LDL-C goal achievement and lipid-lowering therapy in patients by atherosclerotic cardiovascular disease subtype: the SANTORINI study

Background

In the 2019 ESC/EAS guidelines, documented ASCVD is a criterion for patients being categorised as at very high cardiovascular (CV) risk, and stringent low-density lipoprotein cholesterol (LDL-C) reductions of ≥50% plus a goal of <1.4 mmol/L are recommended. Intensive lipid lowering therapy (LLT) is therefore key to reducing the risk of future CV events.

Purpose

To describe patient characteristics, approaches to lipid management and LDL-C goal attainment at baseline in the subgroup of secondary prevention patients with a history of ASCVD enrolled in the SANTORINI study.

Methods

SANTORINI is a multinational observational study (NCT-04271280) evaluating the real-world use of LLT in adult patients with high- and very-high CV risk enrolled from primary and secondary care sites across Europe between March 2020 and February 2021. The ASCVD status of patients was defined based on medical records as either coronary (myocardial infarction; unstable angina; angina pectoris; coronary artery bypass graft surgery; percutaneous transluminal coronary angioplasty; coronary artery disease [CAD]; CAD unequivocal on imaging), cerebral (stroke; transient ischaemic attack; cerebrovascular disease; cerebrovascular disease unequivocal on imaging; carotid artery disease), peripheral/other (peripheral arterial disease [PAD]; lower extremity artery disease; PAD unequivocal on imaging; retinal vascular disease; abdominal aortic aneurysm; renovascular disease) or polyvascular (≥1 ASCVD).

Results

Of the 9044 patients included in the analysis 6954 (76.9%) had a history of ASCVD. Baseline demographics and patient characteristics by type of ASCVD are shown in Table 1. The majority of patients were male (76.9%) and mean (SD) age was 66.1 (10.4) years. Mean (SD) LDL-C level was 2.29 (1.13) mmol/L and a total of 20.7% of patients achieved CV risk-based LDL-C goals. Fewer patients with cerebral ASCVD attained LDL-C goals (15.0%). Despite being at very-high CV risk, 21.4% of all patients had no documented LLT (up to 28.5% for the cerebral ASCVD group). The majority of patients (49.2%) received statin monotherapy, particularly moderate (21.8%) and high-intensity statins (24.9%). The peripheral/other ASCVD and cerebral ASCVD groups recorded the highest use of monotherapy across subgroups (≥57.8%), whereas any other LLT alone was consistently low, including ezetimibe (≤2.5%) and PCSK9i (≤2.0%). Overall, only 25.6% of patients received combination therapy (17.5% statin + ezetimibe; 4.7% PCSK9i + statin and/or ezetimibe; 3.4% other).

Conclusion

The SANTORINI baseline analysis shows that the majority of patients with ASCVD do not achieve their LDL-C goals. The underutilisation of combination therapy in this very high CV risk population highlights the need to move beyond high-intensity statin monotherapy and rather focus on combination therapies which achieve more intensive LDL-C reductions, thus improving LDL-C goal attainment.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

Cardiovascular risk factors in patients with and without a history of atherosclerotic cardiovascular disease in the SANTORINI study and estimation of risk

Background

Strategies for the prevention of atherosclerotic cardiovascular disease (ASCVD) are related to individual risk factors, and according to guidelines the higher the risk, the more intense the treatment required. Identifying patients at highest risk who might benefit the most from interventions is central for tailored solutions and ASCVD prevention, and any underestimation of risk may increase the ASCVD burden in these patients.

Purpose

To describe demographics and cardiovascular (CV) risk factors of patients with and without prior ASCVD enrolled in the SANTORINI study, as well as their CV risk as assigned by the investigator at the time of enrolment.

Methods

SANTORINI is an observational study (NCT04271280) conducted in 14 European countries and including patients aged ≥18 years with high- and very-high CV risk, as assessed by the investigator, and requiring lipid-lowering therapy. Patients were recruited between March 2020 and February 2021. The ASCVD status (coronary; cerebral; peripheral/other; polyvascular) of patients was defined based on medical records and the basis for risk classification was documented. For those whose risk was classified by the investigator based on the 2019 ESC/EAS guidelines, the CV risk was re-assessed centrally based on the information present in the study database to assess concordance.

Results

A total of 9044 patients were included in the analysis; of these, 76.9% had documented history of ASCVD (Table 1). Overall, the majority of patients were male (72.6%) and had a mean (SD) age of 65.3 (10.9) years. Mean (SD) LDL-C was 2.3 (1.13) mmol/L and 2.8 (1.37) mmol/L in the with and without ASCVD groups, respectively. Hypertension was common in both groups, whereas diabetes and familial hypercholesterolaemia were more prevalent in those without than those with ASCVD (44.6% vs 30.3% and 18.6% vs 7.2%, respectively). Patients with and without ASCVD had multiple CV risk factors (Table 1). Overall, ESC/EAS guidelines were cited as the most commonly used basis for risk classification (52.0%). Among all patients, the investigator assessed 26.0% and 84.2% of patients without and with ASCVD, respectively, as being very high-risk. However, central re-estimation for those using ESC/EAS guidelines suggested that 54.7% and 100% of those without and with ASCVD were at very high CV risk (Table 2).

Conclusion

Analysis of the SANTORINI baseline data shows that CV risk factors are common even in patients without documented ASCVD, and that the CV risk of patients both with and without ASCVD is underestimated in clinical practice, potentially contributing to clinical inertia in risk factor control.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

Simulation of bempedoic acid in the lipid-lowering treatment pathway using the European contemporary SANTORINI cohort of high- and very high-risk patients

Background

Lowering LDL-C treatment goals in the 2019 ESC/EAS guidelines necessitates greater use of combination therapies (1). Cost of PCSK9 inhibitors (PCSK9i) and efficacy of ezetimibe alone as add on therapies limit population level achievement of LDL-C goals.

Purpose

This simulation study assessed the addition of oral bempedoic acid (BA) to ezetimibe in the treatment pathway in a real-world cohort of patients in order to assess the proportion of patients who might reach goal.

Methods

SANTORINI is a cohort study of European patients at high or very-high CV risk. Patients who were receiving any known LLT regimen with available data on LDL-C at baseline were eligible for this analysis. For patients not at risk-based LDL-C goals, the following treatment algorithm was applied (Figure 1), first the addition of ezetimibe and subsequently BA for those on statins, or addition of BA for those on ezetimibe and not at goal. Patients on PCSK9i remained in the cohort but no simulation was done. LDL-C reductions associated with ezetimibe and BA treatment were based on probabilistic distributions sourced from clinical trial efficacies based on prior studies (2–3). The effect of treatment on LDL-C levels was simulated through a Monte Carlo simulation run 10,000 times. No statin intensification was simulated as we assumed statin therapy was at maximum tolerated dose.

Results

At baseline (N=6252), mean age was 66 years and mean baseline LDL-C was 80.6 mg/dL with 1444 patients (23%) at goal; 93% (n=5797) were very high risk and 7% (n=455) high risk, of whom 84% (n=5227) were on statins, 23% (n=1447) on ezetimibe and 9% (n=546) on PCSK9i. Out of 4486 patients entering the simulation, 3419 received ezetimibe add-on with a third of those predicted to be achieving their risk-based goal (32%, n=1078/3419). Of those on ezetimibe and not at goal, the addition of BA would be predicted to result in another 36% goal achievement (n=1218/3408). Overall, the number of patients at goal would be expected to increase from 1444 (23%) at baseline to 2522 (40%) and 3740 (60%) after addition of ezetimibe and BA, sequentially. The mean LDL-C for the whole cohort would be expected to fall through this pathway from 80.6 mg/dL at baseline to 69.2 mg/dL and 61.1 mg/dL, respectively.

Conclusion

Few patients in the SANTORINI cohort were at goal at baseline and few would have LDL-C eligible for PCSK9i use. Optimising use of ezetimibe and BA after statins in the ESC/EAS 2019 LLT pathway could result in significantly more patients attaining lipid goals with likely additional health benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH

High long-term persistence to evolocumab treatment regimens in European clinical practice: analysis of the HEYMANS registry

Background

Lipid-lowering treatments (LLTs) require both adherence and persistence to the treatment regimen long-term to maximise treatment benefits. Small molecules require self-medication daily but therapies such as evolocumab are labelled for self-medication every 2 weeks or monthly. Limited data exist concerning the long-term persistence to evolocumab in routine clinical practice.

