European Society Of Cardiology/European Atherosclerosis Society Research Articles

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.

Recurrent atherosclerotic cardiovascular disease events preventable with guideline recommended lipid-lowering treatment following myocardial infarction

Abstract Background The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline provides recommendations for lipid-lowering therapy (LLT) including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) to prevent recurrent atherosclerotic cardiovascular disease (ASCVD) events in adults with established ASCVD. Many adults with ASCVD who are recommended to take statins, ezetimibe and/or PCSK9i do not receive these medications. Purpose To estimate the number of recurrent ASCVD events potentially prevented by population-wide use of guideline recommended LLT following a myocardial infarction (MI). Methods We simulated the population-wide impact of receipt of 2018 AHA/ACC cholesterol guideline recommended LLT over 3 and 5 years among US adults with government health insurance through Medicare or commercial health insurance following hospital discharge for MI. We used data from patients with an MI hospitalization in 2018–2019 to estimate the percentage receiving guideline recommended LLT defined by having the medications available to take in the 30 days after their discharge date. We used data from patients with an MI hospitalization in 2013–2016 to estimate the 3 and 5-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The reduction in ASCVD events associated with guideline recommended LLT was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration. We conducted a sensitivity analysis estimating the number and percentage of ASCVD events prevented if LLT recommendations from the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) cholesterol guideline were followed. We repeated all analyses with recurrent coronary heart disease (i.e., MI or coronary revascularization) and ischemic stroke events as separate outcomes. Results Among 279,395 adults with an MI hospitalization in 2018–2019 (mean age 75 years, 54% men, mean low-density lipoprotein cholesterol 92 mg/dL), 27% were receiving guideline recommended LLT. With current lipid-lowering medication use, we estimated that 70,698 (95% CI: 70,311–71,077) and 89,255 (95% CI: 88,841–89,730) ASCVD events would occur in 3 and 5 years, respectively, after MI hospital discharge (Table, top panel). If all patients were to receive 2018 AHA/ACC guideline recommended LLT, the number of ASCVD events was estimated to be reduced by 21.6%, representing 15,264 (95% CI: 14,451–16,679) events prevented over 3 years and 19,271 (95% CI: 18,245–21,055) events prevented over 5 years. A higher number of recurrent ASCVD events were estimated to be averted following the LLT recommendations of the 2019 ESC/EAS cholesterol guideline (Table, bottom panel). Conclusions Population-wide implementation of guideline recommended LLT in adults with an MI hospitalization could prevent a substantial number of recurrent ASCVD events. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Amgen Inc.

Projected impact of treatment intensification with statin, ezetimibe, and statin plus ezetimibe fixed-dose combination on MACE across six countries.

The 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) dyslipidaemia guidelines recommend achievement of low-density lipoprotein cholestrol (LDL-C) goals based on an individual's risk. We aimed to evaluate the impact of guideline adoption with statin, ezetimibe, and statin plus ezetimibe fixed-dose combination (FDC) on LDL-C goal achievement and incidence of major adverse cardiovascular events (MACE) across six countries. A simulation model with a five-year horizon (2020-2024) was developed based on Institute for Health Metrics and Evaluation Global Burden of Disease Study database with a business-as-usual (BAU) scenario representing status quo, intervention scenario-1 representing treatment with statin and ezetimibe as separate agents, and intervention scenario-2 representing treatment with statin or statin plus ezetimibe FDC. MACE was defined as the composite of myocardial infarction, ischaemic stroke, and cardiovascular death. The mean population LDL-C was reduced from 4.25 mmol/L in the BAU scenario, to 3.65 mmol/L and 3.59 mmol/L in intervention scenarios-1 and -2, respectively. Compared with BAU, intervention scenarios-1 and-2 resulted in relative reduction of MACE by 5.4% and 6.4% representing ∼3.7 and 4.4 million MACE averted, respectively, across six countries over 5 years. The absolute benefit in terms of MACE averted was highest for China, whereas France had highest relative reduction in MACE with both intervention scenarios compared with BAU. The 2019 ESC/EAS guideline-based treatment intensification with strategies based on statin, ezetimibe, and statin plus ezetimibe FDC is estimated to result in a substantial population-level benefit in terms of MACE averted compared with BAU.

