Dyslipidemia Guidelines Research Articles

Association of lipid target achievement and cardiovascular outcomes following statin initiation: a population-based cohort study

Abstract Introduction Non-high density lipoprotein cholesterol (non-HDL-C) is increasingly incorporated into clinical practice guidelines along with low density lipoprotein cholesterol (LDL-C) to guide lipid-lowering therapy decisions. We aimed to examine patterns of LDL-C and non-HDL-C levels after statin initiation for primary prevention of cardiovascular disease (CVD), and their association with incident CV events. Methods We conducted a population-based cohort study of Ontario, Canada residents age ≥66 years who initiated a statin for primary prevention between January 1, 2012 and December 31, 2019. For those surviving 1-year after statin initiation, we determined the proportion with a lipid panel in the 1-year period after a statin was started. For those with a lipid panel, we used the lipid panel closest to the end of the 1-year period to categorize individuals based on the LDL-C and non-HDL-C thresholds in the 2021 Canadian Cardiovascular Society dyslipidemia guidelines (Table 1). We stratified by diabetes/chronic kidney disease (CKD) status. We evaluated the association between LDL-C/non-HDL-C category and a composite of all-cause mortality or hospitalization for myocardial infarction, stroke or revascularization (primary outcome). We also investigated the association between each category and each component of the primary outcome. The index date was the 365 days after a statin was initiated and follow-up was until December 31, 2020. We used a cause-specific hazards model for analysis, adjusted for clinical and sociodemographic confounders. Results Our cohort comprised 173,127 people. In the 1-year period after statin initiation, 72% of people had a follow-up lipid panel performed. Median follow-up after that was 2.5 years. Compared with those meeting both LDL-C and non-HDL-C targets, being above both targets was associated with an increased rate of the primary outcome for people without diabetes/CKD (HR 1.10, 95% CI 1.05 to 1.15) and those with diabetes/CKD (HR 1.16, 95% CI 1.09 to 1.23). Being at LDL-C target but above non-HDL-C target was associated with an increased rate of the primary outcome for people with diabetes/CKD (HR 1.16, 95% CI 1.03 to 1.30) but not for those without diabetes/CKD (HR 1.05, 95% CI 0.93 to 1.17). Conclusions In this population-based cohort, having an LDL-C and non-HDL-C above guideline-recommended targets after statin initiation was associated with an increased rate of adverse outcomes. These findings support the residual risk associated with incompletely controlled LDL-C or non-HDL-C levels after initiating statin therapy for primary prevention.Primary outcome associationsComponents of primary outcome

Evaluation of infectious diseases physicians’ attitudes to dyslipidemia management in PLWH

ABSTRACT Objectives Dyslipidemia is a well-established risk factor for atherosclerotic cardiovascular disease (ASCVD). ASCVD prevalence among people living with HIV (PLWH) is twice that of the general population. This study aimed to evaluate the infectious diseases (ID) physicians’ attitudes on dyslipidemia management in PLWH. Methods This observational, cross-sectional study was conducted as online survey among ID physicians between November 2023 and February 2024. An e-mail with the survey link, title and purpose of the study was sent to physicians through the local ID societies. The survey included questions about physicians’ demographic characteristics and their attitudes toward treating dyslipidemia in PLWH. Results A total of 242 physicians responded to the survey, of whom 59.9% (n = 145) were ID specialists and 40.1% (n = 97) were ID residents. Forty-one percent (n = 100) of physicians reported that they did not follow a guideline, and 26% of physicians reported that they did not use a cardiovascular risk calculator in their clinical practice. Specialists (69%) were more likely than residents (43.3%) to follow clinical guidelines for dyslipidemia management (p < 0.001). Seventy-two percent (n = 174) of physicians doubted the need to treat dyslipidemia, and 73% (n = 177) of physicians were affected by the patient skepticism. Workload and lack of time were identified by 68.6% of physicians as barriers to implementing dyslipidemia guideline recommendations. Conclusion A considerable number of Turkish ID physicians did not prefer using clinical guidelines for dyslipidemia and ASCVD risk calculators. Statin prescribing of physicians was influenced by workload, lack of time, patient skepticism, and lack of knowledge. Training ID physicians in primary prevention of ASCVD and management of dyslipidemia in PLWH is paramount.

