Density Lipoprotein Cholesterol Target Research Articles

Efficacy of combination lipid lowering therapy in achieving low density lipoprotein cholesterol targets after one month of event in patients with acute coronary syndrome

Abstract Introduction Rapid reduction in low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of recurrent events in patients with acute coronary syndrome (ACS) with benefits proportional to LDL-C reduction. Early use of combination lipid-lowering therapy (LLT) is therefore recommended. Proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) combined with high-intensity statins (HIS) improve LDL-C goal attainment but are unaffordable for many patients in India and worldwide. Purpose We share our experience with the use of dual RE (rosuvastatin plus ezetimibe) and triple REB (rosuvastatin plus ezetimibe and bempedoic acid) combination LLT in patients admitted with ACS. Methods All ACS patients admitted to our institute over one year (January 2023 to December 2023) were considered in this retrospective analysis. Those with unavailable lipid profile reports, either at the time of ACS or at 1-month follow-up, were excluded. Clinical and laboratory details were obtained from hospital records. The primary objective was to assess the percentage change in LDL-C levels from index event to 4 weeks follow-up. Results A total of 299 patients were included, out of which 60 were on HIS alone, 71 were on RE, and 168 were on REB (Figure). The majority (99%) of patients in the REB group were statin naïve, compared to the other two groups. The baseline mean LDL-C levels at the time of the index event were 95.3+30.5, 103.2+39.6, and 115.6+32.9 mg/dl, respectively (p<0.001) (Table). The mean LDL-C levels at four weeks post-ACS reduced to 52.9+21.2, 45.9+20.5, and 43.7+15.4 mg/dl, respectively (p<0.01). The percentage reduction in LDL-C level was 44.4%, 55.5%, and 62.2%, respectively (p<0.001). REB enabled 70.8% and 95.2% of patients to achieve the Lipid Association of India, and American College of Cardiology recommended LDL-C targets of <50 mg/dl and <70 mg/dl within 4 weeks. These target levels were achieved in 67.6% and 88.7% of patients on the dual RE therapy and 50% and 81.6% of patients, respectively, on HIS alone. Conclusion Our study demonstrates the capacity to rapidly achieve LDL-C goals after ACS with triple REB therapy, an affordable regimen compared to costly PCSK9i therapy.Figure.Lipid lowering strategies usedComparison of study groups

Current aspects of stable ischemic heart disease. ISСHEMIA study: breakthrough or constant optimism in approaches to treatment. Myocardial ischemia in non-obstructive coronary arteries (INOCA)

Approaches to stable coronary artery disease (CАD) treatment have been subject to debate for a long time. One of the first and fundamental studies in stable coronary artery disease patients treatment is the COURAGE study, which showed the advantage of rational drug therapy in comparison with percutaneous intervention in such patients. However, CAD high prevalence with medical and social significance cause the need for future development of relationship between conservative and invasive approaches in the problem of this disease treatment. It was particularly the focus of recently completed multicentre ISCHEMIA trail. The aim of review is to analyze the available data on the management of stable coronary artery disease patients based on the ISCHEMIA study data. Results. In the largest multicenter randomized clinical trial ISCHEMIA, the primary outcome (cardiovascular death, myocardial infarction, cardiac arrest with effective resuscitation, hospitalization due to heart failure) rate was 13.3% in the routine invasive strategy group and 15.5% in the conservative strategy group (p = 0.34). The main secondary outcome rate also does not differ between groups significantly. Quality of life in the non-invasive group was higher only in those patients who had angina at baseline. Study subanalysis demonstrated that left coronary artery borderline stenosis accompanied by a poor prognosis, and an invasive strategy improves angina symptoms. Also, low density lipoprotein cholesterol target values achievement predictors were determined. In addition, women, participated in ISCHEMIA study had more frequent angina episodes, regardless less extensive coronary artery damage, and less severe ischemia manifestations than men. Among stable CAD accompanied moderate to severe ischemia and severe chronic kidney disease patients, no evidence initial invasive strategy, compared initial conservative strategy, in relation of death or non-fatal myocardial infarction risk reduction was found. Conclusion: ISCHEMIA trial data demonstrated necessity more carefully stable coronary artery disease patients selection for invasive treatment, taking into account angina pectoris severity and modern antianginal therapy possibilities.

