Intensive Statin Research Articles

The impact of SLCO1B1 rs4149056 on LDL-C target achievement after lipid lowering therapy optimization in men and women with familial hypercholesterolemia.

FH women are less likely to receive intensive statin treatment and to obtain a 50% reduction of LDL-C from baseline compared to men with FH. SLCO1B1 rs4149056 might influence statin therapy compliance and thus LDL-C target achievement. Our aim was to evaluate the impact of SLCO1B1 rs4149056 on LDL-C target achievement after lipid lowering therapy (LLT) optimization in men and women with FH. This was a retrospective observational study involving 412 FH subjects with a probable or defined clinical diagnosis of FH who had had genetic analysis from June 2016 to September 2022. Biochemical analysis was obtained from all subjects at baseline and at the last follow-up after LLT optimization. After LLT optimization the percentage of FH subjects on high-intensity statins decreased from the M/SLCO1B1- group to the W/SLCO1B1+ group and the same was found in LDL-C target distribution (for both p for trend < 0.01). The prevalence of SASE fear increased from the M/SLCO1B1- group to the W/SLCO1B1+ group and the same was observed in reported myalgia distribution (for both p for trend < 0.01). Logistic regression analysis showed that the W/SCLO1B1-, M/SCLO1B1+ and W/SCLO1B1+ groups were inversely associated with LDL-C target achievement (p for trend < 0.001) and the W/SCLO1B1+ group exhibited the strongest association. A low prevalence of FH women with SLCO1B1 rs4149056 were on high intensity statins and they rarely achieved LDL-C target. The genotype effect of SLCO1B1 rs4149056 could be more pronounced in FH women than men.

Abstract WP261: Healthcare Utilization Patterns and Disparities in High Intensity Statin Use in Stroke Patients

Objective: Physician adherence to evidence-based clinical guidelines improves outcomes in acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We investigated compliance with the AHA 2008 high intensity statin recommendation for secondary prevention of AIS/TIA, and factors associated with adherence. Methods: In this population-based, cohort study of incident AIS/TIA patients, we included a random sample of U.S. Medicare beneficiaries age≥67 with Part A/B/D coverage, ≥1 ICD code for AIS/TIA in 2015-2018, and no prior AIS/TIA or high intensity statin use (N=76,707). We followed the cohort forward until end of 2019 for high intensity statin use (atorvastatin ≥40mg or rosuvastatin ≥20mg). We used logistic regression to examine factors associated with high intensity statin use within 3 months: demographics, urban residence, Area Deprivation Index (ADI), and provider specialty (neurologist vs. other). Results: Overall, during follow up, only 62.5% of beneficiaries with incident AIS/TIA received neurologist care. In this period only 19.4% incident AIS/TIA patients received a high intensity statin and 27.8% did not receive any statin. Female patients (OR 0.88, 95%CI 0.84-0.92), older beneficiaries (OR 0.984, 95%CI 0.981-0.987 per year), and urban residents (OR 0.84, 95%CI 0.80-0.88) were less likely to receive a high intensity statin within 3 months of their stroke. Race/ethnicity but not ADI was associated with high intensity statin use. Neurologist-treated patients were markedly more likely to receive a high intensity statin than other AIS/TIA patients (OR 3.42, 95%CI 3.22-3.63), even after adjusting for all sociodemographic variables. Conclusions: AIS/TIA patients treated by neurologists received care consistent with the clinical guidelines more often than those not treated by a neurologist. Female, older, and urban beneficiaries were less likely to receive care consistent with the guidelines.

Atherosclerotic plaque stabilization and regression: a review of clinical evidence.

Atherosclerotic plaque results from a complex interplay between lipid deposition, inflammatory changes, cell migration and arterial wall injury. Over the past two decades, clinical trials utilizing invasive arterial imaging modalities, such as intravascular ultrasonography, have shown that reducing levels of atherogenic lipoproteins, mainly serum LDL-cholesterol (LDL-C), to very low levels can safely reduce overall atherosclerotic plaque burden and favourably modify plaque composition. Classically, this outcome has been achieved with intensive statin therapy. Since 2016, newer and potent lipid-lowering strategies, such as proprotein convertase subtilisin-kexin type 9 inhibition, have shown incremental effects on plaque regression and risk of clinical events. Despite maximal reduction in plasma LDL-C levels, considerable residual cardiovascular risk remains in some patients. Therefore, there is a need to study therapeutic approaches that address residual risk beyond LDL-C reduction to promote plaque stabilization or regression. Contemporary imaging modalities, such as coronary computed tomography angiography, enable non-invasive assessment of the overall atherosclerotic plaque burden as well as of certain local plaque characteristics. This technology could allow further study of plaque stabilization and regression using novel therapeutic approaches. Non-invasive plaque assessment might also offer the potential to guide personalized management strategies if validated for this purpose.

