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Szlendak M, Kapała A. Does the ratio of eicosapentaenoic acid to docosahexaenoic acid matter in cancer treatment? A systematic review of their effects on cachexia-related inflammation. Nutrition 2024; 124:112466. [PMID: 38759339 DOI: 10.1016/j.nut.2024.112466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/19/2024]
Abstract
Chronic inflammation is a hallmark of cancer cachexia. Polyunsaturated fatty acids (ω-3 PUFAs): eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are known to contribute to the reduction of inflammation, preservation of lean body mass and total body weight, and reduction of cancer-related symptoms, such as anorexia or neuropathy. This systematic review aimed to assess whether the ratio of EPA to DHA used in supplementation in cancer patients matters in the context of the resolution of inflammation and reduction of the risk of cachexia. The analysis included 20 randomized clinical trials with acceptable quality identified from the Pubmed/MEDLINE database. The significant results concerning the resolution of inflammation or improvement in nutritional status were the highest in the case of a low EPA/DHA ratio, i.e., 67%, and decreased, reaching 50% and 36% for the moderate and high ratios, respectively. Most results concerning body weight from high and moderate EPA/DHA ratios showed no benefit or were insignificant. A significant benefit in reducing any reported inflammatory markers was seen in the low EPA/DHA ratio subgroup at 63%, in the moderate at 29%, and in the high ratio subgroup at 11%. The greatest benefit in CRP reduction was obtained by patients during chemotherapy. The review questions the anticachectic and anti-inflammatory effect of ω-3 PUFAs supplementation with doses of EPA higher than DHA. A population that particularly benefits from ω-3 PUFAs supplementation are patients undergoing chemotherapy for advanced cancer.
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Affiliation(s)
| | - Aleksandra Kapała
- Department of Clinical Nutrition, Department of Oncology Diagnostics, Cardio-Oncology and Palliative Medicine, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Kaur G, Mason RP, Steg PG, Bhatt DL. Omega-3 fatty acids for cardiovascular event lowering. Eur J Prev Cardiol 2024; 31:1005-1014. [PMID: 38169319 DOI: 10.1093/eurjpc/zwae003] [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: 12/31/2023] [Indexed: 01/05/2024]
Abstract
Low-density lipoprotein cholesterol (LDL-C) is the main target for therapeutics aimed at reducing the risk of atherosclerotic cardiovascular disease (ASCVD) and downstream cardiovascular (CV) events. However, multiple studies have demonstrated that high-risk patient populations harbour residual risk despite effective LDL-C lowering. While data support the causal relationship between triglycerides and ASCVD risk, triglyceride-lowering therapies such as omega-3 fatty acids have shown mixed results in CV outcomes trials. Notably, icosapent ethyl, a purified formulation of eicosapentaenoic acid (EPA), has garnered compelling evidence in lowering residual CV risk in patients with hypertriglyceridaemia and treated with statins. In this review, we summarize studies that have investigated omega-3-fatty acids for CV event lowering and discuss the clinical implementation of these agents based on trial data and guidelines.
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Affiliation(s)
- Gurleen Kaur
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Preston Mason
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Elucida Research LLC, Beverly, MA, USA
| | - Ph Gabriel Steg
- Paris Cité University, Public Hospitals of Paris (AP-HP), Bichat Hospital, Paris, France
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Reijnders E, van der Laarse A, Jukema JW, Cobbaert CM. High residual cardiovascular risk after lipid-lowering: prime time for Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive medicine. Front Cardiovasc Med 2023; 10:1264319. [PMID: 37908502 PMCID: PMC10613690 DOI: 10.3389/fcvm.2023.1264319] [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: 07/20/2023] [Accepted: 10/03/2023] [Indexed: 11/02/2023] Open
Abstract
As time has come to translate trial results into individualized medical diagnosis and therapy, we analyzed how to minimize residual risk of cardiovascular disease (CVD) by reviewing papers on "residual cardiovascular disease risk". During this review process we found 989 papers that started off with residual CVD risk after initiating statin therapy, continued with papers on residual CVD risk after initiating therapy to increase high-density lipoprotein-cholesterol (HDL-C), followed by papers on residual CVD risk after initiating therapy to decrease triglyceride (TG) levels. Later on, papers dealing with elevated levels of lipoprotein remnants and lipoprotein(a) [Lp(a)] reported new risk factors of residual CVD risk. And as new risk factors are being discovered and new therapies are being tested, residual CVD risk will be reduced further. As we move from CVD risk reduction to improvement of patient management, a paradigm shift from a reductionistic approach towards a holistic approach is required. To that purpose, a personalized treatment dependent on the individual's CVD risk factors including lipid profile abnormalities should be configured, along the line of P5 medicine for each individual patient, i.e., with Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive approaches.
