Achievement of the low-density lipoprotein cholesterol goal among patients with dyslipidemia in South Korea

A Randomized, Multicenter, Double-blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of a Quadruple Combination of Amlodipine, Losartan, Rosuvastatin, and Ezetimibe in Patients with Concomitant Essential Hypertension and Dyslipidemia

BACKGROUND

Few data are available regarding the efficacy and safety of a single-pill combination (SPC) consisting of four medications in patients with concomitant hypertension and dyslipidemia.

OBJECTIVE

We aimed to determine the efficacy and tolerability of a fixed-dose SPC consisting of 5 mg amlodipine, 100 mg losartan, 20 mg rosuvastatin, and 10 mg ezetimibe (A/L/R/E) in patients with concomitant hypertension and dyslipidemia.

METHODS

This was a 14-week, randomized, multicenter, double-blind, placebo-controlled, phase III clinical trial. In total, 145 patients were randomized to receive A/L/R/E, A/L, or L/R/E. The primary endpoints were the average change in the low-density lipoprotein cholesterol (LDL-C) level in the A/L/R/E and A/L groups and the sitting systolic blood pressure (sitSBP) in the A/L/R/E and L/R/E groups. The numbers of patients with adverse drug reactions (ADRs) were compared as safety variables.

RESULTS

The average percentage change in the LDL-C level as the least squares mean (LSM) from the baseline LDL-C level at the end of the 8-week treatment was - 59.0% in the A/L/R/E group and 0.2% in the A/L group (LSM difference - 59.2, 95% confidence interval [CI] - 68.1 to - 50.4; p < 0.0001). The average change in the sitSBP as the LSM was - 15.8 mmHg in the A/L/R/E group and -4.7 mmHg in the L/R/E group (LSM difference - 11.1, 95% CI - 16.8 to - 5.4; p = 0.0002). No ADRs occurred in the A/L/R/E group.

CONCLUSIONS

A/L/R/E as an SPC could be an effective treatment for patients with hypertension and dyslipidemia without significant safety issues.

CLINICAL TRIALS REGISTRATION

NCT04074551 (registered 30 August 2019).

Undertreatment and Underachievement of LDL-C Target among Individuals with High and Very High Cardiovascular Risk in the Malaysian Community

Dyslipidaemia is a major cause of morbidity and mortality. The aims of this study are to determine the prevalence of dyslipidaemia subtypes, the proportions of lipid-lowering therapy (LLT) use, and the achievement of low-density lipoprotein cholesterol (LDL-C) treatment targets for high-risk (HR) and very high-risk (VHR) Malaysians. This cross-sectional study involves 5279 participants across 11 states in Malaysia. The data were obtained through a standardised questionnaire, anthropometric measurements, venous glucose and lipid profile. The participants with existing cardiovascular disease (CVD) or diabetes with at least one of the other major risk factors (smoking, hypertension or dyslipidaemia) were grouped into the VHR category. Other participants were risk-categorised using the Framingham General CVD Risk Score (FRS-CVD). The prevalence of elevated LDL-C, LLT use and LDL-C target were set according to respective risk categories. Pearson's chi-squared test was used to test the difference in the proportions. The mean ± standard deviation (SD) age was 41.1 ± 14.8 years, and 62.2% (3283/5279) of the group were females. Within the participant group, 51.5% were found to have elevated total cholesterol, 28.8% had low HDL-C, and 33.8% had high triglyceride. As for elevated LDL-C, 9.8% were in VHR, 8.6% in HR, 5.8% in MR and 34.9% in LR categories. Among the VHR group, 75.8% were not on LLT, and only 15.9% achieved the LDL-C target. As for the HR category, 87.7% were not on LLT, and only 16.1% achieved the LDL-C target. Dyslipidaemia is highly prevalent among Malaysians. The majority of VHR and HR participants were not on LLT and did not achieve LDL-C treatment targets. Proactive programs are warranted to combat dyslipidaemia-associated CVD events in these groups.