Effect of preoperative intensive statin on the efficacy and inflammatory response of acute ST-segment elevation myocardial infarction after emergency percutaneous coronary intervention.

It was to explore the application value of individualized nursing oriented by solution-focused nursing mode in postoperative nursing of patients with pelvic fractures. 90 patients with ST-segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI) were enrolled. They were randomly grouped into a control group and an experimental group, with 45 cases in each group. Patients in the general group were treated with conventional treatment, and patients in the enhancement group were treated with high-dose rosuvastatin based on conventional treatment. The experimental group was compared for indicators such as serum inflammatory factors, cardiac function, overall efficacy, and follow-up prognosis before and after the operation. After treatment, the total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) in the enhancement group were better as against the control group (P<0.05). Through treatment, the concentration of high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) in the enhancement group was lower compared to the general group. The total effective rate of the enhancement group (95.56%) was higher relative to the general group (86.67%) (P<0.05). In patients with STEMI, preoperative intensive statin therapy can improve the efficacy of PCI, and reduce the inflammatory response and the incidence of cardiovascular events.

STATIN USE REDUCES ALL-CAUSE MORTALITY IN NURSING HOME RESIDENTS WITH DEMENTIA

Abstract Background Statins are recommended for the prevention of primary and secondary cardio and cerebrovascular events. However, little is known about the benefits of statin therapy in older adults with dementia. Therefore, this retrospective cohort study aims to investigate the association between statin use and all-cause mortality using health insurance claims data of nursing home residents with and also without dementia. Methods Time-variant Cox proportional hazards models were used to evaluate the association of statin use with all-cause mortality and adjusted for potential confounders. Results Overall, N=326,669 individuals were included in the analysis (mean [SD] age 84.02 [8.45] years; 74% women). During a mean observation period of 2.42 years (SD=1.59), a total of 239,321 deaths occurred. The fully adjusted models showed that participants with dementia statin users compared to non-users had a 20% lower risk for all-cause mortality (HR 1.20; 95%CI: 1.19–1.22, p&amp;lt;.001). In a subanalysis, similar trends remained within those with history of atherosclerotic cardiovascular disease (ASCVD) (HR 1.22; 95%CI: 1.21–1.24, p&amp;lt;.001) and without ASCVD disease (HR 1.12; 95%CI: 1.09–1.16, p&amp;lt;.001); and when stratifying by dementia type, Vascular dementia (VaD) (HR 1.27; 95%CI: 1.22-1.32, p&amp;lt; 0.001) and Alzheimer’s disease (AD) (HR 1.19; 95%CI: 1.13-1.26, p&amp;lt; 0.001). Trends remained similar when stratifying by statin intensity, age, nursing home care level required, and sex. Conclusion Our study demonstrates the benefits of statin therapy in highly vulnerable nursing home residents with dementia. This contributes to filling the knowledge gap regarding the harms and benefits of statin therapy in older adults.

POTENTIAL FOR PATHOGENETIC CORRECTION OF PROTEASE-ANTIPROTEASE SYSTEM IMBALANCE IN PATIENTS WITH COMORBIDITY OF STABLE ANGINA PECTORIS OF THE II-III FUNCTIONAL CLASS AND STAGE II-III CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The aim of this study is to assess the clinical effectiveness of the therapy including exogenous L-arginine and statins under the comorbidity of stable angina pectoris of the II-III functional class and chronic obstructive pulmonary disease of the II-III stage.&#x0D; Materials and methods. The study included 50 patients with coronary heart disease and chronic obstructive pulmonary disease (mean age 57 years; male/female ratio 78/22%). In order to assess the clinical effectiveness of the therapy for combined cardiopulmonary pathology, the patients were randomized into 2 subgroups: subgroup 1 included 25 patients who took metabolitotropic medication under high-intensity statin therapy (the basic therapy included L-arginine and rosuvastatin as a hypolipidemic agent in a dose of 20 mg/day); subgroup 2 included 25 patients who received only basic therapy under moderately intensive statin therapy (daily doses of atorvastatin 20 mg, rosuvastatin 10 mg)). The groups were comparable in terms of gender distribution and demographic characteristics. Comparative analysis of smoking experience, initial smoking age and smoking history did not differ significantly between the groups. After 12±1 weeks, a control examination was carried out.&#x0D; Results. The analysis of the ratio of the MMP-9 activity level before and after the therapy showed that the level of MMP-9 expression decreased by 43.28% (p&lt;0.05) in the 1st subgroup and by 13.18% in the 2nd subgroup until the end of the therapy. TIMP activity after 12 weeks of the treatment was +33.11% (p&lt;0.05) and +11.27% for the 1st and 2nd subgroups respectively. The difference between subgroups 1 and 2 in the level of the CRP marker before and after the therapy was -45.65% (p&lt;0.05) and -9.09%, respectively. 76% of people from the 1st subgroup reached the target level of healthy people before the completion of the therapy that is significantly higher than the similar indicator in the 2nd subgroup (32%) at χ2=8.05, p&lt;0.01.&#x0D; Conclusions: The application of L-arginine alongside high-intensity statin therapy for patients presenting with stable angina pectoris of the II-III functional class and stage II-III chronic obstructive pulmonary disease (COPD) resulted in more notable positive changes in the modulation of protease-antiprotease status disorders. This was evidenced by a reduction in the heightened expression of MMP-9 and an increase in the level of TIMP during the course of treatment.

