Lipid-lowering Treatment Research Articles

Pharmacoepidemiologic study of association between apparent treatment resistant hypertension, cardiovascular disease and interaction effect by sex and age

A limited number of studies have been conducted to test the magnitudes of the association between apparent treatment resistant hypertension (aTRH) and risk of cardiovascular disease (CVD). To investigate the association between aTRH and risk of CVD and examine whether sex and age modify this association. We applied an observational analysis study design using data from the United States Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT recruited participants (n = 25516) from 625 primary care settings throughout the United States, Canada, Puerto Rico, and United States Virgin Islands, aged 55 and older with hypertension and at least one additional risk factor for heart disease. aTRH was assessed from the year 2 visit. CVD event was defined as one of the following from the year 2 follow-up visit: Fatal or non-fatal myocardial infarction, coronary revascularization, angina, stroke, heart failure, or peripheral artery disease. Cox proportional hazards regression was used to examine the effect of aTRH on CVD risk. Potential modifications of sex and age on this association were examined on the multiplicative scale by interaction term and additive scale by joint effects and relative excess risk for interaction. Of the total study participants (n = 25516), 5030 experienced a CVD event during a mean of 4.7 years follow-up. aTRH was associated with a 30% increase in risk of CVD compared to non-aTRH [hazards ratio (HR) = 1.3, 95%CI: 1.19-1.42]. Sex and age modified this relationship on both multiplicative and additive scales independently. Stratified by sex, aTRH was associated with a 64% increase in risk of CVD (HR = 1.64, 95%CI: 1.43-1.88) in women, and a 13% increase in risk of CVD (HR = 1.13, 95%CI: 1.01-1.27) in men. Stratified by age, aTRH had a stronger impact on the risk of CVD in participants aged < 65 (HR = 1.53, 95%CI: 1.32-1.77) than it did in those aged ≥ 65 (HR = 1.18, 95%CI: 1.05-1.32). Significant two-way interactions of sex and aTRH, and age and aTRH on risk of CVD were observed (P < 0.05). The observed joint effect of aTRH and ages ≥ 65 years (HR = 1.85, 95%CI: 1.22-2.48) in males was less than what was expected for both additive and multiplicative models (HR = 4.10, 95%CI: 3.63-4.57 and 4.88, 95%CI: 3.66-6.31), although three-way interaction of sex, age, and aTRH on the risk of CVD and coronary heart disease did not reach a statistical significance (P > 0.05). aTRH was significantly associated with an increased risk of CVD and this association was modified by both sex and age. Further studies are warranted to test these mechanisms.

Cardiac rehabilitation can change the destiny of the patient with ST-elevation acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation (CR) has become a basic element in the recovery of patients with acute coronary syndrome, since it achieves greater therapeutic adherence and better control of cardiovascular risk factors. Purpose We aim to describe the characteristics of patients with ST-elevation acute coronary syndrome (STEACS) included in a Cardiac rehabilitation program, as well as the achievement of prevention objectives and the occurrence of mayor adverse cardiovascular events (MACE). Methods Observational prospective study where a total of 664 STEMI patients admitted to a Coronary Unit during the years 2017-2020 were included. They were classified according to their participation in a CR program. We compared medical history, lipid-lowering treatment (prior, at discharge and titration), lipid levels at discharge and at 1-year follow-up, and degree of achievement of lipid targets. MACE (mortality, reinfarction, coronary revascularisation and restenosis) were observed at 2-year follow-up. Results From 664 patients, 351 were excluded due to lack of follow-up or early mortality. From a total of 313 patients (mean age 59.9±11.2 years; 81% male), 55.3% were included in the CR program. This group had a lower mean age (55.46±8.7 vs 65.39±11.5, P&amp;lt;0.001), as well as a higher frequency of early ischaemic heart disease history and smoking, with a lower frequency of hypertension and diabetes (Table). Lipid-lowering treatment at discharge was similar in both groups. In patients undergoing CR, there was a lower level of total cholesterol and low-density lipoprotein cholesterol (LDLc) at one year follow-up (126.2±27 vs 137.2±34, P=0.002; 57.8±23 vs 67.5±26, P&amp;lt;0.001) and a greater reduction in LDLc (41.4% vs 20.86%, P&amp;lt;0.001) was achieved even from higher initial LDLc values. Titration of lipid-lowering treatment was also greater, with the old target of LDLc&amp;lt;70 being achieved in a greater number of cases (81.5% vs 59.3%, P&amp;lt;0.001). At 1-year follow-up, the new lipid reduction target (LDLc&amp;lt;55 + 50% reduction) was achieved in only 26.8% of patients, with a greater reduction in the CR group (34.1% vs 17.9%; P=0.02). Although differences were observed in the follow-up in terms of mortality and new events, in favor of the CR group, these did not reach statistical significance. Conclusions Participation in a CR program is associated with better lipid control in patients admitted for STEACS. These programmes represent a basic tool for achieving lipid and cardiovascular risk factor targets and improved long-term clinical outcomes.

