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Ray KK, Haq I, Bilitou A, Manu MC, Burden A, Aguiar C, Arca M, Connolly DL, Eriksson M, Ferrières J, Laufs U, Mostaza JM, Nanchen D, Rietzschel E, Strandberg T, Toplak H, Visseren FL, Catapano AL. Treatment gaps in the implementation of LDL cholesterol control among high- and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study. Lancet Reg Health Eur 2023; 29:100624. [PMID: 37090089 PMCID: PMC10119631 DOI: 10.1016/j.lanepe.2023.100624] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/08/2023] Open
Abstract
Background European data pre-2019 suggest statin monotherapy is the most common approach to lipid management for preventing cardiovascular (CV) events, resulting in only one-fifth of high- and very high-risk patients achieving the 2019 ESC/EAS recommended low-density lipoprotein cholesterol (LDL-C) goals. Whether the treatment landscape has evolved, or gaps persist remains of interest. Methods Baseline data are presented from SANTORINI, an observational, prospective study that documents the use of lipid-lowering therapies (LLTs) in patients ≥18 years at high or very high CV risk between 2020 and 2021 across primary and secondary care settings in 14 European countries. Findings Of 9602 enrolled patients, 9044 with complete data were included (mean age: 65.3 ± 10.9 years; 72.6% male). Physicians reported using 2019 ESC/EAS guidelines as a basis for CV risk classification in 52.0% (4706/9044) of patients (overall: high risk 29.2%; very high risk 70.8%). However, centrally re-assessed CV risk based on 2019 ESC/EAS guidelines suggested 6.5% (308/4706) and 91.0% (4284/4706) were high- and very high-risk patients, respectively. Overall, 21.8% of patients had no documented LLTs, 54.2% were receiving monotherapy and 24.0% combination LLT. Median (interquartile range [IQR]) LDL-C was 2.1 (1.6, 3.0) mmol/L (82 [60, 117] mg/dL), with 20.1% of patients achieving risk-based LDL-C goals as per the 2019 ESC/EAS guidelines. Interpretation At the time of study enrolment, 80% of high- and very high-risk patients failed to achieve 2019 ESC/EAS guidelines LDL-C goals. Contributory factors may include CV risk underestimation and underutilization of combination therapies. Further efforts are needed to achieve current guideline-recommended LDL-C goals. Trial registration ClinicalTrials.gov Identifier: NCT04271280. Funding This study is funded by Daiichi Sankyo Europe GmbH, Munich, Germany.
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Affiliation(s)
- Kausik K. Ray
- Imperial Centre for Cardiovascular Disease Prevention, ICTU-Global, Imperial College London, London, UK
- Corresponding author. Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK.
| | - Inaam Haq
- Medical Affairs, Daiichi Sankyo Europe, Munich, Germany
| | - Aikaterini Bilitou
- Health Economics and Outcomes Research, Daiichi Sankyo Europe, Munich, Germany
| | | | - Annie Burden
- Biostatistics and Data Management, Daiichi Sankyo Europe, Munich, Germany
| | - Carlos Aguiar
- Advanced Heart Failure and Heart Transplantation Unit, Heart Institute, Carnaxide, Portugal
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza Università di Roma, Rome, Italy
| | - Derek L. Connolly
- Sandwell and West Birmingham NHS Trust, Birmingham City Hospital, Institute of Cardiovascular Sciences, University of Birmingham, and Aston Medical School, Birmingham, UK
| | - Mats Eriksson
- Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jean Ferrières
- Department of Cardiology and INSERM UMR 1295, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Jose M. Mostaza
- Department of Internal Medicine, La Paz-Carlos III Hospital, Madrid, Spain
| | - David Nanchen
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Ernst Rietzschel
- Department of Internal Medicine and Pediatrics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Timo Strandberg
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Hermann Toplak
- Division of Endocrinology and Diabetology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Frank L.J. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alberico L. Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- Multimedica IRCCS, Milan, Italy
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Catapano AL, Manu MC, Burden A, Ray KK. LDL-C goal achievement and lipid-lowering therapy in patients by atherosclerotic cardiovascular disease subtype: the SANTORINI study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
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
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Affiliation(s)
- A L Catapano
- University of Milan, Department of Pharmacological and Biomolecular Sciences , Milan , Italy
| | - M C Manu
- Daiichi Sankyo Europe, Medical Affairs , Munich , Germany
| | - A Burden
- Daiichi Sankyo Europe, Biostatistics and Data Management , Munich , Germany
| | - K K Ray
- Imperial College London, Imperial Centre for Cardiovascular Disease Prevention, ICTU-Global , London , United Kingdom
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Ray KK, Manu MC, Burden A, Catapano AL. Cardiovascular risk factors in patients with and without a history of atherosclerotic cardiovascular disease in the SANTORINI study and estimation of risk. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
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
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Affiliation(s)
- K K Ray
- Imperial College London, Imperial Centre for Cardiovascular Disease Prevention, ICTU-Global , London , United Kingdom
| | - M C Manu
- Daiichi Sankyo Europe, Medical Affairs , Munich , Germany
| | - A Burden
- Daiichi Sankyo Europe, Biostatistics and Data Management , Munich , Germany
| | - A L Catapano
- University of Milan and Multimedica IRCCS, Department of Pharmacological and Biomolecular Sciences , Milan , Italy
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