Protective Effects Against Dementia Undergo Different Statin Type, Intensity, and Cumulative Dose in Older Adult Type 2 Diabetes Mellitus Patients

ObjectivesThis study investigated the relationship between statin use and dementia risk in older adults with type 2 diabetes (T2DM). It also assessed the impact of various statin types, dosage intensity, and cumulative doses on dementia risk. DesignEmploying the inverse probability of treatment weighting (IPTW) Cox hazards model, this research explored the influence of statin utilization on dementia incidence. Setting and ParticipantsThe study included older adult T2DM patients aged 60 years or older who received statins (case group) and those who did not (control group) during the follow-up period. MethodsThe IPTW Cox hazards model quantified the association between statin use and dementia incidence. Subgroup analyses investigated different statin types, usage intensity, and cumulative dose–dependent relationships with dementia risk, measured by adjusted hazard ratios (aHRs) with corresponding 95% CIs. ResultsStatin users experienced a significant reduction in dementia risk (aHR: 0.47, 95% CI: 0.46-0.48). Subgroup analysis using IPTW Cox regression revealed varying dementia incidence reductions among users of different statin types, with aHRs (95% CIs) ranging from 0.09 to 0.69. Multivariate analyses unveiled a dose-dependent relationship, showing reduced dementia incidence based on cumulative defined daily doses (cDDDs) per year. The corresponding aHRs (95% CIs) were 0.20 to 0.72 across quartiles 4 to 1 of cDDD-years, with a significant trend (P < .001). The optimal daily statin use was 0.88 defined daily doses (DDDs), associated with the lowest dementia risk. Conclusions and ImplicationsStatins significantly reduced dementia risk in older adult T2DM patients. Higher cumulative defined daily doses (cDDD-years) were linked to more substantial risk reductions. This research underscores the clinical benefits of statin use in preventing dementia in this population and calls for further investigation into the underlying mechanisms. It also raises the possibility of influencing policy decisions to manage dementia risk in this vulnerable group.

Statin Use and the Risk of Venous Thromboembolism in Women Taking Hormone Therapy

Although hormone therapy (HT) in perimenopausal women is associated with increased risk for venous thromboembolism (VTE), it is unclear to what extent statins may mitigate this HT-associated risk. To estimate VTE risk in women aged 50 to 64 years taking HT with or without statins. This nested case-control study analyzed data from a commercially insured claims database in the US. Eligible participants included women aged 50 to 64 years with at least 1 year of continuous enrollment between 2008 and 2019. Data analysis occurred from January 2022 to August 2023. Filled prescriptions for estrogens, progestogens, and statins were recorded in the 12 months prior to index. Recent HT was defined as any estrogen or progestogen exposure within 60 days before the index date. Current statin exposure was defined as 90 or more days of continuous exposure prior to and including the index date. Statin intensity was defined by the statin exposure 30 days prior to index. Cases were identified with VTE diagnoses (diagnostic codes) preceded by at least 12 months without VTE and followed within 30 days by anticoagulation, an inferior vena cava filter placement, or death. Controls were matched to cases (10:1) on date and age. Conditional logistic regression models estimated risk for HT and statin exposures with odds ratios (OR), adjusted for comorbidities. Conditional logistic regression models were used to estimate VTE risk for HT and statin exposures with odds ratios (ORs), adjusted for comorbidities. Intensity of statin therapy was measured as a subgroup analysis. The total sample of 223 949 individuals (mean [SD] age, 57.5 [4.4] years) included 20 359 cases and 203 590 matched controls. Of the entire sample, 19 558 individuals (8.73%) had recent HT exposure and 36 238 individuals (16.18%) had current statin exposure. In adjusted models, individuals with any recent HT exposure had greater odds of VTE compared with those with no recent HT exposure (OR, 1.51; 95% CI, 1.43-1.60). Individuals receiving current statin therapy had lower odds of VTE compared with those with no current statin exposure (OR, 0.88; 95% CI, 0.84-0.93). When compared with those not recently taking HT or statins, the odds of VTE were greater for those taking HT without statins (OR, 1.53; 95% CI, 1.44-1.63) and for those taking HT with statins (OR, 1.25; 95% CI, 1.10-1.43), but were lower for those taking statins without HT (OR, 0.89; 95% CI, 0.85-0.94). Individuals taking HT with statin therapy had 18% lower odds of VTE than those taking HT without statins (OR, 0.82; 95% CI, 0.71-0.94) and there was greater risk reduction with higher intensity statins. In this case-control study, statin therapy was associated with reduced risk of VTE in women taking HT, with greater risk reduction with high-intensity statins. These findings suggest that statins may reduce risk of VTE in women exposed to HT and that HT may not be contraindicated in women taking statins.