Implications of ACC/AHA Versus ESC/EAS LDL-C Recommendations for Residual Risk Reduction in ASCVD: A Simulation Study From DA VINCI

PurposeLow-density lipoprotein cholesterol (LDL-C) recommendations differ between the 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for patients with atherosclerotic cardiovascular disease (ASCVD) (< 70 vs. < 55 mg/dl, respectively). In the DA VINCI study, residual cardiovascular risk was predicted in ASCVD patients. The extent to which relative and absolute risk might be lowered by achieving ACC/AHA versus ESC/EAS LDL-C recommended approaches was simulated.MethodsDA VINCI was a cross-sectional observational study of patients prescribed lipid-lowering therapy (LLT) across 18 European countries. Ten-year cardiovascular risk (CVR) was predicted among ASCVD patients receiving stabilized LLT. For patients with LDL-C ≥ 70 mg/dl, the absolute LDL-C reduction required to achieve an LDL-C of < 70 or < 55 mg/dl (LDL-C of 69 or 54 mg/dl, respectively) was calculated. Relative and absolute risk reductions (RRRs and ARRs) were simulated.ResultsOf the 2039 patients, 61% did not achieve LDL-C < 70 mg/dl. For patients with LDL-C ≥ 70 mg/dl, median (interquartile range) baseline LDL-C and 10-year CVR were 93 (81–115) mg/dl and 32% (25–43%), respectively. Median LDL-C reductions of 24 (12–46) and 39 (27–91) mg/dl were needed to achieve an LDL-C of 69 and 54 mg/dl, respectively. Attaining ACC/AHA or ESC/EAS goals resulted in simulated RRRs of 14% (7–25%) and 22% (15–32%), respectively, and ARRs of 4% (2–7%) and 6% (4–9%), respectively.ConclusionIn ASCVD patients, achieving ESC/EAS LDL-C goals could result in a 2% additional ARR over 10 years versus the ACC/AHA approach.Graphical abstract

Guidelines versus trial-evidence for statin use in primary prevention: The Copenhagen General Population Study

Background and aimsGuideline-recommended use of risk calculators to select for statin therapy in primary prevention has never been tested in a randomized controlled trial (RCT). We determined the extent to which guideline-based statin recommendations from the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society(CCS), UK National Institute for Health and Care Excellence (NICE), and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) is supported by available evidence from RCTs. Methods79,171 individuals from the Copenhagen General Population Study who were free of ASCVD and statin use at baseline were included. RCT evidence supporting guideline-recommended statin allocation and the estimated number needed to treat (NNT) to prevent one ASCVD event were assessed. ResultsDuring 8.2 years of follow-up, 4031 ASCVD events occurred. Of individuals eligible for statin therapy with the ACC/AHA, CCS, NICE and ESC/EAS guidelines, 86%, 88%, 88% and 84% had direct RCT evidence of statin efficacy, respectively (guideline-positive&RCT-positive). This group represented 26–37% of all 79,171 individuals, while guideline-positive&RCT-negative individuals represented 5–7%, guideline-negative&RCT-positive individuals 28–39%, and guideline-negative&RCT-negative individuals represented 30–31%. The ASCVD events per 1000 person-years were 11.4–12.7 (guideline-positive&RCT-positive), 6.3–8.0 (guideline-positive&RCT-negative), 4.2–5.2 (guideline-negative&RCT-positive), and 2.3–2.5 (guideline-negative&RCT-negative), respectively, while the corresponding NNT to prevent one event in 10 years using high-intensity statin were 19–21, 30–32, 48–60, and 105–125, respectively. ConclusionsThe far majority of individuals eligible for guideline-recommended primary prevention with statins have direct RCT evidence supporting statin use. Allocating statins based on guideline-criteria is more efficient with lower NNT for preventing ASCVD events than allocating statin therapy based solely on RCT evidence.