Primary prevention efforts are poorly developed in people at high cardiovascular risk: A report from the European Society of Cardiology EURObservational Research Programme EUROASPIRE V survey in 16 European countries

European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V in primary care was carried out by the European Society of Cardiology EURObservational Research Programme in 2016-2018. The main objective was to determine whether the 2016 Joint European Societies' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been implemented in clinical practice. The method used was a cross-sectional survey in 78 centres from 16 European countries. Patients without a history of atherosclerotic cardiovascular disease either started on blood pressure and/or lipid and/or glucose lowering treatments were identified and interviewed ≥ 6 months after the start of medication. A total of 3562 medical records were reviewed and 2759 patients (57.6% women; mean age 59.0 ± 11.6 years) interviewed (interview rate 70.0%). The risk factor control was poor with 18.1% of patients being smokers, 43.5% obese (body mass index ≥30 kg/m2) and 63.8% centrally obese (waist circumference ≥88 cm for women, ≥102 cm for men). Of patients on blood pressure lowering medication 47.0% reached the target of <140/90 mm Hg (<140/85 mm Hg in people with diabetes). Among treated dyslipidaemic patients only 46.9% attained low density lipoprotein-cholesterol target of <2.6 mmol/l. Among people treated for type 2 diabetes mellitus, 65.2% achieved the HbA1c target of <7.0%. The primary care arm of the EUROASPIRE V survey revealed that large proportions of people at high cardiovascular disease risk have unhealthy lifestyles and inadequate control of blood pressure, lipids and diabetes. Thus, the potential to reduce the risk of future cardiovascular disease throughout Europe by improved preventive cardiology programmes is substantial.

Alirocumab Administration Experience to Achieve Low Density Lipoprotein Cholesterol Target Levels in Secondary Prevention of Cardiovascular Disease

Aim. To study the effects of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, alirocumab, on lipid levels in patients who receive secondary prevention of cardiovascular diseases (CVD) and require enhanced lipid-lowering therapy.Material and methods. The study included 49 patients (aged of 61.53±1.14 years; 31 [63.3%] men) receiving alirocumab who did not reach the target low density lipoprotein cholesterol (LDL-C) concentrations despite the ongoing optimal lipid-lowering therapy. In all patients, the initial level of lipids was evaluated, as well as their parameters after subsequent alirocumab injections.Results. LDL-C serum level significantly decreased after the first injection compared to the initial level from 2.92±0.22 to 1.65±0.19 mmol/L (p&lt;0.001; Δ45.31±3.61%) and down to 1.74±0.17 mmol/L for the entire study period (p&lt;0.001; Δ41.52±2.69%). The change in LDL-C level between injections did not show statistically significant differences (p=0.141). A direct strong statistically significant correlation between the LDL-C level after the first injection and its average values for the entire observation period was found (r=0.958, p&lt;0.001).Conclusion. The results of the study indicate that the PCSK9 inhibitor, alirocumab, in patients who need secondary prevention of CVD shows a significant additional decrease in the concentration of LDL-C after the first injection. At the same time, approximately half of the patients were able to achieve the recommended levels of LDL-C. The persistence of the achieved low LDL-C levels over time demonstrated that the average concentration of LDL-C during the observation corresponded to the values after the first injection. This finding shows that there is no need for constant monitoring of lipid metabolism parameters when prescribing such therapy.

Efficacy of low- and moderate-intensity statins for achieving low- density lipoprotein cholesterol targets in Thai type 2 diabetic patients

BackgroundLow dose statins are commonly used among Asians, because plasma low-density lipoprotein cholesterol (LDL-C) reductions similar to those observed in Westerners are achieved at lower doses. We aimed to assess the efficacy of low- and moderate-intensity statins for achieving plasma lipid targets in Thai type2 diabetes (T2D) and to evaluate factors associated with greater LDL-C reduction by statins.MethodsT2D patients who were treated with low- and moderate-intensity statins at the Siriraj Diabetes Clinic during the January 2013 to December 2014 study period were eligible for inclusion(n = 978), 400 patients were randomly recruited. Patients were classified into 1 of the following 2 groups according to their plasma LDL-C reductions by statins (N = 393); very favorable response (LDL-C reduction ≥50%) or less favorable response (LDL-C reduction <50%).ResultsOf the 400 patients, 41.3% were low-intensity statin users. Mean age was 64.4 ± 12.7 years, 64% were female. Median duration of diabetes was 13.3 years and mean HbA1C was 8.1 ± 1.9%. Plasma LDL-C goal of <100 mg/dl and <70 mg/dl was achieved in 84.3% and 38.0% respectively, with no significant difference between the low- and moderate-intensity statin users. LDL-C reductions ≥50% can be achieved in 38.4%. Factors associated with very favorable responses from statins were age, hypertension, patients with stable or reduced weight, and better glycemic control.ConclusionLow- and moderate-intensity statins achieved plasma LDL-C goal of <100 mg/dl and <70 mg/dl in 84.3%, and 38.4% of the patients respectively. Due to the improved response to lower doses observed in Asians, a titration dosage strategy should be considered.