Consequences of diabetes and high-risk dyslipidemia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Diabetic patients develop both, microvascular and macrovascular long-term complications, and have double the risk of cardiovascular (CV) disease being the main cause of death. The 97% of diabetic patients are classified as high or very high CV risk. The 2019 ESC guidelines for the managment of dyslipidaemia, classified patients with LDL-c &amp;gt;190 mg/dL as high-risk patients, with the indication of high-intensity statins (LDLc reduction greater than 50% and LDLc below 70 mg/dL). Objective To analyze, in a group of patients with high risk dyslipidaemia (HRD, LDLc &amp;gt;190 mg/dL without secondary cause), the consecuences of its association with type 2 diabetes. Methods Observational retrospective cohort of 153 patients with HRD. We compared 35 diabetic patients (G1) vs 118 non diabetic patients (G2), and we analysed clinical characteristics, cardiovascular risk factor’s (CVRF), tase of cardiovascular disease, the baseline blood test with maximum LDL-c (BT1), lipid profile on the last blood test (BT2) and the effects of lipid-lowering treatment. Results There were no differences in relation to sex. G1 were older (69.2 (±12.8) vs 56.8 (±12.5) years old, p=0.001), had a higher body mass index (BMI) (31.4 (±5.9) vs 28.9 (±4.4) kg/m2, p=0.018), higher number of CVRF (3 CVRF, 54.3% vs 10.2%, p&amp;lt;0.0001, and 4 CVRF, 37.1% vs 0%, p&amp;lt;0.0001). Regarding mayor CV events, 80% develop CV disease vs 38.1% (p&amp;lt;0.0001), and 40% develop early coronary disease (ECD) vs 25% (p&amp;lt;0.0001). In the BT1, G1 presented a more atherogenic lipidogram, lower HDL-c &amp;lt;40-45mg/dL values (22.9% vs 9.3%, p=0.033), higher proportion of triglycerides &amp;gt;150mg/dL (74.3% vs 46.6%, p=0.001), higher proportion of small and dense LDL-c (88.6% vs 62.7%, p=0.004) and a higher proportion of VLDL-c &amp;gt;30mg/dL (74.3% vs 45.8%, p=0.003). There were no differences in lipid-lowering treatment (statin 88.6% vs 86.4%, p= 0.7; ezetimibe 68.6% vs 53.4%, p=0.1) or in the lipid-lowering power of LDL reduction &amp;gt;50% (77.1% vs 70.3%, p=0.4), except for a greater prescription of fibrates in G1 (11.4% vs 1.7%, p=0.027). In BT2, lower rates of HDL-c &amp;lt;40-45mg/dL (34.3% vs 16.1%, p= 0.019) and small and dense LDL-c (80% vs 50.9%) persisted in G1, p=0.002) and a higher proportion of chronic kidney disease (25.8% vs 2.6%, p&amp;lt;0.0001). Conclusions Patients with HRD and diabetes have higher CVRF, a more atherogenic lipid profile that persists despite lipid-lowering treatment, and double the rate of CV disease, were half of these events occurs at early age. This association of CVRF should alert us, implementing an early and agressive prevention treatment of all CVRF.