Target level achievement of low-density lipoprotein cholesterol in patients with peripheral artery disease: Improvement potential despite increased statin use

Background and Aims: Lowering low-density lipoprotein cholesterol (LDL-C) is a key secondary therapeutic measure in patients with peripheral arterial disease (PAD). The 2019 ESC/EAS (European Society of Cardiology/European Atherosclerosis Society) guidelines for the management of dyslipidaemia recommend LDL-C levels of<55 mg/dl for a very high risk subset such as PAD patients. We aimed to assess the trend of statin use over time and the fraction achieving the recommended target level in PAD patients.

Impact of different statins on low-density lipoprotein cholesterol levels in patients with peripheral artery disease

Background and Aims: Patients with peripheral arterial disease (PAD) are at high risk of cardiovascular events and limb threatening complications. According to the 2019 ESC/EAS (European Society of Cardiology/European Atherosclerosis Society) guidelines for the management of dyslipidaemia high intensity statins and ezetimibe are recommended for low-density lipoprotein cholesterol control (LDL-C). We assessed the impact of different types of statins on the lipid profile of patients with PAD and its effect on LDL-C target level achievement.

EAS Task Force gives practical guidance for combination lipid-modifying therapy in high- and very-high-risk patients

‘Lower is better’ underpins the management of low-density lipoprotein cholesterol (LDL-C) in the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) dyslipidaemia guidelines [1]. Recent trials in very high-risk patients with ezetimibe and PCSK9 monoclonal antibody therapy provide robust support, showing incremental reduction in cardiovascular events at lower LDL-C levels [2-4], with no evidence to suggest a threshold for clinical benefit from LDL-C lowering [5]. The available data also do not indicate safety issues associated with very low LDL-C levels attained with these efficacious therapies.

ДИСЛИПИДЕМИИ: ОБЗОР РЕКОМЕНДАЦИЙ ESC/EAS 2019 ПО ДИАГНОСТИКЕ И ЛЕЧЕНИЮ. ЧАСТЬ 2 – ТАРГЕТНАЯ ТЕРАПИЯ

The high incidence of cardiovascular disease leads to a routine individual assessment of the patient's cardiovascular risk, and to the correction of the therapy. In 2019, at the European Congress of Cardiology, updated recommendations of the ESC/EAS (European Society of Cardiology / European Atherosclerosis Society) on the diagnosis and treatment of dyslipidemia were presented, new approaches to cardiovascular risk assessing and correction of dyslipidemia were formulated. The article discusses the main aspects of clinical application of the new recommendations for the treatment of this pathology.

ДИСЛИПИДЕМИИ: ОБЗОР РЕКОМЕНДАЦИЙ ESC/EAS 2019 ПО ДИАГНОСТИКЕ И ЛЕЧЕНИЮ. ЧАСТЬ 1 – ОЦЕНКА РИСКА

The high incidence of cardiovascular disease leads to a routine individual assessment of the patient's cardiovascular risk, and to the correction of therapy. In 2019, at the European Congress of Cardiology, updated recommendations of the ESC/EAS (European Society of Cardiology / European Atherosclerosis Society) on the diagnosis and treatment of dyslipidemia were presented, new approaches to cardiovascular risk assessing and correction of dyslipidemia were formulated. The article discusses the main aspects of clinical use of the new recommendations for the treatment of this pathology.

Similarities and differences between European and American guidelines on the management of blood lipids to reduce cardiovascular risk

The 2018 American Heart Association/American College of Cardiology/Multi-Society (AHA/ACC/MS) Guideline on the Management of Blood Cholesterol and the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) Guidelines for the Management of Dyslipidemias: Lipid Modification to Reduce Cardiovascular Risk, that were recently released by the United States and Europe, provide new recommendations for the management of blood lipid levels based on the latest evidence. Despite many common points, there are several differences in the recommendations, including the definition of very-high-risk patient category, the recommendations for some categories of patients, such as those with diabetes, familial hypercholesterolemia, chronic kidney disease, and aged patients, and the use of ezetimibe and PCSK9 inhibitors. These differences suggest that multiple approaches can be used to manage lipid abnormalities in the context of cardiovascular risk reduction.

Cholesterol target attainment according to the recent ESC/EAS guidelines: Evidence from clinical practice

Background and Aims: We aimed to assess the attainment of the recently proposed low-density lipoprotein cholesterol (LDL-C) targets by the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS).

