerjee
- Baylor Scott & White Research Institute, Cardiology, Dallas, Texas
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Papantoniou E, Arvanitakis K, Markakis K, Papadakos SP, Tsachouridou O, Popovic DS, Germanidis G, Koufakis T, Kotsa K. Pathophysiology and Clinical Management of Dyslipidemia in People Living with HIV: Sailing through Rough Seas. Life (Basel) 2024; 14:449. [PMID: 38672720 PMCID: PMC11051320 DOI: 10.3390/life14040449] [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: 02/29/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Infections with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) represent one of the greatest health burdens worldwide. The complex pathophysiological pathways that link highly active antiretroviral therapy (HAART) and HIV infection per se with dyslipidemia make the management of lipid disorders and the subsequent increase in cardiovascular risk essential for the treatment of people living with HIV (PLHIV). Amongst HAART regimens, darunavir and atazanavir, tenofovir disoproxil fumarate, nevirapine, rilpivirine, and especially integrase inhibitors have demonstrated the most favorable lipid profile, emerging as sustainable options in HAART substitution. To this day, statins remain the cornerstone pharmacotherapy for dyslipidemia in PLHIV, although important drug-drug interactions with different HAART agents should be taken into account upon treatment initiation. For those intolerant or not meeting therapeutic goals, the addition of ezetimibe, PCSK9, bempedoic acid, fibrates, or fish oils should also be considered. This review summarizes the current literature on the multifactorial etiology and intricate pathophysiology of hyperlipidemia in PLHIV, with an emphasis on the role of different HAART agents, while also providing valuable insights into potential switching strategies and therapeutic options.
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Affiliation(s)
- Eleni Papantoniou
- First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.P.); (K.M.); (O.T.)
| | - Konstantinos Arvanitakis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.A.); (G.G.)
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Konstantinos Markakis
- First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.P.); (K.M.); (O.T.)
| | - Stavros P. Papadakos
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Olga Tsachouridou
- First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.P.); (K.M.); (O.T.)
| | - Djordje S. Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, 21137 Novi Sad, Serbia;
- Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Georgios Germanidis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.A.); (G.G.)
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Theocharis Koufakis
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, AHEPA University Hospital, Aristotle University of Thessaloniki, 1 St. Kiriakidi Street, 54636 Thessaloniki, Greece
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Kong X, He G, Quan X, Tan Z, Yan F, Chen X. The impact of the 2019 ESC/EAS dyslipidaemia guidelines on real-world initial lipid-lowering therapy in patients with acute myocardial infarction. Medicine (Baltimore) 2024; 103:e37637. [PMID: 38517999 PMCID: PMC10956955 DOI: 10.1097/md.0000000000037637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 02/26/2024] [Indexed: 03/24/2024] Open
Abstract
This study aimed to investigate the impact of the latest guidelines on the real-world clinical practice of initial lipid-lowering therapy, especially on the use of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in China. All adult patients diagnosed with acute myocardial infarction in our hospital between August 31, 2018, and August 31, 2020, were divided into the following 2 groups: those patients treated before the latest guideline release, and those patients treated after the release. A propensity score-matched method was used, and logistic regression was used to assess the association with intensive statin, ezetimibe and PCSK9 inhibitor usage together with treatment results between the 2 groups. A total of 325 patients were enrolled in this study, including 141 patients who were admitted before the release of the latest guideline and 184 patients who were admitted after the release. After a median follow-up time of 8.20 months, the mean low-density lipoprotein cholesterol was 1.87 ± 0.59 mmol/L (1.87 ± 0.55 in the before group vs 1.88 ± 0.62 in the after group, P = .829). After propensity score matching, the initial usage of intensive statin therapy was decreased after guideline release without statistical significance (17.00% vs 28.00%, P = .090), whereas the usage of ezetimibe and PCSK9 inhibitors was increased (19.00% vs 8.00%, P = .039; and 10.00% vs 3.00%, P = .085, respectively). In logistic regression models, the release of the guideline was associated with a statistically significantly increased use of ezetimibe (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.21, 3.02; P = .005), a marginally decreased use of intensive statins (OR: 0.68; 95% CI: 0.45, 1.03; P = .069) and a marginally increased use of PCSK9 inhibitors (OR: 1.31; 95% CI: 0.98, 1.76; P = .068). In this single-center, real-world data analysis, after the release of the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, an increasing number of patients with a recent acute myocardial infarction were initially receiving ezetimibe and PCSK9 inhibitors.
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Affiliation(s)
| | - Gang He
- Department of Traditional Chinese Medicine, Shenzhen People’s Hospital (The First Affiliated Hospital, Southern University of Science and Technology)
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Afzal MA, Khalid N, Abdullah M, Haiy AU, Hassan MA, Sana H, Elkattawy S, Malik AA, Michael P, Vasudev R, Shamoon F. The Latest Evidence on Bempedoic Acid: Meta-Analysis of Safety and Efficacy in High Cardiovascular Risk Patients With Hypercholesterolemia ⋆. J Community Hosp Intern Med Perspect 2024; 14:12-22. [PMID: 38966502 PMCID: PMC11221435 DOI: 10.55729/2000-9666.1305] [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: 06/24/2023] [Revised: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 07/06/2024] Open
Abstract
Background Bempedoic Acid (BA) is a novel drug that has a potential to serve as an alternative to statins to decrease lipid levels and improve cardiovascular disease (CVD) outcomes, particularly for statin-intolerant individuals. However, insufficient statistical power has limited our understanding of the efficacy and safety of BA. This meta-analysis utilizes the latest data to improve our knowledge of BA's effects on lipids and CVD with increased statistical power. Methods MEDLINE, Embase, Cochrane Central, Clinicaltrials.gov, abstracts of national and international conferences, and reference lists of studies were searched for relevant studies. Rayyan was used to screen the search results, and Revman 5.3 was used for the meta-analysis and sensitivity analysis. Results Our final analysis included seven randomized control trials (RCTs) with 17,782 participants, 53.6 % in the BA group (n = 9535) and 46.4 % in the placebo group (n = 8247). BA significantly decreased major adverse cardiovascular events (MACE) (OR: 0.86; 95 % CI 0.78-0.95; p = 0.03), non-fatal myocardial infarction (OR 0.72; 95 % CI 0.61-0.85; p = 0.0001), and new onset/worsening diabetes (OR:0.55; 95 % CI 0.30-0.98, p = 0.04), while reducing low-density lipoprotein cholesterol (LDL-C) levels by 22.5 % (MD: -22.53 %; 95 % CI -25.54 to -19.52, p < 0.00001). Conclusion The findings of this meta-analysis suggest that BA is a promising and effective alternative to statin therapy, particularly for statin-intolerant and high CVD-risk patients. However, further studies with diverse populations are needed to quantify the long-term efficacy and safety endpoints.
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Affiliation(s)
- Muhammad A. Afzal
- Department of Internal Medicine, St Joseph’s University Medical Center, Paterson, NJ,
USA
| | - Noman Khalid
- Department of Internal Medicine, St Joseph’s University Medical Center, Paterson, NJ,
USA
| | - Muhammad Abdullah
- Department of Medicine, Shaikh Khalifa Bin Zayed Al Nahyan Medical and Dental College, Shaikh Zayed Medical Complex, Lahore,
Pakistan
| | - Ata U. Haiy
- Department of Medicine, King Edward Medical University, Mayo Hospital Lahore,
Pakistan
| | - Mubariz A. Hassan
- Department of Internal Medicine, Howard University Hospital, Washington, DC,
USA
| | - Hania Sana
- Department of Medicine, King Edward Medical University, Mayo Hospital Lahore,
Pakistan
| | - Sherif Elkattawy
- Department of Cardiology, St Joseph’s University Medical Center, Paterson, NJ,
USA
| | - Ahmad A. Malik
- Department of Family and Community Medicine, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah,
Saudi Arabia
| | - Patrick Michael
- Department of Internal Medicine, St Joseph’s University Medical Center, Paterson, NJ,
USA
| | - Rahul Vasudev
- Department of Structural Heart Disease, St Joseph’s University Medical Center, Paterson, NJ,
USA
| | - Fayez Shamoon
- Department of Cardiology, St Joseph’s University Medical Center, Paterson, NJ,
USA
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Duell PB, Banach M, Catapano AL, Laufs U, Mancini GBJ, Ray KK, Broestl C, Zhang Y, Lei L, Goldberg AC. Efficacy and safety of bempedoic acid in patients with heterozygous familial hypercholesterolemia: analysis of pooled patient-level data from phase 3 clinical trials. J Clin Lipidol 2024; 18:e153-e165. [PMID: 38341323 DOI: 10.1016/j.jacl.2023.12.005] [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: 07/08/2023] [Revised: 11/27/2023] [Accepted: 12/13/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Patients with heterozygous familial hypercholesterolemia (HeFH) often cannot reach guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals despite multidrug therapy. OBJECTIVE To evaluate the efficacy and safety of bempedoic acid as an add-on therapy for lowering LDL-C in patients with HeFH. METHODS Pooled data from two 52-week phase 3 clinical trials of patients with atherosclerotic cardiovascular disease and/or HeFH receiving maximally tolerated statin therapy (randomized 2:1 to bempedoic acid or placebo) were analyzed by HeFH status. Endpoints included changes from baseline to week 12 (and up to week 52) in LDL-C and other lipid parameters, achievement of LDL-C goals, and safety. RESULTS A total of 217 (bempedoic acid, 146; placebo, 71) patients with HeFH and 2,792 (bempedoic acid, 1,864; placebo, 928) without HeFH were included (mean baseline LDL-C, 172.8 mg/dL and 102.6 mg/dL, respectively). Bempedoic acid significantly lowered LDL-C at week 12 vs. placebo regardless of HeFH status (with HeFH, -21.2%; without HeFH, -18.2% [both P<0.0001]). Bempedoic acid significantly reduced other lipid parameters and high-sensitivity C-reactive protein vs. placebo regardless of HeFH status (all P≤0.01). Among patients with HeFH treated with bempedoic acid, 32% and 27% achieved LDL-C <100 mg/dL at weeks 12 and 52, respectively. Overall treatment-emergent adverse event incidence was comparable across all four groups (74.7-77.5%). CONCLUSION Bempedoic acid significantly lowered LDL-C levels vs. placebo and was generally well tolerated in all patients, with no new safety findings in patients with HeFH, despite more intensive lipid-lowering therapy in patients with vs. without HeFH.