Purpose

Using data from the HEYMANS registry, the objective of this analysis was to evaluate persistence and discontinuation of evolocumab in Europe.

Methods

HEYMANS was a prospective registry including adults initiating evolocumab treatment in routine clinical practice in 12 European countries between August 2015 and June 2020. Originally designed to have up to 12 months of follow-up, the protocol was amended (February 2018) to extend follow-up for up to 30 months. Patients yet to complete 12 months follow-up at this date, were followed up for up to 30 months. Therefore, we analysed evolocumab discontinuation separately for the two time periods: 0–12 months (all), 12–30 months (subset).

Results

Of the 1951 total patients, 30 patients discontinued participation in the study before 12 months (evolocumab use still ongoing at study discontinuation). Therefore, evolocumab use status was determined for 1921 patients at 12 months. Of these, 1781 (92.7%), remained on evolocumab at 12 months of follow-up (Figure). At 12 months, LDL-C levels were reduced from baseline by a median of 58% (Q1, Q3: 41%, 69%). In total, 1136 patients were eligible for extended follow up after protocol amendment. Of these, 137 patients discontinued study participation before 30 months of follow-up (with evolocumab ongoing). Therefore, evolocumab use status was determined in 999 patients, of whom, 92.2% (921) remained on evolocumab treatment at 30 months of follow-up (Figure). The reductions in LDL-C levels seen at 12 months were sustained throughout the study, with patients continuing to achieve median LDL-C reductions of 58% (Q1, Q3: 42%, 70%) from baseline at 30 months of follow-up.

Conclusions

In this real-world study, representative of European practice, of patients who entered the extension phase, the proportion of patients who remained on evolocumab up to 30 months exceeded 90%, and treatment was associated with sustained LDL-C reductions. These data suggest that the self-administration regimen of evolocumab is both feasible and acceptable in general populations, providing long-term sustained, reductions in LDL-C with likely associated health benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen (Europe) GmbH

Evolocumab treatment is associated with early and sustained reductions in low-density cholesterol (LDL-C) over 30 months: final results from the pan-European observational HEYMANS registry

Background

Variability in LDL-C control at a population level associates with worse CV outcomes. This could in part be related to variations in patient adherence to self-administration regimens or variability in the response to a given therapy. Potent therapies such as PCSK9 inhibitors (PCSK9i) reduce cardiovascular events but some have questioned whether these therapies, which require dosing every 2 weeks, can offer sustained population level control of LDL-C.

Purpose

Using data from the HEYMANS registry, the objective of these analyses was to evaluate, at a population level, various metrics of variability in LDL-C reduction over time with evolocumab treatment.

Methods

HEYMANS was a prospective registry including adults initiating evolocumab treatment in clinical practice in 12 European countries between August 2015 to June 2020. Patient data were collected for ≤6 months before evolocumab initiation (baseline) and ≤30 months post initiation. LDL-C measurements were collected per clinical practice. At each 3-month time point in the study, we analysed median (and 95% CI) reductions in LDL-C, and the proportion of patients achieving ≥30% and ≥50% reductions in LDL-C from baseline.

Results

Data from 1951 patients were included in this final analysis (62% male, mean age 60 years, median baseline LDL-C 3.98 [Q1–Q3 3.17–5.07]) mmol/L). Most patients (85%) were receiving evolocumab for secondary prevention, with 40% not on oral LLT of whom the majority reported a history of statin intolerance. There was a median of 4 (Q1, Q3: 2, 6) LDL-C measurements per patient during follow-up. Within 3 months of initiating evolocumab treatment, LDL-C levels had reduced by a median of 58% and this reduction was maintained over 30 months (Figure 1). Among patients with an LDL-C value, ∼85% achieved a ≥30% reduction at each follow-up throughout the study, and ∼63% achieved a ≥50% reduction at each visit (Figure 2).

Conclusions

In European clinical practice, evolocumab treatment was associated with early and sustained reductions in LDL-C of over 30 months, with limited variability in LDL-C reductions at a population level. Within 3 months of treatment, evolocumab was associated with ∼58% reduction in LDL-C levels that was maintained throughout the study. These data should reassure the clinical community that meaningful, consistent additional reductions in LDL-C can be achieved with use of evolocumab. As greater use of combination therapies is required to achieve lower LDL-C goals, expanding the use of PCSK9i could provide improvements in population level control of LDL-C in European clinical practice.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen (Europe) GmbH

Atherothrombotic residual risk in coronary and peripheral artery disease patients on guideline-recommended antiplatelet monotherapy: baseline preliminary results from the RESRISK study

Introduction

Greater recognition of a multi-factorial approach to risk factor control and use of guideline-recommended evidence-based therapies, including antiplatelets, have led to a decline in recurrent cardiovascular (CV) events among those with atherosclerotic CV disease (ASCVD). While residual risk still persists, recent evidence-based therapies have emerged which could further attenuate CV risk in these individuals, including novel drugs adjunct to antiplatelet therapies.

Purpose

The RESRISK study aims to quantify the residual atherothrombotic risk among a routine care cohort with ASCVD on guideline-recommended antiplatelet monotherapy (APMT). As a first step, we assessed the characteristics of participants at entry in the study, including risk factor burden, comorbidities and use of evidence-based medications.

Methods

A retrospective (2010–18) cohort of 758,325 patients with coronary (CAD) or peripheral artery disease (PAD) aged ≥18 years was derived from the UK Clinical Practice Research Datalink. Patients were selected if they were on recommended APMT according to ESC guidelines and NICE (aspirin for CAD; clopidogrel for PAD), were diagnosed with CAD/PAD prior to initiating APMT, and had ≥1 year of baseline data prior to index date (date of first APMT prescription). History of atrial fibrillation and haemorrhagic stroke led to exclusion.

Results

174,210 patients with CAD (and no prior history of PAD) and 11,050 patients with PAD (and no prior history of CAD) met the inclusion criteria. Within the selection process for the PAD cohort, 51,114 patients were excluded due to being prescribed aspirin instead of clopidogrel. Baseline characteristics are shown in Table. Mean age was ∼70 years for both cohorts. While prevalence of hypertension was similar in both cohorts, presence of diabetes was 1.6 times higher in PAD patients. Stroke was 2.5 times more prevalent among PAD patients. The proportion of patients with systolic/diastolic blood pressure ≤130/≤85 mmHg were 41.6%/84.5% for CAD and 32.2%/80.6% for PAD (corresponding numbers for ≤140/≤90 mmHg were 67.8%/93.4% for CAD, and 58.8%/91.1% for PAD). Mean LDL-C was 2.4±0.9 and 2.6±1.1 mmol/L in CAD and PAD patients, with 10.7% and 9.5% of them, respectively, having an LDL-C <1.4 mmol/L (25.1% and 22.6% for LDL-C <1.8).

Conclusions

Among a contemporary cohort with ASCVD on guideline-recommended APMT, risk factor burden is high and attainment of guideline-recommended targets remains largely suboptimal. Prevalence of diabetes among PAD patients is particularly high. A large gap exists between guideline recommendations and guideline-recommended goal attainment. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce the potential risk of recurrent events among this high-risk population. Subsequent follow-up analysis with linkage to outcomes will provide quantification of the consequences of current practice on residual risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): All financial support for this research has been provided by Bayer plc. Table 1

Treatment of high- and very high-risk patients for the prevention of cardiovascular events in Europe: baseline demographics from the multinational observational SANTORINI study

Background

The ESC/EAS 2019 guidelines recommend ambitious lower goals for low-density lipoprotein cholesterol (LDL-C), especially for patients with high and very high cardiovascular (CV) risk which could necessitate more intensive lipid-lowering therapy (LLT) regimens. Multiple real-world studies in Europe have demonstrated suboptimal achievement of older 2016 LDL-C goals, with combination therapy with ezetimibe or proprotein convertase subtilisin kexin 9 inhibitors (PCSK9i) used in 9% and 1% of patients, respectively. SANTORINI is the first European observational study since the 2019 guidelines to assess whether management of high- and very high-risk patients has improved.