The real-world fiasco in achieving guideline recommended LDL-C goals in atherosclerotic cardiovascular disease patients on high intensity statins.

The real-world fiasco in achieving guideline recommended LDL-C goals in atherosclerotic cardiovascular disease patients on high intensity statins.

Insights into the current management of dyslipidemia from a clinical pharmacological perspective

The low-density lipoprotein cholesterol (LDL-C) is established as a causative agent of atherosclerotic cardiovascular disease (ASCVD) and lowering plasma LDL-C levels represents the main approach to reduce the risk of cardiovascular events. Statins remain the cornerstone of drug therapy for dyslipidemia. Although moderate- to high- intensity statin therapy has demonstrated consistent benefits for secondary prevention of cardiovascular events, statin monotherapy is insufficient to achieve the guideline-recommended LDL-C levels for high- and very high-risk patients. Some patients cannot tolerate statins, especially when taking long-term high doses. Several non-statin drugs that have a complementary mechanism of action to statins are now available, including ezetimibe, monoclonal antibodies targeted to proprotein convertase subtilisin/kexin type 9 (PCSK9 mAb), and, more recently, inclisiran, bempedoic acid, and evinacumab. Considering the recommendations from guidelines by domestic and international cardiovascular associations, combining these drugs should be contemplated to attain treatment goals for patients. Key words: dyslipidemia, atherosclerotic cardiovascular disease, lipid-lowering drugs, familial hypercholesterolemia, hypertriglyceridaemia, nonstatin therapies.

High Intensity Statin With or Without Ezetimibe to Achieve Low Density Lipid Cholesterol Goal in Patients with Acute Coronary Syndrome- A Randomised Controlled Study

High Intensity Statin With or Without Ezetimibe to Achieve Low Density Lipid Cholesterol Goal in Patients with Acute Coronary Syndrome- A Randomised Controlled Study

Comparative Analysis of High-Intensity versus Low-to-Moderate Intensity Statin Therapy in Patients Undergoing Rotational Atherectomy for Calcified Coronary Artery Disease.

(1) Background: Moderate-intensity statin therapy, when compared to high-intensity statin therapy in Asian populations, has shown no significant difference in cardiovascular prognosis in small studies. The aim of this study was to compare the prognosis of patients based on statin intensity following rotational atherectomy (RA) during high-complexity percutaneous coronary intervention (PCI). (2) Methods: The ROCK registry, a multicenter retrospective study, included patients who had undergone rotational atherectomy (RA) during percutaneous coronary intervention (PCI) at nine tertiary medical centers in South Korea between January 2010 and October 2019. The patients were divided into high-intensity statin (H-statin) and moderate/low-intensity statin (M/L-statin) therapy groups. The primary endpoint includes outcomes (cardiac death, target vessel myocardial infarction (MI), and target vessel revascularization (TVR)) within an 18-month follow-up period. (3) Results: In this registry, a total of 540 patients with 583 lesions were included. We excluded 39 lesions from the analysis due to the absence of statin usage. The H-statin group had 394 lesions and the M/L-statin group had 150 lesions. There were no significant differences in baseline characteristics, procedural adverse events without heart failure history, triglycerides, or medications between the two groups. The procedural success rate showed a significant difference between the two groups. Multivariate analysis did not show a significant association between M/L-statin therapy and an increased risk of the primary endpoint. In propensity score matching analysis, no significant difference was observed in the primary endpoint either. (4) Conclusions: In high-complex RA PCI, moderate/low-intensity statin therapy is not inferior to high-intensity statin therapy in Korea.

Eicosapentaenoic and docosahexaenoic acid supplementation and coronary artery calcium progression in patients with coronary artery disease: A secondary analysis of a randomized trial

Background and aimsWe previously reported that an omega-3 fatty acid index ≥4% with high-dose eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) prevented progression of noncalcified plaque. Higher coronary artery calcium (CAC) scores and progression of CAC are associated with increased cardiovascular events and mortality. We examined the effect of EPA + DHA on CAC score. MethodsA total of 242 patients with coronary artery disease (CAD) on statin therapy were randomized to 1.86 g EPA and 1.5 g DHA daily or none (control) for 30 months. The CAC score was measured at baseline and 30-months with non-contrast, cardiac computed tomography. ResultsBoth EPA + DHA and control groups had significant progression in CAC scores over 30 months (median change:183.5 vs 221.0, respectively, p < 0.001) despite a 13.6% reduction in triglyceride level with EPA + DHA. No significant difference was observed between groups for the total group, by baseline CAC scores of <100, 100–399, 400–999 and ≥1000 or quartiles of achieved levels of EPA, DHA and the omega-3 fatty acid index. Similar rates of CAC progression were noted in those on high-intensity statin compared to low- and moderate-intensity statin. ConclusionsEPA and DHA added to statin resulted in similar CAC progression over 30 months regardless of baseline CAC categories, statin intensity and achieved levels of EPA, DHA and the omega-3 fatty acid index.