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Affiliation(s)
- P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute and Division of Endocrinology, Diabetes, and Clinical Nutrition, School of Medicine, Oregon Health & Science University, Portland, OR, USA (Dr Duell).
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Łódź (MUL), Łódź, Poland (Dr Banach)
| | | | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany (Dr Laufs)
| | - G B John Mancini
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada (Dr Mancini)
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, UK (Dr Ray)
| | - Christine Broestl
- Esperion Therapeutics, Inc., Ann Arbor, MI, USA (Drs Broestl, Zhang, Lei)
| | - Yang Zhang
- Esperion Therapeutics, Inc., Ann Arbor, MI, USA (Drs Broestl, Zhang, Lei)
| | - Lei Lei
- Esperion Therapeutics, Inc., Ann Arbor, MI, USA (Drs Broestl, Zhang, Lei)
| | - Anne C Goldberg
- Department of Medicine, Washington University, St. Louis, MO, USA (Dr Goldberg)
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Migliaccio-Walle K, Elsea D, Gupta A, Sarnes E, Griffith K, Pandey R, Gillard K. Treatment intensification with bempedoic acid to achieve LDL-C goal in patients with ASCVD: A simulation model using a real-world patient cohort in the US. ATHEROSCLEROSIS PLUS 2024; 55:98-105. [PMID: 38571880 PMCID: PMC10987878 DOI: 10.1016/j.athplu.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024]
Abstract
Background and aims Guidelines recommend that high-risk patients with atherosclerotic cardiovascular disease (ASCVD) be treated with maximally tolerated statins to lower low-density lipoprotein cholesterol (LDL-C) levels and reduce the risk of major adverse cardiovascular events. In patients whose LDL-C remains elevated, non-statin adjunct therapies, including ezetimibe (EZE), bempedoic acid (BA), and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are recommended. Methods The impact of BA and EZE in a fixed-dose combination (FDC) on LDL-C goal attainment was evaluated using a simulation model developed for a United States cohort of high-risk adults with ASCVD. Treatment was simulated for 73,056 patients not at goal (LDL-C >70 mg/dL), comparing BA + EZE (FDC), EZE only, and no oral adjunct therapy (NOAT). The addition of PCSK9 inibitors was assumed after 1 year in patients not at LDL-C goal. Treatment efficacy was estimated from clinical trials. Patient-level outcomes were predicted over a 10-year horizon accounting for treatment discontinuation and general mortality. Results Baseline mean age of the cohort was 67 years, most were White (79%) and male (56%). A majority had established coronary artery disease (75%), 48% had diabetes, and mean LDL-C was 103.0 mg/dL. After 1 year, 79% of patients achieved LDL-C goal (mean, 61.1 mg/dL) with BA + EZE (FDC) compared to 58% and 42% with EZE (71.7 mg/dL) and NOAT (78.4 mg/dL), respectively. Conclusions This simulation shows that adding BA + EZE (FDC) to maximally tolerated statins would result in more patients achieving LDL-C goal than adding EZE alone or NOAT.
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Affiliation(s)
| | | | - Anand Gupta
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abrahams T, Nelson AJ, Nicholls SJ. How Will Our Practice Change After the CLEAR Outcomes Trial? Curr Atheroscler Rep 2024; 26:83-89. [PMID: 38294660 PMCID: PMC10881600 DOI: 10.1007/s11883-024-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW Bempedoic acid is a novel therapeutic agent that is designed to reduce levels of low-density lipoprotein cholesterol (LDL-C). The purpose of this review is to provide the background for development of bempedoic acid, findings from clinical trials and to discuss clinical implications. RECENT FINDINGS Bempedoic acid inhibits ATP citrate lyase within the liver and reduces cholesterol synthesis, with the potential to avoid muscle symptoms experienced by patients treated with statins. Early clinical studies demonstrated that administration of bempedoic acid resulted in lowering of LDL-C by 20-30% as monotherapy and by 40-50% when combined with ezetimibe, in addition to lowering of high sensitivity C-reactive protein by 20-30%. The CLEAR Outcomes trial of high cardiovascular risk patients, with elevated LDL-C levels and either unable or unwilling to take statins demonstrated that bempedoic acid reduced the rate of major adverse cardiovascular events. A greater incidence of elevation of hepatic transaminase and creatinine, gout, and cholelithiasis were consistently observed in bempedoic acid-treated patients. Bempedoic acid presents an additional therapeutic option to achieve more effective lowering of LDL-C levels and reduction in cardiovascular risk.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Adam J Nelson
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia.
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25
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Revankar S, Park JK, Satish P, Agarwala A. Is there a role for earlier use of combination therapy? Am J Prev Cardiol 2024; 17:100639. [PMID: 38419948 PMCID: PMC10900258 DOI: 10.1016/j.ajpc.2024.100639] [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: 10/31/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
As the global population ages and cardiovascular risk factors rise, we can expect a continued increase in atherosclerotic disease. Low-density lipoprotein cholesterol (LDL-C) reduction is a cornerstone of cardiovascular risk reduction with strong, causal evidence indicating that the greatest benefit is derived from early and large decreases in LDL-C. Despite the adoption of statins as the backbone of lipid-therapy regimens, numerous studies and registry analyses reveal our collective inability to achieve LDL-C goals in high-risk patients. Combination therapy with ezetimibe has been shown to result in statistically significant decreases in LDL-C level, atheroma volume, and cardiovascular adverse event rates. A major barrier to implementing an upfront combination therapy approach is the perceived side effects from therapeutic agents although multiple studies show that a therapeutic patient-physician relationship could overcome this issue. Novel agents such as PCSK-9 inhibitors, bempedoic acid, and inclisiran have the potential to achieve similar outcomes although additional research is needed regarding the cost effectiveness of these approaches. Despite these hurdles, there is a role for the newer agents early in the disease course of high-risk patients such as those with markedly elevated LDL-C >190 mg/dL and FH. The implementation of upfront combination therapy, especially in high-risk patients, will decrease clinical inertia while allowing for earlier consideration of newer, effective agents to decrease cardiovascular burden.
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Affiliation(s)
- Shruti Revankar
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jong Kun Park
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA
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26
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Xu C, Tsihlis G, Chau K, Trinh K, Rogers NM, Julovi SM. Novel Perspectives in Chronic Kidney Disease-Specific Cardiovascular Disease. Int J Mol Sci 2024; 25:2658. [PMID: 38473905 DOI: 10.3390/ijms25052658] [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: 01/19/2024] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
Chronic kidney disease (CKD) affects > 10% of the global adult population and significantly increases the risk of cardiovascular disease (CVD), which remains the leading cause of death in this population. The development and progression of CVD-compared to the general population-is premature and accelerated, manifesting as coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. CKD and CV disease combine to cause multimorbid cardiorenal syndrome (CRS) due to contributions from shared risk factors, including systolic hypertension, diabetes mellitus, obesity, and dyslipidemia. Additional neurohormonal activation, innate immunity, and inflammation contribute to progressive cardiac and renal deterioration, reflecting the strong bidirectional interaction between these organ systems. A shared molecular pathophysiology-including inflammation, oxidative stress, senescence, and hemodynamic fluctuations characterise all types of CRS. This review highlights the evolving paradigm and recent advances in our understanding of the molecular biology of CRS, outlining the potential for disease-specific therapies and biomarker disease detection.