Dyslipidaemia after switch to tenofovir alafenamide (TAF)-based cART regimens in a cohort of HIV-positive patients: what clinical relevance?

Switching from tenofovir (TDF) to tenofovir alafenamide (TAF) affects lipid profile. The aim of this study was to evaluate whether this results in an increased frequency of patients with low-density lipoprotein (LDL) above their cardiovascular-related target. All HIV patients switching from TDF to TAF, with no changes of the anchor drug, and with plasma lipids available within 6months before and after the switch, were included. Demographic, HIV-related parameters, cardiovascular (CV) risk factors and lipid profile on both TDF and TAF were collected. The CV risk score and the relative target of LDL for each patient were calculated according to 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for the management of dyslipidaemias. Modifications in lipid profiles and in the prevalence of patients with LDL above their CV-related target were evaluated after switch to TAF. Overall, 221 HIV patients were included, according to CV risk: 55% at low risk, 34% at moderate risk, and 11% at high/very high risk. By analysing lipid profiles according to CV risk, 38% of patients on TDF had LDL above their CV target; this prevalence increases to 60% after switching to TAF (P<0.0001). The presence of cobicistat in the combination antiretroviral therapy (cART) regimen was associated with an increased risk of LDL above the CV-related target after switch to TAF [adjusted odds ratio (aOR) =2.4, 95% confidence interval (CI): 1-5.1], P=0.03) and with an increased prescription of lifestyle/therapeutic intervention (OR=3.0, 95% CI: 1.7-5.3, P<0.0001). Switching from TDF to TAF affects lipid parameters, and data from real life suggest a clinical relevance of this worsening that often leads clinicians to implement lifestyle/therapeutic interventions.

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

New Recommendations and Revised Concepts in Recent Guidelines on the Management of Dyslipidemias to Prevent Cardiovascular Disease: the 2018 ACC/AHA and 2019 ESC/EAS Guidelines.

The purpose of this review is to discuss the updated guideline recommendations on management of dyslipidemia for prevention and treatment of cardiovascular disease. The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) published revised cholesterol management guidelines in 2018 and 2019, respectively, to reflect new evidence in the field. Broadly speaking, both emphasize refining cardiovascular disease risk estimation and aggressively lowering low-density lipoprotein-cholesterol (LDL-C) with statin and non-statin agents to curb cardiovascular risk. While they share the same guiding principles, there are important differences in the recommendations from both societies including how they define risk categories and goals for LDL-C lowering. This review summarizes current methods of managing dyslipidemia with a focus on the common themes and notable differences between the 2018 ACC/AHA and 2019 ESC/EAS cholesterol management guidelines.

Achievement of LDL-C Targets Defined by ESC/EAS (2011) Guidelines in Risk-Stratified Korean Patients with Dyslipidemia Receiving Lipid-Modifying Treatments.

BackgroundThis study assessed the proportion of risk-stratified Korean patients with dyslipidemia achieving their low-density lipoprotein cholesterol (LDL-C) targets as defined by the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) (2011) guidelines while receiving lipid-modifying treatments (LMTs).MethodsIn this multicenter, cross-sectional, observational study, we evaluated data from Korean patients aged ≥19 years who were receiving LMTs for ≥3 months and had an LDL-C value within the previous 12 months on the same LMT. Data were collected for demographics, cardiovascular (CV) risk factors, medical history, and healthcare consumption. Patients were risk-stratified according to the ESC Systematic COronary Risk Evaluation (SCORE) chart and LDL-C target achievement rate was assessed.ResultsGuideline-based risk-stratification of the 1,034 patients showed the majority (72.2%) to be in the very high-risk category. Investigators’ assessment of risk was underestimated in 71.6% compared to ESC/EAS guidelines. Overall LDL-C target achievement rate was 44.3%; target achievement was the highest (66.0%) in moderate-risk patients and the lowest (39.0%) in very high-risk patients. Overall 97.1% patients were receiving statin therapy, mostly as a single-agent (89.2%). High-intensity statins and the highest permissible dose of high-intensity statins had been prescribed to only 9.1% and 7.3% patients in the very high-risk group, respectively. Physician satisfaction with patients’ LDL-C levels was the primary reason for non-intensification of statin therapy.ConclusionAchievement of target LDL-C level is suboptimal in Korean patients with dyslipidemia, especially in those at very high-risk of CV events. Current practices in LMTs need to be improved based on precise CV risk evaluation posed by dyslipidemia.