Aspirin and statin use in primary prevention after coronary artery calcium score

Abstract Funding Acknowledgements Type of funding sources: None. Introduction A coronary artery calcium (CAC) score of more than 100 places the 10-year cardiovascular risk above 7.5%, justifying the initiation of pharmacological measures in primary prevention. Purpose The present study explores the level of implementation of a primary prevention strategy after CAC score in patients without obstructive coronary disease. Methods The study cohort included all patients from the health area of our city (Galicia, Spain) who underwent a coronary computed tomography (CT) scan between July 2021 and February 2022. Subjects with obstructive coronary disease (CADRADS 3 or higher), atrial fibrillation patients and inconclusive studies were excluded. The final population of the study consisted of 209 patients. The sample was classified according to Agatston Score into three groups: no calcification (CAC=0), non-significant (CAC 1-100), and significant calcification (CAC &amp;gt;101). Multinomial and binomial logistic regression were performed to identify the predictors associated with the prescription of statin and aspirin, respectively. Results 41 patients (19.62%) had significant calcification (CAC &amp;gt;101). Of those, 16 (39.02%) started aspirin and 21 (51.22%) started statin (Figure 1). The CAC score allowed to increase the percentage of patients who benefited from lipid-lowering treatment, from 31.70% to 82.92% (Figure 2). Significant differences were observed in the proportion of patients who initiated aspirin and statins according to the degree of coronary calcification (Chi2 18.76; p=0.000), (Chi2 48.42; p=0.000) respectively. After multivariate adjustment, a CAC score &amp;gt;100 (OR 5.88 (2.29-15.07; p=0.000) and the presence of vulnerable plaque (OR 6.78 (1.01-47.46; p=0.050) were the only predictos which led clinicians to start antiplatelet therapy. Neither age, nor SIS (segment involvement score) were associated. Regarding to lipid-lowering therapy, CAC score 1-100 (OR 5.87 (1.68-20.51; p=0.006) and CAC score &amp;gt;100 (OR 30.78 (5.08-186.47; p=0.000) were independently associated with statin prescription. Conclusions The use of coronary CT allows optimization of the therapeutic strategy in primary prevention, increasing the percentage of patients who may benefit from statins. In this setting, aspirin is little established in our cohort. Therefore, we should transmit to the clinician the possibility of starting antiplatelet therapy, individualizing the indication.

Predictors of cardiovascular disease in a familial hypercholesterolemia unit

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Screening and cascade screening for familial hypercholesterolemia (FH) is advised in patients with early coronary heart disease (ECHD) or high-risk dyslipidemia LDL-c &amp;gt;190 mg/dL without secondary cause. The diagnostic rates of FH by genetic testing are 5-9% in patients with ECHD and 2-5% in patients with high-risk dyslipidemia. Methods Observational retrospective study of a cohort of 615 patients over 18 years of age, included in an HF unit (177 index cases and 438 first-grade relatives). The population was divided into 201 (32.7%) patients with cardiovascular disease (CVD) (Group A), and 414 patients without CVD (Group B). Clinical characteristics, variables of the inclusion blood test in the HF unit and the lipid-lowering treatment implemented were compared. Results Group A patients were older, wiht a higher proportion of male, higher rates of hypertension and diabetes, higher body mass index (BMI), higher percentage of obese, and no difference in historical maximum LDL-c levels compared to Group B. Group A patients, as a result of CVD, receivedmore potent lipid-lowering treatment, had lower levels of LDL-c but without differences in meeting their LDL-c objective (45.7% vs 39%, p=0.19), presented a higher rate of small and dense LDL-c either measured by LDL-c/ApoB ratio &amp;lt;1.3 or Triglycerides/HDL-c &amp;gt;2, and lower HDL-c values with a higher percentage of values minor than 40 mg/dL in men and less than 45 mg/dL in women (HDL-c &amp;lt;40-45). Group A had higher lipoprotein (a) values and higher lipoprotein (a) &amp;gt;180 mg/dL (equivalent to FH), a higher proportion of chronic kidney desease and increased uric acid (table 1). Conclusions In a population of patients with suspected FH, the presence of CV risk factors (male sex, older age, high blood pressure, diabetes, obesity, chronic kidney desease), and atherogenic blood test (HDL&amp;lt;40-45, increased lipoprotein (a), increased uric acid, small and dense LDL-c) were associated with CVD. The detection of these in this patient population of patients should lead us to act early and aggressively to prevent the development of CV events.

