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Reda A, Almahmeed W, Dobrecky-Mery I, Huang PH, Juarez-Herrera U, Ranjith N, Sayre T, Urina-Triana M. A Narrative Review and Expert Panel Recommendations on Dyslipidaemia Management After Acute Coronary Syndrome in Countries Outside Western Europe and North America. Adv Ther 2020; 37:1754-1777. [PMID: 32227306 PMCID: PMC7467479 DOI: 10.1007/s12325-020-01302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 11/28/2022]
Abstract
Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent atherosclerotic cardiovascular disease (CVD) events. Dyslipidaemia, a major risk factor for CVD, is poorly controlled post ACS in countries outside Western Europe and North America, despite the availability of effective lipid-modifying therapies (LMTs) and guidelines governing their use. Recent guideline updates recommend that low-density lipoprotein cholesterol (LDL-C), the primary target for dyslipidaemia therapy, be reduced by ≥ 50% and to < 1.4 mmol/L (55 mg/dL) in patients at very high risk of CVD, including those with ACS. The high prevalence of CVD risk factors in some regions outside Western Europe and North America confers a higher risk of CVD on patients in these countries. ACS onset is often earlier in these patients, and they may be more challenging to treat. Other barriers to effective dyslipidaemia control include low awareness of the value of intensive lipid lowering in patients with ACS, physician non-adherence to guideline recommendations, and lack of efficacy of currently used LMTs. Lack of appropriate pathways to guide follow-up of patients with ACS post discharge and poor access to intensive medications are important factors limiting dyslipidaemia therapy in many countries. Opportunities exist to improve attainment of LDL-C targets by the use of country-specific treatment algorithms to promote adherence to guideline recommendations, medical education and greater prioritisation by healthcare systems of dyslipidaemia management in very high risk patients. Video Abstract
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Affiliation(s)
- Ashraf Reda
- Department of Cardiology, Menoufia University, 127 Mohamed Fareed Street, Babellouk, Cairo, Egypt.
| | - Wael Almahmeed
- Department of Cardiovascular Medicine, Cleveland Clinic, Abu Dhabi, UAE
| | | | - Po-Hsun Huang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | - Miguel Urina-Triana
- Cardiology Division, Faculty of Health Sciences, Simón Bolívar University, Barranquilla, Colombia
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The Clinical Outcomes Based on the Achievement of Low-Density Lipoprotein Cholesterol Targets after ST Elevation Myocardial Infarction. J Clin Med 2019; 9:jcm9010079. [PMID: 31905621 PMCID: PMC7020017 DOI: 10.3390/jcm9010079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/23/2019] [Accepted: 12/25/2019] [Indexed: 12/14/2022] Open
Abstract
The clinical outcome of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), with or without achievement of low-density lipoprotein cholesterol (LDL-C) targets, has rarely been investigated. This study was performed to investigate the comparison of clinical outcome in STEMI patients with or without achievement LDL-C targets (below 70 mg/dL and/or ≥50% reduction). Between November 2013 and December 2016, 689 STEMI patients underwent primary PCI in our hospital. Patients who were deceased, lost to follow-up, had no follow-up lipid profile, or had no side effects after statin use were excluded. A total of 343 patients were classified into group 1 (with LDL-C target achievement) and 172 patients were classified into group 2 (without LDL-C target achievement). Between the two groups, a higher prevalence of left main coronary artery disease, smaller pre-PCI stenosis, and a larger pre-PCI minimal luminal diameter were noted in group 2. The incidence of post-MI angina (8.7% vs. 6.4%; p = 0.393), target vessel revascularization (2.3% vs. 3.5%; p = 0.566), and recurrent MI (1.5% vs. 1.2%; p = 1.000), showed similar results between the two groups during a one-year follow-up period. Initial LDL-C levels ≥130 mg/dL, left main coronary artery disease, and absence of diabetes mellitus were positively associated with non-achievement of LDL-C targets. After STEMI, 66.6% of patients could achieve LDL-C targets one year later. However, such patients did not show better clinical outcomes. Non-DM, initial LDL-C levels ≥130 mg/dL, and left main coronary artery disease were related to non-achievement of LDL-C targets.
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Wang Y, Yan BP, Tomlinson B, Lee VW. Is lipid goal one-size-fits-all: A review of evidence for recommended low-density lipoprotein treatment targets in Asian patients. Eur J Prev Cardiol 2019; 26:1496-1506. [PMID: 31023098 DOI: 10.1177/2047487319843077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The international guideline recommendations for low-density lipoprotein cholesterol (LDL-C) lowering were made based on the results of randomized controlled trials (RCTs), meta-analyses, and observational studies mostly in the White population. It was not clear whether these LDL-C targets could be applicable to other ethnic groups, for example, Asian patients. This review aimed to address major aspects related to the lipid goal and statin therapy in Asia, including the epidemiology of cardiovascular disease, the LDL-C profiles, the lipid goals from localized guidelines, genetics and lifestyles, and the efficacy and safety of statins. Owing to the geographic, ethnic, genetic, and cultural diversity in this region, we observed a geographic pattern of diversity in cardiovascular epidemiology and statin response in Central Asia, East Asia (particularly for Asia-Pacific region), and South Asia. The rapidly growing literature from Asian countries questioning "lower is better" hypothesis was noticed. However, owing to the nature of these dominantly observational data, the conclusion was hardly confirmative. Despite the rapid expansion of the current literature in this region, efforts should be made to ensure an adequate sample size to assess the significance of a given lipid parameter on overall cardiovascular outcomes in this Asian population.
