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Mercep I, Strikic D, Hrabac P, Pecin I, Reiner Ž. PCSK9 inhibition: from effectiveness to cost-effectiveness. Front Cardiovasc Med 2024; 11:1339487. [PMID: 38988669 PMCID: PMC11234837 DOI: 10.3389/fcvm.2024.1339487] [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: 11/16/2023] [Accepted: 06/06/2024] [Indexed: 07/12/2024] Open
Abstract
Dyslipidaemia is a complex disorder characterised by abnormal lipid levels in the blood, including cholesterol and triglycerides, and plays an important role in the development of atherosclerotic cardiovascular disease. Most risk factors for cardiovascular disease are modifiable, and dyslipidaemia is a key factor among them. It can result from a combination of genetic and environmental factors. A distinction is made between primary dyslipidaemia, which is mainly caused by inherited genetic changes, and secondary dyslipidaemia, which is due to underlying diseases or certain medications. The treatment of dyslipidaemia has evolved over the years. In the past, statins were the first choice, but newer drugs, such as proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, have gained prominence due to their effectiveness in lowering lipids. Although recent guidelines recommend PCSK9 inhibitors for high-risk patients and patients who cannot tolerate statins, their widespread use is limited because of cost. Several meta-analyses have confirmed the efficacy and safety of PCSK9 inhibitors and have shown a significant reduction in low-density lipoprotein (LDL) cholesterol levels. However, the long-term side effects and interactions with other risk factors for cardiovascular disease remain uncertain. In addition, cost-effectiveness analyses have shown mixed results, with some countries considering PCSK9 inhibitors to be cost-effective for certain patient groups, while others consider them less economical. Meanwhile, initial data from patients using PCSK9 inhibitors support the results of the clinical trials. To summarise, PCSK9 inhibitors represent a revolutionary solution for lowering LDL cholesterol, but their cost-effectiveness remains controversial. Despite the controversy, they offer clear benefits for high-risk patients and should therefore be considered in the treatment of dyslipidaemia.
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Affiliation(s)
- Iveta Mercep
- Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dominik Strikic
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Pero Hrabac
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Pecin
- Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
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Manolis AA, Manolis TA, Mikhailidis DP, Manolis AS. Are We Using Ezetimibe As Much As We Should? Biomark Insights 2024; 19:11772719241257410. [PMID: 38827240 PMCID: PMC11143858 DOI: 10.1177/11772719241257410] [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: 09/15/2023] [Accepted: 05/09/2024] [Indexed: 06/04/2024] Open
Abstract
Lipid-lowering therapies, particularly non-statin regimens, are underutilized as ~2/3 of patients with atherosclerotic cardiovascular (CV) disease (CVD) are not optimally managed, and do not attain target low-density lipoprotein cholesterol (LDL-C) concentrations, despite statin treatment. Statins have been the mainstay of hypolipidemic therapies; however, they are plagued by adverse effects, which have partly hindered their more widespread use. Ezetimibe is often the first added mode of treatment to attain LDL-C goals as it is efficacious and also allows the use of a smaller dose of statin, while the need for more expensive therapies is obviated. We herein provide a comprehensive review of the effects of ezetimibe in lipid lowering and reducing CV events and improving outcomes. Of the hypolipidemic therapies, oral ezetimibe, in contrast to newer agents, is the most convenient and/or affordable regimen to be utilized as mono- or combined therapy supported by data from CV outcomes studies attesting to its efficacy in reducing CVD risk and events. When combined with a statin, the statin dose could be lower, thus curtailing side-effects, while the hypolipidemic effect is enhanced (by ~20%) as the percentage of patients with target level LDL-C (<70 mg/dL) is higher with combined treatment versus a high-intensity statin. Ezetimibe could also serve as an alternative treatment in cases of statin intolerance. In conclusion, ezetimibe has an excellent safety/tolerability profile; it is the first added treatment to a statin that can attain LDL-C targets. In the combined therapy, the hypolipidemic effect is enhanced while the dose of statin could be lower, thus limiting the occurrence of side-effects. Ezetimibe could also serve as an alternative mode of treatment in cases of statin intolerance.