Measurement of small, dense lipoproteins. Usefulness of the Tg/HDL index compared to direct LDL measurement

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): Ninguna Introduction The Triglyceride/HDL (Tg/HDL) ratio when &amp;gt; 2 is translated into the presence of small, dense lipoproteins (sdLDL), which are more atherogenic and help us measure global lipid risk regardless of LDL levels. There is the possibility of measuring sdLDL directly, but it is not performed in routine clinical practice. The objective of our study was to analyze the correlation of the TG/HDL index with the direct measurement of sdLDL and cardiovascular risk (CVR). Materials and methods Patients who were treated in cardiology from July 1 – July to September 30, 2022 were analyzed consecutively and the determination of the lipid profile with direct measurement of sdLDL was requested. This measurement is considered risk when sdLDL&amp;gt; 50 mg/dl. Results n 75. Mean age 60 ± 15 years. 37.3% were women. 49.3% were hypertensive, 48% dyslipidemic, 22.7% diabetic, 32% smokers, 58.7% very high CVR and 54.7% with lipid-lowering treatment. Mean LDL levels were 84.3±37 mg/dl, non-HDL 110±39 mg/dl, triglycerides 139±75 mg/dl, remnant cholesterol 27.8 ±15 mg/dl, LDL-sd 34±20 mg/dl and Tg/HDL 3.5±±2. Patients with Tg/HDL&amp;gt;2 had mean sdLDL levels 36± 23 mg/dl vs 29.7 ± 14 mg/dl (p0.06) and those with Tg/HDL&amp;gt;3 39.8± 26 mg/dl vs 28.9± 12 mg/dl ±(p&amp;lt;0.02). All patients with LDL&amp;gt; 50 mg/dL levels had Tg/HDL&amp;gt;2, however 60% of patients with Tg/HDL&amp;gt;2 had LDL&amp;lt;50 mg/dL levels (p0.01), but only 37% Tg/HDL&amp;gt;3 (p&amp;lt;0.001). (Table 1. Relationship between lipid profile, Tg/HDl and LDL-SD) 20% of very high/high RCV patients had LDL&amp;gt;50 mg/dl, 9.1% moderate RCV and 12.5% low RCV. Conclusions The Tg/HDL index may be more useful in identifying patients with LDL&amp;gt; 50 mg/dl primarily when it is &amp;gt; 3.

Discordance between LDL cholesterol and apolypoprotein B. Which to prefer to guide treatment?

Abstract Funding Acknowledgements Type of funding sources: None. Current cardiovascular risk guidelines recommend target values of low-density lipoprotein cholesterol (LDLc) &amp;lt; 55 mg/dL and apolipoprotein B (apoB) &amp;lt; 65 mg/dL. However, they don’t clarify what the attitude should be when one of the two targets is not achieved. Our objective was to establish the prevalence of LDLc and ApoB discordance in a secondary prevention population in our cardiac rehabilitation unit and describe the size of LDLc particles in this cohort of patients. We conducted a retrospective observational study including patients with previous ischemic heart disease with lipid-lowering treatment in secondary prevention followed up in our cardiac rehabilitation unit between February 2022 and September 2022. We present a series of 100 patients with a mean age of 60.5 years (S.D. 9.7), 79% male, with high prevalence of cardiovascular risk factors (59% hypertension, 26% diabetes mellitus, 52% smokers). All patients received lipid-lowering therapies, with statins alone or in combination with Ezetimibe. 30 patients (30%) had LDLc &amp;gt; 55 mg/dL and ApoB &amp;lt; 65 mg/dL, 37 (37%) reached target LDL and ApoB levels (LDLc &amp;lt; 55 mg/dL and ApoB &amp;lt; 65 mg/dL), and 33 (33%) did not reach any of the target levels (LDLc &amp;gt; 55mg/dL and ApoB &amp;gt; 65 mg/dL). No patient had LDLc &amp;lt; 55mg/dL and ApoB &amp;gt; 65mg/dL. Among patients with ApoB target level achieved and LDLc &amp;gt; 55mg/dL, the mean LDLc/ApoB ratio was 1.1 (S.D. 0.1). The mean ratios stratified by LDLc level are represented in Figure 1 and specified in Table 1. The conclusion of our study is that in clinical practice we find a group of patients with discrepancy between LDLc and ApoB levels that is not represented in the main studies of cardiovascular outcomes. Therefore, we do not know what therapeutic approach we should take. It is known that these relatively high LDLc values when apoB is in range correspond to larger and less dense particles, and therefore less atherogenic, and it has been suggested that ApoB levels better reflect residual risk than LDLc in statin-treated patients. At this point, the question that arises is: should we take these patients to an LDL &amp;lt; 55mg/dL or is their lipid risk controlled?

