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Wu XD, Ye XY, Liu XY, Lin Y, Lin X, Li YY, Ye BH, Sun JC. Benefits of intensive lipid-lowering therapies in patients with acute coronary syndrome: a systematic review and meta-analysis. Ann Med 2024; 56:2389470. [PMID: 39126262 PMCID: PMC11318487 DOI: 10.1080/07853890.2024.2389470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 04/23/2024] [Accepted: 07/12/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Previous meta-analyses have investigated the efficacy of lipid-lowering therapies for atherosclerotic cardiovascular disease; however, few have focused on patients with acute coronary syndrome (ACS). This meta-analysis aimed to compare the benefits of intensive lipid-lowering therapy with those of background statin therapy in patients with ACS. METHODS Searches were performed on PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for articles published until April 13, 2023. Randomized controlled trials that compared intensive lipid-lowering therapies and background statin therapies in patients with prior ACS and recorded the outcome of three-point major cardiovascular events (MACE) were included. The risk ratio (RR) with 95% confidence interval (CI) was used as a measure of primary and secondary outcomes. RESULTS Nine trials involving 38,640 patients with ACS were identified. Pooled results suggested that intensive lipid-lowering therapies are associated with a reduction in the risk of three-point MACE (RR, 0.88; 95% CI, 0.83-0.94; p < 0.001), recurrent ACS (RR, 0.82; 95% CI, 0.71-0.96; p = 0.013), nonfatal myocardial infarction (MI) (RR, 0.87; 95% CI, 0.81-0.93; p < 0.001), stroke (RR, 0.83; 95% CI, 0.73-0.94; p = 0.003), and unstable angina-related hospitalization (RR, 0.57; 95% CI, 0.33-0.99; p = 0.046), but not all-cause mortality (RR, 0.94; 95% CI, 0.82-1.07; p = 0.329), cardiovascular disease-related mortality (RR, 0.96; 95% CI, 0.88-1.06; p = 0.457) or coronary revascularization (RR, 0.89; 95% CI, 0.79-1.00; p = 0.057). CONCLUSIONS Intensive lipid-lowering therapies may reduce the risk of three-point MACE, recurrent ACS, nonfatal MI, stroke, and hospitalization for unstable angina in patients with ACS undergoing background statin therapy. These results may assist in clinical decision-making for the secondary prevention of cardiovascular events to initiate intensive lipid-lowering therapies immediately after ACS.
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Affiliation(s)
- Xian-Dan Wu
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Xin-Yue Ye
- Shanghai Jiao Tong University, Shanghai, China
| | - Xuan-Yan Liu
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Yue Lin
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Xian Lin
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Yan-Yan Li
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Bin-Hua Ye
- Department of General Medicine, The First people’s hospital of Wenling, Taizhou, Zhejiang, China
| | - Jing-Chao Sun
- Department of Cardiology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
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Lu F, Li E, Yang X. Proprotein convertase subtilisin/kexin type 9 deficiency in extrahepatic tissues: emerging considerations. Front Pharmacol 2024; 15:1413123. [PMID: 39139638 PMCID: PMC11319175 DOI: 10.3389/fphar.2024.1413123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) is primarily secreted by hepatocytes. PCSK9 is critical in liver low-density lipoprotein receptors (LDLRs) metabolism. In addition to its hepatocellular presence, PCSK9 has also been detected in cardiac, cerebral, islet, renal, adipose, and other tissues. Once perceived primarily as a "harmful factor," PCSK9 has been a focal point for the targeted inhibition of both systemic circulation and localized tissues to treat diseases. However, PCSK9 also contributes to the maintenance of normal physiological functions in numerous extrahepatic tissues, encompassing both LDLR-dependent and -independent pathways. Consequently, PCSK9 deficiency may harm extrahepatic tissues in close association with several pathophysiological processes, such as lipid accumulation, mitochondrial impairment, insulin resistance, and abnormal neural differentiation. This review encapsulates the beneficial effects of PCSK9 on the physiological processes and potential disorders arising from PCSK9 deficiency in extrahepatic tissues. This review also provides a comprehensive analysis of the disparities between experimental and clinical research findings regarding the potential harm associated with PCSK9 deficiency. The aim is to improve the current understanding of the diverse effects of PCSK9 inhibition.