Effect of Preoperative Lipidemic Control on Retear Rates After Rotator Cuff Repair in Patients With Hyperlipidemia

Background: In patients with hyperlipidemia, the risk of retear increases after rotator cuff repair (RCR). In particular, it has been reported that preoperative low-density lipoprotein cholesterol (LDL-C) level affects cuff integrity. However, there are no studies assessing whether lipidemic control affects cuff healing. Purpose: To evaluate the effect of preoperative lipidemic control on cuff integrity after arthroscopic RCR across cardiovascular disease risk groups in patients with hyperlipidemia. Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively reviewed the charts of patients with hyperlipidemia who underwent arthroscopic double-row suture bridge RCR between 2014 and 2019. The included patients had LDL-C tested within 1 month before surgery. Magnetic resonance imaging was conducted 6 months after surgery to evaluate the integrity of the repaired cuff tendon. Patients were divided into groups of low, moderate, high, and very high risk according to the 4th Korean Dyslipidemia Guidelines. On the basis of the target LDL-C set in each risk group, patients were categorized into 2 groups: group C (controlled hyperlipidemia, less than target LDL-C) and group U (uncontrolled hyperlipidemia, target LDL-C or greater). The correlation between serum lipid profile, lipidemic control, and post-RCR integrity was evaluated. Results: A total of 148 patients were analyzed, 51 in group U and 97 in group C. The retear rate was significantly higher in group U than in group C (23/51 [45.1%] vs 18/97 [18.6%], respectively; P = .001). The proportion of group U was significantly higher in the retear group than in the healing group (56.1% vs 26.2%; P = .001). In addition, the proportions of patients with uncontrolled diabetes mellitus (DM) (19.5% vs 3.7%; P = .002) and mediolateral (2.6 ± 1.2 cm vs 1.7 ± 1.1 cm; P < .001) and anteroposterior (2.2 ± 1.1 cm vs 1.6 ± 0.8 cm; P = .003) tear sizes were significantly different between the retear and healing groups, respectively. No significant difference in serum lipid profile, including LDL-C level (119.6 ± 31.3 vs 116.7 ± 37.2; P = .650), was observed between the retear and healing groups. Multivariate regression analysis identified uncontrolled hyperlipidemia (OR, 4.005; P = .001), uncontrolled DM (OR, 5.096; P = .022), and mediolateral tear size (OR, 1.764; P = .002) as independent risk factors for retear. The 2.0-cm mediolateral size cutoff and the 3 independent risk factors had significant associations with retear. Conclusion: Poor preoperative lipidemic control was significantly associated with poor healing after RCR. In addition to large mediolateral tear size, uncontrolled hyperlipidemia and DM were significant risk factors for retear. Moreover, poor lipidemic control compared with the recommended target level before surgery was more correlated with an increased retear rate than a preoperative LDL-C level.

It is time to address the contribution of cholesterol in all apoB-containing lipoproteins to atherosclerotic cardiovascular disease.

On average, LDL particles are the most populous lipoprotein in serum under fasting conditions. For many reasons, it has been the primary target of lipid-lowering guidelines around the world. In the past 30 years, we have witnessed remarkable changes in each iteration of dyslipidaemia guidelines, with LDL-cholesterol (LDL-C) targets becoming lower and lower among patients at high and very high risk for atherosclerotic cardiovascular disease (ASCVD). The world over, goal attainment rates are low, and hence, ASCVD prevalence remains unacceptably high. Inadequate LDL-C lowering is a major issue in contemporary cardiovascular (CV) medicine. Another issue that vexes even the most astute clinician is that of 'residual risk', meaning the excess risk that remains even after LDL-C is appropriately reduced. In recent years, an important new component of residual risk has emerged: triglyceride-enriched lipoproteins or remnant lipoproteins. These precursors to LDL particles can assume outsized importance among patients with derangements in triglyceride metabolism (e.g. genetic variants, insulin resistance, and diabetes mellitus) and may be more atherogenic than LDL species. Consequently, to reduce total risk for acute CV events, the time has come to include the entire spectrum of apoB-containing lipoproteins in approaches to both risk evaluation and treatment.

Use of combination therapy is associated with improved LDL-cholesterol management: 1-year follow-up results from the European observational SANTORINI study.

To assess whether implementation of the 2019 ESC/EAS dyslipidaemia guidelines observed between 2020-2021 improved between 2021-2022 in the SANTORINI study. High- or very-high cardiovascular (CV) risk patients were recruited across 14 European countries from March 2020-February 2021, with 1-year prospective follow-up until May 2022. Lipid-lowering therapy (LLT) and 2019 ESC/EAS risk-based low-density lipoprotein cholesterol (LDL-C) goal attainment (defined as <1.4 mmol/L for patients at very high CV risk and <1.8 mmol/L for patients at high CV risk) at 1-year follow-up were compared with baseline. . Of 9559 patients enrolled, 9136 (2626 high risk, 6504 very high risk) had any follow-up data, and 7210 (2033 high risk, 5173 very high risk) had baseline and follow-up LDL-C data. LLT was escalated in one-third of patients and unchanged in two-thirds. Monotherapy and combination therapy usage rose from 53.6% and 25.6% to 57.1% and 37.9%, respectively. Mean LDL-C levels decreased from 2.4 mmol/L to 2.0 mmol/L. Goal attainment improved from 21.2% to 30.9%, largely driven by LLT use among those not on LLT at baseline. Goal attainment was greater with combination therapy compared with monotherapy at follow-up (39.4 vs 25.5%). LLT use and achievement of risk-based lipid goals increased over 1-year follow-up particularly when combination LLT was used. Nonetheless, most patients remained above goal, hence strategies are needed to improve implementation of combination LLT.