Purpose

To describe patient characteristics and treatment patterns of LLT in real-world practice for the management of LDL-C levels in high- and very high-risk patients.

Methods

Baseline data were assessed from SANTORINI, which recruited patients aged ≥18 years with high and very high CV risk requiring LLT. Risk was defined as per a commonly available assessment system, e.g. the Systematic Coronary Risk Estimation (SCORE) system, for which ESC/EAS guidelines classify high-risk and very high-risk as a calculated 10-year risk of fatal CV disease of ≥5–<10% and ≥10%, respectively. Patients were recruited from 14 European countries across primary and secondary care settings, with patient characteristics, medical history, current LLT and other co-medications documented at baseline.

Results

Of 9606 patients recruited from March 2020 to February 2021 (55.0% from secondary care), cleaned data on 4308 were available through to February 2021. In this interim report, mean (standard deviation [SD]) age was 64.8 (10.8) years and 27.8% were female. Mean (SD) LDL-C was 2.45 (1.21) mmol/L. The majority of patients were classified as very high risk (69.3%), with 30.6% high risk. ESC/EAS guidelines were the most common basis for risk classification (51.3%), then clinical experience (33.5%) and national guidelines (10.4%). Concomitant CV risk factors included being a current or former smoker (16.5% and 41.8%, respectively), hypertension (70.9%), diabetes (35.4%) and familial hypercholesterolemia (10.1%). At baseline, 18.6% of patients were not receiving any LLT. 54.1% of patients were receiving LLT monotherapy, including 51.1% on statins, 1.4% ezetimibe, 1.2% a PCSK9i, and 0.5% other oral LLT. Combination therapy was used in 27.3% of patients, including 17.1% receiving statin plus ezetimibe, 4.1% PCSK9i plus oral LLT, and 6.1% any other oral combination therapy.

Conclusions

This large study in patients at high and very high CV risk from 14 European countries suggests that, although the ESC/EAS guidelines are the most frequently used basis for risk classification, LDL-C levels remain substantially higher than recommended goals, with combination therapies underutilised. An expanded data cut from SANTORINI will be reported in 2021.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

Evolocumab use in Europe: clinical guidelines vs. reimbursement thresholds – results from the HEYMANS study

Background

2019 ESC/EAS guidelines recommend a 50% lowering in untreated LDL-C and use of PCSK9 inhibitors (PCSK9i) for patients (pts) at very high cardiovascular (CV) risk when LDL-C goals of <1.4mmol/L are not met despite maximally tolerated statins and ezetimibe. However, the LDL-C threshold at which PCSK9i are reimbursed are higher than the goals recommended in clinical guidelines.

Purpose

This prospective observational cohort study describes clinical characteristics and LDL-C control among pts initiating evolocumab across 12 EU countries.

Methods

Pts are followed from evolocumab initiation (baseline). Demographic/clinical characteristics, lipid lowering therapy (LLT) and lipid values are being collected from medical records (6 months before evolocumab up to 30 months post initiation). We report interim data from pts initiating evolocumab from August 2015 followed-up until July 2020.

Results

Of the 1,952 pts in whom evolocumab was initiated as per local reimbursement criteria, most (1844 [94%]) had 12 months follow-up, 785 (40%) had 24 months follow-up; mean follow-up: 20 months. Mean (SD) age was 60 (10.8) years; 85% of pts had a history of CV disease, 45% had familial hypercholesterolemia, 19% had type 2 diabetes, 65% were hypertensive, 7% had chronic kidney disease and 51% were prior/current smokers. At evolocumab initiation, 60% reported statin intolerance and 41% were on no background LLT. Fewer than half (846 [43%]) were receiving a statin (± ezetimibe); of these, most received a high/moderate intensity (68%/22%), with 13% receiving statin monotherapy. Median (Q1, Q3) baseline LDL-C was 3.98 (3.17, 5.07) mmol/L. Within 3 months of initiation median LDL-C fell by 58% to 1.63mmol/L. This reduction was maintained over time (Figure 1). Overall, 58% of pts achieved at least one LDL-C <1.4mmol/L during follow-up. Among pts receiving background statins ± ezetimibe at evolocumab initiation, 67% (710/1053) achieved at least one LDL-C <1.4mmol/L, versus 44% (317/714) of pts not receiving background statins/ezetimibe. During follow-up background oral LLT did not materially change; 40–45% pts received no LLT, 41–44% received statin ± ezetimibe, 12–14% received statin monotherapy.

Conclusion

In Europe, pts initiated on evolocumab had baseline LDL-C levels almost 3x higher than the present threshold for PCSK9i use recommended in guidelines reflecting disparities between local reimbursement criteria and guidelines. Although evolocumab led to a >50% reduction in LDL-C, only ∼50% pts achieved an LDL-C <1.4mmol/L, as approximately 41% received only evolocumab as monotherapy. LDL-C goal attainment was however higher among pts receiving evolocumab with background LLT. Therefore, lowering the LDL-C threshold for PCSK9i reimbursement, would result in more patients receiving combination therapy with oral LLT plus PCSK9i, thus increasing the likelihood of more pts achieving very-high risk LDL-C goals.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen Europe GmbH

Efficacy and safety of inclisiran in patients with established cerebrovascular disease: pooled, post hoc analysis of the ORION-9, ORION-10 and ORION-11, phase 3 randomised clinical trials

Background

Patients (pts) with hyperlipidaemia and established cerebrovascular disease (CeVD) are at an increased risk of future strokes or other cardiovascular events.[1] In ischaemic stroke survivors, statins and inhibitors of proprotein convertase subtilisin-kexin type 9 (PCSK9) reduce recurrent cardiovascular events including stroke.[2–4] With guidelines increasingly advocating lower LDL-C goals, add-on lipid lowering therapies to statins may be needed. Inclisiran, a first-in-class small interfering RNA (siRNA) targeting PCSK9 messenger RNA, when added to maximally tolerated statin therapy, may provide further LDL-C lowering with a convenient, infrequent dosing schedule in pts with established CeVD.

Purpose

To assess efficacy and safety of inclisiran in pts with established CeVD.

Methods

Pts with HeFH, ASCVD or its risk equivalents from ORION-9 (NCT03397121]), ORION-10 (NCT03399370), and ORION-11 (NCT03400800) were randomised 1:1 to receive inclisiran sodium 300 mg (equivalent to 284 mg inclisiran) or placebo (pbo) at Days 1, 90 and 6-monthly thereafter to Day 540. This post hoc analysis included pts with established CeVD (ischaemic stroke, and/or carotid artery stenosis by angiography or ultrasound >70%, and/or prior percutaneous or surgical carotid artery revascularisation). Percentage LDL-C change from baseline to Day 510 and corresponding time-averaged percentage change from baseline after Day 90 to Day 540 were evaluated. Safety was assessed over 540 days.

Results

Of 202 pts with established CeVD, 110 and 92 received inclisiran and pbo, respectively. At baseline, 90.0% (99/110) of pts in inclisiran and 84.8% (78/92) in pbo group reported prior ischaemic stroke(s); others had carotid artery stenosis and/or carotid revascularisation (Table 1). Mean (95% CI) pbo-corrected LDL-C percentage change from baseline at Day 510 with inclisiran was −55.2% (−64.5 to −45.9); corresponding time-averaged change from baseline after Day 90 to Day 540 was −55.2% (−62.4 to −47.9) (P<0.0001 for each; Table 2). Treatment-emergent adverse event (TEAE) and treatment-emergent serious adverse event (TESAE) were more frequent in the inclisiran vs pbo group but were consistent with the overall pooled (N=3655) population of the combined trials. Clinically relevant TEAEs at the injection site were reported more frequently with inclisiran (3.6% [4/110]) vs pbo (0% [0/92]), but none were severe. Percentage of pts with clinically relevant laboratory measurements was low and similar between treatment groups and consistent with the overall pooled population (Table 2).

