Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Comparative effect of 3 different fix-combination antihypertensive treatments in fasting glucose, fasting insulin, OGTT and HbA1c levels, in prediabetic hypertensive patients

Introduction

The effect of various antihypertensive drugs on the glucose homeostasis has been discussed extensively. Dual combination treatment is advised with current guidelines. We present comparative data of the effect of delapril/manidipine versus valsartan/amlodipine versus telmisartan/amlodipine combination treatments, in fasting glucose, fasting insulin, OGTT and HbA1c levels, before and after the 3-month treatment, in hypertensive prediabetic patients.

Methods

Data were collected from 154 patients from the outpatient clinic for patients with lipid disorders, hypertension and diabetes of our hospital, during the period 2014–2018. A number of 53 persons was randomized in the delapril/manidipine group 30/10 mg per day while 51 persons had been randomized in the group of telmisartan/amlodipine 80/5mg per day and 54 patients in the valsartan/amlodipine 160/5 mg per day. All patients successfully completed the study. Baseline characteristics are presented in Table 1A.

Results

The resulting alternations in glucose, insulin, OGTT and HbA1c levels, before and after the 3-month treatment are presented on Table 1B for the 3 groups of treatment.

Conclusions

In the comparison between the groups, a statistically significant difference was found in the change in INS values from the beginning of treatment until 3 months, for the TEL/AMLO treatment group, where a statistically significant difference from the DEL/MANI treatment group (p-value<0.01) and a strong statistically significant difference from the VAL/AMLO treatment group (p-value<0.001) were noted. The TEL/AMLO group had the only decrease in insulin levels compared to the other treatment groups where an increase was observed, after the treatment. The change in OGTT levels showed a statistically significant difference (p-value<0.05) between the DEL/MANI treatment group (a decrease of 6.63%) compared to the TEL/AMLO treatment group (an increase of 1.53%) after 3 months of treatment.

Funding Acknowledgement

Type of funding sources: None.

Changes in TRG/ApoA-1 ratio, TRG/HDL-C ratio and lipid serum profile after combination therapy with telmisartan/amlodipine in prediabetic patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of telmisartan with amlodipine is a commonly administered combination of an agonist ATII (angiotensin receptor II) and CCB (calcium channel blocker) for the management of hypertension. The purpose of this study is to evaluate the effect of the fixed of combination telmisartan/amlodipine 80/5mg per day on the levels of serum lipids, as well as the levels of serum apolipoproteins and the TRG/ApoA-1, TRG/HDL-C ratios, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-180 mmHg and/or diastolic blood pressure (DBP) 100-110 mmHg) and with prediabetes (IFG/IGT), before and after the 3-month treatment.

Methods

Data from 51 patients who had visited our outpatient clinic for lipid metabolism disorders during the period 2014-2018 and had been randomized in the telmisartan/amlodipine group 80/5mg per day. The patients (35 male/16 female) had BMI: 29.32 [27.37-31.65]. The levels serum lipids and of apolipoproteins B, A1, Lp(a) and E were measured before the beginning of the treatment and 3-months after its administration.

Results

The resulting variations of SBP and DBP levels before and after the 3-month treatment, as well as the variations of serum lipid, apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios are presented on Table 1.

Conclusion

The 3-month telmisartan/amlodipine therapy seems to improved, statistically significant both SBP and DBP levels (decreased by -13.58 % and -13 % respectively, p<0.001, for both values). Serum lipid levels didn’t show any significant variation before and after treatment. Statistically significant changes were not present in apolipoprotein levels, also. Finally, there were no statistically significant variations in either TRG/ApoA-1 or TRG/HDL-C ratios.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with delapril/manidipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Purpose

The administration of the 30mg hydrochloric delapril and 10mg hydrochloric manidipine formulation is indicated for patients with idiopathic hypertension whose arterial pressure cannot be sufficiently managed with monotherapy. The purpose of this study is to investigate the effect of the premade combination delapril/manidipine 30/10mg per day on the variation of HOMA-IR, HOMA-B and QUICKI values, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-180 mmHg and/or diastolic blood pressure (DBP) 100-110 mmHg) and with prediabetes (IFG/IGT) before and after the 3-month treatment with the fixed combination dual-therapy.