The impact of statin intensity on long-term outcomes in elderly patients with acute myocardial infarction who have undergone percutaneous coronary intervention

Abstract Background The data regarding long-term clinical outcomes according to statin intensity in elderly patients who have undergone percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) is unclear. Purpose We aimed to investigate the long-term clinical benefit of high intensity statin versus moderate to low intensity statin in elderly patients underwent PCI for acute MI. Methods Among 13104 patients with acute MI who have undergone PCI in a nationwide, prospective, and real-world registry, 4294 elderly (defined as ≥70 years) patients prescribed statin at discharge were included. 1136 patients were prescribed with high intensity statin, and 3158 patients were prescribed with moderate to low intensity statin. The major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, readmission due to heart failure [HF], or definite/probable stent thrombosis [ST]) and the components of MACE were compared in multivariable Cox regression, propensity score (PS) matched, and underwent PS-adjusted analyses. Results During a median follow-up of 998 days, MACE, all-cause death, and cardiac death occurred in 1297 patients (30.2%), 737 patients (17.2%), and 460 patients (10.7%), respectively. The risks of MACE (entire: 26.9% vs. 31.4%, hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.73-0.95, p=0.005; PS-matched: n=2186, 25.3% vs. 30.8%, HR 0.79, 95% CI 0.67-0.94, p=0.008), all-cause death (entire: 14.4% vs. 18.1%, HR 0.78, 95% CI 0.65-0.93, p=0.005; PS-matched: 13.8% vs. 18.9%, HR 0.69, 95% CI 0.57-0.92, p=0.002), cardiac death (entire: 9.5% vs. 11.4%, HR 0.81, 95% CI 0.67-0.97, p=0.042; PS-matched: 8.7% vs. 11.3%, HR 0.77, 95% CI 0.61-0.96, p=0.031), and readmission due to HF (entire: 5.5% vs. 7.5%, HR 0.72, 95% CI 0.55-0.95, p=0.021; PS-matched: 5.7% vs. 8.1%, HR 0.78, 95% CI 0.59-0.96, p=0.017) were significantly decreased in the patients received high intensity statin compared to in those received moderate to low intensity statin. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, and definite/probable ST between the groups. In patients ≥80 years, compared to the moderate to low intensity statin group, high intensity statin group had the reduced rates of MACE, all-cause death, cardiac death, recurrent MI, any revascularization, stroke, readmission due to HF, or definite/probable ST, but insignificantly. Conclusions From the nationwide registry, we noted that in elderly patients after PCI for acute MI the administration of high intensity statin versus moderate to low intensity statin was contributed to the improved long-term clinical outcomes.

Early lowering of LDL-C is a more cost-effective strategy than lowering LDL-C later in life: a cost-effectiveness analysis using Mendelian Randomisation

Abstract Background Early control of low-density lipoprotein-cholesterol (LDL-C) is an effective way to reduce the risk of coronary heart disease (CHD). However, a comprehensive assessment of cost-effectiveness of different lipid-lowering strategies (LLS) for primary prevention of CHD across different ages is lacking. Objective To assess the cost-effectiveness of four different LLS initiated at ages 30, 40, 50, and 60 years on the primary prevention of CHD from the UK National Health Service perspective. Design, setting and participants: We developed a microsimulation model, based on the causal effect of LDL-C on myocardial infarction (MI) or coronary death derived from Mendelian randomisation, comparing initiation of an LLS to current standard of care (control). Data were primarily drawn from 458,727 participants of the UK Biobank study with available data on date of birth, LDL-C, and who were free of MI at first assessment (between 2006 and 2010), with follow-up until 2021. Interventions: The four LLS were: 1) low/moderate intensity statins; 2) high intensity statins; 3) low/moderate intensity statins and ezetimibe; and 4) inclisiran. Main outcomes measures: The incremental cost-effectiveness ratio (ICER), defined as the incremental healthcare costs divided by the incremental quality-adjusted life years (QALYs) for each LLS compared to control, with 3.5% annual discounting. Results The most effective intervention, low/moderate intensity statins and ezetimibe, was projected to lead to a gain in QALYs of 0.068 per person at age 30 and 0.026 at age 60 compared to control (Figure). The age of intervention with the lowest ICER was age 40, with ICERs of £2,524 (95% uncertainty interval: 1,383, 3,796), £4,466 (3,163, 6,134) £11,118 (8,632, 14,177), and £1,405,123 (1,117,1113, 1,789,012) per QALY gained for strategies 1-4 from age 40 years, respectively (Table). Conclusions LDL-C lowering from early ages is a more cost-effective strategy than late intervention. The approach to primary prevention of CHD may improve with a shift to early and sustained lowering of LDL-C. Figure – Results of 1,000 probabilistic sensitivity analyses presented in a common cost-effectiveness plane, by age of intervention. Inclisiran excluded due to very high costs. Solid line: £20,000 per quality-adjusted life year (QALY) willingness-to-pay threshold; dashed line: £30,000 per QALY willingness-to-pay threshold. Any dot to the right of these lines is considered cost-effective. Table – Summary of LLS interventions by age of intervention. Abbreviations: MI – Myocardial infarction; YLL – Years of life lived; QALYs – Quality-adjusted life-years; ICER – Incremental cost-effectiveness ratio.FigureTable