Conclusions

In pts with established CeVD, a twice-yearly dosing with inclisiran (after the initial and 3-month doses) provided sustained additional LDL-C reduction of ∼55%. A modest excess of mild/moderate TEAEs at the injection site were reported with inclisiran. The cardiovascular benefits of inclisiran among patients with established CeVD are being evaluated in ongoing trials.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma AG, Basel, Switzerland.

Efficacy and safety of inclisiran in patients with polyvascular disease: pooled, post hoc analysis of the ORION-9, ORION-10 and ORION-11, phase 3 randomised controlled trials

Background

Approximately 25% of patients (pts) with atherosclerotic cardiovascular disease (ASCVD) have polyvascular disease (PVD), which involves ≥2 coronary, cerebrovascular, and peripheral artery beds. PVD is an independent predictor of major adverse cardiovascular (CV) events (MACE) and death.[1,2] Agents that inhibit proprotein convertase subtilisin-kexin type 9 (PCSK9) resulted in reduced low-density lipoprotein cholesterol (LDL-C) concentration and MACE incidence in pts with PVD.[3,4] Inclisiran is a small interfering RNA (siRNA) agent targeting PCSK9 messenger RNA that provided effective and sustained reduction in LDL-C concentration and was well tolerated.[5]

Purpose

To describe the effect inclisiran versus placebo (pbo) in pts with and without PVD.

Methods

This was a post hoc analysis from the ORION-9 (NCT03397121), ORION-10 (NCT03399370) and ORION-11 (NCT03400800) trials. Pts with heterozygous familial hypercholesterolaemia, ASCVD or risk equivalents were randomised 1:1 to receive 300 mg inclisiran sodium (equivalent to 284 mg inclisiran) or pbo at baseline, Day 90, and 6-monthly thereafter. LDL-C percentage change from baseline to Day 510 and corresponding time-averaged change from Day 90 and to Day 540 were evaluated by presence or absence of PVD (intention-to-treat population). Safety was assessed over 540 days (safety population).

Results

Of 3454 pts, 470 (13.6%) had PVD and 2984 (86.4%) did not. Baseline characteristics were generally balanced between treatment arms in both groups (Table 1). A greater proportion of pts with vs without PVD had CV risk factors at baseline. Mean LDL-C concentration at baseline was lower in pts with vs without PVD (Table 1). Mean (95% CI) pbo-corrected LDL-C percentage change from baseline to Day 510 with inclisiran was −48.9 (−55.6 to −42.2) in pts with PVD and −51.5 (−53.9 to −49.1) in pts without PVD (Table 2). Proportions of pts with treatment-emergent adverse events (TEAE) and treatment-emergent serious adverse events (TESAE) were similar between treatment arms irrespective of PVD status although reported TESAEs were numerically greater in both treatment arms for pts with PVD (Table 2). Clinically relevant TEAEs at the injection site were reported more frequently with inclisiran vs pbo in both groups but all were mild or moderate (Table 2). Proportions of pts with clinically relevant laboratory measurements were low and similar between treatment arms for both groups (Table 2).

Conclusions

Twice-yearly dosing with inclisiran (after the initial and 3-month doses) provided effective and sustained LDL-C lowering in pts, irrespective of their PVD status, with a safety profile similar to pbo, except for a modest excess of mainly mild TEAEs at the injection site. Notably, TESAEs were reported more frequently in pts with PVD, which was likely due to their more advanced disease. Since pts with PVD are at high risk of CV events, intensive LDL-C lowering may be beneficial to reduce this risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma AG, Basel, Switzerland

Reduction in the risk of MACE with apabetalone in patients with recent acute coronary syndrome and diabetes according to NAFLD fibrosis score: exploratory analysis of the BETonMACE trial

Background/Introduction

Both major adverse cardiovascular events (MACE) and non-alcoholic fatty-liver disease (NAFLD) are highly prevalent in patients with high BMI and long-standing type 2 diabetes (T2DM). NAFLD is characterized by an augmented hepatic inflammation and fat deposition and is strongly associated with metabolic syndrome. Patients with NAFLD are at an increased risk of cardiovascular (CV) events, and MACE is the leading cause of death for patients with NAFLD. Apabetalone (APB) is a novel selective inhibitor of bromodomain and extra-terminal (BET) proteins, epigenetic regulators of gene expression. In the Phase 3 BETonMACE trial treatment of 2,425 T2DM patients post ACS with APB, resulted in hazard ratios (HR) of 0.82 (p=0.11) for the primary endpoint of ischemic MACE (CV death, non-fatal MI or stroke) and 0.59 (p=0.03) for the secondary endpoint of heart failure hospitalization (HFH) vs placebo (PBO). Transient elevations of alanine aminotransferase greater than 5xULN occurred in 3.3% of APB treated patients.

Purpose

In this exploratory post hoc analysis of BETonMACE we evaluated risk modification for a composite of MACE+HFH by APB based on the Angulo NAFLD fibrosis score (FS) using 6 variables (age, BMI, hyperglycemia/diabetes, AST/ALT ratio, platelet count, and albumin). The NAFLD FS categorizes individuals into groups that correlate with differing levels of fibrosis in biopsy studies: (FS F0-F2, no significant fibrosis; FS ID, indeterminant; and FS F3-F4, significant fibrosis).

Methods

Baseline characteristics and blood measurements were used to determine NAFLD FS at baseline. The incidence of MACE+HHF was compared between treatment groups.

Results

Based on FS, there were 618 pts were classified as FS F0-F2 (n=328 APB, n=290 PBO), 1,440 pts were classified as FS ID (n=708 APB, n=732 PBO) and 289 pts were classified as FS F3-F4 (n=144 APB, n=145). MACE+HHF in the PBO group was higher in FS ID and FS F3-F4 compared to FS F0-F2 (17.2% vs 15.0% vs 9.7%) and therefore the former two groups were combined into an elevated risk FS+ group. FS+ pts were older (63 vs 56), had longer duration of T2DM (9.0 vs 7.3 yrs), and higher BMI (30.8 vs 28.6) compared to FS- pts. Overall, APB was associated with fewer MACE+HHF (HR 0.78, 95% CI 0.60–1.01, p=0.06) compared to PBO in the FS+ pts with adjustment for age, duration of T2DM and BMI.

Conclusions

Patients with T2DM and ACS may share common risk factors with patients with NAFLD. Apabetalone appears to exert a favorable effect on MACE in patients with risk factors for NAFLD. Whether apabetalone has a modulatory effect on the development and progression of NAFLD is an important question requiring further investigation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Resverlogix Corp.

4945Inclisiran-mediated reductions in Lp(a) in the ORION-1 trial

Background

PCSK9 inhibitors and statins both lower LDL-C by increasing LDL-receptor (LDLR) function. PCSK9 inhibitors lower Lp(a) by 20–30%, whereas statins do not lower Lp(a). The mechanism by which PCSK9 inhibitors lower Lp(a) is unclear. We assessed the role of the LDLR in Lp(a) reductions produced by inclisiran, an siRNA which prevents hepatic synthesis of PCSK9.

Methods

ORION-1 was a phase 2 trial of inclisiran in subjects at high ASCVD risk with elevated LDL-C on optimized statin therapy. Subjects received one dose of inclisiran (200, 300, or 500 mg) or two doses at days 1 and 90 (100, 200, or 300 mg). We assessed the correlations between % change in Lp(a) and LDL-C at Day 180 for the inclisiran groups using Spearman correlation coefficients. We additionally assessed the correlation between % change in Lp(a) and absolute change in LDL-C as a proxy for LDLR expression. Lp(a) was measured using an isoform-independent assay and LDL-C with β-quantification.

Results

ORION-1 included 501 subjects; mean age 63; 65% male; 73% on statins. Median baseline Lp(a) was 37.0 nmol/l (IQR: 11.5–142.0 nmol/l), median LDL-C was 117.0 (IQR: 92.5–149.5 mg/dL). Inclisiran dose-dependently lowered Lp(a) by 14% to 26%. Overall, there was a significant but weak correlation between % change in Lp(a) LDL-C (Spearman coefficient 0.35, p<0.001). This correlation appeared to be stronger at higher inclisiran doses and with repeat dosing (table), as well as in statin-users versus non-users (Spearman coefficient 0.37 vs. 0.21). The correlation between % Lp(a) change and absolute LDL-C change was weaker (0.27, p<0.001).