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Affiliation(s)
| | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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Pamporis K, Karakasis P, Simantiris S, Sagris M, Bougioukas KI, Fragakis N, Tousoulis D. Effectiveness and safety of injectable PCSK9 inhibitors in dyslipidaemias' treatment and cardiovascular disease prevention: An overview of 86 systematic reviews and a network metaanalysis. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:86-100. [PMID: 38040529 DOI: 10.1016/j.arteri.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Multiple systematic reviews (SR) have been performed on the effects of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), often providing conflicting findings. This overview and network meta-analysis (NMA) aimed to summarize SR findings on the efficacy and safety of PCSK9i and provide an updated NMA. MATERIALS AND METHODS MEDLINE (Pubmed), Scopus, Cochrane, Epistemonikos and Google Scholar were searched from inception to September 21, 2023 for SRs of randomized controlled trials (RCTs) and from January 1, 2020 to September 21, 2023 for additional RCTs. Double-independent study selection, data extraction and quality assessment were performed. Qualitative analysis was performed for SRs and a frequentist random-effects model NMA was performed for RCTs. RESULTS Totally, 86 SRs and 76 RCTs were included. Alirocumab (77/86 [90%]) and evolocumab (73/86 [85%]) were mostly analyzed. Associations from SRs (35/42 [83%]) and the updated NMA indicated PCSK9i benefit on major adverse cardiovascular events (MACEs). Reductions were also noted for cerebrovascular events (47/66 [71%]), coronary revascularization (29/33 [88%]) and myocardial infarction (41/63 [65%]). Alirocumab was associated with reductions on all-cause mortality (RR=0.82, 95%CI [0.72,0.94]). Data on any CV event reduction were conflicting (7/16 [44%]). Inclisiran appeared effective only on MACEs (RR=0.76, 95%CI [0.61,0.94]). No reductions in heart failure were observed (0/16). No increases were identified between PCSK9i and any (0/35) or serious adverse events (0/52). However, PCSK9i were associated with injection-site reactions (20/28 [71%]). CONCLUSION PCSK9i appeared to be effective in CV outcomes and their clinical application was generally safe.
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Affiliation(s)
- Konstantinos Pamporis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece; Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
| | - Paschalis Karakasis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; Second Department of Cardiology, Hippokration General Hospital, Aristotle University of Thessaloniki, Greece
| | - Spyridon Simantiris
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Marios Sagris
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Hippokration General Hospital, Aristotle University of Thessaloniki, Greece
| | - Dimitrios Tousoulis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
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Lin Z, Chen Y, Xiao Z, Xu W, Chen G, Huang C, Feng W, Xie Z, Liao W, Liao Y, Bin J, Feng L, Wang S. Incremental Benefit of Lipid Lowering in a Large Chinese Population Aged 75 Years and Older With Established Atherosclerotic Cardiovascular Disease. Mayo Clin Proc 2023; 98:1280-1296. [PMID: 37661139 DOI: 10.1016/j.mayocp.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/27/2023] [Accepted: 06/05/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE To explore the optimal low-density lipoprotein cholesterol (LDL-C) level in patients aged 75 years and older with established atherosclerotic cardiovascular disease (ASCVD). PATIENTS AND METHODS We conducted a retrospective multicenter cohort study of veterans aged 75 years and older with ASCVD who were regularly hospitalized or medically examined in 15 medical institutions in southern China from January 1, 2006, to December 31, 2013. Follow-up continued through October 1, 2021. The time-weighted average (TWA) LDL-C level represented the average LDL-C level during follow-up. Participants were divided into TWA LDL-C groups of 55.0 mg/dL or lower, 55.1 to 70.0 mg/dL, 70.1 to 85.0 mg/dL, 85.1 to 100.0 mg/dL, and greater than 100.0 mg/dL. The subgroup with LDL-C levels lower than 55.0 mg/dL was