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Affiliation(s)
- Cuicui Xu
- Kidney Injury Group, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, 176 Hawkesbury Road, Westmead, NSW 2145, Australia
| | - George Tsihlis
- Renal and Transplantation Medicine, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Katrina Chau
- Department of Renal Services, Blacktown Hospital, Blacktown, NSW 2148, Australia
- Blacktown Clinical School, School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia
| | - Katie Trinh
- Kidney Injury Group, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, 176 Hawkesbury Road, Westmead, NSW 2145, Australia
- Department of Renal Services, Blacktown Hospital, Blacktown, NSW 2148, Australia
| | - Natasha M Rogers
- Kidney Injury Group, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, 176 Hawkesbury Road, Westmead, NSW 2145, Australia
- Renal and Transplantation Medicine, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, The University of Sydney, Science Rd., Camperdown, NSW 2050, Australia
| | - Sohel M Julovi
- Kidney Injury Group, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, 176 Hawkesbury Road, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, The University of Sydney, Science Rd., Camperdown, NSW 2050, Australia
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Agnello F, Ingala S, Laterra G, Scalia L, Barbanti M. Novel and Emerging LDL-C Lowering Strategies: A New Era of Dyslipidemia Management. J Clin Med 2024; 13:1251. [PMID: 38592091 PMCID: PMC10931739 DOI: 10.3390/jcm13051251] [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: 01/16/2024] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) represents a major global health challenge, significantly contributing to mortality rates. This chronic inflammatory condition affecting blood vessels is intricately linked to hypercholesterolemia, with elevated levels of low-density lipoprotein cholesterol (LDL-C) recognized as a central and modifiable risk factor. The effectiveness of lipid-lowering therapy (LLT) in mitigating ASCVD risk is well established, with studies revealing a substantial reduction in major ischemic events correlating with LDL-C reduction. While statins, often combined with ezetimibe, remain fundamental in dyslipidemia management, a significant proportion of patients on statin therapy continue to experience cardiovascular events. Recent pharmacological advancements, driven by a deeper understanding of atherogenesis, have unveiled novel therapeutic targets and potent drugs. Notably, agents like bempedoic acid and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab, alirocumab, inclisiran) have emerged as effective options to intensify LLT and achieve LDL-C goals, addressing limitations associated with statins, such as myopathy. Molecular insights into alternative pathways have spurred the investigation of emerging agents, offering promising perspectives for novel medications with efficacy comparable to established treatments, associated with advantages in cost and administration. This review provides a comprehensive overview of the evolving landscape of lipid-lowering strategies, highlighting the progress made in addressing ASCVD risk and the potential of upcoming therapies to further optimize cardiovascular prevention.
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Affiliation(s)
- Federica Agnello
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Salvatore Ingala
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Giulia Laterra
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Lorenzo Scalia
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
| | - Marco Barbanti
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy; (F.A.); (S.I.); (L.S.)
- Faculty of Medicine and Surgery, Università degli Studi di Enna “Kore”, 94100 Enna, Italy
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Ferri N, Ruscica M, Fazio S, Corsini A. Low-Density Lipoprotein Cholesterol-Lowering Drugs: A Narrative Review. J Clin Med 2024; 13:943. [PMID: 38398257 PMCID: PMC10889346 DOI: 10.3390/jcm13040943] [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: 01/01/2024] [Revised: 01/26/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
The modern history of cholesterol-lowering drugs started in 1972 when Dr. Akira Endo identified an active compound (compactin) that inhibited cholesterol biosynthesis from the culture broth of blue-green mold (Penicillium citrinum Pen-51). Since 1987, statins have represented the milestone for the treatment of atherosclerotic cardiovascular disease. A new therapy for the treatment of hypercholesterolemia since the discovery of statins is ezetimibe, the first and only agent inhibiting intestinal cholesterol absorption. Ezetimibe was approved by the FDA in October 2002. A year later, the association between gain-of-function PCSK9 genetic mutations and hypercholesterolemia was reported, and this discovery opened a new era in lipid-lowering therapies. Monoclonal antibodies and small-interfering RNA approaches to reduce PCSK9 were developed and approved for clinical use in 2015 and 2022, respectively. Finally, the newly approved bempedoic acid, an oral adenosine triphosphate citrate lyase inhibitor that lowers LDL-C, is able to reduce major adverse cardiovascular events in both primary and secondary prevention. In the present narrative review, we summarize the pharmacological properties and the clinical efficacy of all these agents currently used for a tailored therapy of hypercholesterolemia in patients with atherosclerotic cardiovascular disease.
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Affiliation(s)
- Nicola Ferri
- Department of Medicine (DIMED), University of Padova, 35122 Padova, Italy
- Veneto Institute of Molecular Medicine (VIMM), 35129 Padua, Italy
| | - Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, University of Milan, 20133 Milan, Italy;
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sergio Fazio
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591, USA;
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, University of Milan, 20133 Milan, Italy;
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Del Carpio-Tenorio C, Llerena-Velastegui J, Villacis-Lopez C, Placencia-Silva M, Santander-Fuentes C, Benitez-Acosta K, Sanahuja-Montiel C, Dominguez-Gavilanes D, Carrasco-Perez P, Calderon-Lopez C. Impact of Bempedoic acid on LDL-C reduction and cardiovascular outcomes: A comprehensive meta-analysis of randomized controlled trials. Curr Probl Cardiol 2024; 49:102191. [PMID: 37981266 DOI: 10.1016/j.cpcardiol.2023.102191] [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: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The management of LDL-C levels is pivotal in the prevention of cardiovascular morbidity, particularly among patients at high risk or those intolerant to statins. Bempedoic acid emerges as a novel agent in this therapeutic arena. OBJECTIVES This systematic review and meta-analysis endeavor to quantify the effectiveness of Bempedoic acid in attenuating LDL-C levels and explore its impact on cardiovascular morbidity, emphasizing its role as an adjunctive or alternative therapy in statin-intolerant or high-risk patients. METHODS A comprehensive search spanning PubMed, Google Scholar, and Cochrane Library databases furnished studies for this review. The inclusion was critiqued based on predefined PICOS parameters, ensuring a robust analytical framework. RESULTS Bempedoic acid showcased a significant plunge in LDL-C levels (MD -20.69 %, 95 % CI [-23.20, -18.19]), outperforming placebo and ezetimibe monotherapy. The cardioprotective effect was further echoed with a reduced risk of major adverse cardiac events (MACE) in the Bempedoic acid cohort (RR 0.86, 95 % CI [0.80, 0.94]). However, a dive into the safety profile revealed no substantial augmentation in adverse events, affirming its tolerance and efficacy. CONCLUSIONS Bempedoic acid represents a potent therapeutic ally, affirming its capacity to significantly pare down LDL-C levels and curtail cardiovascular events. Its favorable safety profile underscores its suitability, especially among those with statin intolerance or individuals categorized within the high-risk vascular bracket, necessitating a paradigm shift in current lipid management strategies.
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30
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Paponja K, Pećin I, Reiner Ž, Banach M. Bempedoic acid: new evidence and recommendations on use. Curr Opin Lipidol 2024; 35:41-50. [PMID: 38085172 DOI: 10.1097/mol.0000000000000911] [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] [Indexed: 12/20/2023]
Abstract
PURPOSES OF REVIEW Cardiovascular diseases (CVDs) are the leading cause of mortality and morbidity worldwide. Recognizing the importance of dyslipidemia treatment in the prevention of cardiovascular events has become a part of standard clinical practice. Desired values of LDL cholesterol (LDL-C) have become lower and lower in the last few decades, as evidenced by the most recent guidelines. Therefore, efforts to lower LDL cholesterol concentrations with conventional therapies and combinations of lipid-lowering therapy may not be successful in a high proportion of patients. RECENT FINDINGS Bempedoic acid is a novel agent, first in-class ATP Citrate Lyase (ACL) inhibitor, which targets biosynthesis of the cholesterol in the liver. Considering the results of phase 3 studies, it has been approved for sole use for dyslipidemia treatment for patients who are statin-intolerant or in combination with statin-ezetimibe for those suffering from familial hypercholesterolemia or ASCVD and unable to reach targeted LDL-C values. SUMMARY Bempedoic acid has proven beneficial for further reduction of LDL cholesterol for targeted groups of patients. It is not only efficient but also a well tolerated, affordable, and available agent whose place in lipid-lowering management is yet to be fully understood with new data collected from ongoing clinical research. In this review we suggest the place of bempedoic acid in lipid-lowering management.
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Affiliation(s)
- Kristina Paponja
- University Hospital Center Zagreb, Department of Internal Medicine, Division of Metabolic Diseases
| | - Ivan Pećin
- University Hospital Center Zagreb, Department of Internal Medicine, Division of Metabolic Diseases
- Zagreb School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Reiner
- University Hospital Center Zagreb, Department of Internal Medicine, Division of Metabolic Diseases
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute
| | - Maciej Banach
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Li Y, Gao H, Zhao J, Ma L, Hu D. Safety and efficacy of bempedoic acid among patients with statin intolerance and those without: A meta-analysis and a systematic randomized controlled trial review. PLoS One 2024; 19:e0297854. [PMID: 38277431 PMCID: PMC10817114 DOI: 10.1371/journal.pone.0297854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/07/2024] [Indexed: 01/28/2024] Open
Abstract
OBJECTIVE Bempedoic acid, an innovative oral medication, has garnered significant interest in recent times due to its potential as a therapeutic intervention for hypercholesterolemia. Nonetheless, the outcomes of the initial investigations might have been more definitive and coherent. Our objective was to perform a quantitative meta-analysis in order to evaluate bempedoic acid's safety and effectiveness. METHODS A search was conducted on ClinicalTrials.gov, and PubMed from the time of inception until September 28, 2023. Randomized controlled trials comparing the safety and efficacy of bempedoic acid among patients with statin intolerance and those without were included in our analysis. The trial outcomes were summarized using a random effects model and were provided as mean differences or odds ratios (ORs) with a confidence interval of 95%. Additionally, trial heterogeneity and the possibility of bias were evaluated and investigated. RESULTS Bempedoic acid treatment reduced low-density lipoprotein cholesterol levels more than placebo (mean difference -2.97%, 95% CI -5.89% to -0.05%), according to a pooled analysis of 16 eligible trials. The risk of death (OR 1.18, 95% CI 0.70 to 1.98) and muscle-associated occurrences (OR 1.00, 95% CI 0.77 to 1.31) was not impacted by bempedoic acid. In contrast, discontinuation of treatment was more frequently caused by adverse events in the bempedoic acid group (OR 1.13, 95% CI 1.01 to 1.27). CONCLUSIONS In patients with statin intolerance as well as those without, bempedoic acid is a safe and efficacious lipid-lowering agent, according to findings from randomized controlled trials.