Methods

53 patients (30 male/23 female, from whom 12 smokers and 7 alcohol users) who visited our outpatient clinic for lipid metabolism disorders and fulfilled the study’s criteria joined the study’s sample. They were randomized in the delapril/manidipine group. The patients’ BMI was 28.73 [27.73-30.3] and the SBP and DBP values were: 156 [151-161] and 100 [88-101] mmHg respectively.

Results

The resulting variations of SBP and DBP levels, as well as the variations of glucose and insulin levels and HOMA-IR, HOMA-B and QUICKI are presented on Table 1.

Results

From the sampled patients it seems that the 3-month treatment with delapril/manidipine improved statistically significantly the levels of both SBP and DBP (reduction by -11.54% and -12% respectively, p<0.001 for both values). Glucose levels witnessed a 1.55% decrease with statistical significance while a notable increase in insulin by 4.65% was also observed after the 3-month treatment, albeit without any statistical significance. Concerning HOMA-IR and QUICKI, there were no significant variance, while HOMA-B values showed a statistically significant increase (7%, p=0.006)

Clinical application of the new cardiovascular risk prediction algorithms SCORE2 and SCORE2-OP in patients with dyslipidemia

Funding Acknowledgements

Type of funding sources: None.

Introduction

European Society of Cardiology (ESC) has recently launched the SCORE2 and SCORE2-OP cardiovascular risk prediction algorithms.

Purpose

Cardiovascular risk assessment of patients with dyslipidemia according to SCORE2 and SCORE2-OP in comparison with the HELLENIC SCORE.

Methods

A retrospective observational study involving 1334 dyslipidemic patients followed-up for ≥3 years at our outpatient lipid clinic in our university general hospital. After excluding patients with established cardiovascular disease, diabetes mellitus, familial hypercholesterolemia, chronic renal disease, and those receiving hypolipidemic treatment, patients were categorized according to HELLENIC SCORE and SCORE2 / SCORE2-OP into the following cardiovascular risk groups: low-moderate, high and very high.

Results

A total of 532 patients were included in the present analysis (40% male, 17% smokers, mean age 55 [48-62] years, 8.6%> 70 years). Subjects’ mean cholesterol levels were 257 (228-291) mg/dL, triglycerides 136 (99-196) mg/dL, high-density lipoprotein cholesterol 52 (45-62) mg/dL, and low-density lipoprotein cholesterol 173 (149-200) mg/dL. According to SCORE calculation, 428 patients (80%) were classified into low-moderate, 87 (17%) high and 17 (3%) very high cardiovascular risk group. According to SCORE2 and SCORE2-OP algorithms, the proportion of those considered as high (n=230, 43%) and very high cardiovascular risk (n=89, 17%) increased (Figure).

Conclusions

The proportion of patients classified into high and very cardiovascular risk groups is anticipated to increase by implementing the new SCORE2 and SCORE2-OP.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with telmisartan/amlodipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of telmisartan and amlodipine in tablet form indicated for patients whose arterial blood pressure cannot be fully managed with monotreatment. The purpose of this study was to investigate the effect of the fixed combination telmisartan/amlodipine 80/5mg per day on arterial pressure levels and the variation of HOMA-IR, HOMA-B and QUICKI values in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-179 mmHg and/or diastolic blood pressure (DBP) 100-109 mmHg) and with prediabetes (IFG/IGT) before and after the 3-month treatment with the administration of the fixed combination.

Methods

Data collected from 51 patients who have visited our outpatient clinic for lipid metabolism disorders during the period 2014-2018. 51 persons with BMI: 29.32 [27.37-31.65] (25 male, 16 female) had been randomized in the group for telmisartan/amlodipine 80/5mg per day.

The median values for the study’s sample in SBP and DBP were: 163[158-168] and 100[95-106] mmHg, respectively. Their somatometric and demographic characteristics were recorded in the beginning of the study and are presented on Table 1Α.

Results

The results of the variations in SBP and DBP, as well as the variations in glucose, insulin, HOMA-IR, HOMA-B and QUICKI before and after the 3-month treatment are presented on Table 1B.

Conclusions

From the sampled patients it can be observed that the 3-month treatment with telmisartan/amlodipine statistically significantly improved (p=0.005) the HOMA-IR values while improving fasting glucose and insulin levels. Finally, there was a statistically significant reduction in QUICKI values and a statistically insignificant reduction in HOMA-B.