The impact of the 2019 ESC/EAS dyslipidaemia guidelines on real-world initial lipid-lowering therapy in patients with acute myocardial infarction.

This study aimed to investigate the impact of the latest guidelines on the real-world clinical practice of initial lipid-lowering therapy, especially on the use of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in China. All adult patients diagnosed with acute myocardial infarction in our hospital between August 31, 2018, and August 31, 2020, were divided into the following 2 groups: those patients treated before the latest guideline release, and those patients treated after the release. A propensity score-matched method was used, and logistic regression was used to assess the association with intensive statin, ezetimibe and PCSK9 inhibitor usage together with treatment results between the 2 groups. A total of 325 patients were enrolled in this study, including 141 patients who were admitted before the release of the latest guideline and 184 patients who were admitted after the release. After a median follow-up time of 8.20 months, the mean low-density lipoprotein cholesterol was 1.87 ± 0.59 mmol/L (1.87 ± 0.55 in the before group vs 1.88 ± 0.62 in the after group, P = .829). After propensity score matching, the initial usage of intensive statin therapy was decreased after guideline release without statistical significance (17.00% vs 28.00%, P = .090), whereas the usage of ezetimibe and PCSK9 inhibitors was increased (19.00% vs 8.00%, P = .039; and 10.00% vs 3.00%, P = .085, respectively). In logistic regression models, the release of the guideline was associated with a statistically significantly increased use of ezetimibe (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.21, 3.02; P = .005), a marginally decreased use of intensive statins (OR: 0.68; 95% CI: 0.45, 1.03; P = .069) and a marginally increased use of PCSK9 inhibitors (OR: 1.31; 95% CI: 0.98, 1.76; P = .068). In this single-center, real-world data analysis, after the release of the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, an increasing number of patients with a recent acute myocardial infarction were initially receiving ezetimibe and PCSK9 inhibitors.

European Lipid Guidelines and Cardiovascular Risk Estimation: Current Status and Future Challenges.

Genetic, experimental, epidemiologic, and clinical data support the causal role of elevated levels of low-density lipoprotein cholesterol (LDL-C) in atherosclerosis and cardiovascular disease (CVD). The recommendations of the 2019 European guidelines are based on the concept of differential CV risk, which in turn defines the LDL-C goals that should be achieved. The 2019 ESC/EAS guidelines for dyslipidaemia use the Systematic COronary Risk Evaluation (SCORE) model to assess CV risk, which provides a 10-year risk of fatal CV event. The SCORE model has recently been updated to reflect current rates of cardiovascular disease in Europe. The new SCORE2 model provides estimates of the 10-year risk of fatal and non-fatal CVD events in people aged 40-69 years, thus improving the identification of individuals at higher risk of a CVD event. However, as in the SCORE age is the main determinant of risk, young people have a relatively low estimated 10-year risk of a CV event even with high levels of one or more causal risk factors. Individuals with familial hypercholesterolaemia, who have elevated LDL-C levels from birth and have a high risk of premature CVD, are one example. The concept of cumulative LDL exposure is thus becoming increasingly important. This is also supported by Mendelian randomisation studies showing that carrying genetic variants associated with lower LDL-C levels reduces CV risk. These observations have introduced the concept of "cholesterol-years", which takes into account both LDL-C levels and time of exposure. It is crucial that future European guidelines pay more attention to this point.

Chemical and perfusion markers as predictors of moyamoya disease progression and complication types

To investigate the association between chemical markers (triglyceride, C-reactive protein (CRP), and inflammation markers) and perfusion markers (relative cerebral vascular reserve (rCVR)) with moyamoya disease progression and complication types. A total of 314 patients diagnosed with moyamoya disease were included. Triglyceride and CRP levels were assessed and categorized based on Korean guidelines for dyslipidemia and CDC/AHA guidelines, respectively. Perfusion markers were evaluated using Diamox SPECT. Cox proportional hazard analysis was performed to examine the relationship between these markers and disease progression, as well as complication types (ischemic stroke, hemorrhagic stroke, and rCVR deterioration). Elevated triglyceride levels (≥ 200) were significantly associated with higher likelihood of end-point events (HR: 2.292, CI 1.00–4.979, P = 0.03). Severe decreased rCVR findings on Diamox SPECT were also significantly associated with end-point events (HR: 3.431, CI 1.254–9.389, P = 0.02). Increased CRP levels and white blood cell (WBC) count were significantly associated with moyamoya disease progression. For hemorrhagic stroke, higher triglyceride levels were significantly associated with end-point events (HR: 5.180, CI 1.355–19.801, P = 0.02). For ischemic stroke, severe decreased rCVR findings on Diamox SPECT (HR: 5.939, CI 1.616–21.829, P < 0.01) and increased CRP levels (HR: 1.465, CI 1.009–2.127, P = 0.05) were significantly associated with end-point events. Elevated triglyceride, CRP, and inflammation markers, as well as decreased rCVR, are potential predictors of moyamoya disease progression and complication types. Further research is warranted to understand their role in disease pathophysiology and treatment strategies.