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Affiliation(s)
- Fengyuan Lu
- The Second Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - En Li
- The Second Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Xiaoyu Yang
- The Second Affiliated Hospital, Zhengzhou University, Zhengzhou, China
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
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Hosseini K, Soleimani H, Maleki S, Nasrollahizadeh A, Tayebi S, Nelson J, Heffron SP. Early administration of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in patients with acute coronary syndrome: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:395. [PMID: 39080549 PMCID: PMC11287928 DOI: 10.1186/s12872-024-04057-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/16/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND High-intensity statin therapy is currently recommended initial guideline therapy in ACS treatment. However, only a minority of patients are achieving LDL-C attainment goal at 6 months. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are on recommended guideline therapy post-ACS if LDL-C goal attainment is not achieved after high-intensity statin (4-6 weeks) and after the addition of ezetimibe if guideline goal attainment is not achieved after an additional 4-6 weeks. Thus, it has been recommended that PCSK9 inhibitors be considered earlier post-ACS. However, the efficacy of early PCSK9 inhibitors initiation in ACS patients remains uncertain. METHODS This systematic review and meta-analysis was conducted following PRISMA guidelines. Randomized controlled trials (RCTs) and observational studies involving ACS patients who received PCSK9 inhibitors within 48 h of hospitalization were included. Common and random effects models were used to evaluate the pooled effect of early PCSK9 inhibitor administration. Nine RCTs and three cohort studies were included. RESULTS Early PCSK9 inhibitor administration reduced the incidence of MI, ACS hospitalization, and revascularization at 6-18 months post-ACS. Although there was a drift towards reduced stroke, all-cause mortality, and cardiovascular death, no statistically significant reduction was observed. Additionally, PCSK9 inhibitors significantly enhanced lipid control at 4-12 weeks after index hospitalization. CONCLUSION Early PCSK9 inhibitors initiation in ACS patients reduces MACE and improves lipid profiles. While the results propose promising benefits in terms of stroke and mortality, further research with longer follow-up is required for more decisive evidence.
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Affiliation(s)
- Kaveh Hosseini
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Hamidreza Soleimani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran.
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, 1419733141, Iran.
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, 1411713139, Iran.
| | - Saba Maleki
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- School of Medicine, Guilan University of Medical Sciences (GUMS), Rasht, Guilan Province, Iran
| | - Amir Nasrollahizadeh
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Sima Tayebi
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, SE, Sweden
| | - John Nelson
- California Cardiovascular Institute, Fresno, CA, USA
| | - Sean P Heffron
- Center for the Prevention of Cardiovascular Disease, Leon H. Charney Division of Cardiology, NYU Langone Health, New York University Grossman School of Medicine, New York, NY, USA
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Xu L, Wang Y, Wang Y, Wang L, Du P, Cheng J, Zhang C, Jiao T, Xing L, Tapu MSR, Jia H, Li J. Early Use of PCSK9 Inhibitors in the Prognosis of Patients with Acute Coronary Syndrome by Protecting Vascular Endothelial Function. Pharmacology 2024:1-14. [PMID: 38964284 DOI: 10.1159/000540083] [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: 03/21/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
INTRODUCTION Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) has a protective effect on acute coronary syndrome (ACS). However, most studies have shown that this protective effect is based on a decrease in low-density lipoprotein cholesterol, while other mechanisms remain limited. This study aimed to determine whether PCSK9i can improve the prognosis of ACS patients by protecting endothelial function. METHODS A total of 113 ACS patients were enrolled and randomly assigned to PCSK9i group (PCSK9i combined with statins) and control group (statins only). Blood lipids and endothelial function indicators were measured and analyzed 6 weeks before and after treatment. The effect of PCSK9i on the expression and secretion of endothelial function indicators in vascular endothelial cells were studied by cell experiments. RESULTS After 6 weeks of treatment, endothelial function indicators such as nitric oxide (NO), thrombomodulin, intercellular cell adhesion molecule-1, endothelin-1, and flow-mediated vasodilation were significantly improved in PCSK9i group compared with control group. Only the changes of NO and von Willebrand factor were associated with blood lipid levels, whereas the changes of other endothelial function indicators were not significantly associated with blood lipid levels. PCSK9i reduced the incidence of major adverse cardiovascular events in patients with ACS compared to those in the control group. In cell experiments, PCSK9i treatment significantly ameliorated LPS induced endothelial injury in HUVECs. CONCLUSION PCSK9i can protect vascular endothelial function partly independently of its lipid-lowering effect and ameliorate the prognosis of patients with ACS within 6 weeks. This mechanism may involve heat shock transcription factor 1/heat shock proteins -related signaling pathways. Early use of PCSK9i in patients with ACS should be strongly considered in clinical practice.