Association of statin use and outcomes in elderly with multiple risk factors: insight from the CORE registry Thailand

Abstract Introduction Statin is recommended by for lipid management in adults aged between 40 and 75 years old at risk for atherosclerotic cardiovascular disease (ASCVD). The evidence from meta-analysis suggested that the benefit of statin for primary prevention in the elderly was less robust than in the non-elderly. A dedicated randomized controlled trial of primary prevention with a statin in the elderly is currently ongoing. We aimed to study the association of statin use as a primary prevention for ASCVD on major adverse cardiac events in the elderly versus non-elderly in the Cohort Of patients with a high Risk of cardiovascular Events (CORE). Method The CORE registry was a nationwide study enrolling patients with established ASCVD or those with multiple risk factors (MRFs) between April 2011 and March 2014 in 25 hospitals. Patients with MRFs were included in the present analysis. Patients were stratified according to age and the status of statin use. The Elderly was defined as age over 75 years old. Any type and intensity of statin at baseline were counted as statin use. The primary outcome was the major adverse cardiac events (MACE), defined as the composite of all-cause death, stroke, or myocardial infarction. The association between statin use and outcomes was assessed overall and in the two groups of elderly versus non-elderly in the adjusted Cox regression models. Factors associated with both likelihood of statin use, and outcomes were used as adjusted variables. Results Of the 4,529 patients in the study, 729 patients were elderly (16.1%). The proportion of females was 57%, with a mean age of 65.6 years. The rate of statin use at baseline was similar between the elderly (84.9%) and non-elderly (83.6%) (p 0.41). The average follow-up time was 45.3 months. Statin use was associated with a significantly lower risk of MACE at five years. The incidence of MACE was highest in the elderly without statin use and lowest in non-elderly with statin use. Statin use at baseline was associated with a lower risk of MACE in both the elderly and non-elderly (p interaction 0.29). The risk of heart failure (HF) in the elderly treated with a statin was significantly lower than elderly without statin use (adjusted HR 0.37, 95%CI 0.14-0.96), while the risk of HF was similar between non-elderly with or without statin (adjusted HR 0.58, 95%CI 0.30-1.15). Statin use was associated with a lower risk of peripheral arterial disease in the elderly (adjusted HR 0.07, 95%0.01-0.73) but not in the non-elderly (adjusted HR 0.57, 95%CI 0.18-1.82). There was a trend toward lower risk of stroke, MI, or PAD in the elderly treated with statin than those without statin use (adjusted HR 0.48, 95% 0.22-1.07). Conclusion Statin use was associated with a significantly lower risk of MACE, HF, and PAD in the elderly with multiple risk factors of ASCVD in the CORE registry.MACE according to statin and age groupOutcomes according to statin and elderly

Lipid assessment and achievement of secondary prevention european society of cardiology guideline targets in patients with atherosclerotic cardiovascular disease with and without depression