Adherence to Current Dyslipidemia Guideline in Patients Utilizing Statins According to Risk Groups and Gender Differences: The AIZANOI Study.

The aim of this study was to assess the adherence to the current European Society of Cardiology dyslipidemia guidelines, the ratio of reaching target values according to risk groups, and the reasons for not reaching LDL-cholesterol (LDL-C) goals in patients on already statin therapy in a cardiology outpatient population. The AIZANOI study is a multi-center, cross-sectional observational study including conducted in 9 cardiology centers between August 1, 2021, and November 1, 2021. A total of 1225 patients (mean age 62 ± 11 years, 366 female) who were already on statin therapy for at least 3 months were included. More than half (58.2%) of the patients were using high-intensity statin regimens. Only 26.2% of patients had target LDL-C level according to their risk score. Despite 58.4% of very high-risk patients and 44.4% of high-risk patients have been using a high-intensity statin regimen, only 24.5% of very-high-risk patients and only 34.9% of high-risk patients have reached guideline-recommended LDL-C levels. Most prevalent reason for not using target dose statin was physician preference (physician inertia) (40.3%). The AIZANOI study showed that we achieved a target LDL-C level in only 26.2% of patients using statin therapy. Although 58.4% of patients with a very high SCORE risk and 44.4% of patients with a high SCORE risk were using a target dose statin regimen, we were only able to achieve guideline-recommended LDL-C levels in 24.5% and 34.9% of them, respectively, in cardiology outpatients clinics. Physician inertia is one of the major factors in non-adherence to guidelines. These findings highlight that combination therapy is needed in most of the patients.

Evaluating risk-based allocation strategies for PCSK9 inhibitors: results from a simulation study in a contemporary ASCVD cohort

Abstract Background/Aim Targeting PCSK9 inhibitors (PCSK9i) to patients with high LDL-cholesterol (LDL-C) as well as a high cardiovascular event rate yields the highest therapeutic effect and is thus reasonable from a health economic perspective. The current European dyslipidaemia guideline determines PCSK9i eligibility solely by LDL-C, whereas guidelines from the US/the UK additionally use a set of clinical risk factors. Such selection criteria require evaluation. Methods We determined the cardiovascular event rate and calculated the cost/preventable cardiovascular event for PCSK9i initiation in the target populations according to three scenarios: (i) European Society of Cardiology (ESC) 2019 dyslipidaemia guideline (PCSK9i recommended for all patients with residual LDL-C &amp;gt;55 mg/dl), (ii) American Heart Association/American College of Cardiology (AHA/ACC) 2018 cholesterol guideline (use of PCSK9i restricted to patients with residual LDL-C &amp;gt;70 mg/dl and clinical risk factors) and (iii) UK National Institute for Health and Care (NICE) recommendation (use of PCSK9i restricted to patients with residual LDL-C &amp;gt;155 mg/dl or &amp;gt;135 mg/dl with clinical risk factors). A Monte Carlo simulation taking into account statin intolerance was used to simulate uptitration of lipid lowering medications according to the different scenarios. Analyses were based on patients with atherosclerotic cardiovascular disease (ASCVD) from a contemporary all-comers cohort recruited at a large tertiary care center in Germany. Major adverse cardiovascular events (MACE, defined as the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke) were recorded over a median follow-up of 4.2 years. Results We included 1922 patients with ASCVD (mean age 69.3 years, median baseline LDL-C 86.0 mg/dl, 75.0% male). Eligibility for PCSK9i was simulated to be 39.6% (ESC 2019), 6.2% (AHA/ACC 2018) and 1.4% (NICE). The 3 year cardiovascular event rates in the corresponding PCSK9i target populations were 11.4%, 13.8% and 13.8% respectively. Event rate differences were driven by a higher rate of non-fatal myocardial infarction in the risk-based target populations (5.2%, 8.2%, 7.2%). Annual cost/preventable event differed by up to a factor 3 (689,000 €, 515,000 € and 215,000 €), driven mainly by pre-PCSK9i LDL-C levels in the different target populations (68.8 mg/dl, 76.0 mg/dl and 182.7 mg/dl). (Table 1) Conclusion The AHA/ACC and NICE guidelines, based on both residual LDL-C and clinical risk factors, reduced the eligibility for PCSK9i as well as the cost/preventable cardiovascular event compared to the ESC guideline. However, the clinical criteria used for risk classification yielded limited discrimination for the identification of subpopulations at highest cardiovascular risk. Development of accurate risk prediction tools and their integration into risk-based allocation strategies, both requisites for a cost-effective use of PCSK9i, remain a challenge.Table 1

Cost impact of the ESC/EAS 2019 dyslipidemia guidelines recommended use of PSCK9i in very-high-risk patients with an LDL &amp;lt;1.8mmol/L for secondary prevention