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Affiliation(s)
- Linghao Xu
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuanqi Wang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yiqiong Wang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Liang Wang
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peizhao Du
- Department of Cardiology, Baoshan District Hospital of Integrated Traditional Chinese and Western Medicine of Shanghai, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing Cheng
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chunsheng Zhang
- Department of Cardiology, East Hospital of Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Tiantian Jiao
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lijian Xing
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Md Sakibur Rahman Tapu
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Haonan Jia
- Laboratory of Molecular Neural Biology, School of Life Sciences and Institute of Systems Biology, Shanghai University, Shanghai, China
| | - Jiming Li
- Department of Cardiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
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Li W, Sun L, Yan S. PCSK9 inhibitors and inclisiran with or without statin therapy on incident muscle symptoms and creatine kinase: a systematic review and network meta-analysis. Front Cardiovasc Med 2024; 11:1375040. [PMID: 39040999 PMCID: PMC11260805 DOI: 10.3389/fcvm.2024.1375040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD), a leading cause of global fatalities, has inconsistent findings regarding the impact of muscle symptoms despite promising clinical trials involving PCSK9 inhibitors (PCSK9i) and siRNA as potential therapeutic options. Methods The databases EMBASE, PubMed, Web of Science, Cochrane, and ClinicalTrials.gov were thoroughly searched without any restrictions on language. Review Manager 5.3 software was utilized to calculate relative risks with 95% confidence intervals (CIs) for dichotomous data and mean differences or standardized mean differences with 95%CIs for continuous data. To evaluate publication bias, Egger's test was employed using Stata/SE software. Results This analysis included 26 studies comprising 28 randomized controlled trials (RCTs) involving a total of 100,193 patients, and 4 different lipid-lowering therapy combinations. For events with creatine kinase >3ULN, evolocumab and alirocumab demonstrated significant advantages compared to inclisiran. Evolocumab showed the best results in terms of both new muscle symptom events and creatine kinase >3ULN. Conclusions Based on this network meta-analysis (NMA) results, evolocumab has emerged as a promising treatment option for patients with hyperlipidemia and muscle disorders compared to other PCSK9 inhibitors and inclisiran. Systematic Review Registration PROSPERO [CRD42023459558].
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Affiliation(s)
- Wenshu Li
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lichaoyue Sun
- Department of Pharmacy, Aerospace Central Hospital, Beijing, China
| | - Sichao Yan
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Yifan D, Yue M, Yubin Z, Jiapei G, Xun S, Shenghu H, Li Z, Jing Z. The impact of early in-hospital use of PCSK9 inhibitors on cardiovascular outcomes in acute coronary syndrome patients: A systematic review and meta-analysis. Int J Cardiol 2024; 399:131775. [PMID: 38211676 DOI: 10.1016/j.ijcard.2024.131775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To explore the safety and assess the cardiovascular impact of early in-hospital administration of PCSK9 inhibitors in patients with acute coronary syndrome (ACS). METHODS A systematic search of PubMed, Web of Science, and Embase databases was conducted for studies involving the use of PCSK9 inhibitors in ACS patients from inception to October 2023. Two independent researchers screened the literature, extracted data, and assessed the risk of bias in the included studies. Meta-analysis was performed using STATA 16.0 software. RESULTS Nine studies, encompassing a total of 2896 ACS patients, were included in the analysis. When compared to statin monotherapy, early administration of PCSK9 inhibitors during hospitalization for ACS proved effective in reducing the incidence of major adverse cardiovascular events (MACEs). This encompassed a decrease in coronary revascularization [Relative Risk (RR) = 0.78, 95% CI (0.62, 0.98), P < 0.05], recurrent ACS [RR = 0.62, 95% CI (0.42, 0.94), P < 0.05], readmissions due to unstable angina [RR = 0.71, 95% CI (0.59, 0.85), P < 0.01], and strokes [RR = 0.31, 95% CI (0.09, 1.04), P = 0.058]. There was no significant difference in the incidence of death between the two groups.The use of PCSK9 inhibitors notably hastened the reduction of LDL-C, TG, and Non HDL-C levels in the short term. Additionally, it increased HDL-C levels and the number of individuals meeting LDL-C compliance criteria. Importantly, the risk of adverse drug events, such as ALT increase >3xULN, allergies, and musculoskeletal pain, did not significantly elevate with PCSK9 inhibitor use. CONCLUSION The early administration of PCSK9 inhibitors has been found to safely and effectively lower diverse lipid levels in patients with ACS. This reduction is associated with a noteworthy decrease in MACEs, encompassing revascularization, recurrent ACS, and hospital readmissions.