High risk dyslipidemia: can we predict early coronary disease?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The AHA/ACC guidelines on the management of blood cholesterol (2013 and 2018) classified the LDL-c &amp;gt;190 mg/dL as high-risk patients, with the indication of high-intensity statins (c-LDL reduction greater than 50%). Recently the 2019 ESC guidelines(1) also classify these patients as high cardiovascular (CV) risk. Objective Determine factors associated with the development of early coronary disease (ECD) in patients with high-risk dyslipidemia (HRD). Methods Observational retrospective cohort of 160 patients with historical maximum LDL-c ≥190 mg/dL without secondary cause. We compared the clinical characteristics, the baseline blood test with maximum LDL-c (BT1), and the effects of lipid-lowering treatment on the last blood test (BT2), between patients with ECD (53 patients Group A) and patients without cardiovascular events (107 patients Group B). Results Group A, presented maximum LDL-c at a younger age, had dyslipidemia of longer evolution time, had a higher proportion of men, smokers, diabetics, and had a higher number of associated risk factor's (Table 1). In the BT1 they presented greater proportion of HDL-c values below 45 mg/dL (35.3% vs 12.3%, p=0.001), and a higher proportion of remnant cholesterol (Non HDLc - LDLc = &amp;gt;30 mg/dL, 51% vs 33.3%, p=0.037). Patients with ECD received high-intensity lipid-lowering treatment, statin + ezetimibe (73.6% vs 29.8%, p&amp;lt;0.0001), IPCSK9 (7.5% vs 2.9%, p=0.18), and achieving LDL-c goals (32.1% vs 13.6%, p=0.006) and Non HDL-c (47.2% vs 14.6%, p&amp;lt;0.0001) according to cardiovascular risk. There were no variation between BT1 and BT2 in HDL-c levels in both groups. In the Cox regression model, male sex (HR 2.8 (1.4-5.7), p=0.003), tobacco (HR 2.5 (1.3-4.7), p=0.005), and the relation between Non HDL-c/HDLc (&amp;gt;4.5 male, &amp;gt;4 female, in primary prevention) in BT1 (HR 1.65, (1.15-1.86) p=0.02) increase independently the risk of ECD in patients with HRD. Conclusion In patients with HRD the presence of male sex, tobacco, increase relation between Non HDLc/HDLc, diabetes, a greater number of cardiovascular risk factors, most atherogenic blood test (HDLc &amp;lt;45 mg/dL and remnant cholesterol) have been associated with the development of ECD. We have had some apreciated 5.45 (± 4) years since the BT1 to prevent ECD.

Severe dyslipidemia title: known by patients, but is it treated?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with severe dyslipidemia (&amp;gt; 190 mg / dl) are considered in the clinical practice guidelines of high cardiovascular risk, therefore, diagnosis and treatment is essential, as well as the rest of the CV risk factors. But real-life records give us data of lack of control, justified by lack of adherence to treatment, underdiagnosis and therapeutic inertia among other factors. The aim of our work was to analyze patients knowledge about their dyslipidemia, treatment and the impact on their cardiovascular health. Materials and methods Patients with severe dyslipidemia (&amp;gt;190 mg/dl) from the familial hypercholesterolemia screening program were analyzed consecutively from February 1 – September 30, 2022. It was performed from Clinical Analysis, with an alarm system to detect severe dyslipidemia in people over 18 years of age in coordination with the Cardiovascular Prevention Unit of Cardiology and Genetics. All patients underwent a health questionnaire. Results n = 353. Mean age 52.2 years. 51.6% women (Table 1 baseline characteristics). 86.5% knew that they had dyslipidemia problems, mainly non-DM (85% vs 68%; p0.009), with familiy history (FH) of dyslipidemia (90% vs 81%;p 0.027) and older people (53.7 vs 47.1 years; p.001) But only 14.4% took treatment, patients with DM (31% vs. 13%; p0016), with FH of LDLhigh children (31% vs 12%; p 0.02), with personal history of CV disease (37% vs 13%; p 0.007) and BMI &amp;gt; 30 (20% vs 11%; p 0.017). 53.4% had taken treatment at some time, patients with hypertension (67% vs 49%;p 0.01), with family history of dyslipidemia (59% vs 44%; p 0.005), personal history of CV disease (87% vs 51%; p 0.005) and those over 40 years (55% vs 36%; p 0.016) 91.4% recognized the impact of dyslipidemia on the prognosis CV, mainly those with family history of dyslipidemia (94% vs 86%; p.017) and those under 40 years (100% vs 90.7%; p0.04). Conclusions A high percentage of patients recognize their dyslipidemia problem and the possible impact on their health, but less than 15% take lipid-lowering treatment.