Suboptimal control of cardiovascular risk factors in myocardial infarction survivors in a cardiac rehabilitation program

INTRODUCTION AND OBJECTIVES

As short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program.

METHODS

Observational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program).

RESULTS

A total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p<0.001].

CONCLUSION

Despite contemporary management strategies, including enrollment in a structured EBCR program, a substantial number of patients presented suboptimal control of CV risk factors. Considering the dyslipidemia, hypertension and diabetes results, less than half of the enrolled individuals achieved the recommended targets. These findings highlight a pivotal unmet need which could be particularly relevant in improving CV outcomes by enhancing secondary prevention profiles.

Non-achievement of the Low-Density Lipoprotein Cholesterol Goal in Older Patients with Type 2 Diabetes Mellitus and a Very High Cardiovascular Disease Risk: A Multicenter Study in Vietnam

BACKGROUND

Lowering the low-density lipoprotein cholesterol (LDL-c) level is important for reducing cardiovascular (CV) events. However, little is known about the management of LDL-c in older patients with type 2 diabetes mellitus (T2DM). This study investigated the prevalence and factors associated with the non-achievement of LDL-c goals in older T2DM patients with a very high risk of CV diseases.

METHODS

This multicenter cross-sectional study measured the LDL-c levels of 733 T2DM outpatients from December 2019 to July 2020. The patients were aged ≥60 years, had very high risks of CV disease, and had been on LDL-c-lowering therapy for 6 months or more. The goal of lipid concentrations were assessed based on the recent guidelines of the European Society of Cardiology. We applied logistic regression analysis to identify the factors associated with the non-achievement of the LDL-c goal.

RESULTS

The mean age of the patients was 68.6±7.2 years. In total, 654 patients (89.2%) did not achieve the aggressive LDL-c goal of <1.4 mmol/L. In the adjusted model, the factors associated with the non-achievement of the LDL-c goal were obesity defined by body mass index (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.13-4.81; p=0.022) and high-intensity statin therapy (OR=0.03; 95% CI, 0.01-0.05; p<0.001), while age, sex, education level, smoking habit, and comorbidities were not associated.

CONCLUSION

Older patients with T2DM who are at a very high CV disease risk are often unable to achieve their LDL-c goal. Obesity can increase the probability of not achieving the LDL-c goal, whereas high-intensity statin therapy can decrease this probability.

Attainment of low-density lipoprotein cholesterol goals in statin treated patients: real-world evidence from Australia

OBJECTIVE

Little is known about the attainment of low-density lipoprotein cholesterol (LDL-C) targets in patients treated with statins in Australian primary healthcare setting that are at increased risk of cardiovascular disease.

METHODS

A retrospective cohort study was conducted using data from electronic medical records of patients treated by general practitioners across Australia. LDL-C target attainment was defined as LDL-C levels ≤ 2 mmol/L for all risk groups, in line with Australian guidelines. Multivariable logistic regression was used to identify the factors associated with LDL-C target attainment.

RESULTS

Overall, 61,407 patients were included in the analysis. The mean age was 65 years (± standard deviation [SD] 12.1); 52.0% were males.. Overall, the median LDL-C level was 2.3 mmol/L (IQR = 1.8 - 2.8) and 36.0% of the study population met therapeutic targets. Increased likelihood to achieve LDL-C targets was observed in patients diagnosed with type 2 diabetes (OR 2.07, 95% CI 1.92 - 2.24), stroke (OR = 1.58, 95% CI 1.39 - 1.79, p< 0.001) or chronic heart disease (OR = 1.67, 95% CI 1.55 - 1.81, p<0.001). Patients diagnosed with dyslipidaemia (OR = 0.59, 95% CI 0.55 - 0.64, p < 0.001), hypertension (OR = 0.91, 95% CI 0.83 - 1.00, p< 0.05) and current smokers (OR = 0.71, 95% CI 0.71 - 1.00, p <0.05), were less likely to attain LDL-C targets, regardless of the type, intensity and length of use of the prescribed statin.