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Affiliation(s)
- Deng Yifan
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Taizhou People's Hospital affiliated to Nanjing Medical University, Tai zhou 225300, China; Medical College of Yangzhou University, Yang zhou 225001, China
| | - Ma Yue
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Medical School of Nanjing University, Nanjing 21000, China
| | - Zhang Yubin
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Dalian Medical University, Dalian 116000, China
| | - Gao Jiapei
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Medical College of Yangzhou University, Yang zhou 225001, China
| | - Sun Xun
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Dalian Medical University, Dalian 116000, China
| | - He Shenghu
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou 225001, China
| | - Zhu Li
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Taizhou People's Hospital affiliated to Nanjing Medical University, Tai zhou 225300, China.
| | - Zhang Jing
- Clinical Medical College, Yangzhou University, Yangzhou 225001, China; Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou 225001, China.
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Shi W, Xu Y, Zhou L, Wang W, Huang W, Zhou B. In-hospital initiation of a PCSK9 inhibitor in patients with acute coronary syndrome: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2024; 103:e37416. [PMID: 38457555 PMCID: PMC10919517 DOI: 10.1097/md.0000000000037416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 12/06/2023] [Accepted: 02/07/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to be effective and safe in patients with stable angina and previous myocardial infarction. However, evidence for initiating their use in patients hospitalized with acute coronary syndrome (ACS) is limited. This systematic review and meta-analysis was performed to provide more clinical evidence. METHODS PubMed, Embase, OVID, Cochrane Library and ClinicalTrials.gov were systematically searched for eligible randomized controlled trials up to March 20, 2023. The risk ratios, standardized mean differences and 95% confidence intervals were calculated for primary and secondary outcomes. The bias risk of the included studies was assessed using the Cochrane RoB 2 criteria. RESULTS About 8 randomized controlled trials involving 1255 inpatients with ACS were included. PCSK9 inhibitor treatment significantly reduced low-density lipoprotein cholesterol (LDL-C) (SMD -1.28, 95% CI -1.76 to -0.8, P = .001), triglycerides (TG) (SMD -0.93, 95% CI -1.82 to -0.05, P = .03), total cholesterol (SMD -1.36, 95% CI -2.01 to -0.71, P = .001), and apolipoprotein B (Apo B) (SMD -0.81, 95% CI -1.09 to -0.52, P = .001) within approximately 1 month. PCSK9 inhibitor treatment significantly reduced the total atheroma volume (TAV) (SMD -0.33, 95% CI -0.59 to -0.07, P = .012). It also significantly increased minimum fibrous cap thickness (FCT) (SMD 0.41, 95% CI 0.22-0.59, P = .001) in long-term follow-up (>6 months). PCSK9 inhibitor treatment significantly reduced the risk of readmission for unstable angina (RR 0.32, 95% CI 0.12-0.91, P = .032) in short-term follow-up (<6 months). There were no significant differences in all-cause mortality, cardiovascular death, myocardial infarction, ischemic stroke, coronary revascularization or heart failure. Only nasopharyngitis (RR 1.71, 95% CI 1.01-2.91, P = .047) adverse events were significantly observed in the PCSK9 inhibitor group. CONCLUSION Application of a PCSK9 inhibitor in hospitalized patients with ACS reduced lipid profiles and plaque burdens and was well tolerated with few adverse events.