Alternations in markers of insulin resistance: HOMA-IR, HOMA-B, QUICKI, after dual therapy combination with valsartan/amlodipine in prediabetic hypertensive patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of valsartan with amlodipine is more effective than monotherapy for managing HT. The purpose of this study was to investigate the effect of the fixed combination of valsartan/amlodipine 160/5 mg per day on HOMA-IR (homeostatic model assessment for insulin resistance), HOMA-B (HOMA for β cell function) and QUICKI (quantitative insulin-sensitivity check index) values in patients with stage 2 hypertension (systolic arterial pressure 160-179 mmHg and/or diastolic pressure 100-109 mmHg) and prediabetes (IFG/IGT) before and after 3 months of treatment with the dual therapy.

Methods

Data from 54 patients who visited our outpatient clinic for lipid metabolism during the period 2014-2018. 54 persons were randomized in the valsartan/amlodipine group 160/5 mg per day (33 males/21 females from whom 14 were smokers and 8 were alcohol consumers) with BMI: 28.09[26.81-29.89], all of whom successfully completed the study. The median values of systolic and diastolic arterial pressure for the study population: 162 [159.25-165] and 100 [92-103.75] mmHg, respectively.

Results

The resulting variations of systolic and diastolic arterial pressure as well as the variations of HOMA-IR, HOMA-B and QUICKI are presented on Table 1.

Conclusions

From the studied group it is concluded that the 3-month treatment with valsartan/amlodipine improved with statistical significance the values of both systolic and diastolic arterial pressure (reduction by -13.58% and -13% for systolic and diastolic arterial pressure, respectively, p<0.001, for both values). Regarding glucose levels, there has also been a reduction by -0.04%, without statistical significance, while the increase of insulin levels (+16.13%) by the end of the 3-month period was also deemed statistically insignificant. Additionally, there have been noted statistically insignificant increases in HOMA-IR (+12.65%) and HOMA-B (+17%). Finally, no change has been observed in QUICKI values.

Blood pressure target attainment according to the recent ESC cardiovascular prevention guidelines

Funding Acknowledgements

Type of funding sources: None.

Introduction

New cardiovascular prevention guidelines have recently been issued by the European Society of Cardiology (ESC).

Purpose

To record blood pressure (BP) target attainment according to the recent ESC cardiovascular prevention guidelines.

Methods

A retrospective observational study involving 1334 dyslipidemic patients followed-up for ≥3 years at the Outpatient Lipid Clinic in University General Hospital of Ioannina, Greece. BP target attainment was recorded. ESC 2021 guidelines recommend a general target of BP <140/80 mmHg and individual targets of: i) diastolic BP <80 mmHg in all patients and ii) systolic BP 120-130 mmHg in patients 18-69 years of age without chronic kidney disease, or systolic BP 130-140 mmHg in patients 18-69 years of age with chronic kidney disease, or in those ≥70 years of age.

Results

Among the 1334 subjects, 935 (45% men, 68 [60-75 years old]) were diagnosed with hypertension and received antihypertensive treatment. Of those, 19% were diagnosed with chronic kidney disease, 24% with atherosclerotic cardiovascular disease and 23% with type 2 diabetes. Of those, 75% were receiving an angiotensin receptor blocker, 52% a thiazide diuretic, 52% a calcium channel blocker, 37% a β-blocker, 13% an angiotensin converting enzyme inhibitor, 6% an aldosterone receptor blocker and 2% a centrally acting antihypertensive drug. Half of subjects had BP <140/80 mmHg, but only 21% achieved the individualized BP targets.

Conclusions

A considerable proportion of hypertensive patients do not achieve target BP values.

Changes in TRG/ApoA-1 ratio, TRG/HDL-C ratio and lipid serum profile after combination therapy with valsartan/amlodipine in prediabetic patients

Funding Acknowledgements

Type of funding sources: None.