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Affiliation(s)
- Yi Li
- Department of Cardiology, No 1 Hospital Of Baoding, Baoding, Hebei, China
| | - Hongyu Gao
- Department of Cardiology, No 1 Hospital Of Baoding, Baoding, Hebei, China
| | - Jinghui Zhao
- Department of Cardiology, No 1 Hospital Of Baoding, Baoding, Hebei, China
| | - Liqing Ma
- Department of Cardiology, No 1 Hospital Of Baoding, Baoding, Hebei, China
| | - Dan Hu
- Department of Cardiology, No 1 Hospital Of Baoding, Baoding, Hebei, China
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Li X, Peng X, Zoulikha M, Boafo GF, Magar KT, Ju Y, He W. Multifunctional nanoparticle-mediated combining therapy for human diseases. Signal Transduct Target Ther 2024; 9:1. [PMID: 38161204 PMCID: PMC10758001 DOI: 10.1038/s41392-023-01668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 09/14/2023] [Accepted: 10/10/2023] [Indexed: 01/03/2024] Open
Abstract
Combining existing drug therapy is essential in developing new therapeutic agents in disease prevention and treatment. In preclinical investigations, combined effect of certain known drugs has been well established in treating extensive human diseases. Attributed to synergistic effects by targeting various disease pathways and advantages, such as reduced administration dose, decreased toxicity, and alleviated drug resistance, combinatorial treatment is now being pursued by delivering therapeutic agents to combat major clinical illnesses, such as cancer, atherosclerosis, pulmonary hypertension, myocarditis, rheumatoid arthritis, inflammatory bowel disease, metabolic disorders and neurodegenerative diseases. Combinatorial therapy involves combining or co-delivering two or more drugs for treating a specific disease. Nanoparticle (NP)-mediated drug delivery systems, i.e., liposomal NPs, polymeric NPs and nanocrystals, are of great interest in combinatorial therapy for a wide range of disorders due to targeted drug delivery, extended drug release, and higher drug stability to avoid rapid clearance at infected areas. This review summarizes various targets of diseases, preclinical or clinically approved drug combinations and the development of multifunctional NPs for combining therapy and emphasizes combinatorial therapeutic strategies based on drug delivery for treating severe clinical diseases. Ultimately, we discuss the challenging of developing NP-codelivery and translation and provide potential approaches to address the limitations. This review offers a comprehensive overview for recent cutting-edge and challenging in developing NP-mediated combination therapy for human diseases.
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Affiliation(s)
- Xiaotong Li
- School of Pharmacy, China Pharmaceutical University, Nanjing, 2111198, PR China
| | - Xiuju Peng
- School of Pharmacy, China Pharmaceutical University, Nanjing, 2111198, PR China
| | - Makhloufi Zoulikha
- School of Pharmacy, China Pharmaceutical University, Nanjing, 2111198, PR China
| | - George Frimpong Boafo
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, PR China
| | - Kosheli Thapa Magar
- School of Pharmacy, China Pharmaceutical University, Nanjing, 2111198, PR China
| | - Yanmin Ju
- School of Pharmacy, China Pharmaceutical University, Nanjing, 2111198, PR China.
| | - Wei He
- Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China.
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Danilov A, Frishman WH, Aronow WS. Antihyperlipidemic Treatment Options in Statin Resistance and Intolerance. Cardiol Rev 2024; 32:51-56. [PMID: 36305712 DOI: 10.1097/crd.0000000000000498] [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] [Indexed: 11/26/2022]
Abstract
Cardiovascular disease is the global leading cause of death and hypercholesterolemia is implicated as one of its top contributors. Moreover, there is growing recognition that lower low-density lipoprotein cholesterol levels offer greater protection against cardiovascular disease. Statins are the first-line lipid-lowering agents for both primary and secondary prevention of cardiovascular disease in patients with hypercholesterolemia. However, statin resistance and intolerance lead to undertreatment in patients who would likely derive the most benefit from antihyperlipidemic drugs. Several non-statin therapies are increasingly prescribed to such patients, most commonly ezetimibe and the PCSK9 monoclonal antibodies, but numerous other options have been developed in recent years and investigations into new therapies are ongoing. The use of these non-statin therapies requires the clinician to take a highly personalized approach to cholesterol reduction in complex patients. In this review, we describe current non-statin options for statin-resistant and statin-intolerant patients in addition to areas of active research.
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Affiliation(s)
| | - William H Frishman
- Department of Medicine, New York Medical College, and Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Medicine, New York Medical College, and Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Ray KK, Nicholls SJ, Li N, Louie MJ, Brennan D, Lincoff AM, Nissen SE. Efficacy and safety of bempedoic acid among patients with and without diabetes: prespecified analysis of the CLEAR Outcomes randomised trial. Lancet Diabetes Endocrinol 2024; 12:19-28. [PMID: 38061370 DOI: 10.1016/s2213-8587(23)00316-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Statins reduce LDL cholesterol and cardiovascular events among those with or without diabetes but have been reported to increase new-onset diabetes. The CLEAR Outcomes trial demonstrated that bempedoic acid reduced the risk of major adverse cardiovascular events among statin-intolerant patients at high cardiovascular risk. In this prespecified analysis, our dual aims were to evaluate the cardiovascular benefits of bempedoic acid, an ATP-citrate lyase inhibitor, in individuals with diabetes, and to evaluate the risk of new-onset diabetes and HbA1c among those without diabetes in the CLEAR Outcomes trial. METHODS CLEAR Outcomes was a randomised, double-blind, placebo-controlled trial conducted across 1250 primary care and outpatient sites in 32 countries. Patients with or without cardiovascular disease who were unwilling or unable to take guideline-recommended doses of statins and an LDL cholesterol of 2·59 mmol/L or more were randomly assigned (1:1) in a double-blinded manner to either bempedoic acid 180 mg once per day or placebo. In this prespecified analysis, the efficacy endpoint was a time-to-event analysis of four-component major adverse cardiovascular event (MACE-4), which is the composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularisation, using the intention-to-treat population stratified by baseline glycaemia status. The prespecified analysis of risk of new-onset diabetes and HbA1c increase was evaluated in patients without diabetes at baseline. The CLEAR Outcomes trial was completed on Nov 7, 2022, and is registered with ClinicalTrials.gov (NCT02993406). FINDINGS Between Dec 22, 2016, and Nov 7, 2022, 13 970 patients were screened and randomly assigned; 6373 (45·6%) with diabetes, 5796 (41·5%) with prediabetes, and 1801 (12·9%) with normoglycaemia. Over a median of 3·4 years follow up, patients with diabetes had significant relative and absolute cardiovascular risk reductions in MACE-4 endpoints with bempedoic acid (HR 0·83; 95% CI 0·72-0·95; absolute risk reduction of 2·4%) compared to placebo, with no statistical evidence of effect modification across glycaemic strata (interaction p=0·42). The proportion of patients who developed new-onset diabetes were similar between the bempedoic acid and placebo groups, with 429 of 3848 (11·1%) with bempedoic acid versus 433 of 3749 (11·5%) with placebo (HR 0·95; 95% CI 0·83-1·09). HbA1c concentrations at month 12 and the end of the study were similar between randomised groups in patients who had prediabetes and normoglycaemia. Placebo-corrected LDL cholesterol concentrations and high-sensitivity C-reactive protein at 6 months were reduced in each glycaemic stratum (diabetes, prediabtes, and normoglycaemia) for patients randomly assigned to bempedoic acid (all p<0·001). INTERPRETATION Among patients with diabetes, bempedoic acid reduces LDL cholesterol and high-sensitivity C-reactive protein and risk of cardiovascular events. Patients without diabetes had no increase in new-onset diabetes or worsening HbA1c with bempedoic acid. The efficacy and cardiometabolic safety profile of bempedoic acid makes it a clinical option for those with and without diabetes. FUNDING Esperion Therapeutics.
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Affiliation(s)
- Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College London, London, UK.
| | | | - Na Li
- Esperion Therapeutics, Ann Arbor, MI, USA
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Marcos-Garcés V, Merenciano-González H, Martínez Mas ML, Palau P, Climent Alberola JI, Perez N, López-Bueno L, Esteban Argente MC, Valls Reig M, Muñoz Alcover R, Pradillas Contreras I, Arizón Benito A, Payá Rubio A, Ríos-Navarro C, de Dios E, Gavara J, Chorro FJ, Sanchis J, Bodi V. Short-Course High-Intensity Statin Treatment during Admission for Myocardial Infarction and LDL-Cholesterol Reduction-Impact on Tailored Lipid-Lowering Therapy at Discharge. J Clin Med 2023; 13:127. [PMID: 38202134 PMCID: PMC10780070 DOI: 10.3390/jcm13010127] [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: 11/14/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
We hypothesized that a short-course high-intensity statin treatment during admission for myocardial infarction (MI) could rapidly reduce LDL-C and thus impact the choice of lipid-lowering therapy (LLT) at discharge. Our cohort comprised 133 MI patients (62.71 ± 11.3 years, 82% male) treated with atorvastatin 80 mg o.d. during admission. Basal LDL-C levels before admission were analyzed. We compared lipid profile variables before and during admission, and LLT at discharge was registered. Achieved theoretical LDL-C levels were estimated using LDL-C during admission and basal LDL-C as references and compared to LDL-C on first blood sample 4-6 weeks after discharge. A significant reduction in cholesterol from basal levels was noted during admission, including total cholesterol, triglycerides, HDL-C, non-HDL-C, and LDL-C (-39.23 ± 34.89 mg/dL, p < 0.001). LDL-C levels were reduced by 30% in days 1-2 and 40-45% in subsequent days (R2 0.766, p < 0.001). Using LDL-C during admission as a reference, most patients (88.7%) would theoretically achieve an LDL-C < 55 mg/dL with discharge LLT. However, if basal LDL-C levels were considered as a reference, only a small proportion of patients (30.1%) would achieve this lipid target, aligned with the proportion of patients with LDL-C < 55 mg/dL 4-6 weeks after discharge (36.8%). We conclude that statin treatment during admission for MI can induce a significant reduction in LDL-C and LLT at discharge is usually prescribed using LDL-C during admission as the reference, which leads to insufficient LDL-C reduction after discharge. Basal LDL-C before admission should be considered as the reference value for tailored LLT prescription.