Apolipoprotein B and non-high-density lipoprotein cholesterol reveal a high atherogenicity in individuals with type 2 diabetes and controlled low-density lipoprotein-cholesterol

BackgroundLipid-lowering therapy is guided by Low-density-lipoprotein cholesterol (LDL-c) levels, although the cardiovascular disease (CVD) risk could be better reflected by other lipid parameters. This study aimed at comparing a comprehensive lipid profile between patients with type 2 diabetes mellitus (T2DM) with LDL-c concentration within and above target.MethodsA comprehensive lipid profile was characterized in 96 T2DM patients. The European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) 2016 and 2019 Guidelines for the Management of Dyslipidemias were used to define LDL-c targets.ResultsIn this population, only 28.1 and 16.7% of patients had mean LDL-c levels within target, as defined by the 2016 and 2019 guidelines, respectively. Applying the 2016 guidelines criteria, in patients with LDL-c within target, 22, 25 and 44% presented non-high-density lipoprotein cholesterol (non-HDL-c), Apolipoprotein B (ApoB) and oxidized LDL-c levels above the recommended range, respectively, whereas according to the 2019 guidelines criteria, 50, 39 and 44% of the patients with LDL-c within target had elevated high-density lipoprotein cholesterol (HDL-c), ApoB and oxidized LDL-c levels, respectively. LDL-c was strongly correlated with non-HDL-c (r = 0.850), ApoB (r = 0.656) and oxidized LDL-c (r = 0.508). Similarly, there was a strong correlation between non-HDL-c with both ApoB (r = 0.808) and oxidized LDL-c (r = 0.588).ConclusionsThese findings emphasize the limitations of only considering LDL-c concentration for cardiovascular (CV) risk assessment. Targeting only LDL-c could result in missed opportunities for CV risk reduction in T2DM patients. These data suggest that non-HDL-c, ApoB and oxidized LDL-c levels could be considered as an important part of these patients’ evaluation allowing for a more accurate estimation of CV risk and hopefully better management of these high-risk patients.

2019 vs. 2016 ESC/EAS statin guidelines for primary prevention of atherosclerotic cardiovascular disease.

The 2019 vs. 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) dyslipidaemia guidelines contains new recommendations for primary prevention with statins; however, the potential impact of these changes is unclear. We compared the 2019 and 2016 guidelines regarding statin eligibility and potential impact on prevention of atherosclerotic cardiovascular disease (ASCVD) in the general population. We examined 45 750 individuals aged 40-75 from the Copenhagen General Population Study, all free of ASCVD and statin use at baseline. During the 9.2-year follow-up, 3337 experienced ASCVD (myocardial infarction, stroke, and cardiovascular death). For Class I/A recommendations, 32.3% (95% confidence interval: 31.8-32.7) and 15.4% (15.1-15.7) of individuals were statin eligible according to the 2019 and 2016 guidelines. The increased statin eligibility by the 2019 guidelines was explained by lower low-density lipoprotein cholesterol (LDL-C) thresholds alone (explaining 33.2%), older age range alone (49.4%), older age range in combination with lower LDL-C thresholds (14.7%), and updated SCORE risk algorithm (2.8%). If fully implemented, the estimated percentage of ASCVD events that can be prevented by using high-intensity statins for 10 years were 25% and 11% with the 2019 and 2016 guidelines. Mainly because of older age range in the 2019 guidelines, the corresponding estimated numbers needed to treat (NNT) to prevent one ASCVD event were 19 and 20. Due to lower LDL-C threshold and older age range, the 2019 vs. 2016 ESC/EAS guidelines doubles the number of individuals eligible for primary prevention with statins. This considerably improves the potential for ASCVD prevention in the general population, with similar NNT to prevent one event.