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Affiliation(s)
- Wenhai Shi
- Department of Cardiology, The Sixth People’s Hospital of Chengdu, Chengdu 610000, China
| | - Yong Xu
- Department of Cardiology, The Sixth People’s Hospital of Chengdu, Chengdu 610000, China
| | - Lin Zhou
- Department of Cardiology, The Sixth People’s Hospital of Chengdu, Chengdu 610000, China
| | - Wuwan Wang
- Department of Cardiac Ultrasound, Peking Union Medical College Hospital, Beijing 100005, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Bo Zhou
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Schonck WAM, Stroes ESG, Hovingh GK, Reeskamp LF. Long-Term Efficacy and Tolerability of PCSK9 Targeted Therapy: A Review of the Literature. Drugs 2024; 84:165-178. [PMID: 38267805 PMCID: PMC10981656 DOI: 10.1007/s40265-024-01995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
Increased plasma levels of low-density lipoprotein cholesterol (LDL-C) are causally associated with atherosclerotic cardiovascular disease (ASCVD), and statins that lower LDL-C have been the cornerstone of ASCVD prevention for decades. However, guideline-recommended LDL-C targets are not achieved in about 60% of statin users. Proprotein convertase subtilisin/kexin type 9 (PCSK9)-targeted therapy effectively lowers LDL-C levels and has been shown to reduce ASCVD risk. A growing body of scientific and clinical evidence shows that PCSK9-targeted therapy offers an excellent safety and tolerability profile with a low incidence of side effects in the short term. In this review, we present and discuss the current clinical and scientific evidence pertaining to the long-term efficacy and tolerability of PCSK9-targeted therapy.
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Affiliation(s)
- Willemijn A M Schonck
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Global Chief Medical Office, Novo Nordisk, Copenhagen, Denmark
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Atia A, Aboeldahab H, Wageeh A, Elneny M, Elmallahy M, Elawfi B, Aboelkhier MM, Elrosasy A, Abdelwahab MM, Sayed S, Abdelaziz A. Safety and Efficacy of Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors After Acute Coronary Syndrome: A Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2024; 24:83-102. [PMID: 38241002 PMCID: PMC10806009 DOI: 10.1007/s40256-023-00621-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Elevated circulating cholesterol levels in patients with acute coronary syndrome (ACS) increase morbidity and mortality. Recent studies reported that PCSK9 inhibitors (PCSK9i) have a beneficial effect on various domains of patients' lipid profiles and cardiovascular and mortality outcomes. Here, we aim to further investigate the efficacy and safety of PCSK9i in patients with ACS or who experienced recent episodes. METHODS We comprehensively searched PubMed, Scopus, Web of Science and Cochrane CENTRAL to identify all randomized controlled trials comparing PCSK9i versus placebo. Data were extracted and analysed using Stata/MP version 17.0. RESULTS Eleven studies (n = 24,732) were included in this meta-analysis. In terms of efficacy outcomes, compared with the control group, PCSK9i significantly decreased levels of LDL-C, TC, TG, Lp (a) and Apo-B, with the following values, respectively: Cohen's d of - 1.25, 95% confidence interval (CI - 1.64 to - 0.87); Cohen's d of - 1.32, 95% CI (- 1.83 to - 0.81); Cohen's d of - 0.26, 95% CI (- 0.37 to - 0.14); Cohen's d of - 0.70, 95% CI (- 1.15 to - 0.26); and Cohen's d of - 1.46, 95% CI (- 1.97 to - 0.94). The levels of HDL-C and Apo-A1 increased by: Cohen's d 0.27, 95% CI (0.16-0.39) and Cohen's d of 0.30, 95% CI (0.17-0.42), respectively. Regarding safety outcomes, PCSK9i was associated with lower odds of myocardial infarction (MI) and cerebrovascular events with the following values, respectively: OR = 0.87, 95% CI (0.78-0.97) and OR = 0.71, 95% CI (0.52-0.98). CONCLUSIONS PCSK9i was associated with better lipid profile and quality of life of patients and can be recommended as an optimal treatment strategy. Further trials should study combinations of PCSK9i with other lipid-lowering drugs.
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Affiliation(s)
- Ahmed Atia
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba Aboeldahab
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Ahmed Wageeh
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed Elneny
- Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | | | | | - Menna M Aboelkhier
- Master program, Faculty of Science, Suez Canal University, Ismailia, Egypt
| | - Amr Elrosasy
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Somaya Sayed
- Faculty of Medicine, Minia University, Minya, Egypt
| | - Ahmed Abdelaziz
- Medical Research Group of Egypt (MRGE), Cairo, Egypt.