Introduction-Purpose

The combination of valsartan with amlodipine is a commonly administered combination of an agonist ATII (angiotensin receptor II) and CCB (calcium channel blocker) for the management of hypertension. There is already data from different studies that describe the effect of each of those medications in the lipidemic profile. Ratios TRG/ApoA-1, TRG/HDLC are useful markers of insulin resistance. The purpose of this study is to investigate the effect of the fixed combination of valsartan/amlodipine 160/5mg per day on the levels of serum lipids, as well as the levels of serum apolipoproteins and the TRG/ApoA-1, TRG/HDLC ratios, in patients with stage 2 hypertension (systolic blood pressure (SBP) 160-179 mmHg and/or diastolic blood pressure (DBP) 100-109 mmHg) and prediabetes (IFG/IGT), before and after the 3-month treatment.

Methods

Data from 54 patients who were referred to our outpatient clinic for lipid metabolism disorders during the period 2014-2018 and had been randomized in the valsartan/amlodipine group 160/5mg per day. Those patients (33 male/21 female from whom 14 were smokers and 8 alcohol users) all completed the study successfully with mean BMI: 28.09[26.81-29.89]. The median values of SBP and DBP for the sample group were: 162 [159.25-165] και 100 [92-103.75] mmHg, respectively. The levels of apolipoproteins B, A-1, Lp(a) and E were measured prior to the beginning of treatment and 3-months after its administration.

Results

The resulting alternations of SBP and DBP levels before and after the 3-month treatment, as well as the changes of serum lipid, apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios are presented in Table 1.

Conclusions

From the sample group it seems like that the 3-month therapy with valsartan/amlodipine improved statistically significant both SBP and DBP levels (decreased by -13.58% and -13% respectively, p<0.001 for both values). Concerning lipid levels, no significant variation was observed across the board. Finally, no significant change was observed in apolipoprotein levels and TRG/ApoA-1, TRG/HDL-C ratios.

Statin-associated muscle symptoms in clinical practice: evidence from a 6-year retrospective study

Introduction

There is conflicting evidence regarding the prevalence of statin-associated muscle symptoms (SAMS) in clinical practice and randomized clinical trials.

Aims

We aimed to record SAMS prevalence in the setting of a specialized lipid clinic.

Methods

This was a retrospective study including adults with dyslipidemia who were followed-up for ≥3 years (1999–2015) at the outpatient Lipid Clinic of our University General Hospital, Greece. We evaluated subjects' clinical and laboratory data with an emphasis on the prevalence of SAMS (including myalgias, muscle crumps and creatine kinase, CK, increase >10 upper limit of normal values) and recorded the rates of low-density lipoprotein cholesterol (LDL-C) target attainment according to the current ESC/EAS guidelines.

Results

Among 1,334 dyslipidemic subjects followed-up for 6 years (4–10), the prevalence of SAMS was 3% (n=41); 2% reported myalgias/crumples and 1% exhibited increased CK levels once. Only 7% (n=3) of those were statin intolerant, whereas the rest were able to receive any maximally tolerated statin dose. The corresponding prescription rates for low-, moderate- and high-intensity statins were 12%, 61% and 20%, respectively, whereas 32% received combination treatment with ezetimibe. None of the statin intolerant patients and 12% of those treated with any tolerated statin dose had optimal LDL-C levels.

Conclusions

The prevalence of SAMS is low in the setting of a specialized lipid clinic. Therefore, physicians should cautiously work-up to identify individuals with clinically relevant SAMS to offer alternative therapeutic regimens satisfactorily addressing their cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None.

Residual cardiovascular risk of patients with dyslipidemia receiving multifactorial cardiovascular prevention therapy

Background

Few studies have reported on the incidence and risk factors of cardiovascular disease (CVD) in patients with dyslipidemia receiving multifactorial treatment.

Purpose

To record CVD incidence and risk factors in patients with dyslipidemia receiving multifactorial CVD prevention therapy.

Methods

This was a retrospective observational study including consecutive adult patients with dyslipidemia who were followed for ≥3 years at the outpatient Lipid Clinic of our University General Hospital. We recorded CVD incidence and compared it with ATTICA study, an epidemiological prospective cohort assessing the 10-year cardiovascular risk in a representative sample of the general population in Greece. Factors that were significantly associated with incident CVD were additionally identified.