P4389Effect of cigarette smoking on carotid artery atherosclerosis: a community-based cohort study

Abstract Background Cigarette smoking is closely associated with the development of cardiovascular diseases (CVD), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines recommend smoking bans.On the other hand, the relationship between cigarette smoking and subclinical atherosclerosis has not been fully studied. Carotid intima-media thickness (cIMT) is commonly used as a subclinical atherosclerosis marker, and a carotid plaque feature is also known to be an important predictor of cardiovascular diseases. Purpose We sought to clarify the association between cigarette smoking and subclinical atherosclerosis by evaluating carotid plaque including cIMT and carotid plaque features in general population. Methods and results Among 1,209 participants with no prior coronary artery disease who received a medical check-up with cardiovascular examination at our institution, 450 participants (37.2%) were smokers (including both past and current smokers). We defined carotid plaque as cIMT ≥1.1 mm and high-risk plaque as carotid plaque with hypoechoic dominant and/or plaque ulceration. The value of cIMT and the rate of carotid plaque were not different between smokers and never smokers (Figure A &amp; B). However, the rate of carotid high-risk plaque was significantly higher in participants with smokers than those with never smokers (29.7%, vs 23.5%, p=0.011) (Figure C). Even after adjustment with covariates including age, gender and traditional cardiovascular risk factors, cigarette smoking was independently associated with high-risk plaque formation (odds ratio 1.384, 95% CI 1.020–1.877; p=0.037). According to the subgroup analysis classified by age, cigarette smoking was associated with not only the development of high-risk plaque but also the increased value of cIMT in the subgroup over 60 years old, whereas only the rate of high-risk plaque was higher in smokers than never smokers in the subgroup under 60 years old. Carotid plaque and smoking Conclusion The development of high-risk carotid artery plaque may precede thickening of cIMT in cigarette smokers, suggesting that the novel insight for the pathological mechanism underlying cardiovascular events and cigarette smoking.

Unmet need for primary prevention in individuals with hypertriglyceridaemia not eligible for statin therapy according to European Society of Cardiology/European Atherosclerosis Society guidelines: a contemporary population-based study.

To identify individuals at high risk of atherosclerotic cardiovascular disease (ASCVD), who are not definite statin eligible according to the 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines, based on high concentrations of plasma triglycerides. From the Copenhagen General Population Study (2003-2015) 58547 individuals aged 40-65 and free of ASCVD, diabetes, and statin use at baseline were included. Of these, 14% were definite statin eligible, 7% were not eligible and had triglycerides ≥3.0 mmol/L (264 mg/dL), and 79% were not statin eligible and had triglycerides <3.0 mmol/L (264 mg/dL). During 456057 person-years of follow-up, 1770 individuals experienced a major adverse cardiovascular event (MACE) and 734 experienced a myocardial infarction (MI). The cumulative incidences of MACE at age 70 were 8.1% (95% confidence interval 7.3-8.9%) and 14.6% (12.6-16.8%) in statin non-eligible individuals with triglycerides <3.0 mmol/L (264 mg/dL) and ≥3.0 mmol/L (264 mg/dL), and 16.5% (14.0-19.3%) in statin eligible individuals. Corresponding cumulative incidences of MI were 3.0% (2.7-3.3%), 7.8% (6.4-9.5%), and 7.1% (5.9-8.4%), respectively. The estimated 10-year risks of MACE were 2.8% (2.6-3.0%) and 5.7% (4.9-6.6%) in statin non-eligible individuals with triglycerides <3.0 mmol/L (264 mg/dL) and ≥3.0 mmol/L (264 mg/dL), and 7.6% (6.9-8.3%) in statin eligible individuals; the median age in these three groups were 51, 51, and 60 years, respectively. Corresponding risks of MI were 1.0% (0.9-1.1%), 3.0% (2.4-3.7%), and 3.3% (2.8-3.7%), respectively. Statin non-eligible individuals with triglycerides ≥3.0 mmol/L (264 mg/dL) had risk of ASCVD similar to statin eligible individuals, defined according to the 2016 ESC/EAS guidelines. This illustrates an unmet need for primary prevention, calling for expansion of guidelines on statin eligibility, and the potential for placebo-controlled randomized clinical trials in individuals with hypertriglyceridaemia.