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Affiliation(s)
- Yun Wang
- 1 Department of Medicine, Monash University, Melbourne, Australia
| | - Bryan P Yan
- 2 Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Brian Tomlinson
- 3 Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Vivian Wy Lee
- 4 School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Low-density lipoprotein cholesterol target achievement in patients surviving an acute coronary syndrome in Hong Kong and Taiwan - findings from the Dyslipidemia International Study II. Int J Cardiol 2019; 265:1-5. [PMID: 29885676 DOI: 10.1016/j.ijcard.2018.01.099] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Individuals are at increased risk for cardiovascular events following an acute coronary syndrome (ACS). Effective management of hyperlipidemia, an associated risk factor, is essential for improving outcomes. We aimed to quantify the extent of hyperlipidemia and its treatment in ACS survivors in Hong Kong and Taiwan. METHODS The multinational, observational Dyslipidemia International Study (DYSIS) II included patients hospitalized for an ACS. Lipid levels and use of lipid-lowering therapy (LLT) were evaluated at baseline and 4 months post-discharge. The proportions of patients attaining the recommended LDL-C target for individuals at very high cardiovascular risk (<70 mg/dL) was assessed and potential predictors of this outcome evaluated. RESULTS In total, 270 patients were enrolled, 125 (46.3%) of which were being treated with LLT prior to hospitalization. Of these, 28.8% had an LDL-C level < 70 mg/dL, compared to only 6.9% of those not being treated. Statin monotherapy was the most commonly employed LLT, with a mean atorvastatin-equivalent dosage of 14 mg/day. By 4-month follow-up, target attainment had risen to 45.1% for patients treated with LLT at baseline, and 43.3% for those who had not been treated. LLT was being used by 88.4% of patients at follow-up, with a mean atorvastatin dosage of 18 mg/day. Use of statins in combination with ezetimibe/other non-statin was scarce. No predictors of LDL-C target attainment were identified. CONCLUSIONS In patients hospitalized with an ACS, rates of LDL-C target achievement were poor. While LLT was widely employed, statin intensity was low and combination therapy underused, indicating scope for improvement.
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Blais JE, Chan EW, Law SW, Mok MT, Huang D, Wong IC, Siu CW. Trends in statin prescription prevalence, initiation, and dosing: Hong Kong, 2004–2015. Atherosclerosis 2019; 280:174-182. [DOI: 10.1016/j.atherosclerosis.2018.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/29/2018] [Accepted: 11/08/2018] [Indexed: 02/08/2023]
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Wang Y, Yan BPY, Tomlinson B, Nichol MB, Lee VWY. Clinical and Economic Analysis of Lipid Goal Attainments in Chinese Patients with Acute Coronary Syndrome Who Received Post-Percutaneous Coronary Intervention. J Atheroscler Thromb 2018; 25:1255-1273. [PMID: 29962381 PMCID: PMC6249357 DOI: 10.5551/jat.44818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/07/2018] [Indexed: 01/04/2023] Open
Abstract
AIM The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups. METHODS A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression. RESULTS Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of <2.6, <2.0, and <1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of <2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain. CONCLUSIONS Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.