CONCLUSION

Longer duration and higher intensity statin were associated with more patients achieving targeted LDL-C goal, however nearly two thirds of Australians still failed to achieve targeted outcome even after 24 months of statin therapy.

Current Status of Low-Density Lipoprotein Cholesterol Target Achievement in Patients with Type 2 Diabetes Mellitus in Korea Compared with Recent Guidelines

BACKGROUND

We evaluated the achievement of low-density lipoprotein cholesterol (LDL-C) targets in patients with type 2 diabetes mellitus (T2DM) according to up-to-date Korean Diabetes Association (KDA), European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS), and American Diabetes Association (ADA) guidelines.

METHODS

This retrospective cohort study collected electronic medical record data from patients with T2DM (≥20 years) managed by endocrinologists from 15 hospitals in Korea (January to December 2019). Patients were categorized according to guidelines to assess LDL-C target achievement. KDA (2019): Very High-I (atherosclerotic cardiovascular disease [ASCVD]) <70 mg/dL; Very High-II (target organ damage [TOD], or cardiovascular risk factors [CVRFs]) <70 mg/dL; high (others) <100 mg/dL. ESC/EAS (2019): Very High-I (ASCVD): <55 mg/dL; Very High-II (TOD or ≥3-CVRF) <55 mg/dL; high (diabetes ≥10 years without TOD plus any CVRF) <70 mg/dL; moderate (diabetes <10 years without CVRF) <100 mg/dL. ADA (2019): Very High-I (ASCVD); Very High-II (age ≥40+ TOD, or any CVRF), for high intensity statin or statin combined with ezetimibe.

RESULTS

Among 2,000 T2DM patients (mean age 62.6 years; male 55.9%; mean glycosylated hemoglobin 7.2%) ASCVD prevalence was 24.7%. Of 1,455 (72.8%) patients treated with statins, 73.9% received monotherapy. According to KDA guidelines, LDL-C target achievement rates were 55.2% in Very High-I and 34.9% in Very High-II patients. With ESC/EAS guidelines, target attainment rates were 26.6% in Very High-I, 15.7% in Very High-II, and 25.9% in high risk patients. Based on ADA guidelines, most patients (78.9%) were very-high risk; however, only 15.5% received high-intensity statin or combination therapy.

CONCLUSION

According to current dyslipidemia management guidelines, LDL-C goal achievement remains suboptimal in Korean patients with T2DM.

Prevalence, awareness, treatment, and control of dyslipidemia among diabetes mellitus patients and predictors of optimal dyslipidemia control: results from the Korea National Health and Nutrition Examination Survey

BACKGROUND

This study aimed to investigate the prevalence, awareness, treatment, and control rates of dyslipidemia and identify the predictors of optimal control (low-density lipoprotein cholesterol < 100 mg/dL) among patients with diabetes mellitus (DM).

METHODS

A cross-sectional study was conducted using the representative Korea National Health and Nutrition Examination Survey (2014-2018). Overall, 4311 patients with DM, aged ≥19 years, and without cardiovascular diseases were selected, and the prevalence, awareness, treatment, and control rates of dyslipidemia were calculated. Univariate and multivariate logistic regression analyses were conducted to evaluate the factors influencing the optimal control of dyslipidemia.