Abstract Background Patients who have a diagnosis of atherosclerotic cardiovascular disease (aCVD) who also have depression (Dep) have a worse CV prognosis than those without Dep. Appropriate secondary prevention greatly improves CVD outcomes. The European Society of Cardiology (ESC) provide guideline targets for lipid levels (2016 &amp; 2019). It is unknown how well these targets are achieved and maintained over time in patients with aCVD at a population level and whether this differs in those with and without Dep. Purpose To investigate the assessment of lipid levels and/or achievement of guideline targets in patients with aCVD with and without Dep over an 11-year period. Methods A retrospective observational cohort study of patients with aCVD was conducted on individual-level linked electronic health record data between 2009 &amp;2019 using the all-Wales SAIL databank. Clinical codes were used to identify aCVD and Dep diagnoses, lipid assessments and lipid-lowering therapy (LLT) from GP data. The proportions of those having lipid assessments during each calendar year, lipid levels achieving ESC 2016 guideline targets and current LLT were documented. Results In 2009, the aCVD cohort comprised of 183,275 patients (44% female) with a mean age (70.6 ±12.3 years), of whom 22% had a Dep diagnosis (56.6% female). In 2009, lipid levels were assessed in 63.1% of patients, dropping to 48.3% by 2019 (68.06% Dep, 61.65% non-Dep in 2009 and 51.7% Dep, 46.84% non-Dep in 2019. Table and Figure). Over the period of study an increasing proportion of patients were prescribed High intensity statins (HIS) and a decreasing proportion were prescribed low intensity statin (LIS) and/or Ezetimibe. Dep patients were more likely to be treated with HIS and/or Ezetimibe and less likely to receive LIS throughout compared with non-Dep (table). An increasing trend for lipid targets being achieved was observed between 2009 and 2019 in those being tested (Table and Figure). However, a significantly smaller proportion of those with Dep met the ESC targets vs non-Dep over the period of study (Table and Figure). Conclusion The proportion of aCVD patients having their lipids checked fell progressively between 2009 and 2019, although a greater proportion of those "checked" patients had achieved LDL-C and non-HDL-C targets, although the proportion who met these targets remained low. Despite patients with aCVD and Dep being more likely to have their lipids assessed and to be prescribed more intensive LLT those without Dep, with the "gap" widening over time. Considerable additional effort will be required in the future to meet the more intensive 2019 targets in these very high risk patients.

Almost 1 in 2 patients with acute coronary syndrome are extremely high-risk and potential candidates for in-hospital triple lipid-lowering therapy: data from the CALLINICUS-Hellas Registry

Abstract Introduction The great heterogeneity of acute coronary syndrome (ACS) patients in the risk for cardiovascular events recurrence, prompted a recent position paper endorsed by the International Lipid Expert Panel to propose criteria, i.e. coexistence of multivessel coronary artery disease (CAD), polyvascular disease, heterozygous familial hypercholesterolemia (heFH), diabetes mellitus (DM) with estimated glomerular filtration rate (eGFR) &amp;lt;60 ml/min/1.73 m2 and/or lipoprotein (a) [Lp(a)] &amp;gt;50 mg/dL etc., which define the extremely high-risk ACS patients for whom an low-density lipoprotein cholesterol (LDL-C) &amp;lt;40 mg/dL was proposed. Purpose To estimate the proportion of patients with ACS that fulfill the criteria of the extremely high-risk group and are potential candidates for "extremely" intensive early lipid-lowering therapy (LLT) aiming at an LDL-C &amp;lt;40 mg/dL. Methods We recruited 780 consecutive patients with ACS who were participants of the CALLINICUS-Hellas Registry which is a prospective multicenter observational study that explores the adherence to LLT, the achievement of LDL-C targets and the cardiovascular events at 6- and 24-months after hospital discharge of patients with ACS. Results The prevalence of high risk components was: heFH 13.5%, multivessel CAD 44%, polyvascular disease 3.2%,and DM with eGFR &amp;lt;60 ml/min/1.73 m2 and/or Lp(a) &amp;gt;50 mg/dL 8.1%. By excluding the overlapping between these conditions, 430 ACS patients (55.1%) had at least one of the characteristics which define the extremely high-risk patients (Figure). Presuming a 65% LDL-C reduction of the levels (the pretreatment if on LLT prior admission or the admission if not on prior LLT) of the extremely high-risk ACS patients by taking a maximum dual LLT (intense statin plus ezetimibe), 312 patients, i.e., 40% of all initially recruited patients would fail to achieve an LDL-C &amp;lt;40 mg/dL suggesting that they require additional LLT, namely, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). Conclusions Almost 1 in 2 patients with ACS have extremely high-risk characteristics and are candidates for in-hospital triple LLT (statin plus ezetimibe plus PCSK9i) aiming at an LDL-C &amp;lt;40 mg/dL, a strategy shown to improve plaque stability and possibly to reduce the recurrence rate of early coronary events.Figure

Strike Early and Strike Strong: application of a strategy comprising first-line combination of high-intensity statins and ezetimibe for patients with acute myocardial infarction in routine practice