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Affiliation(s)
- E. Reijnders
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - A. van der Laarse
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - J. W. Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | - C. M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, Netherlands
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Verma S, Kosmopoulos A, Bhatt DL, Fitchett D, Ofstad AP, Wanner C, Mattheus M, Zinman B, Lawler PR, Leiter LA. Generalizability of REDUCE-IT eligibility criteria in a large diabetes cardiovascular outcomes trial: A post hoc subgroup analysis of EMPA-REG outcome: Analysis of EMPA-REG OUTCOME using REDUCE-IT criteria. Am J Prev Cardiol 2023; 15:100510. [PMID: 37384110 PMCID: PMC10293663 DOI: 10.1016/j.ajpc.2023.100510] [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: 02/16/2023] [Revised: 05/19/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023] Open
Abstract
Objectives REDUCE-IT showed that icosapent ethyl (IPE) improved cardiovascular (CV) outcomes in participants with established CV disease (CVD) or type 2 diabetes (T2D) and at least one additional risk factor plus mild-moderate hypertriglyceridemia and reasonably controlled low-density lipoprotein cholesterol (LDL-C). As the generalizability of REDUCE-IT has not been investigated in a T2D population with established CVD, this post hoc analysis investigated how many participants from EMPA-REG OUTCOME, which tested the effects of empagliflozin versus placebo on CV outcomes in participants with T2D and CVD, would have been eligible for IPE treatment, and whether CV outcomes differed based on eligibility for IPE treatment. Methods Participants from EMPA-REG OUTCOME were screened for inclusion using both REDUCE-IT-like criteria (baseline statin therapy, triglycerides 135-499 mg/dL and LDL-C 41-100 mg/dL) and slightly amended FDA indication criteria (triglycerides ≥150 mg/dL). Analyses were conducted to characterize the study population and CV outcomes in participants eligible for IPE versus those not eligible for IPE. Results Of the 7020 participants from EMPA-REG OUTCOME, 1810 (25.8%) fulfilled REDUCE-IT criteria and 3182 (45.3%) fulfilled FDA criteria for IPE treatment. Treatment effects of empagliflozin versus placebo on CV and kidney outcomes and mortality were consistent in participants meeting REDUCE-IT and FDA criteria and those who did not. Conclusions These results indicate that a sizable proportion of patients with diabetes and established CVD, such as those in EMPA-REG OUTCOME, may be eligible for IPE treatment to lower residual CV risk. Treatment benefit with empagliflozin was consistent, regardless of REDUCE-IT or FDA eligibility criteria.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Andrew Kosmopoulos
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, United States
| | - David Fitchett
- St Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Anne Pernille Ofstad
- Boehringer Ingelheim Norway Ks, Asker, Norway
- Oslo Diabetes Research Center, Oslo, Norway
| | | | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, ON, Canada
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Teramoto T, Ogawa H, Ueshima H, Okada Y, Haze K, Matsui S, Fujikawa K, Hashimoto T, Sakui S, Nishimura K, Kajita M, Horimoto A, Fernandez J. Effect of omega-3 fatty acids on cardiovascular events in high-risk patients with hypertriglyceridemia in Japan: a 3-year post-marketing surveillance study (OCEAN3 survey). Expert Opin Drug Saf 2023; 22:81-90. [PMID: 35772177 DOI: 10.1080/14740338.2022.2094914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Studies on the efficacy of prescription omega-3 polyunsaturated fatty acids to reduce cardiovascular events have produced conflicting results. RESEARCH DESIGN AND METHODS This 3-year prospective post-marketing surveillance study evaluated the effect of omega-3-acid ethyl esters (O3AEE; usual dosage 2 g/day) on cardiovascular events in high-risk statin-treated Japanese patients with hypertriglyceridemia. Statin-treated patients not receiving O3AEE were included as a reference cohort. The