Cardiac rehabilitation in women. Have we improved care in recent years?

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): Ninguna. Introduction Cardiovascular disease is the main cause of morbidity and mortality worldwide, but there are inequalities in diagnosis and treatment between men and women. Although there is greater awareness of cardiovascular disease in women, diagnostic techniques are less used in women, they receive fewer pharmacological and invasive treatments, and have less access to cardiac rehabilitation. Objective To compare the assistance offered to men and women in our Cardiac Rehabilitation Unit up to 2018 with the assistance given from 2019 to 2022. Methods Patients treated in the Cardiac Rehabilitation Unit before 2018 (group 1) and from 2019 to 2022 (group 2) were analyzed, comparing the characteristics of male and female patients, as well as the attendance rate to Cardiac Rehabilitation and treatments indicated. Results In group 1, we analyzed the data of 399 patients, 19.8% women. In group 2, which included 167 patients, the rate of women rose to 26.3%, this difference being statistically significant (p&amp;lt;0. 05). Women were older than men in both groups (63 vs 59 years in group 1; 64 vs 59 years in group 2), less smokers (26.3% vs 57.3% in group 1; 25% vs 50.4% in group 2). The percentage of hypertensive patients was the same in both sexes in group 2. Until 2018, fewer coronary angiographies were performed on women (94% vs 99%, p&amp;lt;0.05); however, in the second period (group 2, 2019-2022), the percentage was similar in both sexes, (96% vs 98%, p= n.s.). Revascularization is less, possibly due to the characteristics of coronary disease in women (Table 1). Lipid-lowering treatments are used equally in both groups (Table 1). Conclusion In recent years, care for cardiovascular disease in women has been improving. The percentage of women who are included in Cardiac Rehabilitation program and who undergo coronary angiography has increased. The raising awareness that this disease has the same severity in both sexes has allowed the optimal medical treatment implemented to be similar.

Genotyping of patients with severe dyslipidemia in a screening program for familial hypercholesterolemia. Studio Gioconda

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Familial hypercholesterolemia (FH) is one of the diseases of genetic origin that produces early cardiovascular disease (CVD), because the levels of low-density lipoproteins (LDL) are increased from an early age. In addition, when there are genetic variants in certain genes, the cardiovascular prognosis worsens. The objective of our work, was to evaluate those conditions that influence the genotyping of severe dyslipidemia in the context of a FH detection program. Material and methods We prospectively included all patients in the HF screening program at our center from February 1 to September 30, 2022. It was performed from Clinical Analysis, with an alarm system to detect severe dyslipidemia in patients over 18 years of age (LDL &amp;gt;190 mg/dl) in coordination with the Cardiology and Genetics Cardiovascular Prevention Unit, to select cases suitable for genetic study (Lipid Score of the Dutch Guidelines ³6 points). Results n = 353. Mean age 52.2 years. 51.6% women. 30% were hypertensive, 6% diabetic, 36% obese and 24% smokers. 33% had a family history (FaH) of CVD, 60% FaH of severe dyslipidemia and 10% FaH&amp;lt;18 years-LDLhigh. 2.6% had had a previous coronary event. Only 13% were on lipid-lowering treatment. The mean LDL-C levels were 207mg/dl and the rest of the lipid profile are shown in Table 1. 26.4% of patients underwent genetic study, 6.2% had pathogenic variants and 14% variants of uncertain significance (VUS). Patients with some genetic variant had higher levels of LDL (217 vs209 mg/dl;p0.016), Lp(a) (92vs40mg/dl;p0.003) and Non-HDL (248 vs 236 mg/dl;p0.015), were younger (45 vs. 52 years; p0.019) and FaH&amp;lt;18 years-LDLhigh (43vs8%;p&amp;lt;0.001). Patients with pathogenic variants had higher levels of LDL (219vs201 mg/dl;p0.008), Lp(a) (102vs43mg/dl;p&amp;lt;0.001) and Non-HDL (270vs236mg/dl;d&amp;lt;0.001), were younger (32vs52years;p0.003), FaH of&amp;lt;18 years-LDLhigh (100% vs9%:p&amp;lt;0.001) and CVD FaH (100% vs32%;p&amp;lt;0.014), with no differences between patients with pathogenic variants and VUS in terms of lipid levels, but if age [pathogenic variants (32 years) vs VUS (50 years);p 0.016]. Conclusions In our study, 20% of probable diagnoses of FH present some type of genetic variant, influenced by age, LDL levels, Lp(a), Non-HDL and FaH of CVD and dyslipidemia.