Results

A total of 1,334 individuals were included and followed-up for 6 (4–10) years. Lipid-lowering treatment was overall prescribed to 94% of study participants, while 70% were on antihypertensive and 20% on glucose-lowering therapy. During follow-up, 95 subjects (7%) developed CVD events. Despite higher baseline cardiovascular risk, CVD incidence rate in this study was lower compared with ATTICA (10.4 vs 15.7/1,000 person-years, respectively). Diabetes (HR: 2.09, 95% CI: 1.18–3.70, p<0.001), established CVD at baseline (HR: 2.04, 95% CI: 1.21–3.43, p<0.001), smoking (HR: 1.82, 95% CI: 1.17–2.84, p<0.001) and age (HR: 1.07, 95% CI: 1.4–1.9, p<0.001) were independently associated with incident CVD.

Conclusions

CVD incidence rate of high-risk dyslipidemic patients receiving multifactorial treatment was lower compared with general population. Diabetes, smoking, age, and baseline CVD remain the residual CVD risk factors in dyslipidemic patients receiving prevention therapy.

Funding Acknowledgement

Type of funding sources: None.

Increased lipoprotein(a) multiplies coronary heart disease risk in patients with familial hypercholesterolemia

Background

Familial hypercholesterolemia (FH) and elevated lipoprotein(a) (Lp[a]) are individually associated with increased coronary heart disease (CHD) risk.

Purpose

To determine the independent and joint associations of FH and Lp(a) with CHD.

Methods

This was a cross-sectional study including adult patients with dyslipidemia followed at our University General Hospital, Greece. FH diagnosis was based on the Dutch Clinic Lipid Network Criteria (score ≥5), while elevated Lp(a) levels were defined as >30 mg/dL. Independent and joint associations of FH and Lp(a) with CHD prevalence were determined using binary logistic regression models adjusted for traditional cardiovascular risk factors.

Results

Among 941 participants (49 years, 47% males, 54% with FH, 36% with increased Lp[a]), the prevalence of CHD was 7.7% (n=72). Compared with subjects without FH and non-elevated Lp(a) (n=296), those with either FH (adjusted OR: 3.21, 95% CI: 1.35–7.62, n=271) or elevated Lp(a) (adjusted OR: 1.89, 95% CI: 0.76–4.69, n=180) were at higher CHD risk. The patients with both FH and elevated Lp(a) had the highest CHD risk (adjusted OR: 7.31; 95% CI: 3.09–17.32, n=195). Among FH patients, increased Lp(a) doubled CHD risk (adjusted OR: 2.22, 95% CI: 1.02–4.83), whereas among patients with elevated Lp(a), FH was associated with a 5-fold increase in CHD risk (adjusted OR: 4.96, 95% CI: 1.83–13.43).

Conclusions

FH and elevated Lp(a) have independent and additive associations with CHD prevalence. This may have therapeutic implications regarding treatment intensity.

Funding Acknowledgement

Type of funding sources: None.

The new LDL-C target <55 mg/dL is achieved by less than 40% of very high risk patients with familial hypercholesterolaemia despite receiving PCSK9 inhibitors: real world data

Background

The recently published ESC/EAS guidelines for the management of dyslipidaemias have lowered the low-density lipoprotein cholesterol (LDL-C) target in the very high risk patients below 55 mg/dL.

Purpose

To examine how achievable is this target in very high risk patients receiving a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) on top of lipid-lowering treatment (LLT).

Methods

The cohort comprised 158 patients who attended the lipid clinic of 3 hospitals in Greece and started treatment with PCSK9i. Patients were requested to attend the lipid clinic 3 months after the initiation of PCSK9i.

Results

Ninety percent of patients had heterozygous familial hypercholesterolaemia (heFH) and 75% had cardiovascular disease (CVD). One hundred forty patients were classified as very high risk because they had either cardiovascular disease (CVD) or heFH with an additional risk factor for whom a target <55 mg/dL is currently recommended. Of those very high risk patients, 105 (75%) were given PCSK9i due to failure to achieve LDL-C targets despite maximum LLT (high intensity statin at maximum tolerated dose + ezetimibe) while in the rest of cases the indication was statin intolerance. The mean reduction of LDL-C at 3 months was 56.2%. Among 105 very high risk patients (all had heFH), LDL-C below 55 mg/dL was achieved by 37.1% while the previously LDL-C target <70 mg/dL was achieved by 60% (Figure 1).