composite primary endpoint was cardiovascular death, myocardial infarction, stroke, angina requiring coronary revascularization, or peripheral arterial disease requiring surgery or peripheral arterial intervention. RESULTS At 3 years, Kaplan-Meier estimated cumulative incidence of the primary endpoint was 2.5% (95% confidence interval, 2.1%-2.9%) in O3AEE-treated patients (N = 6,580) and 2.7% (2.4%-3.1%) in non-O3AEE-treated patients (N = 7,784; hazard ratio, 0.99; 95% confidence interval, 0.79-1.23). Incidence of heart failure requiring hospitalization was 0.4% with O3AEE versus 0.8% in non-O3AEE-treated patients (hazard ratio, 0.47; 95% confidence interval, 0.28-0.78; P < 0.05). CONCLUSIONS Among patients receiving statins, cardiovascular event incidence did not differ significantly between O3AEE-treated patients and non-O3AEE-treated patients. Further studies are required before definitive conclusions can be drawn on the effect of O3AEE on cardiovascular event incidence in high-risk patients with hypertriglyceridemia. TRIAL REGISTRATION ClinicalTrials.gov, NCT02285166.
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Affiliation(s)
- Tamio Teramoto
- Teikyo Academic Research Center (TARC), Teikyo University, Tokyo, Japan
| | | | - Hirotsugu Ueshima
- NCD Epidemiology Research Center, Shiga University of Medical Science, Shiga, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazuo Haze
- Department of Cardiology, Kashiwara Municipal Hospital, Kashiwara, Japan
| | | | - Keita Fujikawa
- Japan Medical Office, Takeda Pharmaceutical Company, Tokyo, Japan
| | - Takamasa Hashimoto
- Statistical and Quantitative Sciences, Takeda Pharmaceutical Company, Osaka, Japan
| | - Sho Sakui
- Statistical and Quantitative Sciences, Takeda Pharmaceutical Company, Osaka, Japan
| | | | - Mika Kajita
- Japan Medical Office, Takeda Pharmaceutical Company, Tokyo, Japan
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Shen M, Aghajani Nargesi A, Nasir K, Bhatt DL, Khera R. Contemporary National Patterns of Eligibility and Use of Novel Lipid-Lowering Therapies in the United States. J Am Heart Assoc 2022; 11:e026075. [PMID: 36102276 PMCID: PMC9683659 DOI: 10.1161/jaha.122.026075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The emergence of PCSK9i (proprotein convertase subtilisin kexin type 9 inhibitor) and icosapent ethyl (IPE) has expanded the role of lipid-lowering therapies beyond statins. Despite recommendations by clinical practice guidelines, their national eligibility and use rates remain unclear. Methods and Results In the National Health and Nutrition Examination Survey data from 2017 to 2020, we assessed eligibility and the use of statins, PCSK9i, and IPE among US adults according to American College of Cardiology/American Heart Association guideline recommendations. Eligibility for PCSK9i and IPE were determined in the following 2 scenarios: (1) assuming existing lipid-lowering therapy as the maximum tolerated before assessing eligibility for novel therapies and (2) assessing eligibility after assuming initiation and maximal escalation of preexisting lipid-lowering therapies and accounting for expected lipid improvements. Of 2729 sampled individuals, representing 149.3 million adults, 1376 had indications for statins, representing 65.8 million or 44.0% (95% CI, 40.9%-47.2%) of adults. Current statin use was 45% of those eligible and was low across demographic groups. A total of 9.7 and 11.6 million adults would benefit from PCSK9i and IPE, respectively, based on lipid profiles and existing therapies. Assuming maximal escalation of statins and addition of ezetimibe, 4.1% (95% CI, 2.8%-5.4%) of adults or 6.1 million would benefit from PCSK9i and 6.8% (95% CI, 5.4%-8.3%) or 10.2 million from IPE. Conclusions Six and 10 million individuals have clinical profiles whereby PCSK9i and IPE, respectively, would be expected to improve cardiovascular outcomes even after maximum escalation of statins and ezetimibe use, but remain undertreated with lipid-lowering therapies. Optimal use of lipid-targeted agents that include these novel agents is needed to improve population health outcomes.