Abstract ESC/EAS 2019 dyslipidemia guidelines give a class 1 recommendation to achieve a goal LDL-C of 1.4mmol/L in patients deemed very high risk. It is recommended to use a high dose statin and ezetimibe as first/second line therapies(1). In secondary prevention a class 1 recommendation is given for the addition of a PCSK9 inhibitors, if an LDL-C of 1.4mmol/L is not achieved. ODYSSEY and FOURIER used an LDL-C of &amp;gt;1.8mmol/l for trial inclusion, mean baseline LDL-C 2.25mmol/L and 2.38mol/l respectively(2, 3). Current Irish reimbursement criteria limit availability of PCSK9i due to high cost. Our aim was to determine the cost of PCSK9i therapy in patients post-PCI with an LDL-C of 1.5 – 1.8mmol/L and the potential cardiovascular benefit of a 1mmol/L reduction in LDL-C in this cohort. Methods We retrospectively analyzed patients at 6 - 8 weeks post-PCI in University Hospital Limerick (UHL) between January 2016 to December 2019. The cost analysis was based on a hierarchal analysis of patients on high dose statin, with an LDL-C &amp;gt;1.4mmol/L. Due to a low rate of prescribed ezetimibe we calculated the expected LDL-C, in patients on high dose statin with a presumed 25% reduction in LDL-C with the addition of ezetimibe. PCSK9i cost was based on the cohort of patients who would have an expected LDL-C &amp;gt;1.4 &amp; &amp;lt;1.8mmol/L despite treatment with high dose statin and ezetimibe. Cost was based on current pack reimbursement price of evoculmab, €8117.17 yearly. To calculate the benefit of a 1mmol/L LDL-C reduction in secondary prevention with PCSK9i therapy, we used a number needed to treat (NNT) of 21 over 5 years to prevent 1 CV death or myocardial infarctions based on meta-analysis data(4). Results A total of 784 patients were included in our analysis, who would be potentially eligible for a PCSK9i based on current ESC/EAS 2019 dyslipidemia guidelines with an expected LDL-C &amp;gt;1.4mmol/L. Baseline characteristics, mean age 63.6years, male 76.8%, 64.28% hypertension, 51.4% diabetes mellitus, smoking history 23.5%. Of the 784 patients potentially eligible for a PCSK9i, 375/784 (47.8%) had LDL-C of between 1.4mmol/L – 1.8mmol/L. Current cost for PSCK9i therapy for this patient cohort at our institution would result in potential total cost of €3,043,938.75 per year. In comparison expected cost of statin therapy in this group is €81,883.2 per year. 5 years of treatment with PCSK9i, assuming at least 1mmol/L reduction in LDL-C would be expected to prevent 17.8 CV deaths or MI’s in our cohort or €171,007.79 per event. In comparison the cost of statin therapy in this total cohort is €81,883.2 per year. Discussion Current cost of PCSK9i therapy in relation to first/second line lipid therapies makes prescribing prohibitive for patients with an LDL-C &amp;lt;1.8mmol/L. Additionally, the estimated cost of PCSK9i therapy to prevent one CVD/MI, limits the ability for this to become standard practice in Ireland, within the cohort of post-PCI patients with an LDL 1.4 – 1.8mmol/L.

Impact of ESC Guidelines implementation on lipid lowering strategy in a tertiary hospital cohort of STEMI patients: Can we aspire to do better than the EUROASPIRE V registry?

Abstract Background Treatment with LDL-C-lowering-drug therapy (LLT) is essential in the management of patients who have suffered an acute coronary syndrome. The latest 2019 ESC/EAS Guidelines for the management of dyslipidaemias recommend an LDL-C target of &amp;lt;55mg/dL and 50% reduction in these very high risk patients. However, the impact of these recommendations on contemporary LLT prescription is uncertain. Purpose To analyse the impact of the publication of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias on the prescription of LLT in our centre in patients who have suffered a ST elevation myocardial infarct (STEMI) and its impact on the achievement of treatment objectives and major adverse cardiovascular events (MACEs) in the first year of treatment. Methods All patients who suffered a STEMI at our centre in 2018 and 2021 were retrospectively registered. We compared baseline characteristics, ESC Guidelines objectives achievement at first follow-up visit and MACE in the first 1 year of treatment in both groups. The 2016 ESC Guidelines objective was defined as an LDL-C &amp;lt;70mg/dL and the 2019 ESC Guidelines objective was defined as an LDL-C &amp;lt;55 mg/dL. MACEs were defined as a combination of mortality, acute coronary syndrome, stroke, peripheral ischemia and need for revascularization. Those patients whose follow-up time until LDL-C after discharge was greater than 1 year were excluded from the final analysis. Results Of a total 726 STEMI patients, 520 patients were included in the final analysis. 239 in 2018 and 281 in 2021. No significant differences were found in baseline characteristics. LDL-C at admission was 115.7±39.3 mg/dL in 2018 and 110.6±38.6 mg/dL in 2021 (p 0.11). The prescription of ezetimibe in association with a high potency statin at discharge was significantly higher in 2021 (125 patients; 33.6%) compared to 2018 (17 patients; 5.07%) (p&amp;lt;0.001) and it was independently associated with the presence of prior lipid-lowering treatment (p &amp;lt; 0.011) and higher LDL-C at admission (p &amp;lt; 0.001). In 2018 there were 105 patients (50.24%) with LDL-C &amp;lt;70mg/dL and 52 patients (24.88%) with LDL-C &amp;lt;55mg/dL. This was significantly lower than in 2021, with 178 patients (66.67%) with LDL-C &amp;lt;70mg/dL and 112 patients (41.95%) with LDL-C &amp;lt;55mg/dL (p&amp;lt;0.001). MACEs after 1 year of treatment occurred in 27 patients (8.88%) in 2018 and in 31 patients (9.06%) in 2021 (p 0.935). Conclusions The adoption of the 2019 ESC/EAS Dyslipidaemia Guidelines recommendations has fostered a change in the LLT strategy in our centre leading to a greater number of patients reaching the LDL-C goal. Unfortunately, nearly 60% of them still have an LDL-C &amp;gt;55 mg/dL. This should prompt us to seek structured clinical pathways in order to improve our results.Figure 1