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
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10
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Deng CJ, Yan J, Zheng YY, Wu TT, Pan Y, Hou XG, Wang SF, Sirajidin S, Aimaitijiang M, Xie X. Effectiveness of lipid-lowering therapy on mortality and major adverse cardiovascular event outcomes in patients undergoing percutaneous coronary intervention: a network meta-analysis of randomised controlled trials. BMJ Open 2023; 13:e070827. [PMID: 37967998 PMCID: PMC10660972 DOI: 10.1136/bmjopen-2022-070827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 10/16/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Emergency percutaneous coronary intervention (PCI) can quickly restore myocardial perfusion after acute coronary syndrome. Whether and which lipid-lowering regimens are effective in reducing major adverse cardiovascular events (MACEs) and mortality risk after PCI remain unclear. OBJECTIVE This study assessed the benefits of different lipid-lowering regimens on the risk of MACEs and mortality in the post-PCI population by network meta-analysis. METHODS Public databases, including PubMed, Embase and the Cochrane Library, were searched from inception to August 2022. Randomised controlled trials (RCTs) on lipid-lowering regimens in post-PCI populations were included and analysed. The outcomes were the incidence of all-cause mortality and MACEs, whether reported as dichotomous variables or as HRs. RESULTS Thirty-nine RCTs were included. For MACEs, alirocumab plus rosuvastatin (OR: 0.18; 95% CI: 0.07 to 0.44), evolocumab plus ezetimibe and statins (OR: 0.19; 95% CI: 0.06 to 0.59), eicosapentaenoic acid (EPA) plus pitavastatin (HR: 0.67; 95% CI: 0.49 to 0.96) and icosapent ethyl plus statins (HR: 0.73; 95% CI: 0.62 to 0.86) had significant advantages and relatively high rankings. For mortality, rosuvastatin (OR: 0.30; 95% CI: 0.11 to 0.84), ezetimibe plus statins (OR: 0.55; 95% CI: 0.43 to 0.89) and icosapent ethyl plus statins (OR: 0.66; 95% CI: 0.45 to 0.96) had significant advantages compared with the control. CONCLUSION EPA, especially icosapent ethyl, plus statins had a beneficial effect on reducing the risk of MACEs and mortality in post-PCI patients. Proprotein convertase subtilisin/kexin type-9 inhibitors plus statins were able to reduce the risk of MACEs, but the risk of mortality remained unclear. PROSPERO REGISTRATION NUMBER CRD42018099600.
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Affiliation(s)
- Chang-Jiang Deng
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ju Yan
- cardiovascular medicine department, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Ying-Ying Zheng
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ting-Ting Wu
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ying Pan
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Xian-Geng Hou
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Si-Fan Wang
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Subinur Sirajidin
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Mikereyi Aimaitijiang
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Xiang Xie
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
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Nagendra L, Mahajan K, Gupta G, Dutta D. Impact of early initiation of proprotein convertase subtilisin/kexin type 9 inhibitors in patients with acute coronary syndrome: A systematic review meta-analysis. Indian Heart J 2023; 75:416-422. [PMID: 37777180 PMCID: PMC10774595 DOI: 10.1016/j.ihj.2023.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023] Open
Abstract