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Affiliation(s)
- Víctor Marcos-Garcés
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
| | - Héctor Merenciano-González
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
| | - María Luz Martínez Mas
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
| | - Patricia Palau
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Josefa Inés Climent Alberola
- Department of Rehabilitation, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (J.I.C.A.); (L.L.-B.); (M.C.E.A.); (A.P.R.)
| | - Nerea Perez
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
| | - Laura López-Bueno
- Department of Rehabilitation, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (J.I.C.A.); (L.L.-B.); (M.C.E.A.); (A.P.R.)
| | - María Concepción Esteban Argente
- Department of Rehabilitation, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (J.I.C.A.); (L.L.-B.); (M.C.E.A.); (A.P.R.)
| | - María Valls Reig
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
| | - Raquel Muñoz Alcover
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
| | - Inmaculada Pradillas Contreras
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
| | | | - Alfonso Payá Rubio
- Department of Rehabilitation, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (J.I.C.A.); (L.L.-B.); (M.C.E.A.); (A.P.R.)
| | - César Ríos-Navarro
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
| | - Elena de Dios
- Network Biomedical Research Center for Cardiovascular Diseases (CIBER-CV), 28029 Madrid, Spain;
| | - Jose Gavara
- Centre for Biomaterials and Tissue Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
| | - Francisco Javier Chorro
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
- Network Biomedical Research Center for Cardiovascular Diseases (CIBER-CV), 28029 Madrid, Spain;
| | - Juan Sanchis
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
- Network Biomedical Research Center for Cardiovascular Diseases (CIBER-CV), 28029 Madrid, Spain;
| | - Vicente Bodi
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (H.M.-G.); (M.L.M.M.); (P.P.); (M.V.R.); (R.M.A.); (I.P.C.); (F.J.C.); (J.S.)
- INCLIVA Health Research Institute, 46010 Valencia, Spain; (N.P.); (C.R.-N.)
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
- Network Biomedical Research Center for Cardiovascular Diseases (CIBER-CV), 28029 Madrid, Spain;
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Catapano AL. Emerging therapies in dyslipidaemias. Vascul Pharmacol 2023; 153:107229. [PMID: 37716371 DOI: 10.1016/j.vph.2023.107229] [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: 07/27/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/18/2023]
Abstract
Several observations have shown that elevated levels of low-density lipoprotein cholesterol (LDL-C) are a cause of cardiovascular disease. Lowering LDL-C is a key strategy for reducing cardiovascular risk, with a continuous linear correlation between LDL-C reduction and cardiovascular benefit. Based on these observations, current guidelines have further lowered LDL-C goals and call for the use of more effective therapeutic interventions. In addition to statins, ezetimibe and the monoclonal antibodies targeting PCSK9, several new lipid-lowering agents are currently in phase 3 clinical trials to evaluate their clinical effects, and more are in development. The use of combination therapies targeting different pathways can increase the effectiveness of treatment.
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Affiliation(s)
- Alberico L Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy; Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.
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Srivastava RAK. New opportunities in the management and treatment of refractory hypercholesterolemia using in vivo CRISPR-mediated genome/base editing. Nutr Metab Cardiovasc Dis 2023; 33:2317-2325. [PMID: 37805309 DOI: 10.1016/j.numecd.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 10/09/2023]
Abstract
AIMS Refractory hypercholesterolemia (RH), caused primarily by the loss-of-function mutation of LDL receptor (LDLR) gene seen in HoFH and HeFH patients, remains a major risk factor for atherosclerotic cardiovascular disease (ASCVD). Statin and ezetimibe combination therapy lower circulating LDL by 30% in HoFH patients. PCSK9 mAB, being an LDLR-dependent therapy, is not effective in HoFH, but lowers LDL by 25% in HeFH patients. A maximum reduction of 50% was noted in HoFH patients treated with ANGPTL3 mAB, which was not enough to achieve therapeutic goal of LDL. Therefore, new approaches are warranted to offer hopes to individuals intolerant to higher dose statins and not able to achieve recommended LDL level. DATA SYNTHESIS New approaches to lower LDL include gene therapy and gene editing. AAV-based gene therapy has shown encouraging results in animal models. Using CRISPR/Cas9-mediated genome/base editing, gain of function and loss of function have been successfully done in animal models. Recent progress in the refinement of genome/base editing has overcome the issues of off-target mutagenesis with ∼1% mutagenesis in case of PCSK9 and almost no off-target mutagenesis in inactivating ANGPTL3 in animal models showing 50% reduction in cholesterol. Current approaches using CRISPR-Cas9 genome/base editing targeting LDLR-dependent and LDLR-independent pathways are underway. CONCLUSIONS The new information on gain of LDLR function and inactivation of ANGPTL3 together with developments in genome/base editing technology to overcome off-target insertion and deletion mutagenesis offer hope to refractory hypercholesterolemic individuals who are at a higher risk of developing ASCVD.
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Iurlo A, Cattaneo D, Bucelli C, Spallarossa P, Passamonti F. Cardiovascular Adverse Events of Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: Clinical Relevance, Impact on Outcome, Preventive Measures and Treatment Strategies. Curr Treat Options Oncol 2023; 24:1720-1738. [PMID: 38047977 DOI: 10.1007/s11864-023-01149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2023] [Indexed: 12/05/2023]
Abstract
OPINION STATEMENT The introduction of TKIs into the therapeutic armamentarium of CML has changed the disease paradigm, increasing long-term survival from 20% to over 80%, with a life expectancy now approaching that of the general population. Although highly effective, TKIs also have a toxicity profile that is often mild to moderate, but sometimes severe, with multiple kinases involved in the development of adverse events (AEs). Among others, cardiovascular AEs observed in TKI-treated CML patients may represent a significant cause of morbidity and mortality, and their pathogenesis is still only partially understood. In view of the recent introduction into daily clinical practice of new TKIs, namely the STAMP inhibitor asciminib, with a distinct safety profile, hematologists now more than ever have the opportunity to select the most suitable TKI for each patient, an aspect that will be fundamental in terms of personalized preventive and therapeutic strategies. Furthermore, physicians should be aware of the feasibility of TKI dose modifications at all stages of the patients' treatment journey, both at diagnosis for frail or elderly subjects or with multiple comorbidities, and during follow-up for those patients who experience toxicity, as well as to prevent it, with the main objective of reducing side effects while maintaining the response. Consequently, preserving the cardiovascular health of CML patients will likely be a more urgent topic in the near future, with specific measures aimed at controlling cardiovascular risk factors through a multidisciplinary approach involving a panel of healthcare professionals together with the hematologist.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy.
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - Italian IRCCS Cardiology Network, Genova, Italy
| | - Francesco Passamonti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Uddin N, Syed AA, Ismail SM, Ashraf MT, Khan MK, Sohail A. Clinical Efficacy and Safety of Bempedoic Acid in High Cardiovascular Risk Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Curr Probl Cardiol 2023; 48:102003. [PMID: 37516330 DOI: 10.1016/j.cpcardiol.2023.102003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 07/31/2023]
Abstract
Bempedoic acid (BA) is the new addition to lipid-lowering medications. This systematic review and meta-analysis of randomized controlled trials (RCTs) assess the clinical efficacy and safety of BA in high cardiovascular (CV) risk patients along with its effects on low-density lipoprotein cholesterol (LDL-C) and total cholesterol. PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov were searched for RCTs comparing BA with placebo, reporting CV outcomes. Seven RCTs with a total of 17,816 patients were selected for the analysis. Results showed that BA significantly reduced the risk of MACE (RR 0.87, 95% CI 0.80-0.94; P = 0.007), nonfatal myocardial infarction (RR 0.73; 95% CI 0.62-0.85; P < 0.0001), hospitalization for unstable angina (RR 0.69; 95%CI 0.54-0.88; P = 0.003), coronary and noncoronary revascularization (RR 0.82; 95%CI 0.73-0.92; P = 0.0007) and (RR 0.41; 95%CI 0.18-0.96; P = 0.04), respectively. However, BA increased the risk of gout (RR 1.55; 95% CI 1.26-1.90; P < 0.0001), hyperuricemia (RR 1.94; 95% CI 1.73-2.18; P < 0.00001) and worsening renal function (RR 1.34; 95%CI 1.21-1.48; P < 0.00001). BA also reduced LDL-C (MD -22.38%; 95% CI -25.94 to - 18.82; P < 0.00001) and total cholesterol (MD -13.86%; 95% CI -15.82 to -11.91; P < 0.0000) compared with placebo. Bempedoic acid is an addition to the arsenal of lipid-lowering drugs used in patients that are statin intolerant or need additional lipid-lowering therapy.