Conclusions

The new LDL-C target <55 mg/dL is achieved by <40% of very high risk patients with heFH despite receiving triple LLT, i.e. PCSK9i + statin + ezetimibe. This therapeutic gap suggests that there is still need for more effective LLT in very high risk heFH patients to maximize their clinical benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None

P5324Children with familial hypercholesterolemia: lipid profile, treatment and evaluation of different formulas for calculating low-density lipoprotein cholesterol: an analysis from the HELLAS-FH registry

Introduction

There is limited data on cardiometabolic characteristics and treatment of underage patients with familial hypercholesterolemia (FH). Accurate estimation of low-density lipoprotein cholesterol is essential to tailor hypolipidemic treatment.

Purpose

To report lipid profile and current treatment of underage patients with FH in Greece as recorded in the HELLAS-FH registry. Also, to compare the Friedewald with the Martin/Hopkins equation, (which provides a customized estimation of VLDL-C) and the Dahlen's formula [(which adjusts the LDL-C measurements for the amount of cholesterol in Lp(a)].

Methods

Underage patients with FH were evaluated. Lipid profile, current treatment regimen as well as LDL-C levels as assessed with different formulas were evaluated.

Results

A total of 191 children were included (51.0% boys, 11.0±3.5 years old). Children at baseline had mean LDL-C as calculated by the Friedewald equation (LDL-CF) 233±65 mg/dL and median Lp(a) 15.3 (IQR 8–51) mg/dL. A total of 59.2% of subjects were receiving hypolipidemic treatment, mainly statins (29.4%) and sterols/stanols (25.5%). Children on hypolipidemic therapy had mean LDL-CF 183±98 mg/dL with 22.1% achieving an LDL-C≤130 mg/dL. When LDL-C was calculated based on the Martin-Hopkins equation (LDL-CM/H) respective values were 180±58 mg/dL and 24.8%. When LDL-C was corrected for Lp(a) [= LDL-CM/H − (Lp(a) * 0.30)], LDL-C was 174±105 mg/dL with 33.3% of patients within the LDL-C target.

Conclusions

Nearly two-thirds of children were receiving some kind of hypolipidemic treatment at the time of registration. For those on treatment, LDL-C goal is achieved by one in five, which rises to 1 in 3 when LDL-C is corrected for Lp(a) levels.

P5321The association of Lp(a) levels and cardiovascular disease in adult patients with familial hypercholesterolemia: analysis from the HELLAS-FH registry

Introduction

Familial hypercholesterolemia (FH) as well as elevated Lp(a) levels are both associated with increased cardiovascular disease (CVD) risk. There are limited data on the association of Lp(a) levels with CVD in FH Patients.

Purpose

To evaluate the association between Lp(a) levels and CVD in adult FH patients included in the HELLAS-FH registry in Greece.

Methods

Adult patients with FH and measured Lp(a) levels were included in this analysis. Demographics, CVD prevalence and lipid profile were evaluated.

Results

A total of 337 patients were evaluated (46% male, 48.3±15.4 years old). The median [IQR] of Lp(a) at baseline was 22.6 (9.7–56.2) mg/dL. Patients were categorized into 4 different groups according to the Lp(a) levels quartiles. There was no gender or age difference between the 4 groups. Moreover, all groups had similar smoking status, hypertension, body mass index and type 2 diabetes prevalence. There was no significant difference between groups regarding baseline and on treatment lipid profile. We observed a significant positive association between Lp(a) quartile and coronary artery disease (CAD) prevalence (p=0.004). Patients in the highest vs lowest quartile had greater CAD prevalence (21.7% vs 7%, p=0.006). No association was observed between Lp(a) quartile and the prevalence of cerebrovascular disease or peripheral artery disease.

Conclusions

Elevated Lp(a) levels have a positive correlation with CAD in patients with FH.

P5365Microsomal triglyceride transfer protein inhibitor (lomitapide) efficacy in the treatment of patients with homozygous familial hypercholesterolemia phenotype

Introduction

The majority of patients with homozygous familial hypercholesterolemia (HoFH) phenotype are treated additionally to lipid lowering (LL) drugs (statin + ezetimibe ± colesevelam) with lipoprotein apheresis (LA) sessions. The aim of this study was to evaluate the effect of microsomal triglyceride transfer protein inhibitor (lomitapide) in HoFH patients.

Patients and methods

In 12 HoFH patients treated with LL drugs ± biweekly LA sessions (9 patients) the 5–40 mg daily of lomitapide was added. Lipid profile [total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high density lipoprotein cholesterol (HDL-C)] before (LL drugs ± LA) and after lomitapide treatment were evaluated.