Personalised physician learning intervention to improve hypertension and lipid control: randomised trial comparing two methods of physician profiling

PurposeTo assess the impact of personalised physician learning (PPL) interventions using simulated learning cases on control of hypertension and dyslipidaemia in primary care settings.MethodsA total of 132 primary care physicians,...

The ideal management of blood cholesterol: a review of the updated 2013 ACC/AHA cholesterol guideline for reducing cardiovascular risk

질환에 의하여 사망한다[1]. 죽상경화성 심혈관질환은 건강한 Atherosclerotic cardiovascular disease (ASCVD) is the most important public health problem worldwide in terms of the size of expenditures in most healthcare budgets. In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce ASCVD risk in adults. Based on the design and results of the randomized clinical trials and meta-analyses published through July 2013, four groups of individuals were identified for whom an extensive body of randomized clinical tria evidence demonstrated a clear reduction in ASCVD events from statin therapy with a good margin of safety. Together with ASCVD, in severe hypercholesterolemic (low-density lipoprotein cholesterol ≥190 mg/dL) or diabetic subjects, the guideline recommends the use of statins if the newly-developed Pooled Cohort Equations estimate a 10-year ASCVD risk of equal to or higher than 7.5%. The guideline recommendations represent a new paradigm for treating cholesterol focused on using the appropriate intensity of statin therapy for those most likely to benefit, while the guideline has eliminated low-density lipoprotein cholesterol and non–high–density lipoprotein cholesterol targets. Non-statin therapies were discouraged due to the lack of evidence for their production of acceptable ASCVD risk reduction benefits. This radical shift away from the set of previous guidelines has created controversy and confusion. This article reviews the 2013 ACC/AHA guideline for the treatment of blood cholesterol to reduce ASCVD risk in adults and the optimal strategies for using this guideline in clinical practice.

Atherosclerosis: from biology to pharmacological treatment.

A recent explosion in the amount of cardiovascular risk has swept across the globe. Primary prevention is the preferred method to lower cardiovascular risk. Lowering the prevalence of obesity is the most urgent matter, and is pleiotropic since it affects blood pressure, lipid profiles, glucose metabolism, inflammation, and atherothrombotic disease progression. Given the current obstacles, success of primary prevention remains uncertain. At the same time, the consequences of delay and inaction will inevitably be disastrous, and the sense of urgency mounts. Pathological and epidemiological data confirm that atherosclerosis begins in early childhood, and advances seamlessly and inexorably throughout life. Risk factors in childhood are similar to those in adults, and track between stages of life. When indicated, aggressive treatment should begin at the earliest indication, and be continued for many years. For those patients at intermediate risk according to global risk scores, C-reactive protein, coronary artery calcium, and carotid intima-media thickness are available for further stratification. Using statins for primary prevention is recommended by guidelines, is prevalent, but remains under prescribed. Statin drugs are unrivaled, evidence-based, major weapons to lower cardiovascular risk. Even when low density lipoprotein cholesterol targets are attained, over half of patients continue to have disease progression and clinical events. Though clinical evidence is incomplete, altering or raising the blood high density lipoprotein cholesterol level continues to be pursued. The aim of this review is to point out the attention of key aspects of vulnerable plaques regarding their pathogenesis and treatment.

Low density Lipoprotein cholesterol target: Changing goal posts

Elevated low density lipoprotein cholesterol (LDL) has been identified as one of the strongest correctable risk factors for cardiovascular disease in patients with diabetes. The reduction in cardiovascular events with pharmacological therapy aimed at LDL lowering is well documented in both primary prevention and secondary prevention. In this article, we review the evolving trend of aggressive LDL cholesterol lowering strategies.

The role of clinical pharmacist on lipid control in dyslipidemic patients in North of Jordan