RESULTS

Dyslipidemia was prevalent in 83.3% of patients with DM, but the awareness and treatment rates were 36.5 and 26.9%, respectively. The control rate among all patients with dyslipidemia was 18.8%, whereas it was 61.1% among those being treated. Prevalence and awareness rates were also significantly higher in women than in men. Dyslipidemia was most prevalent in those aged 19-39 years, but the rates of awareness, treatment, and control among all patients with dyslipidemia in this age group were significantly lower than those in other age groups. The predictors of optimal control were age ≥ 40 years [range 40-49 years: adjusted odds ratio (aOR) 3.73, 95% confidence interval (CI) 1.43-9.72; 50-59 years: aOR 6.25, 95% CI 2.50-15.65; 60-69 years: aOR 6.96, 95% CI 2.77-17.44; 70-79 years: aOR 9.21, 95% CI 3.58-23.74; and ≥ 80 years: aOR 4.43, 95% CI 1.60-12.27]; urban living (aOR 1.44, 95% CI 1.15-1.80); higher body mass index (aOR 1.27, 95% CI 1.13-1.42); lower glycated hemoglobin levels (aOR 0.71, 95% CI 0.67-0.76); hypertension (aOR 1.53, 95% CI 1.22-1.92); poorer self-rated health status (aOR 0.72, 95% CI 0.62-0.84); and receiving regular health check-ups (aOR 1.58, 95% CI 1.25-2.00).

CONCLUSIONS

Most patients with DM were diagnosed with dyslipidemia, but many were unaware of or untreated for their condition. Therefore, their control rate was suboptimal. Thus, by understanding factors influencing optimal control of dyslipidemia, physicians should make more effort to encourage patients to undergo treatment and thus, adequately control their dyslipidemia.

A randomized, open-label, parallel, multi-center Phase IV study to compare the efficacy and safety of atorvastatin 10 and 20 mg in high-risk Asian patients with hypercholesterolemia

Background

Although accumulating evidence suggests a more extensive reduction of low-density lipoprotein cholesterol (LDL-C), it is unclear whether a higher statin dose is more effective and cost-effective in the Asian population. This study compared the efficacy, safety, and cost-effectiveness of atorvastatin 20 and 10 mg in high-risk Asian patients with hypercholesterolemia.

Methods

A 12-week, open-label, parallel, multicenter, Phase IV randomized controlled trial was conducted at ten hospitals in the Republic of Korea between October 2017 and May 2019. High-risk patients with hypercholesterolemia, defined according to 2015 Korean guidelines for dyslipidemia management, were eligible to participate. We randomly assigned 250 patients at risk of atherosclerotic cardiovascular disease to receive 20 mg (n = 124) or 10 mg (n = 126) of atorvastatin. The primary endpoint was the difference in the mean percentage change in LDL-C levels from baseline after 12 weeks. Cost-effectiveness was measured as an exploratory endpoint.

Results

LDL-C levels were reduced more significantly by atorvastatin 20 mg than by 10 mg after 12 weeks (42.4% vs. 33.5%, p < 0.0001). Significantly more patients achieved target LDL-C levels (<100 mg/dL for high-risk patients, <70 mg/dL for very high-risk patients) with atorvastatin 20 mg than with 10 mg (40.3% vs. 25.6%, p < 0.05). Apolipoprotein B decreased significantly with atorvastatin 20mg versus 10 mg (−36.2% vs. −29.9%, p < 0.05). Lipid ratios also showed greater improvement with atorvastatin 20 mg than with 10 mg (total cholesterol/high-density lipoprotein cholesterol ratio, −33.3% vs. −29.4%, p < 0.05; apolipoprotein B/apolipoprotein A1 ratio, −36.7% vs. −31.4%, p < 0.05). Atorvastatin 20 mg was more cost-effective than atorvastatin 10 mg in terms of both the average and incremental cost-effectiveness ratios. Safety and tolerability of atorvastatin 20 mg were comparable to those of atorvastatin 10 mg.

Conclusion

In high-risk Asian patients with hypercholesterolemia, atorvastatin 20 mg was both efficacious in reducing LDL-C and cost-effective compared with atorvastatin 10 mg.