Results

The follow-up period of lomitapide treatment for 12 patients was 3–24 months (13.8±7.9). The median baseline LDL-C levels was 1000 mg/dL (339–1150). During LL drug therapy, patients showed a median LDL-C level of 383.5 mg/dL (Range: 214–866 mg/dL) and with LL drugs + Time-averaged levels (CAVG) the median was 288.1 mg/dL (Range: 183.69–716.65 mg/dL). The addition of lomitapide at the average dosage of 21.4 mg/day lowered LDL-C levels by 56.8% comparing to LL drugs alone therapy [mean reduction 262.12, 95% CI (105.53, 418.71), p=0.005] and by 54% [mean reduction −182.89, 95% CI (−342.35, −23.43), p=0.031] comparing to LL drugs + LA (CAVG). The CAVG of LDL-C in LL drugs + LA patients compared with LL drugs + lomitapide was 54% in favour of lomitapide (p=0.031). After lomitapide administration to LL drugs + LA treatment, 78% patients discontinued LA and 2 patients reduced their LA frequency by 50%. During follow-up, 2 patients (16.6%) reported side effects (transient diarrhea, 1 patient had liver transaminase >5× ULN and had to decrease dose of lomitapide). Two patients stopped lomitapide due to diet and alcohol restrictions.

Median and ranges of lipid and lipoprotein values before any intervention, after LL drugs, LL drugs plus LA, LL drugs plus LA (CAVG) and LL drugs plus lomitapide Total Cholesterol LDL-C HDL-C Triglycerides Before any intervention 1000 (339–1150) 900 (245–1070) 34.5 (25–50) 125 (87–314) After LL drugs 434 (278–915) 383.5 (214–866) 36 (27–51) 113 (62–198) LL drugs + LA (CAVG) 336.13 (248.57–784.16) 288.07 (183.69–716.65) 42.81 (25.84–46.68) 105.09 (55.79–166.68) LL drugs + Lomitapide 228.5 (118–554) 173.5 (74–515) 37.5 (29–50) 83.5 (23–316)

LDL graph

Conclusions

Treatment with lomitapide in HoFH patients has beneficial effect with constant decrease of LDL-C by 57% compared with classical LL therapy and by 54% compared with classical LL therapy and CAVG and seems to be with good safety profile. Although, in some cases the hybrid (all availably drug treatment and LA) therapy may be needed.

Proton pump inhibitors and statins: a possible interaction that favors low-density lipoprotein cholesterol reduction?

BACKGROUND

Proton pump inhibitors (PPIs) might influence the metabolism of cholesterol and statins in the liver.

AIM

The impact of PPIs on low-density lipoprotein cholesterol (LDL-C) levels in statin-treated patients.

METHODS

Retrospective observational study including consecutive statin-treated individuals followed for ≥3 years in a university hospital lipid clinic. Demographic characteristics as well as clinical and laboratory data were recorded at baseline and the most recent visit. High, moderate and low-intensity statin therapy was defined according to the expected LDL-C reduction (≥50%, 30-50%, and <30%, respectively). We compared the LDL-C reduction in subjects receiving statin + PPI with those on statin alone and assessed the overall effect of PPI administration on LDL-C lowering.

RESULTS

Of 648 statin-treated subjects, 7% were also taking a PPI. There was no difference between PPI vs. non-PPI group regarding baseline characteristics and intensity of lipid-lowering therapy. Stepwise linear regression analysis showed that PPI use was significantly associated with LDL-C reduction (b =0.104, p =0.005) along with baseline LDL-C levels (b =0.482, p <0.001), treatment with ezetimibe (b =0.198, p <0.001), presence of diabetes (b =0.168, p <0.001), compliance with treatment (b =0.205, p <0.001), intensity of statin treatment (b =0.101, p =0.005) and cardiovascular risk (b =0.082, p =0.049). Subjects receiving statin + PPI had a higher LDL-C reduction by 6.4% compared with those taking a statin alone (fully adjusted p =0.005).

CONCLUSIONS

PPIs may modestly boost the statin-mediated LDL-C reduction. This effect should be confirmed by prospective clinical studies. Hippokratia 2015; 19 (4): 332-337.