Correlation coefficients LDL-C – Lp(a) Single-dose groups Two-dose groups Inclisiran overall 200 mg (n=60) 300 mg (n=60) 500 mg (n=60) 100 mg (n=59) 200 mg (n=60) 300 mg (n=59) Lp(a) ∼ % change LDL-C 0.22 0.26 0.22 0.29 0.47 0.51 0.35 Lp(a) ∼ absolute change LDL-C 0.35 0.12 0.04 0.22 0.45 0.24 0.27 Lp(a) ∼ % change LDL-C - Statin users 0.16 0.28 0.28 0.31 0.45 0.55 0.37 Lp(a) ∼ % change LDL-C - Non statin users 0.80 -0.08 0.09 0.10 0.63 0.09 0.21

Conclusion

The dose-dependent correlation between % changes in LDL-C and Lp(a) suggests that the LDLR may be partially responsible for Lp(a) reductions produced by inclisiran. The numerically stronger correlation in statin-users supports the idea that LDL-C may compete with Lp(a) for LDLR binding especially at low LDL-C levels.

Acknowledgement/Funding

The Medicines Company

P5364Safety profile of bempedoic acid: pooled analysis of 4 phase 3 clinical trials

Background/Introduction

Bempedoic acid (BA), an oral, first-in-class, ATP-citrate lyase inhibitor, lowers low-density lipoprotein cholesterol (LDL-C) in patients who do not achieve sufficient lipid lowering with guideline-recommended first-line therapies.

Purpose

We evaluated the safety profile of BA in phase 3 trials.

Methods

Data were pooled from 4 randomised, double-blind, placebo-controlled studies that enrolled patients with hyperlipidaemia who were receiving stable lipid-lowering therapy (LLT; maximally tolerated statins +/− nonstatin therapies) and required additional LDL-C lowering. Patients were randomised (2:1) to BA 180 mg or placebo daily for 12 to 52 weeks.

Results

Median exposure for 3621 patients (2424 BA, 1197 placebo) was 363 days. Background LLT included a statin +/− other LLT (83.8%), nonstatin LLT alone (9.4%), or none (6.8%). Adverse event (AE) and serious AE rates were similar between groups (Table). The most common AEs in the BA and placebo groups were nasopharyngitis (7.4% vs 8.9%), myalgia (4.9% vs 5.3%), and urinary tract infection (4.5% vs 5.5%). Rates of new-onset/worsening diabetes were 4.0% for BA and 5.6% for placebo. No AEs leading to discontinuation differed by ≥0.5% between treatments. All fatal AEs were judged by the investigator as unrelated to treatment. A trend was observed for a lower 3-component major adverse cardiac event rate with BA vs placebo (hazard ratio, 0.85; 95% confidence interval: 0.53 to 1.37). Changes in uric acid, creatinine, and haemoglobin were apparent at week 4, stable over time, and reversible after stopping BA. Gout occurred in 1.4% and 0.4% of patients in the BA and placebo groups, respectively. The safety profile of BA was consistent across background therapies, demographics, and disease characteristics.

Table 1. Safety summary Placebo (n=1197) BA (n=2424) Any AE / SAE, % (n) 72.5 (868) / 13.3 (159) 73.1 (1171) / 14.1 (341) Drug discontinuation due to an AE, % (n) 7.8 (93) 11.3 (273) AE with a fatal outcome, % (n) 0.3 (4) 0.8 (19) Aminotransferase elevation >3 x ULN, % (n) 0.3 (3) 0.7 (18) Aminotransferase elevation >5 x ULN, % (n) 0.2 (2) 0.2 (6) Creatine kinase elevation >5 x ULN, % (n) 0.2 (2) 0.3 (8) Creatinine, mean change at week 12, mg/dL −0.002±0.11 0.046±0.12 Uric acid, mean change at week 12, mg/dL −0.02±0.82 0.82±0.97 Haemoglobin, mean change at week 12, g/dL 0.06±0.69 −0.31±0.71

Conclusion(s)

BA added to LLT was well tolerated, with a safety profile comparable to placebo.

P4608BET-inhibition with Apabetalone in Post-ACS Patients with Diabetes: Design and Baseline Characteristics of the BETonMACE trial

Background

Diabetes (DM) is associated with increased risk of macro/microvascular disease and cognitive decline. Inflammation and vascular calcification may be contributing factors. Bromodomain and extraterminal (BET) proteins coordinate gene transcription and modify the transcriptional response to hyperglycemia, and inflammation. Apabetalone competitively and selectively inhibits binding between BET proteins and acetyl-lysine marks on histone tails: normalizing transcriptional profiles to physiological levels; reducing in vitro alkaline phosphatase (ALP) transcription and in vivo plasma ALP in a dose-dependent manner. Phase 2 trials with apabetalone show improved renal function in the chronic kidney disease (CKD) subgroups. Furthermore, treatment showed a 55% reduction in CVD events with more pronounced benefit among patients with DM, low HDL-cholesterol (HDL-C) and high sensitivity C-reactive protein (hsCRP).

Methods

The double-blind, placebo controlled phase 3 BETonMACE trial is testing the hypothesis that apabetalone 100 mg b.i.d., added to standard care, reduces major adverse cardiovascular events (MACE: CV death, non-fatal myocardial infarction or stroke) in patients with DM, acute coronary syndrome (ACS) within the preceding 7–90 days, low HDL-C (<40 mg/dL in men; <45 mg/dL in women), and estimated glomerular filtration rate (eGFR) >30 mL/min/1.7m2. The trial will continue until at least 250 MACE, providing 80% power to detect a 30% reduction. Secondary endpoints include changes in eGFR in patients with baseline eGFR 30 to <60 mL/min/1.7m2, inflammatory markers, lipids, and ALP. In addition the Montreal Cognition Assessment (MoCA) test was performed in patients ≥70 years of age at baseline and annually.

Results

Enrollment of 2425 patients across 13 countries and 195 centers is now complete. Baseline characteristics [median (IQR)] include LDL-C 65.0 (36) mg/dL, HDL-C 33.0 (7) mg/dL, HbA1c 7.3 (2.3) %, hsCRP 2.8 (4.9) mg/L, mean blood pressure 129/76 mmHg, and CKD in 266 patients (10.8%). Background care was based on guideline recommendations. Diabetes medications include metformin (79%), insulin (36%), sulfonylureas (28%), DPP4 inhibitors (11%), SGLT2 inhibitors (9.7%) and GLP1 receptor agonists (0.3%). The CKD subpopulation vs. total population differed significantly from the whole population with regard to age (71 vs. 62 y. o.), male sex (58% vs. 75%), history of hypertension (46% vs. 88%), history of stroke (1.5% vs. 7.5%), and current smokers (6.1% vs. 13%). In the 70 year and older (n=466, 19%) population 54% (n=243) showed a baseline MoCA score 25 and lower suggesting cognitive impairment.

Summary

The BETonMACE trial is testing the hypothesis that selective BET-inhibition with apabetalone, added to established, evidence-based treatment, reduces MACE in high-risk patients with DM, recent ACS, and low HDL-C. The study will also assess apabetalone's effect on renal function and cognition.

P654Effectiveness of evolocumab for patients with familial hypercholesteraemia (FH) in European clinical practice

Background

FH is a genetic disorder which causes lifelong elevations in LDL-C from birth, resulting in a significantly increased risk of premature atherosclerotic cardiovascular disease (ASCVD). In clinical trials among patients with heterozygous FH (HeFH) and homozygous FH (HoFH), evolocumab significantly reduced LDL-C by approximately 40–60% from baseline. Few data are available on evolocumab use among FH patients treated in a real-world setting.

Purpose

Describe the characteristics of FH patients receiving evolocumab in routine clinical practice and their response to therapy.

Methods

This observational study across 10 European countries follows subjects from the date of evolocumab initiation (baseline) for up to 2.5 years, with relevant clinical data abstracted from medical charts (for subjects on apheresis, LDL-C measures included those obtained directly following apheresis). We analysed a cohort of FH subjects from an interim analysis which included subjects initiating evolocumab from Aug 2015 through Jun 2018. FH was diagnosed by the treating physician using standard criteria.