The purpose of this study is to investigate the effectiveness of introducing clinical pharmacy services in achieving goal lipid profile in dyslipidemia patients in North of Jordan. Setting the study was carried out in a primary care facility in North of Jordan. One hundred fifty two dyslipidemia patients were randomized into intervention and control groups and followed for 6 months period. Intervention group patients were followed intensively by a clinical pharmacist who worked closely with physicians in controlling lipid profiles according to the third edition of recommendations by The National Cholesterol Education Program Adult Treatment Panel, control group patients were provided with standard medical care. Main outcome measure percent of patients at their low density lipoprotein cholesterol target in the intervention group compared to percent of patients at their low density lipoprotein cholesterol target in the control group by the end of the study. One hundred twenty five patients completed the study duration. After 6 months, 94.5% of intervention group patients and 71.2 % of control group patients reached their goal low density lipoprotein cholesterol levels (P value < 0.001, Pearson Chi-Square test) compared to 24.7 and 28.8% respectively at baseline. Majority of pharmacist recommendations (90.4%) were followed by physicians and overall lipid lowering agents use was increased to 91.8% in intervention group patients and 86.5% in control group patients compared to 69.9 and 78.8% respectively at baseline. Implementing clinical pharmacy services in Jordan has improved the lipid profiles of dyslipidemic patients.

Low Density Lipoprotein Cholesterol Target Goal Attainment Rate and Physician Perceptions about Target Goal Achievement in Korean Patients with Diabetes

BackgroundThis study aims to investigate the discrepancy between clinicians' perceptions and actual achievement rates of low density lipoprotein cholesterol (LDL-C) in Korean patients with diabetes according to updated American Diabetes Association (ADA)/American College of Cardiology Foundation (ACC) recommendations.MethodsThis is a multi-center, retrospective, non-interventional, observational study. Diabetic patients aged 18 years or older were eligible if they had been diagnosed with hypercholesterolemia or were receiving a lipid-lowering therapy between May 2010 and August 2010. The information was obtained by reviewing medical records and using a self-completed questionnaire to examine physician perceptions.ResultsA total of 2,591 subjects who satisfied the inclusion criteria were enrolled. Highest-risk and high-risk patients accounted for 61.9% and 38.1% of the patients, respectively. Although most (96.3%) underwent a statin monotherapy or a statin-based combination therapy, just 47.4% of patients attained the LDL-C target. However, the physicians' perceptions on target achievement rate (70.6%) were different from the actual results (47.4%). Many patients (65.3%) remained on the starting doses of statins, despite evidence of poor achievement of lipid goals.ConclusionOnly less than half of patients with diabetes attained the LDL-C goal. The surveys showed that poor physician performance might be due to the lack of recognition on ADA/ACC consensus causing a low LDL-C target attainment rate. Therefore, changes in doctor perception are needed to attain target LDL-C level and reduce cardiovascular risk in Korean patients with diabetes.

Low Density Lipoprotein Cholesterol Target Goal Attainment Rate in Korean Patients with Diabetes

Hypertension, dyslipidemia, and smoking are all factors that increase the risk of cardiovascular disease in patients with type 2 diabetes [1]. Among them, one of the most important risk factors is dyslipidemia. Among lipoproteins, low density lipoprotein cholesterol (LDL-C) level is the most important predicting factors for cardiovascular disease, and many large-scale studies have been ongoing for many years to determine the target value for LDL-C treatment [2]. Since the risk of cardiovascular disease in type 2 diabetes patients is higher than that in healthy, the target LDL-C value in diabetes patients has been emphasized as being even more important than other metrics [3]. When the recommended LDL-C treatment goals of the 2003 Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP) and the 2008 American Diabetes Association (ADA) released consensus with the American College of Cardiology (ACC) [4] and the dyslipidemia treatment goal guidelines in accordance with the 2011 European Society of Cardiology (ESC) and the European Society of Arteriosclerosis (ESA) were examined, recent trends generally call for more aggressive LDL-C reduction than what has been seen in previous guidelines particularly in the patient group with the highest risk, where an LDL-C target value less than 70 mg/dL is encouraged [5]. Based on the ESC and the ESA guidelines, cardiovascular disease, severe chronic kidney disease, and target organ damage are all included in the highest risk factors for the diabetes group. Even when diabetes is the only risk factor, the target value for LDL-C is recommended to be less than 70 mg/dL [5]. The LDL-C treatment target values have gradually been getting more aggressive all over the world. Although the changes in these values are aggressive, there is no set guideline for LDL-C treatment target values in Koreans, specifically Koreans who have diabetes. There are also very few studies that show the actual level of success of dyslipidemia treatment according to this guideline or how effectively the treatment target value is achieved (achievement rate). Hwang et al. [6] performed a study on diabetes patients over 18 years of age who were receiving treatment for hyperlipidemia. Research was conducted on the difference between the achievement rate of actual treatment target value of LDL-C and recognition rate of target values by medical personnel (expected achievement rate). Among the patients who had received treatment, 35.9% (approximately 1/3 of the total participants) reached the actual LDL-C target value, while that the expected achievement rate was reported in 70.6% of the total participants. In addition, even when lipid levels did not reach the target value, 65.3% of patients were receiving the same statin dosage as when the treatment was started. The authors felt that these results were due to a lack of recognition of the target lipid values by the medical personnel. So, in order to decrease the risk of cardiovascular disease in Korean diabetes patients and in order for LDL-C treatment goals to be reached, they proposed that the recognition standards of the medical personnel be changed [6]. A limitation to this study is that they did not consider whether participants performed any sort of diet or exercise, and drug compliance was also not considered. In actual clinical practice, it could easily be seen that lipid levels did not reach the target values, and clinicians were able to provide adequate care. In particular, in diabetes patients at relatively high risk for cardiovascular disease, statin dosage is increased, being able to reach the target value is the most feasible basis. In the future, even when patients receive treatment, prospective studies regarding the difficulty to reach the lipid target value (due to the low success rate) are required. In addition, during dyslipidemia treatment, statin drug therapy is not the only treatment method used; diet management and exercise are often combined with the treatment process. Additional studies on other positive effects, the need for education, and effectiveness of these treatments will be very helpful in the treatment of dyslipidemia.