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Affiliation(s)
- Miles Shen
- Department of Internal MedicineYale School of MedicineNew HavenCT
| | - Arash Aghajani Nargesi
- Department of Internal MedicineYale School of MedicineNew HavenCT
- Heart and Vascular CenterBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Khurram Nasir
- Division for Cardiovascular Prevention and Wellness, Department of CardiologyHouston Methodist DeBakey Heart and Vascular CenterHoustonTX
- Center for Outcomes ResearchHouston MethodistHoustonTX
| | - Deepak L. Bhatt
- Heart and Vascular CenterBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCT
- Center for Outcomes Research and EvaluationYale‐New Haven HospitalNew HavenCT
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Miller M, Tokgozoglu L, Parhofer KG, Handelsman Y, Leiter LA, Landmesser U, Brinton EA, Catapano AL. Icosapent ethyl for reduction of persistent cardiovascular risk: a critical review of major medical society guidelines and statements. Expert Rev Cardiovasc Ther 2022; 20:609-625. [DOI: 10.1080/14779072.2022.2103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Michael Miller
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Klaus G. Parhofer
- Medizinische Klinik IV – Grosshadern, Klinikum der Universität München, Munich, Germany
| | | | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ulf Landmesser
- Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Benefits of Icosapent Ethyl for Enhancing Residual Cardiovascular Risk Reduction A Review of Key Findings from REDUCE-IT. J Clin Lipidol 2022; 16:389-402. [DOI: 10.1016/j.jacl.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 11/20/2022]
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Chapman MJ, Zamorano JL, Parhofer KG. Reducing residual cardiovascular risk in Europe: Therapeutic implications of European medicines agency approval of icosapent ethyl/eicosapentaenoic acid. Pharmacol Ther 2022; 237:108172. [PMID: 35304222 DOI: 10.1016/j.pharmthera.2022.108172] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/19/2022] [Accepted: 03/10/2022] [Indexed: 12/18/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) and its atherothrombotic complications impose a substantial disease burden in Europe, representing a cost of €210 billion per year for the European Union. Hypertriglyceridemia, a major risk factor for premature ASCVD, is present in more than 20% of the European population, and is a key feature of atherogenic dyslipidemia. Recent findings from the Progression of Early Subclinical Atherosclerosis (PESA) cohort in Spain showed that even in apparently healthy, middle-aged individuals without a history of cardiovascular (CV) risk, elevated triglyceride levels are associated with subclinical atherosclerosis and arterial inflammation. Emerging evidence from epidemiologic and genetic studies supports an independent causative role of triglycerides, triglyceride-rich lipoproteins, and their remnants in this pathology. Icosapent ethyl (IPE) is a highly purified, stable ethyl ester of eicosapentaenoic acid (EPA) that was initially approved by the United States Food and Drug Administration to treat severe hypertriglyceridemia, and subsequently received an expanded indication to reduce the risk of CV events in adult statin-treated patients. Approval was based on the pivotal, randomized, placebo-controlled, double-blind Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT), which showed that high-dose IPE (4 g/day) significantly reduced the risk of primary and secondary composite endpoints comprising major CV events and CV death relative to placebo. In 2021, the European Medicines Agency (EMA) approved IPE to reduce the risk of CV events in adult statin-treated patients at high CV risk with elevated triglyceride levels (≥1.7 mmol/L [≥150 mg/dL]) and established CV disease, or diabetes and at least one other CV risk factor. Clinical studies in Europe, which included patients with acute myocardial infarction, coronary artery disease, and those undergoing cardiac rehabilitation, established that 12.5% to 23.3% of these high-risk populations may benefit from treatment with IPE. Such clinical benefit may in part result from the moderate triglyceride-lowering properties of IPE/EPA; equally however, concentrations of atherogenic remnant particle-cholesterol are markedly reduced. Furthermore, IPE/EPA exerts pleiotropic actions beyond its lipid-lowering properties, which include modulation of endothelial function, attenuation of intra-plaque inflammation and oxidative stress, and reduction in macrophage accumulation. Plasma phospholipids, into which EPA is primarily incorporated and transported, appear to serve as precursors for a series of anti-inflammatory metabolites involving the resolvins RvE1 to RvE3, a pathway which may confer cardioprotective benefits. In addition, plaque imaging data from the Effect of Icosapent Ethyl on Progression of Coronary Atherosclerosis in Patients With Elevated Triglycerides on Statin Therapy (EVAPORATE) and the Combination Therapy of Eicosapentaenoic Acid and Pitavastatin for Coronary Plaque Regression Evaluated by Integrated Backscatter Intravascular Ultrasonography (CHERRY) trials show that plaque stabilization may be