Results

A total of 502 FH subjects were included, 477 had HeFH (95%) and 25 HoFH (5%). The main diagnostic methods used included: the Dutch Lipid Clinic Network criteria (39% of HeFH, 28% of HoFH), genetic testing (27% of HeFH, 36% of HoFH), LDL-C values alone (23% HeFH, 16% HoFH). Mean (95% Confidence Interval [CI]) age was 58 (57–59) years for HeFH and 56 (50–61) for HoFH; 71% and 84% <65 years, respectively. 60% of HeFH subjects were male (HoFH: 40% male). In the overall FH cohort, additional CV risk factors were common (59% hypertension, 15% diabetes, 6% chronic kidney disease ≥ stage 2, 17% current smoker, 22% BMI≥30), with the majority having experienced a prior CV event (77% of HeFH, 80% of HoFH). Among HeFH subjects, 40% were receiving a high intensity statin at baseline, 11% medium intensity, 2% low intensity and 47% no statins. For HoFH, the corresponding values were 36%, 16%, 0 and 40%, respectively. Baseline ezetimibe use was 53% in HeFH and 48% in HoFH. Among HeFH patients, median (IQR) baseline LDL-C was 4.30 (3.41, 5.50) mmol/L; this dropped to 1.73 (1.03, 2.97) mmol/L within 3 months of evolocumab initiation, median LDL-C reduction 56% (Figure 1). Only 20 HoFH patients had a baseline LDL-C value; median (IQR), 4.07 (2.68, 6.17) mmol/L which dropped to 2.59 (1.63, 3.40) by month 3 [n=16]. No serious and no fatal adverse reactions were observed.

Figure 1

Conclusions

In this real-world study of evolocumab use in clinical practice, a large proportion of FH patients were not on statins and had LDL-C levels >4 mmol/L. After initiation of evolocumab median LDL-C fell by about one half in HeFH and by about one third in HoFH. Evolocumab was well-tolerated.

Acknowledgement/Funding

This study was fully funded by Amgen Inc

Mercury based drug in ancient India: The red sulfide of mercury in nanoscale

Mercury is one of the elements which had attracted the attention of the chemists and physicians of ancient India and China. Among the various metal based drugs which utilize mercury, we became interested in the red sulfide of mercury which is known in ancient Indian literature as rasasindur (alias rasasindura, rasasindoor, rasasinduram, sindur, or sindoor) and is used extensively in various ailments and diseases. Following various physico-chemical characterizations it is concluded that rasasindur is chemically pure α-HgS with Hg:S ratio as 1:1. Analysis of rasasindur vide Transmission Electron Microscopy (TEM) showed that the particles are in nanoscale. Bio-chemical studies of rasasindur were also demonstrated. It interacts with Bovine Serum Albumin (BSA) with an association constant of (9.76 ± 0.56) × 10³ M⁻¹ and behaves as a protease inhibitor by inhibiting the proteolysis of BSA by trypsin. It also showed mild antioxidant properties.

Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm

BACKGROUND

Perioperative mortality is low for patients undergoing abdominal aortic aneurysm (AAA) repair, but long-term survival remains poor. Although patients diagnosed with AAA have a significant burden of cardiovascular disease and associated risk factors, there is limited understanding of the contribution of cardiovascular risk management to long-term survival.

METHODS

General practice records within The Health Improvement Network (THIN) were examined. Patients with a diagnosis of AAA and at least 1 year of registered medical history were identified from 2000 to 2012. Medical therapies for cardiovascular risk were classified as antiplatelet, statin or antihypertensive agents. Progression to death was investigated using the G-computation formula with time-dependent co-variables to account for differences in exposure to cardiovascular risk-modifying treatments and the confounding between exposure, co-morbidities and death.

RESULTS

Some 12 485 patients had a recorded diagnosis of AAA. From 2000 to 2012, prescription of medications that modify cardiovascular risk increased: from 26·6 to 76·7 per cent for statins, from 56·5 to 73·9 per cent for antiplatelet agents and from 75·3 to 84·0 per cent for antihypertensive drugs. Adjusted Kaplan-Meier curves demonstrated a better 5-year survival rate in patients receiving statins (68·4 versus 42·2 per cent), antiplatelet agents (63·6 versus 39·7 per cent) or antihypertensive agents (61·5 versus 39·1 per cent), compared with rates in patients not receiving each therapy.

CONCLUSION

Appropriate risk factor modification could significantly reduce long-term mortality in patients with AAA. In the UK, up to 30 per cent of patients are not currently receiving these medications.

Cardiovascular and non-cardiovascular safety of dipeptidyl peptidase-4 inhibition: a meta-analysis of randomized controlled cardiovascular outcome trials

The full licensing of dipeptidyl peptidase-4 (DPP-4) inhibitors in the USA and Europe requires demonstration of cardiovascular (CV) safety with an upper boundary of harm of <30%. We report a total of 3334 CV events during 86,716 person-years of follow-up in 36,543 patients, when combining data from three trials with formal and prospectively assessed endpoints. Fixed-effect meta-analysis showed that, compared with placebo, DPP-4 inhibition did not increase the upper boundary of risk for the composite endpoint, nor for any individual component by >30%. Relative risks (RRs) were: 0.99 [confidence interval (CI) 0.93-1.06] for composite CV-specific death, non-fatal myocardial infarction (MI) and non-fatal stroke; 1.01 (CI 0.91-1.12) for CV-specific death; 0.98 (CI 0.89-1.09) for non-fatal MI; and 1.00 (CI 0.86-1.16) for non-fatal stroke. The risk of acute pancreatitis was increased (RR 1.79; CI 1.13-2.81), equating to 5.5 extra cases/10,000 patients/year (weighted mean) and a number needed to harm of 1940/year. These data provide reassurance about the safety of DPP-4 inhibitors with regard to individual atherothrombotic events and a safety signal for pancreatitis.

A meta-analysis of published studies of endothelial dysfunction does not support its routine clinical use

BACKGROUND

Endothelial dysfunction is a marker of future cardiovascular disease (CVD) risk, yet epidemiological studies have yielded inconsistent results. We therefore studied the association between endothelial dysfunction and CVD under diverse circumstances.

METHODS AND RESULTS

Literature-based meta-analysis of prospective observational studies with ≥ 12 months of follow-up published in Medline and having information on endothelial function and CVD outcomes. Tabular data on participant characteristics, endothelial function assessments and incident CVD outcomes were abstracted from individual studies. Random-effects meta-analysis was used to quantify pooled associations, and I(2) statistic to evaluate between-study heterogeneity. Potential sources of heterogeneity were explored by subgroup analyses and meta-regression. Thirty five studies involving 17,206 participants met the inclusion criteria. During more than 80,000 person-years of observation, up to 2755 CVD events were accrued, yielding a pooled relative risk (RR) of 1.25 (95% confidence interval 1.15-1.35) for CVD comparing top (i.e. more severe) vs. bottom (less severe) third of endothelial dysfunction. There was significant between-study heterogeneity and evidence of publication bias. RRs varied importantly according to the method used to ascertain endothelial function, and were higher among older individuals and among participants with risk factors for CVD or established CVD at baseline.

CONCLUSIONS

Although endothelial dysfunction is an important determinant of cardiovascular outcomes in people with pre-existing CVD, current evidence base does not support its use as a potentially useful measurement for risk stratification in people at lower risk of CVD.

Cardiovascular safety of the glucagon-like peptide-1 receptor agonist taspoglutide in people with type 2 diabetes: an individual participant data meta-analysis of randomized controlled trials

AIMS

To study the short-term cardiovascular effects of the once-weekly glucagon-like peptide-1 receptor agonist taspoglutide.

METHODS

We conducted a meta-analysis of individual-participant data from nine randomized controlled trials in the T-Emerge programme, which assessed the efficacy and safety of taspoglutide in type 2 diabetes. Our primary outcome was a composite of death from cardiovascular disease (CVD) and acute myocardial infarction, stroke and hospitalization for unstable angina.

