Efficacy of more intensive lipid-lowering therapy on cardiovascular diseases: a systematic review and meta-analysis

Whether and Why Do We Need a Vaccine Against Atherosclerosis? Can We Expect It Anytime Soon?

PURPOSE OF REVIEW

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of premature death. Lipid disorders, particularly elevated serum low-density lipoprotein cholesterol (LDL-C), contribute significantly to ASCVD. The risk of developing ASCVD is influenced by the duration of exposure to elevated LDL-C concentrations (cholesterol-years concept). Implementing lipid-lowering treatments based on the principles of "the earlier the better," "the lower the better," and "the longer the better" has been shown to reduce cardiovascular risk and significantly extend lifespan. Despite the availability of numerous lipid-lowering drugs, achieving satisfactory control of lipid disorders remains very challenging. Therefore, there is a need for novel approaches to improve treatment adherence.

RECENT FINDINGS

One promising solution under investigation is the development of an anti-PCSK9 vaccine, which could be administered annually to provide long-term control over LDL-C concentrations. Experimental studies and the sole clinical trial conducted thus far have demonstrated that the anti-PCSK9 vaccine induces a durable immune response associated with lipid-lowering and anti-atherosclerotic effects. Furthermore, it has exhibited good tolerability and a satisfactory safety profile. However, we still need data from phase 2, 3, and cardiovascular outcome trial to confirm its safety and efficacy and add value in the armamentarium of available and perspective lipid-lowering drugs. This article highlights the significance of developing an anti-PCSK9 vaccine and provides an overview of the current knowledge on various anti-PCSK9 vaccines.

Position paper of the Polish Expert Group on the use of pitavastatin in the treatment of lipid disorders in Poland endorsed by the Polish Lipid Association

Lipid disorders, primarily hypercholesterolemia, are the most common cardiovascular (CV) risk factor in Poland (this applies even 3/4 of people). The low-density lipoprotein cholesterol (LDL-C) serum level is the basic lipid parameter that should be measured to determine CV risk and determines the aim and target of lipid-lowering treatment (LLT). Lipid-lowering treatment improves cardiovascular prognosis and prolongs life in both primary and secondary cardiovascular prevention. Despite the availability of effective lipid-lowering drugs and solid data on their beneficial effects, the level of LDL-C control is highly insufficient. This is related, among other things, to physician inertia and patients' fear of side effects. The development of lipidology has made drugs available with a good safety profile and enabling personalisation of therapy. Pitavastatin, the third most potent lipid-lowering statin, is characterised by a lower risk of muscle complications and new cases of diabetes due to its being metabolised differently. Thus, pitavastatin is a very good therapeutic option in patients at high risk of diabetes or with existing diabetes, and in patients at cardiovascular risk. This expert opinion paper attempts at recommendation on the place and possibility of using pitavastatin in the treatment of lipid disorders.

Time trajectories of key cardiometabolic parameters and of cardiovascular risk in subjects with diabetes in a real world setting

BACKGROUND AND AIMS

Diabetes is associated with increased cardiovascular risk. Glycated haemoglobin (HbA_1c), lipid parameters and blood pressure are known risk factors for adverse outcome. The aim of the study was to explore the time trajectories of these key parameters and of the associated cardiovascular risk.

METHODS

We linked the diabetes electronic health records to the laboratory information system so as to investigate the trajectories of key metabolic parameters from 3 years prior to the diagnosis of diabetes to 10 years after diagnosis. We calculated the cardiovascular risk at the different time points during this period using the United Kingdom Prospective Study (UKPDS) risk engine.

RESULTS

The study included 21,288 patients. The median age at diagnosis was 56 years and 55.3% were male. There was a sharp decrease in HbA_1c after diagnosis of diabetes, but there was a progressive rise thereafter. All lipid parameters after diagnosis also improved in the year of diagnosis, and these improvements persisted even up to 10 years post-diagnosis. There was no discernible trend in mean systolic or diastolic blood pressures following diagnosis of diabetes. There was a slight decrease in the UKPDS-estimated cardiovascular risk after diagnosis of diabetes followed by a progressive increase. Estimated glomerular filtration rate declined at an average rate of 1.33 ml/min/1.73 m²/year.