Effectiveness and safety of bempedoic acid in routine clinical practice: 1-year follow-up snapshot of the MILOS German cohort

Abstract Background Low-density lipoprotein cholesterol (LDL-C) has an established role in the development of atherosclerotic cardiovascular disease. The 2019 ESC/EAS dyslipidaemia guidelines recommended more intensive treatment goals, however, many patients do not reach them. Bempedoic acid (BA) is a first-in-class ATP citrate lyase inhibitor that lowers LDL-C levels. There is limited data on the use of BA and BA + ezetimibe (EZE) fixed-dose combination (FDC) in clinical practice. Purpose The purpose of this snapshot of 1-year follow-up data from the MILOS study is to evaluate the effectiveness and safety of BA and its FDC in routine clinical practice in Germany. Methods MILOS is a European, prospective, observational, non-interventional study in adult patients with primary hypercholesterolaemia or mixed dyslipidaemia. Patients were recruited from 126 sites in Germany between January 2021 and January 2022, and are followed up for 1–2 years after baseline measurements. Here, we summarise 1-year follow-up data from a snapshot taken on January 13th, 2023. Results Of 992 patients enrolled in Germany, 714 had either completed their 1-year follow-up or discontinued the study prematurely, and 524 of these 714 patients attended their 1-year follow-up visit. For this snapshot, 714 patients are used when determining cardiovascular (CV) outcomes and safety endpoints, and 524 patients are used when reporting efficacy data. The overall mean (SD) age of the population (n=524) was 64.7 (10.0) years, and 60.7% were male. Patients treated with BA/BA+EZE FDC had an overall mean LDL-C level of 2.18 mmol/L (84.1 mg/dL) at 1 year compared with 3.20 mmol/L (123.6 mg/dL) pre-treatment, representing a mean relative LDL-C reduction of 27.3%. Overall, 25.8% (135/524) of patients had reached their LDL-C goal after 1 year of treatment compared with 4.0% (21/524) pre-treatment (Figure 1A and 1B). The overall incidence rate of the composite endpoint of major adverse cardiovascular event (4-component MACE) including CV death, non-fatal myocardial infarction, non-fatal stroke, and coronary revascularisation (n=714) was 3.36%. At 1-year follow-up, 19% (136/714) of patients had an adverse drug reaction (ADR) suspected to be related to BA/BA+EZE FDC, and 0.8% (6/714) had serious ADRs, as deemed by the investigator. Conclusion This snapshot analysis of 1-year follow-up data suggests that the addition of BA to other lipid-lowering therapies increases the proportion of patients at LDL-C goal by ∼6-fold in the observed cohort. The safety and tolerability profile of bempedoic acid are in line with data from randomised controlled trials.

Flash'O real-world evidence programme - Attitude and practices toward the use of omega-3 FA by physicians from Middle East Countries.

The Flash'O project was designed to provide insights into the current use of prescription omega-3 and their perceived benefits by physicians in real-world clinical practice, in Russia, Saudi Arabia, Thailand, and Gulf countries, and to determine the adherence of physicians to dyslipidemia management guidelines. The present study focuses on Flash'O's process and results in Middle East countries. A total of 338 physicians and specialists completed the online questionnaire. Most responding physicians were male (91.7%), general practitioners (42.6%) with more than 5 years of seniority (80.4%) and saw more than 50 patients a week (71.5%). Most surveyed physicians (64.2%) reported using guidelines in their daily practice for the management of their patients with dyslipidemia. They mostly followed national guidelines (68.6%). American or European ones were less commonly used. Responding physicians thought that omega-3 supplementation could be more beneficial in all types of dyslipidemia, except high non- hight density lipoproteins, and for patients suffering from obesity, type 2 diabetes mellitus, acute coronary syndrome with ST-segment elevation myocardial infarction and high cardiovascular diseases risk (score ≥ 5% and < 10%), but less beneficial in chronic kidney disease. Respondents recommended omega-3 to their patients mainly after statin treatment in patients with dyslipidemia and for the treatment of dyslipidemia. This survey confirmed that omega-3 fatty acids are at the heart of the cardiovascular medical strategy.