OBJECTIVE Scant data is available on the efficacy and safety of proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) for early and rapid reduction of low-density lipoprotein cholesterol (LDL-C) within 4-8 weeks of an acute event in patients with acute coronary syndrome (ACS). We undertook this meta-analysis to address this knowledge-gap. METHODS Electronic databases were searched for RCTs involving patients with ACS receiving PCSK9i in intervention arm, and placebo/active comparator in control arm. Primary outcome was to evaluate changes in 1-month LDL-C post ACS. Secondary outcomes were to evaluate alterations in other lipid parameters and adverse events. RESULTS From initially screened 194 articles, data from 3 studies was analyzed. After 4-weeks therapy, patients receiving PCSK9i had lower LDL-C [MD -0.95 mmol/L (95%CI:-1.51 to -0.40); P = 0.0007; I2 = 96%, total cholesterol (TC) [MD-1.05 mmol/L (95%CI:-1.83 to -0.27); P = 0.009; I2 = 94%] and triglycerides (TG) [MD-0.27 mmol/L (95%CI:-0.44 to -0.10); P = 0.002; I2 = 0%] compared to controls. After 4-8 weeks therapy, patients receiving PCSK9i has lower apolipoprotein B [MD-27.74% (95%CI:-42.59 to -12.89); P = 0.0003; I2 = 89%] as compared to controls. High density lipoprotein cholesterol (HDL-C) [MD 0.05 mmol/L (95%CI:-0.00-0.11); P = 0.05; I2 = 0%], lipoprotein(a) [MD-20.63 mmol/L (95%CI:-41.86- 0.59); P = 0.06; I2 = 54%] and apolipoprotein A1 [MD 0.02 g/L (95%CI:-0.02-0.07); P = 0.32; I2 = 0%] were comparable between groups. Hospital readmission for ACS was significantly lower in group receiving PCSK9i compared to controls [OR0.25 (95%CI:0.07-0.85); P = 0.03; I2 = 0%]. Occurrence of cardiac death [OR3.75 (95%CI:0.41-34.22); P = 0.24; I2 = 0%], serious adverse events [OR0.71 (95% CI:0.13-3.83); P = 0.69; I2 = 70%] and total adverse events [OR1.01 (95%CI: 0.19-5.30); P = 0.99; I2 = 92%] was comparable between groups. CONCLUSION PCSK9i are highly effective in early reduction of LDL-C along with reduction of early hospital readmissions post-ACS.
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Affiliation(s)
- Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India.
| | - Kunal Mahajan
- Department of Cardiology, Himachal Heart Institute, Mandi, Himachal Pradesh, India.
| | - Gunjan Gupta
- Department of Otorhinolaryngology, Mandav Hospital, Mandi, Himachal Pradesh, India.
| | - Deep Dutta
- Department of Endocrinology, Center for Endocrinology Diabetes Arthritis & Rheumatism (CEDAR) Superspeciality Healthcare, Dwarka, New Delhi, India.
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Merćep I, Vujević A, Strikić D, Radman I, Pećin I, Reiner Ž. Present and Future of Dyslipidaemia Treatment-A Review. J Clin Med 2023; 12:5839. [PMID: 37762780 PMCID: PMC10531957 DOI: 10.3390/jcm12185839] [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: 08/05/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
One of the greatest burdens on the healthcare systems of modern civilization is cardiovascular diseases (CVDs). Therefore, the medical community is looking for ways to reduce the incidence of CVDs. Simple lifestyle changes from an unhealthy to a healthy lifestyle are the cornerstone of prevention, but other risk factors for cardiovascular disease are also being currently targeted, most notably dyslipidaemia. It is well known that lowering serum lipid levels, and in particular lowering elevated LDL-cholesterol, leads to a reduction in major cardiovascular events. Although the focus to date has been on LDL-cholesterol levels and lowering them with statin therapy, this is often not enough because of increased concentrations of other lipoprotein particles in the serum and residual cardiovascular risk. Since lowering LDL-cholesterol levels is successful in most cases, there has been a recent focus on lowering residual cardiovascular risk. In recent years, new therapeutic options have emerged that target triglyceride-rich lipoproteins, lipoprotein (a) and apolipoproteins C and B. The effects of these drugs on serious adverse cardiovascular events are not yet known, but recent studies with some of these drugs have shown significant results in lowering total lipid levels. The aim of this review is to present the current therapeutic options for the treatment of dyslipidaemia and to describe the newly approved drugs as well as the drugs that are still in development. Although at this stage we cannot say with certainty whether these agents will be approved and widely used, it is safe to say that our views on the treatment of dyslipidaemia are certainly changing.
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Affiliation(s)
- Iveta Merćep
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (I.M.); (I.P.)