CONCLUSIONS

Our data suggest that lipid control should be tightened with increasing duration of diabetes since this is more readily achievable than HbA_1c lowering and since other factors such as age and duration of diabetes are unmodifiable.

Improving service efficiency and throughput of cardiac surgery patients using Monte Carlo simulation: a queueing setting

Bed occupancy rate (BOR) is important for healthcare policymakers. Studies showed the necessity of using simulation approach when encountering complex real-world problems to plan the optimal use of resources and improve the quality of services. So, the aim of the present study is to estimate average length of stay (LOS), BOR, bed blocking probability (BBP), and throughput of patients in a cardiac surgery department (CSD) using simulation models. We studied the behavior of a CSD as a complex queueing system at the Farshchian Hospital. In the queueing model, customers were patients and servers were beds in intensive care unit (ICU) and post-operative ward (POW). A computer program based on the Monte Carlo simulation, using Python software, was developed to evaluate the behavior of the system under different number of beds in ICU and POW. The queueing simulation study showed that, for a fixed number of beds in ICU, BOR in POW decreases as the number of beds in POW increases and LOS in ICU increases as the number of beds in POW decreases. Also, based on the available data, the throughput of patients in the CSD during 800 days was 1999 patients. Whereas, the simulation results showed that, 2839 patients can be operated in the same period. The results of the simulation study clearly demonstrated the behavior of the CSD; so, it must be mentioned, hospital administrators should design an efficient plan to increase BOR and throughput of patients in the future.

The relationship between hemoglobin and triglycerides in moyamoya disease: A cross-sectional study

Hemoglobin (Hb) and lipid metabolism are critical in the pathophysiology of moyamoya disease (MMD), and Hb and triglycerides (TGs) both play roles in the development of cerebrovascular illness. However, there is little evidence of a link between Hb and TGs in patients with MMD. This study aimed to determine the association between Hb and TGs in patients who had recently been diagnosed with MMD. From March 2013 to December 2018, 337 patients clinically diagnosed with MMD were admitted to our hospital. Among these, 235 were selected for analysis in this retrospective, cross-sectional study. Each patient's clinical features were documented. For analysis, we used univariate analysis, smoothed-curve fitting, and multivariable, piecewise linear regression. Overall, the mean±standard deviation patient age was 48.14 ± 11.24 years, 44.68% were men, and the mean Hb concentration was 135.72 ± 18.99 g/L. After controlling for relevant confounders, smoothed-curve fitting revealed a nonlinear association between the Hb and TG concentrations (P = 0.0448). When the Hb concentration was below 141 g/L, multivariate piecewise linear regression analysis revealed a significant association between the Hb and TG concentrations [β: 0.01, 95% confidence interval (CI): 0.00, 0.01; P = 0.0182], although the association disappeared above this threshold (β:-0.00, 95% CI:-0.01, 0.01; P = 0.4429). In individuals newly diagnosed with MMD, there is a significant correlation between Hb and TGs, which may be connected to MMD pathogenesis.

Management of High-Risk Hypercholesterolemic Patients and PCSK9 Inhibitors Reimbursement Policies: Data from a Cohort of Italian Hypercholesterolemic Outpatients

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are effective and safe lipid-lowering treatments (LLT). The primary endpoint of the study was to assess the prevalence of patients eligible for treatment with PCSK9 inhibitors in a real-life clinical setting in Italy before and after the recent enlargement of reimbursement criteria. For this study, we consecutively considered the clinical record forms of 6231 outpatients consecutively admitted at the Lipid Clinic of the University Hospital of Bologna (Italy). Patients were stratified according to whether they were allowed or not allowed to access to treatment with PCSK9 inhibitors based on national prescription criteria and reimbursement rules issued by the Italian Medicines Agency (AIFA). According to the indications of the European Medicines Agency (EMA), 986 patients were candidates to treatment with PCSK9 inhibitors. However, following the prescription criteria issued by AIFA, only 180 patients were allowed to access to PCSK9 inhibitors before reimbursement criteria enlargement while 322 (+14.4%) with the current ones. Based on our observations, low-cost tailored therapeutic interventions for individual patients can significantly reduce the number of patients potentially needing treatment with PCSK9 inhibitors among those who are not allowed to access to the treatment. The application of enlarged reimbursement criteria for PCSK9 inhibitors could mildly improve possibility to adequately manage high-risk hypercholesterolemic subjects in the setting of an outpatient lipid clinic.