further subdivided into groups with LDL-C levels from 40.1 to 55.0 mg/dL and 40.0 mg/dL or less. The association of TWA LDL-C levels with outcomes was evaluated with Cox proportional hazards models. RESULTS Overall, 6387 patients aged 75 years or older with ASCVD were included (mean age, 79.4 years). In total, 4267 major adverse cardiovascular events, 1518 stroke events, and 515 myocardial infarction events occurred during a mean follow-up of 12.7 years. Generally, lower TWA LDL-C level was associated with a lower risk of cardiovascular events but was not associated with a higher risk of adverse events in elderly individuals with ASCVD, with the lowest cardiovascular risk observed for LDL-C levels of less than 55.0 mg/dL. After multivariable adjustment, the risk of a major adverse cardiovascular event was 1.30 (95% CI, 1.26 to 1.34; P<.001) for a per SD increment in TWA LDL-C level. Compared with TWA LDL-C levels of 40.1 to 55.0 mg/dL, TWA LDL-C levels of 40.0 mg/dL or less were associated with an increased risk of hemorrhagic stroke (hazard ratio, 3.71; 95% CI, 1.89 to 7.26). CONCLUSION Low-density lipoprotein cholesterol levels from 40.1 to 55.0 mg/dL exhibited the maximum cardiovascular benefit in patients aged 75 years and older who had ASCVD. Lowering LDL-C levels to 40.0 mg/dL or less might increase the risk of hemorrhagic stroke.
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Affiliation(s)
- Zhongqiu Lin
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Geriatrics, General Hospital of Southern Theater Command, PLA, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanmei Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiwen Xiao
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenlong Xu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guojun Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chixiong Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weijing Feng
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiquan Xie
- Department of Geriatrics, General Hospital of Southern Theater Command, PLA, Guangzhou, China
| | - Wangjun Liao
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yulin Liao
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianping Bin
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Li Feng
- Department of Cardiology, Zhongshan People's Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Shifei Wang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Sato T, Saito Y, Kitahara H, Kobayashi Y. Relation of GRACE Risk Score to Coronary Lipid Core Plaques in Patients with Acute Coronary Syndrome. Life (Basel) 2023; 13:life13030630. [PMID: 36983786 PMCID: PMC10054497 DOI: 10.3390/life13030630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
The GRACE risk score is established to predict thrombotic events in patients with acute coronary syndrome (ACS). Although thrombotic events including myocardial infarction after ACS are mainly attributable to vulnerable plaque formation, whether the GRACE score correlates with coronary lipid-rich plaque is unclear. A total of 54 patients with ACS undergoing primary percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were included in a prospective manner. Patients were divided into two groups according to the median of the GRACE risk score. Coronary lipid plaques in the target vessel were assessed by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). The receiver operating characteristics (ROC) curve analysis was performed based on the major adverse cardiovascular events as an exploratory analysis. The GRACE risk score was significantly and positively correlated with LCBI (r = 0.31, p = 0.03) and maxLCBI4mm (r = 0.38, p = 0.006). LCBI (111.7 ± 85.7 vs. 169.0 ± 83.5, p = 0.02) and maxLCBI4mm (428.5 ± 227.1 vs. 600.6 ± 227.7, p = 0.009) in the target vessel were significantly higher in the high GRACE risk score group than their counterpart. In the ROC curve analysis, LCBI and maxLCBI4mm were predictive for clinical events. In conclusion, the higher GRACE risk score may serve as a discriminator of risk comprising more lipid-rich plaques as an underlying mechanism of an increased risk of thrombotic events after ACS. In patients with ACS, the higher GRACE risk score was significantly and modestly associated with greater coronary lipid plaques in the target vessel.
