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Rabih AM, Niaj A, Raman A, Uprety M, Calero MJ, Villanueva MRB, Joshaghani N, Villa N, Badla O, Goit R, Saddik SE, Dawood SN, Mohammed L. Reduction of Cardiovascular Risk Using Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors in Patients With Acute Coronary Syndrome: A Systematic Review. Cureus 2023; 15:e34648. [PMID: 36895542 PMCID: PMC9990958 DOI: 10.7759/cureus.34648] [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: 07/07/2022] [Accepted: 02/05/2023] [Indexed: 02/09/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a hepatic enzyme that regulates blood cholesterol levels by degrading low-density lipoprotein (LDL) receptors from the surface of hepatocytes. Studies have shown that inhibiting this molecule decreases the cardiovascular risk in individuals with atherosclerotic cardiovascular disease (ASCVD) by lowering low-density lipoprotein cholesterol (LDL-C). Two major cardiovascular outcome trials showed that the use of the PCSK9 inhibitors (alirocumab and evolocumab) in patients with recent acute coronary syndrome (ACS) is associated with a lower risk of further cardiovascular (CV) events. Information regarding the use of these monoclonal antibodies for primary prevention has also been reported by these trials. The goal of this systematic review is to describe the mechanism of PCSK9 inhibitors and further discuss their ability to reduce CV risk in high-risk populations. The search strategy was used in a systematic way using PubMed Central, Google Scholar, and ScienceDirect. We included randomized control trials (RCTs), systematic reviews, and narrative reviews in English published in the last five years. Observational studies, case reports, and case studies were excluded. The quality of the studies was evaluated using the Cochrane Collaboration Risk of Bias Tool, Assessment of Multiple Systematic Reviews 2, and Scale for the Assessment of Narrative Review Articles. A total of 10 articles were included in this systematic review. These included an RCT, a systematic review, and eight narrative reviews. Our study suggested that adding PCSK9 inhibitors to background statin therapy for selected patients with high-risk factors demonstrated substantial benefits in reducing overall CV morbidity and mortality after ACS. Multiple studies have demonstrated the short-term safety of low LDL-C levels caused by these drugs. However, long-term safety must be assessed with further studies.
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Affiliation(s)
- Ahmad M Rabih
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ahmad Niaj
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aishwarya Raman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Manish Uprety
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maria Jose Calero
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Narges Joshaghani
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nicole Villa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Omar Badla
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Raman Goit
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Samia E Saddik
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sarah N Dawood
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Wolff G, Lin Y, Akbulut C, Brockmeyer M, Parco C, Hoss A, Sokolowski A, Westenfeld R, Kelm M, Roden M, Schlesinger S, Kuss O. Meta-analysed numbers needed to treat of novel antidiabetic drugs for cardiovascular outcomes. ESC Heart Fail 2022; 10:552-567. [PMID: 36337026 PMCID: PMC9871670 DOI: 10.1002/ehf2.14213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Absolute treatment effects-i.e. numbers needed to treat (NNTs)-of novel antidiabetic drugs for cardiovascular outcomes have not been comprehensively evaluated. We aimed to perform a meta-analysis of digitalized individual patient outcomes to display and compare absolute treatment effects. METHODS AND RESULTS Individual patient time-to-event information from Kaplan-Meier plots of cardiovascular mortality (CM) and/or hospitalization for heart failure (HHF) endpoints from cardiovascular outcome trials (CVOTs) evaluating dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium glucose transporter 2 (SGLT2) inhibitors vs. placebo were digitalized using WebPlotDigitizer 4.2 and the R code of Guyot et al.; Weibull regression models were generated, validated, and used to estimate NNT for individual trials; random-effects meta-analysis generated Meta-NNT with 95% confidence intervals. Sixteen CVOTs reported time-to-event information (14 in primary diabetes and 2 in primary heart failure populations). Thirteen studies including 96 860 patients were meta-analysed for CM: At the median follow-up of 30 months, Meta-NNTs were 178 (64 to ∞ to -223) for DPP-4 inhibitors, 261 (158 to 745) for GLP-1 receptor agonists, and 118 (68 to 435) for SGLT2 inhibitors. Ten studies including 96 128 patients were meta-analysed for HHF: At the median follow-up of 29 months, estimated Meta-NNTs were -644 (229 to ∞ to -134) for DPP-4 inhibitors, 441 (184 to ∞ to -1100) for GLP-1 receptor agonists, and 126 (91 to 208) for SGLT2 inhibitors. SGLT2 inhibitors were especially effective for HHF in primary heart failure populations [Meta-NNT 25 (19 to 39)] vs. primary diabetes populations [Meta-NNT 233 (167 to 385)] at 16 months of follow-up. CONCLUSIONS We found only modest treatment benefits of GLP-1 receptor agonists and SGLT2 inhibitors for CM and HHF in primary type 2 diabetes mellitus populations. In primary heart failure populations, SGLT2 inhibitor benefits were substantial and comparable in efficacy to established heart failure medication.
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Affiliation(s)
- Georg Wolff
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Yingfeng Lin
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Cihan Akbulut
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany,Centre for Health and Society, Faculty of MedicineHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Maximilian Brockmeyer
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Claudio Parco
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Alexander Hoss
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Alexander Sokolowski
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Ralf Westenfeld
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Malte Kelm
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany,Cardiovascular Research Institute Düsseldorf (CARID)Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Michael Roden
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Cardiovascular Research Institute Düsseldorf (CARID)Heinrich Heine University DüsseldorfDüsseldorfGermany,Department of Endocrinology and Diabetology, Internal Medicine, Medical FacultyHeinrich Heine University DüsseldorfDüsseldorfGermany,Institute for Clinical Diabetology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Sabrina Schlesinger
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Oliver Kuss
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany,Centre for Health and Society, Faculty of MedicineHeinrich Heine University DüsseldorfDüsseldorfGermany
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Fogacci F, Giovannini M, Grandi E, Imbalzano E, Degli Esposti D, Borghi C, Cicero AFG. Management of High-Risk Hypercholesterolemic Patients and PCSK9 Inhibitors Reimbursement Policies: Data from a Cohort of Italian Hypercholesterolemic Outpatients. J Clin Med 2022; 11:jcm11164701. [PMID: 36012937 PMCID: PMC9410302 DOI: 10.3390/jcm11164701] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Federica Fogacci
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marina Giovannini
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Elisa Grandi
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Daniela Degli Esposti
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Claudio Borghi
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Arrigo F. G. Cicero
- Hypertension and Atherosclerosis Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-512-142-224
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