RESULTS

Overall, 7056 individuals were included in the analysis, and there were 67 primary endpoint events during 7478 person-years of follow-up (40 vs 27 events in the intervention vs control groups, respectively). The odds ratio for the composite endpoint among people randomized to taspoglutide was 0.94 (95% confidence interval 0.57-1.56), which was robust across multiple subgroups. Longer-term data were not available as the development of taspoglutide was stopped because of gastrointestinal intolerance and serious hypersensitivity reactions.

CONCLUSIONS

The available data suggest that short-term, once-weekly administration of taspoglutide was not associated with an excess risk of CVD, and provide insights relevant to the development of other novel once-weekly incretin mimetics.

STATISTICAL PATTERN RECOGNITION TECHNIQUE FOR IMPROVED REAL-TIME MYOELECTRIC SIGNAL CLASSIFICATION

The authors in this paper propose a statistical technique for pattern recognition of electromyogram (EMG) signals along with effective feature ensemble to achieve an improved classification performance with less processing time and memory space. In this study, EMG signals from 10 healthy subjects and two transradial amputees for six motions of hand and wrist is considered for identification of the intended motion. From four channels myoelectric signals, the extracted time domain features are grouped into three ensembles to identify the effectiveness of feature ensemble in classification. The three feature ensembles obtained from multichannel continuous EMG signals are applied to the new classifiers namely simple logistic regression (SLR), J48 algorithm for decision tree (DT), logistic model tree (LMT) and feature subspace ensemble using k-nearest neighbor (kNN). Novel classifiers SLR, DT and LMT, select only the dominant features during training to develop the model for pattern recognition. This selection of features reduces the processing time as well as memory space of the controller for real-time application. The performance of SLR, DT, LMT and feature subspace ensemble using kNN classifiers are compared with other conventional classifiers, such as neural network (NN), simple kNN and linear discriminant analysis (LDA). The average classification accuracy with SLR is found to be better with feature ensemble-1 compared to the other classifiers. Also, the statistical Kruscal–Wallis test shows, the classification performance of SLR is not only better but also takes less time and memory space compared to other classifiers for classification. Also the performance of the classifier is tested in real-time with transradial amputees for actuation of drive for two intended motions with TMS320F28335eZdsp controller. The experimental results show that the SLR classifier improves the controller response in real-time.

The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis

AIMS/HYPOTHESIS

It is well established that diabetes mellitus increases the risk of cardiovascular disease (CVD) and all-cause mortality. Observational studies suggest that a history of diabetic foot ulceration (DFU) may increase this risk further still. We sought to determine to what extent DFU is associated with excess risk over and above diabetes.

METHODS

We identified studies reporting on associations of DFU with CVD and all-cause mortality. We obtained data on incident events of all-cause mortality, fatal myocardial infarction and fatal stroke. Study-specific estimates were pooled using a random-effects meta-analysis and the statistical heterogeneity of included studies was assessed using the I (2) statistic.

RESULTS

The eight studies included reported on 3,619 events of all-cause mortality during 81,116 person-years of follow-up. DFU was associated with an increased risk of all-cause mortality (RR 1.89, 95% CI 1.60, 2.23), fatal myocardial infarction (2.22, 95% CI 1.09, 4.53) and fatal stroke (1.41, 95% CI 0.61, 3.24). CVD mortality accounted for a similar proportion of deaths in DFU and non-DFU patients.

CONCLUSIONS/INTERPRETATION

Patients with DFU have an excess risk of all-cause mortality, compared with patients with diabetes without a history of DFU. This risk is attributable, in part, to a greater burden of CVD. If this result is validated in other studies, strategies should evaluate the role of further aggressive CVD risk modification and ulcer prevention in those with DFU.

Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies

BACKGROUND

Uncertainties persist about the magnitude of associations of diabetes mellitus and fasting glucose concentration with risk of coronary heart disease and major stroke subtypes. We aimed to quantify these associations for a wide range of circumstances.

METHODS

We undertook a meta-analysis of individual records of diabetes, fasting blood glucose concentration, and other risk factors in people without initial vascular disease from studies in the Emerging Risk Factors Collaboration. We combined within-study regressions that were adjusted for age, sex, smoking, systolic blood pressure, and body-mass index to calculate hazard ratios (HRs) for vascular disease.

FINDINGS

Analyses included data for 698 782 people (52 765 non-fatal or fatal vascular outcomes; 8.49 million person-years at risk) from 102 prospective studies. Adjusted HRs with diabetes were: 2.00 (95% CI 1.83-2.19) for coronary heart disease; 2.27 (1.95-2.65) for ischaemic stroke; 1.56 (1.19-2.05) for haemorrhagic stroke; 1.84 (1.59-2.13) for unclassified stroke; and 1.73 (1.51-1.98) for the aggregate of other vascular deaths. HRs did not change appreciably after further adjustment for lipid, inflammatory, or renal markers. HRs for coronary heart disease were higher in women than in men, at 40-59 years than at 70 years and older, and with fatal than with non-fatal disease. At an adult population-wide prevalence of 10%, diabetes was estimated to account for 11% (10-12%) of vascular deaths. Fasting blood glucose concentration was non-linearly related to vascular risk, with no significant associations between 3.90 mmol/L and 5.59 mmol/L. Compared with fasting blood glucose concentrations of 3.90-5.59 mmol/L, HRs for coronary heart disease were: 1.07 (0.97-1.18) for lower than 3.90 mmol/L; 1.11 (1.04-1.18) for 5.60-6.09 mmol/L; and 1.17 (1.08-1.26) for 6.10-6.99 mmol/L. In people without a history of diabetes, information about fasting blood glucose concentration or impaired fasting glucose status did not significantly improve metrics of vascular disease prediction when added to information about several conventional risk factors.

INTERPRETATION

Diabetes confers about a two-fold excess risk for a wide range of vascular diseases, independently from other conventional risk factors. In people without diabetes, fasting blood glucose concentration is modestly and non-linearly associated with risk of vascular disease.

FUNDING

British Heart Foundation, UK Medical Research Council, and Pfizer.

Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies

BACKGROUND

Uncertainties persist about the magnitude of associations of diabetes mellitus and fasting glucose concentration with risk of coronary heart disease and major stroke subtypes. We aimed to quantify these associations for a wide range of circumstances.

METHODS

We undertook a meta-analysis of individual records of diabetes, fasting blood glucose concentration, and other risk factors in people without initial vascular disease from studies in the Emerging Risk Factors Collaboration. We combined within-study regressions that were adjusted for age, sex, smoking, systolic blood pressure, and body-mass index to calculate hazard ratios (HRs) for vascular disease.

FINDINGS

Analyses included data for 698 782 people (52 765 non-fatal or fatal vascular outcomes; 8.49 million person-years at risk) from 102 prospective studies. Adjusted HRs with diabetes were: 2.00 (95% CI 1.83-2.19) for coronary heart disease; 2.27 (1.95-2.65) for ischaemic stroke; 1.56 (1.19-2.05) for haemorrhagic stroke; 1.84 (1.59-2.13) for unclassified stroke; and 1.73 (1.51-1.98) for the aggregate of other vascular deaths. HRs did not change appreciably after further adjustment for lipid, inflammatory, or renal markers. HRs for coronary heart disease were higher in women than in men, at 40-59 years than at 70 years and older, and with fatal than with non-fatal disease. At an adult population-wide prevalence of 10%, diabetes was estimated to account for 11% (10-12%) of vascular deaths. Fasting blood glucose concentration was non-linearly related to vascular risk, with no significant associations between 3.90 mmol/L and 5.59 mmol/L. Compared with fasting blood glucose concentrations of 3.90-5.59 mmol/L, HRs for coronary heart disease were: 1.07 (0.97-1.18) for lower than 3.90 mmol/L; 1.11 (1.04-1.18) for 5.60-6.09 mmol/L; and 1.17 (1.08-1.26) for 6.10-6.99 mmol/L. In people without a history of diabetes, information about fasting blood glucose concentration or impaired fasting glucose status did not significantly improve metrics of vascular disease prediction when added to information about several conventional risk factors.

INTERPRETATION

Diabetes confers about a two-fold excess risk for a wide range of vascular diseases, independently from other conventional risk factors. In people without diabetes, fasting blood glucose concentration is modestly and non-linearly associated with risk of vascular disease.