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Affiliation(s)
- Naseer Uddin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Abdul Ahad Syed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Muhammad Ismail
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Talal Ashraf
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Affan Sohail
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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De Filippo O, D'Ascenzo F, Iannaccone M, Bertaina M, Leone A, Borzillo I, Ravetti E, Solano A, Pagliassotto I, Nebiolo M, Bruno F, Giacobbe F, Muscoli S, Monticone S, Brizzi MF, Biondi Zoccai G, De Ferrari GM. Safety and efficacy of bempedoic acid: a systematic review and meta-analysis of randomised controlled trials. Cardiovasc Diabetol 2023; 22:324. [PMID: 38017541 PMCID: PMC10685600 DOI: 10.1186/s12933-023-02022-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND AIMS Bempedoic Acid (BA) is a novel Lipid-Lowering Therapy (LLT). We performed a systematic review and meta-analysis to assess the efficacy and safety of BA in patients with hypercholesterolemia. METHODS PubMed, Scopus, and Cochrane library databases were searched for randomised controlled trials evaluating the efficacy and/or safety of BA compared with placebo. Trials investigating dosages other than 180 mg/die were excluded. Major adverse cardiovascular events (MACE) were the primary efficacy endpoint. LDL-cholesterol reduction was the primary laboratory endpoint. Pre-specified safety endpoints included muscle-related adverse events, new-onset diabetes, and gout. The protocol was registered on PROSPERO (temporary ID:399,867). RESULTS Study search identified 275 deduplicated results. 11 studies, encompassing 18,315 patients (9854 on BA vs 8461 on placebo/no treatment) were included. BA was associated with a reduced risk of MACE (OR 0.86, 95% CI 0.79-0.95), myocardial infarction (OR 0.76, 95% CI 0.64-0.88) and unstable angina (OR 0.69, 95% CI 0.54-0.88) compared to control, over a median follow up of 87 (15-162) weeks. BA was associated with a reduction of LDL-Cholesterol (mean difference [MD]-22.42,95% CI - 24.02% to - 20.82%), total cholesterol (- 16.50%,95% - 19.21% to - 13.79%), Apo-B lipoprotein (- 19.55%, - 22.68% to - 16.42%) and high-sensitivity CRP (- 27.83%, - 31.71% to - 23.96%) at 12 weeks. BA was associated with a higher risk of gout (OR 1.55, 95% CI 1.27-1.90) as compared with placebo. Efficacy on laboratory endpoints was confirmed, with a variable extent, across patients on statin or ezetimibe background therapy. CONCLUSIONS The improved cholesterol control achieved with BA translates into a reduced risk of MACE, including myocardial infarction and coronary revascularisation. The drug has a satisfactory safety profile except for an increased risk of gout.
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Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy.
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città Di Torino, Turin, Italy
| | - Maurizio Bertaina
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città Di Torino, Turin, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Irene Borzillo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Emanuele Ravetti
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Andrea Solano
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Ilaria Pagliassotto
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Marco Nebiolo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
| | - Federico Giacobbe
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Saverio Muscoli
- Division of Cardiology, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Silvia Monticone
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Maria Felice Brizzi
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Corso Bramante 88, 10126, Turin, Italy
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Venkatraman S, Das S, Eerike M, Cherian JJ, Bagepally BS. Efficacy and safety of bempedoic acid lipid-lowering therapy: a systematic review and meta-analysis of randomized controlled trials. Eur J Clin Pharmacol 2023; 79:1453-1463. [PMID: 37672112 DOI: 10.1007/s00228-023-03555-8] [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: 07/19/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
AIM This systematic review and meta-analysis was conducted to synthesize the efficacy and safety of bempedoic acid in patients requiring lipid-lowering therapy. METHODS PubMed, Embase, and Scopus databases were searched for randomized controlled trials from inception till June 2023. The primary outcome was major adverse cardiovascular events (MACE), and secondary outcomes were all-cause mortality, serum lipid profile, and adverse events between bempedoic acid and comparators. ROB2 was used for risk of bias assessment. We pooled mean differences or relative risks (RR) along with 95% confidence intervals (random-effects model). RESULTS Five-hundred and thirty-one studies were screened and 17 (n = 21,131) were included for review. There was a significant reduction in the risk of MACE [RR, 0.88 (95% CI: 0.77 to 0.99), p = 0.03)] and all-cause mortality [RR, 0.90 (95% CI: 0.82 to 0.98), p = 0.02] following bempedoic acid treatment. Treatment with bempedoic acid led to a significant reduction in the mean serum total cholesterol [- 34.41 mg/dl (95% CI: - 42.43 to - 26.39), p < 0.001], low-density lipoprotein cholesterol (LDL-C) [- 33.91 mg/dl (95% CI: - 39.66 to - 28.17), p < 0.001], as well as high-density lipoprotein cholesterol (HDL-C) [- 2.40 mg/dl (95% CI: - 3.09 to - 1.71), p < 0.001] levels. However, there was a significant increase in the risk of hyperuricemia [RR, 2.05 (95% CI: 1.81 to 2.33), p < 0.001] following bempedoic acid treatment. The number needed to harm was large for all safety outcomes. The GRADE of evidence was moderate for all outcomes. CONCLUSION Bempedoic acid reduces the risk of MACE and all-cause mortality, lowers serum total cholesterol and LDL-C levels, and has a favorable safety profile. Trial registration ClinicalTrial.gov Identifier: CRD42023412837.
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Affiliation(s)
- Shravan Venkatraman
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Saibal Das
- Indian Council of Medical Research-Centre for Ageing and Mental Health, Kolkata, India
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Madhavi Eerike
- Department of Pharmacology, All India Institute of Medical Sciences, Bibinagar, Telangana, India
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Albosta M, Grant JK, Michos ED. Bempedoic Acid: Lipid Lowering for Cardiovascular Disease Prevention. Heart Int 2023; 17:27-34. [PMID: 38419721 PMCID: PMC10900064 DOI: 10.17925/hi.2023.17.2.1] [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: 06/03/2023] [Accepted: 08/22/2023] [Indexed: 03/02/2024] Open
Abstract
The management of low-density lipoprotein cholesterol (LDL-C) levels is a central strategy for the prevention of atherosclerotic cardiovascular disease. Current United States (2018 American Heart Association/American College of Cardiology/Multisociety) and European (2019 European Society of Cardiology/European Atherosclerosis Society) guidelines endorse statin therapy as the first-line therapy for pharmacologic LDL-C lowering. However, in clinical practice up to 30% of patients report partial or complete intolerance to statin therapy. While the nocebo effect with statins is well described, perceived statin intolerance prevents many patients from achieving LDL-C thresholds associated with clinical benefit. Bempedoic acid is a novel, oral, non-statin lipid-l owering therapy that works by inhibiting adenosine triphosphate-citrate lyase, an enzymatic reaction upstream of 3-hydroxy-3-methylglutaryl coenzyme A reductase in the hepatic cholesterol synthesis pathway. Bempedoic acid confers reduction in LDL-C of ~18% on background statin therapy,~21% in patients with statin intolerance, and ~38% when given in fixed-dose combination with ezetimibe. The CLEAR Outcomes trial, which enrolled high-risk primary and secondary prevention patients with reported statin intolerance and LDL-C levels ≥100 mg/dL, showed that bempedoic acid compared with placebo reduced 4-component major adverse cardiovascular events (MACE) by 13% (hazard ratio 0.87, 95% confidence interval 0.79-0.96). Bempedoic acid also reduced 3-component MACE by 15%, myocardial infarction by 23% and coronary revascularization by 19%. The benefit was even greater in the primary prevention cohort (hazard ratio 0.70, 95% confidence interval 0.55-0.89) for 4-component MACE. Bempedoic acid was associated with increases in uric acid levels and cholelithiasis, but numerically fewer events of myalgia and new-onset diabetes. These findings confirm that bempedoic acid is an effective approach to reduce cardiovascular outcomes in high-risk patients with statin intolerance who require further reduction in LDL-C.
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Affiliation(s)
- Michael Albosta
- Internal Medicine Department, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Jelani K Grant
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Alunno A, Carubbi F, Campanozzi E, Bellisario F, Schoones JW, Mariani FM, Di Ruscio E, Altieri P, Ferri C. Untangling the relationship between bempedoic acid and gout: results from a systematic literature review. Front Cardiovasc Med 2023; 10:1234601. [PMID: 37953764 PMCID: PMC10634504 DOI: 10.3389/fcvm.2023.1234601] [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: 06/04/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Background Bempedoic acid (BA) is a small-molecule first-in-class of inhibitor of ATP citrate lyase that significantly lowers low-density lipoproteins cholesterol (LDL-c) in statin-intolerant and inadequate responders. Increased serum uric acid (SUA) levels and gout incidence have been described in BA-treated patients. The aim of this systematic review was to investigate the safety of BA regarding SUA levels and gout in randomised controlled trials (RCTs). Methods A search on 7 databases was performed from inception to May 4, 2023. RCTs of BA monotherapy or combination with other lipid-lowering treatment (LLT) in patients with increased LDL-c were included. Dual data extraction was performed with disagreements resolved through consensus. Due to the methodological purpose of this review risk-of-bias assessment of studies was not performed. Results 6 Phase 3 RCTs (N = 17,975 patients of which 9,635 received BA) 9 Phase 2 RCTs (N = 362 patients of which 170 received BA) and an open-label extension of a Phase 3 RCT were included. Gout and/or hyperuricemia were not mentioned as exclusion criteria, previous/current use of urate-lowering therapies (ULT) and/or colchicine and/or dietary patterns were not reported. Phase 3 RCTs: 2 studies specified the number of patients experiencing hyperuricemia over the study period (BA: 4.9%-11%; placebo: 1.9%-5.6%) and the effect size was significant only in 1 study (OR = 2.0, 95% CI 1.8-2.3). Four RCTs reported a higher incidence of gout in the BA arm however, when we calculated the effect size, it was small and often not significant. Two studies reported 0 cases of gout. The paucity of information about SUA levels at baseline and/or at the end of follow-up do not allow us to quantify the effect sizes for BA-induced SUA elevation. Data on gout from Phase 2 RCTs is scant. Conclusions Data from phase 2 and 3 RCTs do not allow for confirming a clear association between BA and gout. It is conceivable that a careful assessment of SUA levels/history of gout at baseline and the concomitant use of urate-lowering agents may be instrumental to minimise the risk of new-onset gout/gout flares in patients treated with BA.