favorably affected. These factors may act synergistically to stabilize atherosclerotic plaques and reduce CV risk. In addition to robust efficacy data, multiple cost-utility studies across several countries indicate that IPE/EPA is a cost-effective treatment option that is favorably situated relative to some common willingness-to-pay thresholds. This review will evaluate the relevance of hypertriglyceridemia to residual ASCVD burden in statin-treated dyslipidemic patients, the potential of IPE/EPA to reduce the risk of ASCVD and cardiovascular mortality in high-risk patient populations, and the mechanisms which may underlie these effects. Finally, the clinical implications of the EMA label for IPE will be critically appraised in light of the updated 2019 European Society of Cardiology/European Atherosclerosis Society guidelines on the management of dyslipidemia and the recent European Atherosclerosis Society consensus statement on triglyceride-rich lipoproteins and their remnants, together with considerations of its cost-effectiveness across several countries.
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Affiliation(s)
- M John Chapman
- Sorbonne University, Endocrinology and Cardiovascular Disease Prevention, Pitié-Salpétrière University Hospital, and National Institute for Health and Medical Research (INSERM), Paris, France.
| | | | - Klaus G Parhofer
- Medical Clinic IV - Grosshadern Hospital of the University of Munich, Munich, Germany
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10
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Smith E. Welcome to the 18th volume of Future Cardiology. Future Cardiol 2021; 18:1-3. [PMID: 34844440 DOI: 10.2217/fca-2021-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Eloise Smith
- Future Science Group, Unitec House, 2 Albert Place, London, N3 1QB, UK
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11
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Warden BA, Purnell JQ, Duell PB, Craigan C, Osborn D, Cabot E, Fazio S. Real-world utilization of pharmacotherapy with new evidence-based cardiovascular indications in an academic preventive cardiology practice. Am J Prev Cardiol 2021; 5:100144. [PMID: 34327487 PMCID: PMC8315383 DOI: 10.1016/j.ajpc.2020.100144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To determine the real-world use of pharmacotherapy with new evidence-based cardiovascular indications in an academic Preventive Cardiology Clinic. Methods A retrospective study of patients seen in our Center for Preventive Cardiology (CPC) and who received a new prescription, according to Food and Drug Administration (FDA) approved indications, for one of the following pharmacotherapies with new evidence-based cardiovascular indications from May 2019 to May 2020: proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), eicosapentaenoic acid (EPA), sodium-glucose cotransporter 2 inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA). Treatment endpoints were prescription patterns, medication access, patient out-of-pocket expenses, medication tolerability, and clinical cardiovascular events while on these therapies. Results Of the 2390 patients seen in our CPC clinic over the observation period, 532 (22.3%) had already started and 291 (12.2%) were newly initiated on pharmacotherapy with new evidence-based cardiovascular indications with a median treatment duration of 9.1 months. Of these, 291 patients (for a total of 320 separate drug orders) – 93 (29.1%) were prescribed PCSK9i, 131 (40.9%) EPA, 46 (14.4%) SGLT2i, and 50 (15.6%) GLP-1 RA. Nearly 80% of cases required some form of provider intervention post-prescription (authorization, appeal, financial assistance, and/or side effect management). A total of 70% of adult patients with type 2 diabetes on metformin and with an HgbA1C >7% were treated with a SGLT2i and/or GLP-1 RA – either initiated prior to or during the study period. Median monthly drug cost for the total cohort was reduced from $595.00 pre-insurance approval to $70.50 post-insurance approval, to $7.00 post-financial assistance intervention. The medications were well tolerated with any side effect occurring in 28.3%, and discontinuation due to side effects in 5.8% of cases. Clinical cardiovascular events occurred in 2.7%, of which 1.9% was due to ASCVD and 0.8% to hospitalization for heart failure. Differences in medication access, cost, tolerability and clinical cardiovascular events varied widely between the medication classes. Conclusions Initiation and management of pharmacotherapy with new evidence-based cardiovascular indications in a real-world setting requires substantial provider intervention, a workflow amenable to a multi-disciplinary approach which allows for high rates of medication access and cost minimization, and low rates of medication side effects and clinical cardiovascular events. Over 12 months, PCSK9i, EPA, SGLT2i, and GLP-1 RA where prescribed in 291 patients. Nearly 80% of cases required some form of provider intervention post-prescription. Multi-disciplinary efforts reduced median monthly patient cost from $595 to $7. Cost was the leading factor for medication non-adherence. Drugs with new CV indications were well tolerated with low rates of CV events.