Pharmaceutical and personal care products as emerging environmental contaminants in Nigeria: A systematic review

The increasingly broad and massive use of pharmaceuticals (human, veterinary) and personal care products in industrially developing nations makes their uncontrolled environmental and ecological impact a true concern. Focusing on Nigeria, this systematic literature search (databases: PubMed, ScienceDirect, Google Scholar, EMBASE, Scopus, Cochrane library and African Journals Online) aims to increase visibility to the issue. Among 275 articles identified, 7 were included in this systematic review. Studies indicated the presence of 11 personal care products (15.94 %) and 58 pharmaceutical products (84.06 %) in surface and ground water, leachates, runoffs, sludge, and sediments. The 42.86% (3/7) of reviewed studies reported 17 analgesics; 71.42 % (5/7) reported 16 antibiotics; 28.57 % (2/7) reported 5 lipid lowering drugs; 28.57% reported anti-malaria and fungal drugs; 14.29 % (1/7) reported estrogen drugs. Different studies report on sunscreen products, hormone, phytosterol, insect repellent, and β1 receptor. Gemfibrozil (<4-730 ng/L), Triclosan (55.1-297.7 ng/L), Triclocarban (35.6-232.4 ng/L), Trimethoprim (<1-388 ng/L) and Tramadol (<2-883 ng/L) had the highest range of concentrations. Findings confirm the need of i) legislation for environmental monitoring, including biota, ii) toxicological profiling of new market products, and iii) sensitization on appropriate use and disposal of pharmaceuticals and personal care products.

2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association

Poor diet quality is strongly associated with elevated risk of cardiovascular disease morbidity and mortality. This scientific statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. Evidence-based dietary pattern guidance to promote cardiometabolic health includes the following: (1) adjust energy intake and expenditure to achieve and maintain a healthy body weight; (2) eat plenty and a variety of fruits and vegetables; (3) choose whole grain foods and products; (4) choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms); (5) use liquid plant oils rather than tropical oils and partially hydrogenated fats; (6) choose minimally processed foods instead of ultra-processed foods; (7) minimize the intake of beverages and foods with added sugars; (8) choose and prepare foods with little or no salt; (9) if you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake; and (10) adhere to this guidance regardless of where food is prepared or consumed. Challenges that impede adherence to heart-healthy dietary patterns include targeted marketing of unhealthy foods, neighborhood segregation, food and nutrition insecurity, and structural racism. Creating an environment that facilitates, rather than impedes, adherence to heart-healthy dietary patterns among all individuals is a public health imperative.

Osteopontin Gene Polymorphisms Are Associated with Cardiovascular Risk Factors in Patients with Premature Coronary Artery Disease

Osteopontin (OPN) is considered a clinical predictor of cardiovascular disease. We aimed to evaluate the association of the OPN gene polymorphisms rs2728127 and rs11730582 with the development of premature coronary artery disease (pCAD), cardiovascular risk factors, and cardiometabolic parameters. We evaluated 1142 patients with pCAD and 1073 controls. Both polymorphisms were determined by Taqman assays. Similar allele and genotype frequencies were observed in both groups; additionally, an association of these polymorphisms with CAD and cardiometabolic parameters was observed in both groups. In patients with pCAD, the rs11730582 was associated with a high risk of hypoadiponectinemia (OR = 1.300, P _additive = 0.003), low risk of hypertension (OR = 0.709, P _{codominant 1} = 0.030), and low risk of having high non-HDL cholesterol (OR = 0.637, P _additive = 0.038). In the control group, the rs2728127 was associated with a low risk of fatty liver (OR = 0.766, P _additive = 0.038); while the rs11730582 was associated with a low risk of hypoadiponectinemia (OR = 0.728, P _dominant = 0.022), and risk of having elevated apolipoprotein B (OR = 1.400, P _dominant = 0.031). Our results suggest that in Mexican individuals, the rs11730582 and rs2728127 OPN gene polymorphisms are associated with some abnormal metabolic variables in patients with pCAD and controls.