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Affiliation(s)
- Alessia Alunno
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Francesco Carubbi
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Elena Campanozzi
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Federico Bellisario
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Jan W. Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, Netherlands
| | - Francesco Maria Mariani
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Evy Di Ruscio
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Piera Altieri
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
| | - Claudio Ferri
- Department of Clinical Medicine, Life, Health & Environmental Sciences, Internal Medicine and Nephrology Division, ASL1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, University of L’Aquila, L'Aquila, Italy
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Singeisen H, Renström F, Laimer M, Lehmann R, Bilz S, Brändle M. An estimation of the consequences of reinforcing the 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines on current lipid-lowering treatment in patients with type 2 diabetes in tertiary care-a SwissDiab study. Eur J Prev Cardiol 2023; 30:1473-1481. [PMID: 37226890 DOI: 10.1093/eurjpc/zwad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/26/2023]
Abstract
AIMS In 2019, the European Society of Cardiology/European Atherosclerosis Society updated the 2016 guidelines for the management of dyslipidaemias recommending more stringent low-density lipoprotein cholesterol (LDL-C) targets in diabetes mellitus type 2 (DM2). Based on a real-world patient population, this study aimed to determine the feasibility and cost of attaining guideline-recommended LDL-C targets, and assess cardiovascular benefit. METHODS AND RESULTS The Swiss Diabetes Registry is a multicentre longitudinal observational study of outpatients in tertiary diabetes care. Patients with DM2 and a visit between 1 January 2018 and 31 August 2019 that failed the 2016 LDL-C target were identified. The theoretical intensification of current lipid-lowering medication needed to reach the 2016 and 2019 LDL-C target was determined and the cost thereof extrapolated. The expected number of major adverse cardiovascular events (MACE) prevented by treatment intensification was estimated. Two hundred and ninety-four patients (74.8%) failed the 2016 LDL-C target. The percentage of patients that theoretically achieved the 2016 and 2019 target with the indicated treatment modifications were high-intensity statin, 21.4% and 13.3%; ezetimibe, 46.6% and 27.9%; proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i), 30.6% and 53.7%; ezetimibe and PCSK9i, 1.0% and 3.1%; whereas one (0.3%) and five patients (1.7%) failed to reach target, respectively. Achieving the 2016 vs. 2019 target would reduce the estimated 4-year MACE from 24.9 to 18.6 vs. 17.4 events, at an additional annual cost of medication of 2140 Swiss francs (CHF) vs. 3681 CHF per patient, respectively. CONCLUSIONS For 68% of the patients, intensifying statin treatment and/or adding ezetimibe would be sufficient to reach the 2016 target, whereas 57% would require cost-intensive PCSK9i therapy to reach the 2019 target, with limited additional medium-term cardiovascular benefit.
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Affiliation(s)
- Hélène Singeisen
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Division of Endocrinology and Diabetes, Department of Internal Medicine, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Frida Renström
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Markus Laimer
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Roger Lehmann
- Division of Endocrinology, Diabetology and Clinical Nutrition, Zürich University Hospital, Zürich, Switzerland
| | - Stefan Bilz
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Michael Brändle
- Division of Endocrinology and Diabetes, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Division of General Internal Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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Jadhav SB, Amore BM, Bockbrader H, Crass RL, Chapel S, Sasiela WJ, Emery MG. Population pharmacokinetic and pharmacokinetic-pharmacodynamic modeling of bempedoic acid and low-density lipoprotein cholesterol in healthy subjects and patients with dyslipidemia. J Pharmacokinet Pharmacodyn 2023; 50:351-364. [PMID: 37243877 PMCID: PMC10460718 DOI: 10.1007/s10928-023-09864-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/01/2023] [Indexed: 05/29/2023]
Abstract
Population pharmacokinetics (popPK) of bempedoic acid and the popPK/pharmacodynamic (popPK/PD) relationship between bempedoic acid concentrations and serum low-density lipoprotein cholesterol (LDL-C) from baseline were characterized. A two-compartment disposition model with a transit absorption compartment and linear elimination best described bempedoic acid oral pharmacokinetics (PK). Multiple covariates, including renal function, sex, and weight, had statistically significant effects on the predicted steady-state area under the curve. Mild (estimated glomerular filtration rate (eGFR) 60 to < 90 mL/min vs. ≥ 90 mL/min) and moderate (eGFR 30 to < 60 mL/min vs. ≥ 90 mL/min) renal impairment, female sex, low (< 70 kg vs. 70-100 kg) and high (> 100 kg vs. 70-100 kg) body weight were predicted to have a 1.36-fold (90% confidence interval (CI) 1.32, 1.41), 1.85-fold (90% CI 1.74, 2.00), 1.39-fold (90% CI 1.34, 1.47), 1.35-fold (90% CI 1.30, 1.41), and 0.75-fold (90% CI 0.72, 0.79) exposure difference relative to their reference populations, respectively. An indirect response model described changes in serum LDL-C with a model-predicted 35% maximal reduction and bempedoic acid IC50 of 3.17 µg/mL. A 28% reduction from LDL-C baseline was predicted for a steady-state average concentration of 12.5 µg/mL after bempedoic acid (180 mg/day) dosing, accounting for approximately 80% of the predicted maximal LDL-C reduction. Concurrent statin therapy, regardless of intensity, reduced the maximal effect of bempedoic acid but resulted in similar steady-state LDL-C levels. While multiple covariates had statistically significant effects on PK and LDL-C lowering, none were predicted to warrant bempedoic acid dose adjustment.
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Affiliation(s)
- Satyawan B Jadhav
- Ann Arbor Pharmacometrics Group, 900 Victors Way #328, Ann Arbor, MI, 48108, USA
| | - Benny M Amore
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arbor, MI, 48108, USA.
| | - Howard Bockbrader
- Ann Arbor Pharmacometrics Group, 900 Victors Way #328, Ann Arbor, MI, 48108, USA
| | - Ryan L Crass
- Ann Arbor Pharmacometrics Group, 900 Victors Way #328, Ann Arbor, MI, 48108, USA
| | - Sunny Chapel
- Ann Arbor Pharmacometrics Group, 900 Victors Way #328, Ann Arbor, MI, 48108, USA
| | - William J Sasiela
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arbor, MI, 48108, USA
| | - Maurice G Emery
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arbor, MI, 48108, USA
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Vallejo-Vaz AJ, Bray S, Villa G, Brandts J, Kiru G, Murphy J, Banach M, De Servi S, Gaita D, Gouni-Berthold I, Kees Hovingh G, Jozwiak JJ, Jukema JW, Gabor Kiss R, Kownator S, Iversen HK, Maher V, Masana L, Parkhomenko A, Peeters A, Clifford P, Raslova K, Siostrzonek P, Romeo S, Tousoulis D, Vlachopoulos C, Vrablik M, Catapano AL, Poulter NR, Ray KK. Implications of ACC/AHA Versus ESC/EAS LDL-C Recommendations for Residual Risk Reduction in ASCVD: A Simulation Study From DA VINCI. Cardiovasc Drugs Ther 2023; 37:941-953. [PMID: 35567726 PMCID: PMC10516778 DOI: 10.1007/s10557-022-07343-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Low-density lipoprotein cholesterol (LDL-C) recommendations differ between the 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for patients with atherosclerotic cardiovascular disease (ASCVD) (< 70 vs. < 55 mg/dl, respectively). In the DA VINCI study, residual cardiovascular risk was predicted in ASCVD patients. The extent to which relative and absolute risk might be lowered by achieving ACC/AHA versus ESC/EAS LDL-C recommended approaches was simulated. METHODS DA VINCI was a cross-sectional observational study of patients prescribed lipid-lowering therapy (LLT) across 18 European countries. Ten-year cardiovascular risk (CVR) was predicted among ASCVD patients receiving stabilized LLT. For patients with LDL-C ≥ 70 mg/dl, the absolute LDL-C reduction required to achieve an LDL-C of < 70 or < 55 mg/dl (LDL-C of 69 or 54 mg/dl, respectively) was calculated. Relative and absolute risk reductions (RRRs and ARRs) were simulated. RESULTS Of the 2039 patients, 61% did not achieve LDL-C < 70 mg/dl. For patients with LDL-C ≥ 70 mg/dl, median (interquartile range) baseline LDL-C and 10-year CVR were 93 (81-115) mg/dl and 32% (25-43%), respectively. Median LDL-C reductions of 24 (12-46) and 39 (27-91) mg/dl were needed to achieve an LDL-C of 69 and 54 mg/dl, respectively. Attaining ACC/AHA or ESC/EAS goals resulted in simulated RRRs of 14% (7-25%) and 22% (15-32%), respectively, and ARRs of 4% (2-7%) and 6% (4-9%), respectively. CONCLUSION In ASCVD patients, achieving ESC/EAS LDL-C goals could result in a 2% additional ARR over 10 years versus the ACC/AHA approach.