FUNDING

British Heart Foundation, UK Medical Research Council, and Pfizer.

In-vitro and in-vivo correlation for two gliclazide extended-release tablets

The aim of this study was to perform an in-vitro-in-vivo correlation (IVIVC) for two 60-mg gliclazide extended-release formulations (Fast and Slow release) given once a day and to compare their plasma concentrations over time. In-vitro release rate data were obtained for each formulation using the USP apparatus II, paddle stirrer at 50 and 100 rev min−1 in 0.1 M HCl and pH 7.4 phosphate buffer. The similarity factor (f2) was used to analyse the dissolution data. Eighteen healthy subjects participated in the study, conducted according to a completely randomized, two-way crossover design. The formulations were compared using area under the plasma concentration-time curve, AUC0-∞′, time to reach peak plasma concentration, Tmax', and peak plasma concentration Cmax', while correlation was determined between in-vitro release and in-vivo absorption. A linear correlation model was developed using percent absorbed data versus percent dissolved data from the two formulations. Predicted gliclazide concentrations were obtained by use of a curve fitting equation. Prediction errors were estimated for Cmax and area under the curve AUC0-∞ to determine the validity of the correlation. 0.1 M HCl at 50 rev min−1 was found to be the most discriminating dissolution method. Linear regression analysis of the mean percentage of dose absorbed versus the mean percentage of in-vitro release resulted in a significant correlation (r2 &gt; 0.98) for the two formulations. An average percent prediction error for Cmax was 4.15% for Fast release and 3.99% for Slow release formulation whereas for AUC0-∞ it was 6.36% and 4.66% for Fast release and Slow release formulation, respectively.

WITHDRAWN: Caregiver support for postpartum depression

BACKGROUND

Supportive relationships during the perinatal period may enhance a mother's feeling of wellbeing and control. Support to women during labour and after birth has shown benefits and this may also be the case for mothers with postpartum depression.

OBJECTIVES

The objective of this review was to assess the effect of professional and/or social support interventions for the treatment of postpartum depression.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: January 2001.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing additional support from caregivers with usual forms of care in the postpartum period, in women who were clinically depressed in the six months after giving birth.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by both reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Two studies involving 137 women were included. There is potential for bias in at least one study, due to large numbers of women refusing to take part in the trial as well as significant losses to follow-up during the trial. Treatment of postpartum depression with support was associated with a reduction in depression at 25 weeks after giving birth (odds ratio 0.34, 95% confidence intervals 0.17 to 0.69).

AUTHORS' CONCLUSIONS

There is some indication that professional and/or social support may help in the treatment of postpartum depression. The types of support should be investigated to assess which models are most effective.

Recent trials of lipid lowering

The global burden of coronary artery disease has pushed lipid-lowering therapy to the forefront of medical management of this condition. Recent clinical trials have compared the efficacy of more intensive lipid lowering with statins against the normal standard of care. Other agents such as fibrates, glitazones, which also favourably modify lipid levels have also been assessed recently. This narrative review summarises the key recent clinical trials of lipid lowering since 2004 and their implications for future patient care.

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 <or= cTnT < 0.1 microg/l), non-ST elevation MI (NSTEMI) (cTnT >or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.

A potential pharmacogenomic strategy for anticoagulant treatment in non-ST elevation acute coronary syndromes: the role of interleukin-1 receptor antagonist genotype

OBJECTIVES

Our aim was to determine a pharmacogenomic approach to heparin use in non-ST elevation acute coronary syndromes, specifically the impact of interleukin (IL)-1 receptor antagonist polymorphisms upon von Willebrand factor (vWF) responses to unfractionated heparin (UFH) and low molecular weight heparin (LMWH).

BACKGROUND

In acute coronary syndromes (ACS), identification of specific biological or genetic targets to direct pharmacological treatment remains a challenge. vWF has been shown to predict future cardiovascular risk and the response to anticoagulant treatments during non-ST elevation ACS. IL-1 receptor antagonist (IL-1RN) polymorphisms predict the change in vWF between 24 and 48 h (Delta vWF) during non-ST elevation ACS.

METHODS

We genotyped at the IL-1 locus, 67 patients with non-ST elevation ACS who received either LMWH or UFH, and measured vWF levels at 24 and 48 h.

RESULTS

LMWH was superior to UFH in reducing the rise in vWF between 24 and 48 h in the cohort as a whole. However, when patients were stratified by IL-1RN genotype, LMWH was superior to UFH in reducing Delta vWF only in allele *2 carriers (0.51 iU mL(-1) vs. 1.37, P < 0.01), but not in non-carriers (- 0.03 iU mL(-1) vs. 0.15, P = NS).

CONCLUSION

IL-1RN genotype may be a useful marker to identify patients that benefit from LMWH in non-ST elevation ACS.

Coronary artery stenting in unstable angina pectoris: a comparison with stable angina pectoris

OBJECTIVE

To compare early complication rates in unselected cases of coronary artery stenting in patients with stable v unstable angina.

SETTING

Tertiary referral centre.

PATIENTS

390 patients with stable angina pectoris (SAP) and 306 with unstable angina (UAP). Patients treated for acute myocardial infarction (primary angioplasty) or cardiogenic shock were excluded.

INTERVENTIONS

268 coronary stents were attempted in 211 patients (30.3%). Stents used included AVE (63%), Freedom (14%), NIR (7%), Palmaz-Schatz (5%), JO (5%), and Multilink (4%). Intravascular ultrasound was not used in any of the cases. All stented patients were treated with ticlopidine and aspirin together with periprocedural unfractionated heparin.

RESULTS

123 stents were successfully deployed in 99 SAP patients v 132 stents in 103 UAP patients. Failed deployment occurred with nine stents in SAP patients, v four in UAP patients (NS). Stent thrombosis occurred in four SAP patients and 11 UAP patients. Multivariate analysis showed no relation between stent thrombosis and clinical presentation (SAP v UAP), age, sex, target vessel, stent length, or make of stent. Stent thrombosis was associated with small vessel size (p < 0.001) and bailout stenting (p = 0.01) compared with elective stenting and stenting for suboptimal PTCA, with strong trends toward smaller stent diameter (p = 0.052) and number of stents deployed (p = 0.06). Most stent thromboses occurred in vessels < 3 mm diameter.

CONCLUSIONS

Coronary artery stenting in unstable angina is safe in vessels >/= 3 mm diameter, with comparable initial success and stent thrombosis rates to stenting in stable angina.

Infiltrating carcinoma of the lung

Images

Intravascular monitoring of successful reperfusion following rescue angioplasty

Images

Coronary spasm in acute myocardial infarction

A 30 year old man had an acute anterolateral myocardial infarction following which he developed unstable angina requiring percutaneous transluminal coronary angioplasty. He subsequently developed further angina with recurrence of coronary artery lesions that were reversed by intracoronary nitrate. A diagnosis of prinzmetal (vasospastic) angina was made and this had been the apparent cause of his myocardial infarction. He was treated with a calcium antagonist and an oral long acting nitrate with resolution of symptoms. He remained well and symptom free, and was reviewed in the outpatient clinic six weeks after discharge without problems.

Successful granulocyte transfusion therapy for gram-negative septicemia. A prospectively randomized controlled study

We prospectively randomized 27 granulocytopenic patients who experienced a total of 30 episodes of gram-negative septicemia. The control group received an appropriate antibiotic regimen alone, whereas the "transfusion" group received infusions of granulocytes in addition to the antibiotics. Five of 14 controls survived, and 12 of 16 in the transfusion group survived, and 12 of 16 in the transfusion group survived (P less than 0.04). An important factor in the outcome of treatment was the recovery of bone-marrow function (return of peripheral granulocyte count greater than or equal to 1000 per microliter). Eighty-three per cent (five of six) of the control group and all (four of four) of the transfusion group with recovery of granulocyte levels survived the episode of sepsis. In contrast, none of the eight control patients, as compared to 67 per cent (eight of 12) of the transfusion group, survived persistent granulocytopenia (P less than 0.005). Granulocyte transfusions appear to complement appropriate antibiotic treatment of gram-negative-septicemia due to granulocytopenia.