Knowledge and adherence to National Institute of Clinical Excellence 2020, dyslipidaemia management guidelines and its associations among medical officers in Gampaha district, Sri Lanka: a descriptive study

Introduction: Dyslipidaemia is an important risk factor for cardiovascular diseases(CVD) and optimal management helps prevent CVD burden in a country. Knowledge of medical officers(MOs) on dyslipidaemia management is critical in this regard. We assessed knowledge and adherence of MOs of Gampaha district to the National Institute of Clinical Excellence (NICE) guideline 2020 on management of dyslipidaemia. Methods: We conducted a cross-sectional study at five secondary/tertiary-care hospitals in Gampaha District in January 2022. Knowledge and adherence were studied using a self-administered questionnaire consisting of 25 multiple-choice questions. Each question was scored "1" and the cumulative score was converted to 100. A score &gt;80 was considered "good knowledge and adherence" and its associations were studied using logistic regression.Results: A total of 413 MOs (63.4% females, mean age 45±7.6 years) participated in the study. Of them, 73.1% had worked in a medical ward previously. The mean knowledge and adherence score was 77±9.3. Only 30% had a score &gt;80. Good knowledge and adherence was significantly associated with being &lt;45 years (p .004) in age, having work experience in a medical ward (p&lt;.001), having post-graduate training (p&lt;.001), working in a tertiary care hospital(p=.007), and involved in private practice(p=.002). There was no significant association with attendance at continuing medical education programmes (p=.320) or the duration of service(p=.120).Conclusions: Only a third of MOs of Gampaha district had good Knowledge and adherence to NICE-2020 dyslipidaemia guidelines. Knowledge and adherence to the guideline was better in MOs who are young, in postgraduate training, with previous experience in medical wards, working in tertiary care hospitals or engaged in private practice.

Optimal implementation of the 2019 ESC/EAS dyslipidaemia guidelines in patients with and without atherosclerotic cardiovascular disease across Europe: a simulation based on the DA VINCI study.

The impact of the stepwise implementation of the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) treatment algorithm on low-density lipoprotein cholesterol (LDL-C) goal attainment was simulated in patients from the DA VINCI study. Monte Carlo simulation was used to evaluate treatment optimisation scenarios, based on a patient's risk category: statin intensification (step 1), addition of ezetimibe (step 2), and addition of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (step 3). Residual cardiovascular risk and predicted relative and absolute risk reduction (RRR and ARR) in cardiovascular events were assessed. In DA VINCI, 2482 patients did not achieve their 2019 ESC/EAS LDL-C goals and were included in the simulation. In patients without atherosclerotic cardiovascular disease (ASCVD) (n=962), 27.0% (n=259) and 57.0% (n=548) are likely to achieve their LDL-C goals at step 1 and step 2, respectively. Of those at very high risk without ASCVD (n=74), 88.1% (n=65) are likely to achieve their LDL-C goals at step 3. In patients with ASCVD (n=1520), 12.0% (n=183), 42.1% (n=641) and 93.2% (n=1416) are likely to achieve their LDL-C goals at steps 1, 2 and 3, respectively. In patients with and without ASCVD, treatment optimisation may result in mean simulated RRR of 24.0% and 17.7%, respectively, and ARR of 8.1% and 2.6%, respectively. Most patients at high cardiovascular risk are unlikely to achieve LDL-C goals through statin optimisation and ezetimibe, and will require a PCSK9 inhibitor, leading to greater reduction in cardiovascular risk. Amgen.

Exploring the implemented guidelines for dyslipidemia treatment and care among nurses and physicians in jordanian hospitals

Abstract Funding Acknowledgements Type of funding sources: None. Background Dyslipidemia is a major risk factor for ischemic heart disease in the world. The last updated American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/ European Atherosclerosis Society (ESC/EAS) guidelines for dyslipidemia management aimed to control blood cholesterol and reduce cardiovascular risk. In Jordan, no national guidelines have been published to date, so these guidelines are commonly used. There are a few studies exploring the implementation of these guidelines in Jordan. Purpose To explore the implementation of updated ACC/AHA and ESC/EAS guidelines for the treatment and care of dyslipidemia among nurses and physicians in Jordan. Methods: A mixed-method study was utilized with a convenience sample from three hospitals in Jordan to provide a comprehensive understanding for the investigated concepts in the current study. The quantitative part, the researcher developed a questionnaire. A questionnaire was completed by 150 nurses and 50 physicians, and moreover, 250 patients' medical records were reviewed. The qualitative part, three focus group with open-ended questions was conducted. Results The total mean scores to implement the guidelines among nurses were (1.67, 1.6 out of 4) for ACC/AHA and ESC/EAS guidelines respectively. The percentages for implementing dyslipidemia management guidelines among physicians were 22.6% consistent with ACC/AHA and 29.6% with ESC/EAS. There were high percentages of uncontrolled lipids among patients with dyslipidemia as observed in medical records. Focus group interviews revealed many barriers, like workload and limited resources and many suggestions to implement dyslipidemia management guidelines. Conclusion Results indicated limited implementation of any dyslipidemia management guidelines among Jordanian nurses and physicians in their clinical practices.

