P2781How to bridge residual distance to target low-density-lipoprotein cholesterol in stroke patients after initial statin therapy?

Abstract

Abstract Background Current guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering to target LDL-C <1.8mmol/L after ischemic stroke (IS). Residual distance to LDL-C target can help select further treatment options after initial statin therapy. Purpose We aimed to evaluate residual distance to target LDL-C and the proportion of IS patients who are projected to reach target LDL-C by different statin and non-statin lipid lowering strategies. Methods We retrospectively analyzed 5,025 patients admitted with IS or transient ischemic attack who survived 1 year from an academic institution in Hong Kong between Jan 2005 and Sep 2017. Patients were divided into (i) high potency (HP-S; rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg); (ii) non-high potency (NHP-S; other statin doses) statin users and (iii) no statin therapy. We calculated the mean distance and percentage LDL-C reduction required to reach target LDL-C. We assumed up-titration from NHP-S to HP-S would further reduce LDL-C by 5–15%; addition of ezetimibe 15–25%; up-titrate to HP-S plus ezetimibe 20–40% and combine statin with proprotein convertase subtilsin-kexin type 9 inhibitor (PCSK-9) 40–60%. Results Of 5,025 patients (56.3% males, mean age 69.1±11.5 years), 62.4% (3134/5025) had LDL-C ≥1.8mmol/L at 12-months after index stroke with 16.7% (839/5025), 80.9% (4064/5025) and 2.4% (122/5025) of patients on no statin, NHP-S and HP-S, respectively. 58.1% (2362/4064) of NHP-S and 60.7% (74/122) of HP-S users did not reach LDL-C target. Among these patients, the mean LDL-C was 2.5±0.6 and 2.8±1.0mmol/L; mean residual distance to target 0.7±0.6 and 1.0±1.0mmol/L; and mean percentage LDL-C reduction required to reach target LDL-C goal was 23.3±15.1% and 29.5±18.1%, respectively. The proportion of NHP-S users projected to reach target LDL-C is 34.9% (824/2362) by up-titrating/switching to HP-S, 57.2% (n=1352/2362) by addition of ezetimibe, 84.5% (n=1997/2362) by up-titration to HP-S plus ezetimibe and 98.6% (2330/2362) with PCSK-9 inhibitor (Figure 1). The proportion of HP-S users projected to reach target LDL-C is 43.2% (32/74) by addition of ezetimibe and 94.6% (70/74) with PCSK-9 inhibitor (Figure 1). Conclusion The use of high-potency statin is low and more than 50% of statin users did not reach target LDL-C at 12-months after index stroke. Combined up-titration to high-potency statin plus addition of ezetimibe is expected to bridge residual distance to target LDL-C in majority of stroke patients. Acknowledgement/Funding Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme (Asia) Ltd.