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Siew KSW, Abdul Hafidz MI, Mohd Zaidan FZB, Hadi MFB. Approaches to management of rhabdomyolysis as the adverse effect of drug interaction between atorvastatin and sacubitril/valsartan: a case report. Eur Heart J Case Rep 2022; 6:ytac091. [PMID: 35261962 PMCID: PMC8895310 DOI: 10.1093/ehjcr/ytac091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/06/2021] [Accepted: 02/18/2022] [Indexed: 12/11/2022]
Abstract
Background Atorvastatin and sacubitril/valsartan (Entresto™) have been cornerstones in managing patients with coronary artery disease and heart failure (HF). We report a case of life-threatening rhabdomyolysis associated with the co-administration of atorvastatin and sacubitril/valsartan. Case summary A 58-year-old male with coronary heart disease and chronic HF treated with the optimal dose of atorvastatin and other cardiovascular medications was frequently admitted for acute decompensation of HF. We decided to optimize his condition by adding sacubitril/valsartan to his treatment regime. He presented to our outpatient clinic with worsening myalgia and oliguria 6 days later. He was readmitted with markedly elevated serum creatinine kinase (CK) (94 850 U/L; normal range 32–294 U/L), deranged liver function tests, and acute kidney injury. We withheld atorvastatin and sacubitril/valsartan and treated him with renal replacement therapy. Discussion Sacubitril inhibits the excretion of statins, thereby elevating serum statin concentration and increasing the likelihood of developing muscle-related toxicity. Co-administration of atorvastatin and sacubitril/valsartan should be monitored closely with laboratory investigations of CK and liver and renal function. The physician may consider starting low-dose atorvastatin at 20 mg daily in combination with sacubitril/valsartan 24 mg/26 mg twice daily and titrating accordingly to optimal doses. Rosuvastatin could be an alternative to atorvastatin, as it has less drug–drug interaction with sacubitril, thereby reducing the adverse effect.
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Affiliation(s)
- Kelvin Shenq Woei Siew
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100 Kuala Lumpur, Malaysia
| | - Muhammad Imran Abdul Hafidz
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100 Kuala Lumpur, Malaysia
| | - Fatimah Zahrah Binti Mohd Zaidan
- Department of Primary Care Medicine, University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100 Kuala Lumpur, Malaysia
| | - Mohd Firdaus bin Hadi
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100 Kuala Lumpur, Malaysia
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Pitavastatin: Coronary Atherosclerotic Plaques Changes and Cardiovascular Prevention. High Blood Press Cardiovasc Prev 2022; 29:137-144. [DOI: 10.1007/s40292-021-00496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022] Open
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Scicchitano P, Milo M, Mallamaci R, De Palo M, Caldarola P, Massari F, Gabrielli D, Colivicchi F, Ciccone MM. Inclisiran in lipid management: A Literature overview and future perspectives. Biomed Pharmacother 2021; 143:112227. [PMID: 34563953 DOI: 10.1016/j.biopha.2021.112227] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
Primary and secondary prevention protocols aim at reducing the plasma levels of lipids - with particular reference to low-density lipoprotein cholesterol (LDL-C) plasma concentrations - in order to improve the overall survival and reduce the occurrence of major adverse cardiovascular events. The use of statins has been widely considered as the first-line approach in lipids management as they can dramatically impact on the cardiovascular risk profile of individuals. The introduction of ezetimibe and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors overcame the adverse effects of statins and ameliorate the achievement of the target lipids levels. Indeed, advances in therapies promote the use of specific molecules - i.e. short strands of RNA named small-interfering RNAs (siRNAs) - to suppress the transcription of genes related to lipids metabolism. Recently, the inclisiran has been developed: this is a siRNA able to block the mRNA of the PCSK9 gene. About 50% reduction in low-density lipoprotein cholesterol levels have been observed in randomized controlled trials with inclisiran. The aim of this review was to summarize the literature regarding inclisiran and its possible role in the general management of patients with lipid disorders and/or in primary/secondary prevention protocols.
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Affiliation(s)
| | - Michele Milo
- Cardiology Section, Department of Emergency and Organ Transplantation, University of Bari "A. Moro", Bari, Italy
| | - Rosanna Mallamaci
- Department of Bioscience, Biotechnology and Biopharmaceutics, University Aldo Moro Bari, Bari, Italy
| | - Micaela De Palo
- Cardiac Surgery Section, Department of Emergency and Organ Transplantation, University of Bari "A. Moro", Bari, Italy
| | | | | | - Domenico Gabrielli
- Cardiology Unit, Cardiotoracovascular Department, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | | | - Marco Matteo Ciccone
- Cardiology Section, Department of Emergency and Organ Transplantation, University of Bari "A. Moro", Bari, Italy
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