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Affiliation(s)
- Yun Wang
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bryan Ping Yen Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Brian Tomlinson
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Michael Bruce Nichol
- Sol Price School of Public Policy, Leonard D. Schaeffer Center for Health Policy and Economics, Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Vivian Wing Yan Lee
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Leong IL, Tomlinson B, Zhang Y, Chan P, Liu ZM. Attaining cholesterol goals: will aiming for lower targets improve the score? Curr Med Res Opin 2018; 34:297-299. [PMID: 29183171 DOI: 10.1080/03007995.2017.1411341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Iat-Lon Leong
- a Division of Cardiology, Department of Internal Medicine , Kiang Wu Hospital , Macau , PR China
| | - Brian Tomlinson
- b Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine , Shanghai , PR China
- c Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Shatin , Hong Kong, PR China
| | - Yuzhen Zhang
- b Research Center for Translational Medicine, Shanghai East Hospital Affiliated to Tongji University School of Medicine , Shanghai , PR China
| | - Paul Chan
- d Division of Cardiology, Department of Internal Medicine , Wan Fang Hospital, Taipei Medical University , Taipei City , Taiwan
| | - Zhong-Min Liu
- e Department of Cardiac Surgery , Shanghai East Hospital, Tongji University , Shanghai , PR China
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Gao XQ, Li Y, Jiang ZL. Comparison of Secondary Prevention Status between Percutaneous Coronary Intervention and Coronary Artery Bypass Patients. Arq Bras Cardiol 2017; 109:466-474. [PMID: 29267627 PMCID: PMC5729783 DOI: 10.5935/abc.20170153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/13/2017] [Indexed: 11/25/2022] Open
Abstract
Background Data are scarce regarding disparities in cardiovascular risk factor
management between patients treated with percutaneous coronary intervention
(PCI) and those treated with coronary artery bypass grafting (CABG). Objective Whether the goal achievement rates of cardiovascular risk factors were
different between PCI and CABG patients. Methods We retrospectively reviewed the data retrieved from a clinical record
database of patients admitted to Beijing Anzhen Hospital between January 1,
2014, and December 31, 2014, who underwent PCI or CABG. Results Compared with the CABG group, low-density lipoprotein cholesterol (LDL-C)
< 1.8 mmol/L (28.6% vs. 24.7%; p < 0.01), LDL-C < 2.07 mmol/L
(43.5% vs. 39.4%; p < 0.01) and blood pressure (BP) < 140/90 mm Hg
(85.6% vs. 77.7%; p < 0.01) goal achievement rates were significantly
higher in the PCI group. Compared with patients ≥ 60 years old:
patients < 60 years old had better BP < 140/90 mm Hg goal achievement
rates (87.7% vs. 84.4%; p < 0.01) in the PCI group, and better fasting
blood-glucose (FBG) < 7 mmol/L (79.4% vs.72.0%; p < 0.01) and HbA1c
< 7% (79.4% vs. 70.1%; p < 0.01) goal achievement rates in the CABG
group. Compared with females: males had better LDL-C < 2.07 mmol/L (24.7%
vs. 28.5%; p < 0.01), FBG < 7 mmol/L (71.8% vs.75.2%; p < 0.01) and
HbA1c < 7% (70.4% vs. 74.1%; p < 0.01) goal achievement rates in the
PCI group. Conclusion Patients in the PCI group were generally more likely than those in the CABG
group to achieve LDL-C < 1.8 mmol/L and BP goals. The control of
cardiovascular risk factors differed between patients ≥ 60 years old
and < 60 years old. Female patients were less likely to achieve LDL-C,
FBG and HbA1c goals.
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Affiliation(s)
- Xia-Qing Gao
- Beijing Anzhen Hospital - Capital Medical University, Beijing - China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing - China
| | - Yanfang Li
- Beijing Anzhen Hospital - Capital Medical University, Beijing - China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing - China
| | - Zhi-Li Jiang
- Beijing Anzhen Hospital - Capital Medical University, Beijing - China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing - China
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Wang Y, Yan BP, Nichol MB, Tomlinson B, Lee VW. Real-world study of low-density lipoprotein cholesterol levels and cardiovascular outcomes in Chinese: A retrospective cohort study in post-percutaneous coronary intervention acute coronary syndrome patients. Int J Cardiol 2017; 249:18-24. [DOI: 10.1016/j.ijcard.2017.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/12/2017] [Accepted: 07/07/2017] [Indexed: 10/18/2022]
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Zhang W, Ji F, Yu X, Wang X. Factors associated with unattained LDL-cholesterol goals in Chinese patients with acute coronary syndrome one year after percutaneous coronary intervention. Medicine (Baltimore) 2017; 96:e5469. [PMID: 28072688 PMCID: PMC5228648 DOI: 10.1097/md.0000000000005469] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Reducing low-density lipoprotein cholesterol (LDL-C) to target ≤1.81 mmol/L is a common therapeutic goal after acute coronary syndrome (ACS). This study aimed to examine the factors associated with reaching or not this LDL-C target after 1 year of optimal statin therapy postpercutaneous coronary intervention (PCI). This was a retrospective study of 633 consecutive prospectively enrolled patients with ACS treated between January 2011 and December 2012 at the Beijing Hospital (China). All patients were treated with PCI and statins for 1 year. A multivariate analysis was carried out to identify the factors associated with reaching the LDL-C target of ≤1.81 mmol/L. The rate of unreached LDL-C goal after 1 year was 48%. Compared with those who achieved their LDL-C goal, patients not achieving their LDL-C goal showed a higher proportion of females (37.9% vs 28.7%, P < 0.001), higher LDL-C levels at admission (2.82 ± 0.75 vs 2.08 ± 0.70 mmol/L, P < 0.001), lower proportion of patients with a history of PCI (17.6% vs 24.8%, P = 0.03), and younger age (66.7 ± 10.6 vs 68.9 ± 10.1 years, P = 0.009). A multivariate analysis showed that lower LDL-C levels on admission were predictive of LDL-C goal achievement (odds ratio [OR] = 4.81; 95% confidence interval [CI]: 3.46-6.70; P < 0.001), together with older age (OR: 0.98; 95% CI: 0.96-0.997; P = 0.026), and male gender (OR: 0.64; 95% CI: 0.42-0.98; P = 0.040). Higher LDL-C levels at admission, younger age, and female gender were independently associated with not reaching the LDL-C target after 1 year of optimal statin therapy after PCI.
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