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Affiliation(s)
- Antonio J Vallejo-Vaz
- School of Public Health, Imperial College London, London, UK
- Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Sevilla/CSIC, Seville, Spain
| | - Sarah Bray
- Global Biostatistical Science, Amgen Ltd, Cambridge, UK
| | - Guillermo Villa
- Global Health Economics, Amgen Europe (GmbH), Rotkreuz, Switzerland
| | - Julia Brandts
- Imperial Centre for Cardiovascular Disease Prevention Imperial Clinical Trials Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Gaia Kiru
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Jennifer Murphy
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Maciej Banach
- Department of Hypertension, Medical University of Łódź, Łódź, Poland
- Polish Mother's Memorial Hospital-Research Institute (PMMHRI), Łódź, Poland
- Cardiovascular Research Centre, University of Zielona Góra, Zielona Góra, Poland
| | | | - Dan Gaita
- Institutul de Boli Cardiovasculare, Fundatia Cardioprevent, Victor Babeş University of Medicine and Pharmacy, Timisoara, Romania
| | - Ioanna Gouni-Berthold
- Centre for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Jacek J Jozwiak
- Department of Family Medicine and Public Health, Faculty of Medicine, University of Opole, Opole, Poland
| | | | | | | | - Helle K Iversen
- Department of Neurology, Stroke Centre Rigshospitalet, Copenhagen, Rigshospitalet, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vincent Maher
- Trinity College Dublin, Dublin, Ireland
- Advanced Lipid Management and Research Centre, Tallaght University Hospital, Dublin, Ireland
| | - Luis Masana
- Universitat Rovira I Virgili, IISPV, CIBERDEM, Saint Joan University Hospital, Reus, Spain
| | | | - André Peeters
- Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Piers Clifford
- Imperial Hospitals NHS Trust (Hammersmith Campus), London, UK
| | | | | | - Stefano Romeo
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Clinical Nutrition, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
- Cardiology Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dimitrios Tousoulis
- National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Michal Vrablik
- 1st Medical Faculty, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention Imperial Clinical Trials Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK.
- Imperial Clinical Trials Unit, Imperial College London, London, UK.
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Ferri N, Ruscica M, Santos RD, Corsini A. Fixed Combination for the Treatment of Dyslipidaemia. Curr Atheroscler Rep 2023; 25:691-699. [PMID: 37715044 PMCID: PMC10564832 DOI: 10.1007/s11883-023-01142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE OF REVIEW It is clear from epidemiological studies that patients at high and very-high risk of atherosclerotic cardiovascular diseases (ASCVD) risk do not reach lipid guideline-recommended targets. Thus, fixed-dose combinations of statins/ezetimibe, bempedoic acid/ezetimibe and statins/fibrates may represent a further armamentarium in the field of lipid-lowering approaches in these individuals. RECENT FINDINGS The combination therapy of moderate-intensity statin with ezetimibe is not inferior to high-intensity statin monotherapy in reducing cardiovascular outcomes. Drug discontinuation or dose reduction is inferior with fixed-dose combination. The fixed-dose combination of bempedoic acid with ezetimibe is superior to bempedoic acid in monotherapy in lowering LDL-C and in reducing high-sensitivity C-reactive protein concentrations. The combination fenofibrate with atorvastatin is superior to monotherapies in lowering triglycerides. Lipid-lowering fixed-dose combinations may guarantee a higher therapy adherence, representing a better approach to control plasma lipids and thus ameliorate ASCVD burden. Additional studies will define the advantages on cardiovascular outcomes in high and very high-risk patients.
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Affiliation(s)
- Nicola Ferri
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
- Veneto Institute of Molecular Medicine (VIMM), Via Orus 2, 35129, Padua, Italy.
| | - Massimiliano Ruscica
- Department of Pharmacological and Biomolecular Sciences "Rodolfo Paoletti", University of Milan, 20133, Milan, Italy
- Department of Cardio-Thoracic-Vascular Diseases - Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences "Rodolfo Paoletti", University of Milan, 20133, Milan, Italy
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Mutschlechner D, Tscharre M, Huber K, Gremmel T. Cardiovascular events in patients treated with bempedoic acid vs. placebo: systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:583-591. [PMID: 37463824 DOI: 10.1093/ehjcvp/pvad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
AIMS Reduction of low-density lipoprotein cholesterol (LDL-C) decreases cardiovascular mortality and morbidity. Bempedoic acid represents a promising novel lipid-modifying agent for patients who cannot reach guideline recommended LDL-C goals or statin-intolerant patients, but data on safety and cardiovascular outcomes are limited. We therefore aimed to systematically review randomized controlled trials investigating bempedoic acid vs. placebo in patients with hyperlipidaemia. METHODS A systematic search on the databases PubMed, Web of Science, and Embase until 20 March 2023 was performed. All randomized trials comparing bempedoic acid (180 mg daily) with placebo in patients with an indication for lipid-lowering therapy were included. As a primary endpoint, we analysed three-point major adverse cardiovascular events (MACEs) consisting of cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. The analysis was carried out using the odds ratio (OR) as the outcome measure. Due to the expected heterogeneity across studies, a random-effects model was fitted to the data. RESULTS Out of 258 manuscripts, 10 manuscripts fulfilled the inclusion criteria. In total, these trials included 18 200 patients (9765 on bempedoic acid, 8435 on placebo). Bempedoic acid significantly reduced MACEs compared with placebo (OR 0.84 [95% confidence interval (CI) 0.76-0.96]; P < 0.001; I2 = 0%). The endpoint reduction was driven by a lower rate of non-fatal MI, whereas bempedoic acid had no significant effect on stroke (OR 0.86 [95% CI 0.69-1.08]; P = 0.20, I2 = 0%) and all-cause mortality (OR 1.19 [95% CI 0.73-1.93]; P = 0.49; I2 = 18%). CONCLUSION Bempedoic acid reduced non-fatal MI in patients with hyperlipidaemia, whereas it had no significant effect on stroke and all-cause mortality.
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Affiliation(s)
- David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstraße 67, 2130 Mistelbach, Austria
| | - Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Corvinusring 3-5, 2700 Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, Julius Raab-Promenade 49/1, 3100 St. Pölten, Austria
| | - Kurt Huber
- Medical Department, Cardiology and Intensive Care Medicine, Hospital Ottakring, Montleartstraße 37, 1160 Vienna, Austria
- Medical School, Sigmund-Freud University, Freudpl. 1+3, 1020 Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstraße 67, 2130 Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, Julius Raab-Promenade 49/1, 3100 St. Pölten, Austria
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Duarte Lau F, Giugliano RP. Adenosine Triphosphate Citrate Lyase and Fatty Acid Synthesis Inhibition: A Narrative Review. JAMA Cardiol 2023; 8:879-887. [PMID: 37585218 DOI: 10.1001/jamacardio.2023.2402] [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] [Indexed: 08/17/2023]
Abstract
Importance Adenosine triphosphate citrate lyase (ACLY) is a key regulatory enzyme of glucose metabolism, cholesterol and fatty acid synthesis, and the inflammatory cascade. Bempedoic acid, an ACLY inhibitor, significantly reduces atherogenic lipid markers, including low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol, and apolipoprotein B. Additional effects of ACLY inhibition include antitumor growth; reduction of triglycerides and proinflammatory molecules such as high-sensitivity C-reactive protein; less insulin resistance; reduction of hepatic lipogenesis; and weight loss. Observations While numerous ACLY inhibitors have been identified, most of the clinical data have focused on bempedoic acid. The Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen (CLEAR) program was a series of phase 3 clinical trials that evaluated its effects on lipid parameters and safety, leading to US Food and Drug Administration approval in 2020. CLEAR Outcomes was a phase 3, double-blind, randomized, placebo-controlled trial in individuals with a history of statin intolerance, serum LDL-C level of 100 mg/dL or higher, and a history of, or at high risk for, cardiovascular disease. Bempedoic acid modestly reduced the primary 4-way cardiovascular composite end point as well as the individual components of myocardial infarction and coronary revascularization but did not reduce stroke, cardiovascular death, or all-cause mortality. Rates of gout and cholelithiasis were higher with bempedoic acid, and small increases in serum creatinine, uric acid, and hepatic-enzyme levels were also observed. Conclusions and relevance ACLY inhibition with bempedoic acid has been established as a safe and effective therapy in high-risk patients who require further LDL-C lowering, particularly for those with a history of statin intolerance. The recently published CLEAR Outcomes trial revealed modest reductions in cardiovascular events with bempedoic acid, proportional to its LDL-C lowering, in high-risk individuals with statin intolerance and LDL-C levels of 100 mg/dL or higher. The additional effects of ACLY inhibition have prompted a more thorough search for novel ACLY inhibitors for conditions such as cancer, hypertriglyceridemia, chronic inflammation, type 2 diabetes, fatty liver disease, obesity, and metabolic syndrome. Similarly, therapies that reduce fatty acid synthesis are being explored for their use in cardiometabolic conditions.
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Affiliation(s)
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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