Association of baseline as well as change in lipid levels with the risk of cardiovascular diseases and all-cause deaths

High baseline atherogenic lipid level has been an established risk factor for the risk of cardiovascular events. Evidence concerning the role of lipid changes in cardiovascular and death risks are inconclusive. A cohort study was conducted based on the Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (n = 4072, mean 44.8 years, 53.5% women) assessing lipid levels of the participants repeatedly measured in 2002 and 2007. Combined baseline and changes in lipid levels were classified into four groups-stable or decreasing lipid changes and increasing lipid changes with low- and high-risk baseline lipid levels. Developing cardiovascular events (n = 225) and all-cause deaths (n = 345) were ascertained during a median follow-up of 13.3 years. Participants with increasing and higher total cholesterol level were more likely to develop cardiovascular risks. Similar patterns for cardiovascular events were observed across other lipid profile changes. However, participants with increasing total cholesterol, LDL-C, and non-high-density lipoprotein cholesterol (non-HDL-C) levels were more likely to be at a lower risk for all-cause deaths. Baseline and changes in total cholesterol, triglycerides, and LDL-C levels were positively associated with the risk of cardiovascular diseases, whereas baseline and changes in total cholesterol and LDL-C and non-HDL-C levels were inversely associated with all-cause deaths.

Optimization of the Statin Therapy Algorithm in Outpatient Practice: Adherence and Economic Benefits

Aim. To study adherence to recommended treatment, additional clinical and economic benefits of a titration-free statin therapy regimen.

Material and methods. Ambulatory patients (n=300) with a high or very high risk of hypercholesterolemia who have indications for statin treatment for primary or secondary prevention of cardiovascular diseases is included in a non-randomized trial. Patients are divided into 2 groups. Group 1 had a titration regimen of statins in accordance with current recommendations (group 1A [n=50] – primary cardiovascular prevention; group 1B [n=100] – secondary cardiovascular prevention). Group 2 received a titration-free statin regimen in fixed doses (group 2A [n=50] – primary cardiovascular prevention; group 2B [n=100] – secondary cardiovascular prevention). Patients were prescribed atorvastatin (10-80 mg/day) or rosuvastatin (10- 40 mg/day). Group 1 patients had visits to the doctor after 1, 3, 6 and 12 months from the start of statin use, group 2 patients after 3 and 12 months. Treatment adherence, effects on surrogate and hard endpoints, and cost-effectiveness of the two statin regimens were evaluated.

Results. The target level of low-density lipoprotein cholesterol (LDL-C) after 12 months in group 2 was achieved in 56.4% of patients versus 53.4% in group 1. The average level of LDL-C decreased by 1.84±0.44 mmol / l in group 2 versus a decrease of 1.61±0.47 mmol / L in group 1. The costeffectiveness ratio was 9658.72 rubles in group 2 versus 8341.73 rubles in group 1 for a 1 mmol / l LDL-C level decrease in 1 patient within a year. An increase in annual costs per patient in group 2 compared with group 1 by 75.76 rubles reduced the relative risk of developing a combined endpoint by 1% per year.

Conclusion. The use of a titration-free statin treatment regimen allowed us not only to more effectively control of LDL-c levels in patients with high and very high cardiovascular risk compared to the traditional statin therapy regimen, but also to obtain economic advantages in patients with high and very high cardiovascular risk.

Diabetes, Lipids, and CV Risk

PURPOSE OF REVIEW

Diabetes is often associated with diabetic dyslipidemia. Both hyperglycemia and disorders of lipid metabolism strongly contribute to development of atherosclerosis, the crucial factor of cardiovascular disease. The aim of the manuscript is to summarize possible treatment to reduce cardiovascular risk.

RECENT FINDINGS

Maximal cardiovascular risk reduction is maintained by targeting more pathologic disturbances together. While antihypertensive treatment has not changed much recently, novel PCSK9 inhibitors have significantly improved management of dyslipidemia. Similarly, modern antihyperglycemic agents (SGLT2 inhibitors and GLP-1 receptor agonists) show both significant metabolic effects and cardiovascular benefits. Diabetes treatment is no longer glucocentric. Apart from glucose management, there are effective pharmacologic tools for significant reduction of cardiovascular risk.