The German CaRe high registry for familial hypercholesterolemia – Sex differences, treatment strategies, and target value attainment

Background and aimsFamilial hypercholesterolemia (FH) is among the most common genetic disorders in primary care. However, only 15% or less of patients are diagnosed, and few achieve the goals for low-density lipoprotein cholesterol (LDL-C). In this analysis of the German Cascade Screening and Registry for High Cholesterol (CaRe High), we examined the status of lipid management, treatment strategies, and LDL-C goal attainment according to the ESC/EAS dyslipidemia guidelines. MethodsWe evaluated consolidated datasets from 1501 FH patients diagnosed clinically and seen either by lipid specialists or general practitioners and internists. We conducted a questionnaire survey of both the recruiting physicians and patients. ResultsAmong the 1501 patients, 86% regularly received lipid-lowering drugs. LDL-C goals were achieved by 26% and 10% of patients with atherosclerotic cardiovascular disease (ASCVD) according to the 2016 and 2019 ESC/EAS dyslipidemia guidelines, respectively. High intensity lipid-lowering was administered more often in men than in women, in patients with ASCVD, at higher LDL-C and in patients with a genetic diagnosis of FH. ConclusionsFH is under-treated in Germany compared to guideline recommendations. Male gender, genetic proof of FH, treatment by a specialist, and presence of ASCVD appear to be associated with increased treatment intensity. Achieving the LDL-C goals of the 2019 ESC/EAS dyslipidemia guidelines remains challenging if pre-treatment LDL-C is very high.

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

The low-density lipoprotein cholesterol goals in the 2019 European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guidelines necessitate greater use of combination therapies. We describe areal-world cohort of patients in Austria and simulate the addition of oral bempedoic acid and ezetimibe to estimate the proportion of patients reaching goals. Patients at high or very high cardiovascular risk on lipid-lowering treatments (excluding proprotein convertase subtilisin/kexin type9 inhibitors) from the Austrian cohort of the observational SANTORINI study were included using specific criteria. For patients not at their risk-based goals at baseline, addition of ezetimibe (if not already received) and subsequently bempedoic acid was simulated using aMonte Carlo simulation. Acohort of patients (N = 144) with amean low-density lipoprotein cholesterol of 76.4 mg/dL, with 94% (n = 135) on statins and 24% (n = 35) on ezetimibe monotherapy or in combination, were used in the simulation. Only 36% of patients were at goal (n = 52). Sequential simulation of ezetimibe (where applicable) and bempedoic acid increased the proportion of patients at goal to 69% (n = 100), with adecrease in the mean low-density lipoprotein cholesterol from 76.4 mg/dL at baseline to 57.7 mg/dL overall. The SANTORINI real-world data in Austria suggest that aproportion of high and very high-risk patients remain below the guideline-recommended low-density lipoprotein cholesterol goals. Optimising use of oral ezetimibe and bempedoic acid after statins in the lipid-lowering pathway could result in substantially more patients attaining low-density lipoprotein cholesterol goals, likely with additional health benefits.

Primary disorders of lipid metabolism: their place in current dyslipidemia guidelines and treatment innovations

According to current guidelines, the selection and intensity of lipid-effective therapies are based on the risk to be treated. The sole clinical categories of primary and secondary prevention of cardiovascular diseases result in over- and under-treatment, which may be acontributory cause of incomplete implementation of current guidelines in everyday practice. For the extent of benefit in cardiovascular outcome studies with lipid-lowering drugs, the importance of dyslipdemia for the pathogenesis of atherosclerosis-related diseases is crucial. Primary lipid metabolism disorders are characterized by life-long increased exposure to atherogenic lipoproteins. This article describes the relevance of new data for low density lipoprotein-effective therapy: inhibition of proprotein convertase subtilisin/kexin type9 (PCSK9), adenosine triphosphate (ATP) citrate lyase with bempedoic acid, and ANGPTL3 with special consideration of primary lipid metabolism disorders, which are insufficiently taken into account, or not taken into account at all, in current guidelines. This is due to their apparently low prevalence rate and thus the lack of large outcome studies. The authors also discuss the consequences of increased lipoprotein(a), which cannot be sufficiently reduced until the ongoing intervention studies examining antisense oligonucleotides and small interfering RNA (siRNA) against apolipoprotein(a) are completed. Another challenge in practice is the treatment of rare, massive hypertriglyceridemia, especially with the aim of preventing pancreatitis. For this purpose, the apolipoprotein C3 (ApoC3) antisense oligonucleotide volenasorsen is available, which binds to the mRNA for ApoC3 and lowers triglycerides by around three quarters.