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Andro Vujević
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Dominik Strikić
- Division of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Ivana Radman
- Department of Ophthalmology, Sestre Milosrdnice University Hospital Centre, 10000 Zagreb, Croatia;
| | - Ivan Pećin
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (I.M.); (I.P.)
| | - Željko Reiner
- Division of Metabolic Diseases, Department of Internal Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
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Alzarroug AF, Al Gahtani HK, Algahtani S, Alghamdi HK, Alhinti MF, Almutairi KA, Algahtani S. Safety and Effectiveness of Evolocumab During Acute and Sub-acute Phases of Acute Coronary Syndrome (ACS): A Systematic Review and Meta-analysis. Cureus 2023; 15:e35514. [PMID: 37007377 PMCID: PMC10051038 DOI: 10.7759/cureus.35514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Coronary artery disease (CAD), manifested mainly as acute coronary syndrome (ACS), continues to be a major cause of mortality globally and a significant contributing factor to the global disease burden. Elevation of low-density lipoprotein cholesterol levels attributed to proprotein convertase subtilisin/Kexin type-9 (PCSK9) during and following ACS puts patients at high risk of subsequent adverse events. Evolocumab is a PCSK9 inhibitor that is associated with a significant reduction in low-density lipoprotein cholesterol (LDL-C) levels through PCSK9 inhibition in comparison to traditional statin therapy. METHODS We conducted a systematic review and meta-analysis of literature addressing the efficacy and safety of evolocumab compared to other lipid-lowering therapies or placebo. An extensive internet-based literature search using pre-determined key phrases supported by medical sub-headings and Boolean operators was performed in October 2022 to identify literature pertinent to the research topic. The search was primarily based on the National Library of Medicine (PubMed and Clinical Trials), MEDLINE, Cochrane, and the Science direct literature databases. Subsequently, the researchers devised PICOs-based screening criteria which had to be met by each identified study for inclusion in the review and meta-analysis. Two independent reviewers conducted data stratification and quality assessment of identified studies. Statistical analysis of the primary and secondary outcomes was conducted on the Cochrane REVMAN 5.4 statistical software for randomized trials. RESULTS Two thousand five hundred and seventy-six potential studies were identified for inclusion in the systematic review. Data stratification, screening, and quality assessment of these studies based on the eligibility criteria led to the exclusion of two thousand five hundred and sixty-seven studies as they did not meet the standards set. Nine randomized controlled trials progressed to numerical analysis for validity and reliability. Eight studies were included in the meta-analysis. Meta-analytical results showed a significant decrease in LDL-C changes from initiation of evolocumab therapy to 8 weeks following ACS compared to placebo. Similar results were derived in the sub-acute phase of ACS [SMD -1.95 (95% CI -2.29, -1.62)]. The meta-analysis revealed no statistically significant relationship between the risk of adverse effects, serious adverse effects, and major adverse cardiovascular events (MACE) from treatment using evolocumab in comparison to placebo [(relative risk, RR 1.04 (95% CI 0.99, 1.08) (Z = 1.53; p=0.12)]. CONCLUSION Early evolocumab therapy initiation was associated with a significant decrease in LDL-C levels and was not associated with an increased risk of adverse effects in comparison to placebo.
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Chen H, Chen X. PCSK9 inhibitors for acute coronary syndrome: the era of early implementation. Front Cardiovasc Med 2023; 10:1138787. [PMID: 37200976 PMCID: PMC10185746 DOI: 10.3389/fcvm.2023.1138787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/17/2023] [Indexed: 05/20/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, a new cholesterol-lowering strategy, can decrease low-density lipoprotein cholesterol (LDL-C) levels by inhibiting PCSK9 and reducing the degradation of LDL receptors; thus, they are impacting the management of dyslipidemia to the prevention of cardiovascular events. Recent guidelines recommend PCSK9 inhibitors for patients who fail to achieve target lipids after ezetimibe/statin therapy. As PCSK9 inhibitors have been demonstrated to significantly and safely reduce LDL-C, discussions have begun to explore its optimal timing in coronary artery disease, especially in subjects with acute coronary syndrome (ACS). Also, their additional benefits, such as anti-inflammatory effects, plaque regression effects, and cardiovascular event prevention, have become the focus of recent research. Several studies, including EPIC-STEMI, suggest the lipid-lowering effects of early PCSK9 inhibitors in ACS patients, while some studies such as PACMAN-AMI suggest that early PCSK9 inhibitors can decelerate plaque progression and reduce short-term risks of cardiovascular events. Thus, PCSK9 inhibitors are entering the era of early implementation. In this review, we are committed to summarizing the multidimensional benefits of early implementation of PCSK9 inhibitors in ACS.
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