Prevalence and management of hypercholesterolemia in France, the Esteban observational study

Hypercholesterolemia is a major risk factor for cardiovascular diseases. However, its management in everyday clinical practice is often suboptimal. The aims of the Esteban study were to estimate the prevalence of hypercholesterolemia and to describe its management in France in 2015.Esteban is a cross-sectional, publicly funded survey, representative of the French population. Data were collected using questionnaires and biological and clinical examinations in 3021 adults aged 18-74.The lipid-lowering treatments were obtained by matching the individual data of the subjects included in the Esteban survey with data from the Système national de données de santé. Hypercholesterolemia was defined as either a low density lipoprotein cholesterol value higher than the goal set in the European Society of Cardiology/European Atherosclerosis Society guidelines as a function of individual cardiovascular risk level, or at least 1 delivery of lipid-lowering treatment. Adherence was defined by the proportion of days covered by the lipid-lowering treatment in the 6 months preceding clinical examination. Prevalence of hypercholesterolemia in France was 23.3% (27.8% in men, 19.0% in women). Mean low density lipoprotein cholesterol was 3.38 mmol/l in French participants. Among them, 7.2% were treated (8.5% of men, 5.8% of women), while 16.1% of adults went untreated (19.3% of men, 13.2% of women). Only 29.7% of secondary prevention adults had a delivery of lipid-lowering treatments in the 6 months preceding clinical examination. Fewer than 1 in 3 treated adults were adherent, i.e. more than 80% of days covered by a treatment. This proportion reached 37.4% in the high-risk group, with no significant difference of adherence in people with or without a personal history of cardiovascular disease in this group.This study showed that hypercholesterolemia is a common metabolic disease in France, affecting 23.3% of the population. Lipid-lowering prescriptions diverged greatly from current recommendations, with less than a third of eligible patients being treated.

[Management of patients with dyslipidaemia in Spain. The Cardio Right Care Control of cardiovascular risk project]

OBJECTIVE

To ascertain the opinion of physicians about diagnostic criteria, control targets, control rates, and therapeutic approach of patients with dyslipidaemia in Spain.

METHODS

A specific questionnaire was created about diagnostic criteria, control targets, control rates, lipid lowering therapies, and therapeutic inertia in patients with dyslipidaemia. Physicians completed the questionnaire online during a 4-month period.

RESULTS

A total of 959 questionnaires were collected from all over Spain. The most frequent scale to stratify cardiovascular risk is SCORE (54.9%), and guidelines from the European Society of Cardiology are the most common guidelines used (50.5%). The majority of patients are on primary prevention (57.7%), and 31.4% have a high-very high cardiovascular risk. More than 70% of investigators considered that the target among patients at very high risk and those in secondary prevention is an LDL cholesterol < 70 mg/dL. It is considered by 60.0% and 66.4% of investigators that their patients on primary and secondary prevention, respectively, achieve control targets. Statins are the most common lipid lowering drugs used, followed by ezetimibe. In the majority of cases, when a patient is not adequately controlled with statins, there is an increase in the dose or a change to another statin. Poor adherence to treatment and therapeutic inertia are the main reasons for poor LDL cholesterol control.

CONCLUSIONS

The Cardio Right Care CVR Control project allows those aspects to be identified, as well as areas of improvement in patients with dyslipidaemia in Spain.

Statin intolerance: an updated, narrative review mainly focusing on muscle adverse effects

INTRODUCTION

Statins have been established as the standard of care for dyslipidemia and preventing cardiovascular diseases while posing few safety concerns. However, misconceptions about statin intolerance lead to their underuse, indicating a need to improve the understanding of the safety of this treatment.

AREAS COVERED

We searched PubMed and reviewed literatures related to statin intolerance published between February 2015 and February 2020. Important large-scale or landmark studies published before 2015 were also cited as key evidence.

EXPERT OPINION

Optimal lowering of low-density lipoprotein cholesterol with statins substantially reduces the risk of cardiovascular events. Muscle adverse events (AEs) were the most frequently reported AEs by statin users in clinical practice, but they usually occurred at a similar rate with statins and placebo in randomized controlled trials and had a spurious causal relationship with statin treatment. We proposed a rigorous definition for identifying true statin intolerance and present the criteria for defining different forms of muscle AEs and an algorithm for their management. True statin intolerance is uncommon, and every effort should be made to exclude false statin intolerance and ensure optimal use of statins. For the management of statin intolerance, statin-based approaches should be prioritized over non-statin approaches.