Abstract Aim Rapid and intense LDL-c reduction for patients with acute myocardial infarction (AMI) using a systematic combination of high intensity statins and ezetimibe, dubbed "Strike Early and Strike Strong" (SESS), has been proposed in a position paper endorsed by ESC. The applicability of this strategy in routine practice, and the tolerance and biological efficacy of such lipid lowering treatment (LLT) are poorly documented. Methods Single-center, prospective, observational study including 500 consecutive patients admitted for AMI. Unless there was known intolerance, a SESS policy was advocated at admission for AMI, irrespective of baseline LDL-c. Actual discharge LLT, LDL-c level during follow-up (3 to 8 months) and the rate of patients at ESC LDL-c target were recorded. We considered LLT to be maintained when observed LDL-c level at follow-up (FU) was not 20% higher than that expected from baseline LDL- and LLT intensity at discharge. Results Between January 2020 and July 2021, 527 patients were included, 387(75%) were male, 110(22%) had diabetes, mean age was 63±12 years. Admission LDL-c was 127±44mg/dL, 431(78%) had no previous LLT. At discharge, 456 (97%) a high intensity statin, and combined with ezetiibe in 430/456(92%). The mean capacity of the discharge LLT to decrease LDL-c was 63±10%. 12-month FU with biology was available for 273 randomly selected patients. The combination of high intensity statins and ezetimibe was maintained in 87%, although ezetimibe was stopped in 9% and the statin dose was reduced in 15% (mainly reduction from atorvastatin 80 to 40 mg/day). As a result, capacity of the LLT to decrease LDL-c was reduced to 59±11%. Mean LDL-c was 53±33 mg/dL. ESC LDL-c therapeutic goals were reached in 53%: LDL-c&amp;lt;55mg/dL in 62% and &amp;gt;50% decrease in baseline LDL-c in 74%. Regarding the need for PCSK9 inhibitors, the rate was 14% for a threshold for prescription set at a LDL-c≥ 70mg/dL, and 7% for a threshold set at ≥100mg/dL. An LDL-c level &amp;lt;30mg/dL was observed in 19%. Conclusion The SESS strategy before discharge after ACS is feasible in routine practice. At 12 months, LLT intensity was maintained in the majority of cases, yielding an average LDL-c level of 53±33 mg/dL, and 53% of patients at LDL-c goals.

No-reflow, acute heart failure and ventricular fibrillation are more common in STEMI patients in wartime conditions

Abstract Stress and logistical problems during the wartime can change the course of STEMI and contribute to the development of in-hospital complications. The aim of our work was to analyze in-hospital complications in STEMI pts admitted during the first months of full-scale invasion of Ukraine and compare them with patients hospitalized during the same period of 2019 (pre COVID-19 era). The total number of STEMI patients hospitalized in 2022 was half as much as in 2019 (49 vs. 98 patients), which can be partly explained by civilian migration and mobilization. The average age of patients (61.0±10.7 in 2019 vs 63.5±11.7 in 2022, p=0.197) and the number of women (20.4% vs 26.5%, p=0.420) did not change. There were no significant differences in other main clinical characteristics between groups. The GRACE score in groups was almost the same (154.3±33.0 pts vs 160.8±43.5 pts, p=0.366) and about 50% of pts had anterior MI. Acute heart failure (Killip 2-3) at admission was diagnosed in 27.4% and 20.4%, cardiogenic shock (Killip 4) in 9.4% and 8.2% in 2019 and 2022, accordingly. Despite the absence of a significant difference in the level of arterial pressure, heart rate at admission was 10 bpm more during the wartime (84,0±15,4 bpm vs 74,9±20,6 bpm, p=0.005). 11.3% of STEMI pts in 2019 and 24.5% of pts in 2022 (p=0.064) were admitted after the first 24 hrs from symptoms onset. The mean time to hospitalization in pts admitted during the first 24 hrs was 4.4±3.8 hrs in 2019 and 6.4±5.6 hrs in 2022 (p=0.044). This time delay led to a lower number of pPCI made during the wartime (82.5% vs. 59.2%, p=0.005), despite the same total number of coronary angiographies (90.7% in 2019 vs. 91.5% in 2022, p=0.821) and total PCI numbers (86.6% in 2019 vs. 79.6% in 2022=0.304). No-reflow (determined as TIMI&amp;lt;3 or MBG&amp;lt;2) was registered in 34.3% of pts in 2022 and 12.9% in 2019, p=0.039. There were no differences in medical treatment between groups. DAPT was used in 97.6% and 100% (&amp;gt;80% ticagrelor), high intensity statins in 98.0% and 98.0%, beta-blockers in 89.5% and 90.9%, ACREI/ARB in 89.5% and 91.1%, MRA in 56.0% and 55.6% in 2019 and 2022, accordingly. In-hospital mortality in STEMI pts in wartime period was two times higher (but not significant) than in 2019 (4.9% in 2019 vs 10.2% in 2022, p=0.302). Patients with STEMI hospitalized during the first three months of the war had significantly higher rate of ventricular fibrillations (4.3% in 2019 vs 15.3% in 2022, p=0.043). Despite the lack of differences at admission acute heart failure was also significantly higher in pts treated during wartime on the 3d day of STEMI (11.2% in 2019 vs 24.5% in 2022, p=0.049). During hostilities, patients with STEMI are hospitalized later, have worse results of revascularization and a greater number of in-hospital complications.