Effect of ezetimibe in patients who cannot tolerate statins or cannot get to the low density lipoprotein cholesterol target despite taking a statin

ABSTRACTBackground: Recent guidelines underline the need for high-risk patients to reach strict low density lipoprotein cholesterol (LDL‑C) targets (1.8–2.6 mmol/L; 70–100 mg/dL), and specifically mention the possible use of combination therapy (e.g. statin + ezetimibe) to achieve these goals.Methods: A retrospective case-note audit was carried out to assess the response to administering ezetimibe in patients unable to tolerate statins (Group 1), or high dose of statins (Group 2) and patients who cannot achieve the LDL‑C target (2.6 mmol/L; 100 mg/dL) despite taking a statin (Group 3).Results: Ezetimibe lowered LDL‑C levels by 20–29% across the 3 patient groups after 2–3 months of treatment. High density lipoprotein cholesterol (HDL‑C) levels tended to remain unchanged, although there was a consistent trend for a fall if baseline values were ‘high’. However, the LDL-C/HDL-C ratio changed significantly and favourably in all groups. The fall in fasting triglyceride levels in all groups was greater (reaching 19–25%) when baseline levels were ≥ 1.5 or 1.7 mmol/L (136–150 mg/dL). There were no marked abnormalities in liver function tests or creatine kinase activity. In Group 3 there was a significant trend for a fall in serum creatinine levels across the tertiles of baseline creatinine values.Limitations of the present study include the small sample size (especially in Groups 1 and 2), its short-term duration and the absence of event-based end-points. Therefore, the results are hypothesis-generating rather than conclusive.Conclusions: When used alone or added to a statin, ezetimibe favourably altered the LDL‑C/HDL‑C ratio and lowered triglyceride levels. Ezetimibe was well tolerated in patients with statin intolerance and was associated with a 26% fall in LDL‑C. An additional action may be some degree of improved renal function. Further studies are needed to confirm these findings.

A Randomized Multicenter Trial Comparing and Efficacy of Simvastatin and Fluvastatin.

BACKGROUND: Inhibitors of hydroxymethylglutaryl co-enzyme A reductase are widely used for the treatment of hypercholesterolemia. Physicians and third-party payers need an accurate measure of their relative potency and hypolipidemic efficacy. We have therefore compared simvastatin against fluvastatin, the newest member of this class. METHODS AND RESULTS: One hundred fifty-eight hypercholesterolemic patients in seven United States lipid clinics participated in this balanced double-blind incomplete block study. After a placebo-diet run-in period, patients received treatment with active drug for three consecutive 5-week periods, with measurement of lipids in a NHLBI-CDC standardized central laboratory at the end of each period. Each patient was randomly assigned to three of the following five treatments: simvastatin 5 mg, 10 mg, and 20 mg and fluvastatin 20 mg and 40 mg. The mean percent reductions in low density lipoprotein cholesterol from baseline were 21, 27, 32, 16, and 23 respectively. The simvastatin/fluvastatin milligram potency ratio was 6.8 (95% CI, 5.3-9.3). At the same 20 mg dose, simvastatin produced an effect on LDL cholesterol approximately double that of fluvastatin and resulted in 46% of patients achieving their National Cholesterol Education Program low density lipoprotein cholesterol target levels, compared to 12% for fluvastatin. CONCLUSIONS: Fluvastatin at its maximal dose of 40 mg daily is approximately equivalent to simvastatin 5 mg daily. Higher doses of simvastatin are considerably more effective in the treatment of primary hypercholesterolemia.