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Affiliation(s)
- Bruce A Warden
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Jonathan Q Purnell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Courtney Craigan
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Diane Osborn
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Emily Cabot
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sergio Fazio
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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Lakshmanan S, Budoff MJ. The Evolving Role of Omega 3 Fatty Acids in Cardiovascular Disease: Is Icosapent Ethyl the Answer? Heart Int 2021; 15:7-13. [DOI: 10.17925/hi.2021.15.1.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
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Pal A, Metherel AH, Fiabane L, Buddenbaum N, Bazinet RP, Shaikh SR. Do Eicosapentaenoic Acid and Docosahexaenoic Acid Have the Potential to Compete against Each Other? Nutrients 2020; 12:nu12123718. [PMID: 33276463 PMCID: PMC7760937 DOI: 10.3390/nu12123718] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/23/2020] [Accepted: 11/28/2020] [Indexed: 12/15/2022] Open
Abstract
Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are n-3 polyunsaturated fatty acids (PUFAs) consumed in low abundance in the Western diet. Increased consumption of n-3 PUFAs may have beneficial effects for a wide range of physiological outcomes including chronic inflammation. However, considerable mechanistic gaps in knowledge exist about EPA versus DHA, which are often studied as a mixture. We suggest the novel hypothesis that EPA and DHA may compete against each other through overlapping mechanisms. First, EPA and DHA may compete for residency in membrane phospholipids and thereby differentially displace n-6 PUFAs, which are highly prevalent in the Western diet. This would influence biosynthesis of downstream metabolites of inflammation initiation and resolution. Second, EPA and DHA exert different effects on plasma membrane biophysical structure, creating an additional layer of competition between the fatty acids in controlling signaling. Third, DHA regulates membrane EPA levels by lowering its rate of conversion to EPA's elongation product n-3 docosapentaenoic acid. Collectively, we propose the critical need to investigate molecular competition between EPA and DHA in health and disease, which would ultimately impact dietary recommendations and precision nutrition trials.
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Affiliation(s)
- Anandita Pal
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, The University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB# 7400, 135 Dauer Drive, Chapel Hill, NC 27516, USA; (A.P.); (L.F.); (N.B.)
| | - Adam H. Metherel
- Department of Nutritional Sciences, Medical Sciences Building, 5th Floor, Room 5358, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada; (A.H.M.); (R.P.B.)
| | - Lauren Fiabane
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, The University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB# 7400, 135 Dauer Drive, Chapel Hill, NC 27516, USA; (A.P.); (L.F.); (N.B.)
| | - Nicole Buddenbaum
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, The University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB# 7400, 135 Dauer Drive, Chapel Hill, NC 27516, USA; (A.P.); (L.F.); (N.B.)
| | - Richard P. Bazinet
- Department of Nutritional Sciences, Medical Sciences Building, 5th Floor, Room 5358, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada; (A.H.M.); (R.P.B.)
| | - Saame Raza Shaikh
- Department of Nutrition, Gillings School of Global Public Health and School of Medicine, The University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB# 7400, 135 Dauer Drive, Chapel Hill, NC 27516, USA; (A.P.); (L.F.); (N.B.)
- Correspondence: ; Tel.: +1-919-843-4348
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