HIV infection and cardiovascular disease have both shared and distinct monocyte gene expression features: Women's Interagency HIV study.

Persistent inflammation contributes to the development of cardiovascular disease (CVD) as an HIV-associated comorbidity. Innate immune cells such as monocytes are major drivers of inflammation in men and women with HIV. The study objectives are to examine the contribution of circulating non-classical monocytes (NCM, CD14dimCD16+) and intermediate monocytes (IM, CD14+CD16+) to the host response to long-term HIV infection and HIV-associated CVD. Women with and without chronic HIV infection (H) were studied. Subclinical CVD (C) was detected as plaques imaged by B-mode carotid artery ultrasound. The study included H-C-, H+C-, H-C+, and H+C+ participants (23 of each, matched on race/ethnicity, age and smoking status), selected from among enrollees in the Women's Interagency HIV Study. We assessed transcriptomic features associated with HIV or CVD alone or comorbid HIV/CVD comparing to healthy (H-C-) participants in IM and NCM isolated from peripheral blood mononuclear cells. IM gene expression was little affected by HIV alone or CVD alone. In IM, coexisting HIV and CVD produced a measurable gene transcription signature, which was abolished by lipid-lowering treatment. In NCM, versus non-HIV controls, women with HIV had altered gene expression, irrespective of whether or not they had comorbid CVD. The largest set of differentially expressed genes was found in NCM among women with both HIV and CVD. Genes upregulated in association with HIV included several potential targets of drug therapies, including LAG3 (CD223). In conclusion, circulating monocytes from patients with well controlled HIV infection demonstrate an extensive gene expression signature which may be consistent with the ability of these cells to serve as potential viral reservoirs. Gene transcriptional changes in HIV patients were further magnified in the presence of subclinical CVD.

Association of low-density lipoprotein-cholesterol with all-cause and cause-specific mortality

AimsTo explore the association between low-density lipoprotein-cholesterol (LDL-C) and all-cause and cause-specific mortality based on a prospective cohort study. MethodsAmong 10850 individuals enrolled from National Health and Nutrition Examination Survey (NHANES) 1999–2014, 1355 (12.5%) died after an average follow-up of 5.7 years. Cox proportional regression models were used to determine the association between LDL-C with the risk of mortality. ResultsThe level of LDL-C was L-shaped associated with the risk of all-cause mortality, namely a low level was related to an increased mortality risk. The level of LDL-C associated with the lowest risk of all-cause mortality was 124 mg/dL (3.2 mmol/L) in the overall population, and 134 mg/dL (3.4 mmol/L) in individuals not receiving lipid lowering treatment. Compared with participants with LDL-C of 110–134 mg/dL (2.8–3.5 mmol/L), the multivariable adjusted hazard ratio was 1.18 (95% confidence interval 1.01 to 1.38) for individuals with the lowest quartile for all-cause mortality. In participants with coronary heart diseases, the conclusion was similar but the critical point was lower. ConclusionsWe found that low levels of LDL-C increased the risk of all-cause mortality, and the lowest risk of all-cause mortality for LDL-C concentration was 124 mg/dL (3.2 mmol/L). Our results provide a reasonable range of LDL-C when to initiate a statin therapy in clinical practice.

Prediction of the 10-year risk of atherosclerotic cardiovascular disease in the Korean population.

Proper risk assessment is important for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, no validated risk prediction tools are currently in use in Korea. This study sought to develop a 10-year risk prediction model for incident ASCVD. Using the National Sample Cohort of Korea, 325,934 subjects aged 20-80 years without previous ASCVD were enrolled. ASCVD was defined as a composite of cardiovascular death, myocardial infarction, and stroke. The Korean atherosclerotic cardiovas cular disease risk prediction (K-CVD) model was developed separately for men and women using the development dataset and validated in the validation dataset. Furthermore, the model performance was compared with the Framingham risk score (FRS) and pooled cohort equation (PCE). Over 10 years of follow-up, 4,367 ASCVD events occurred in the overall population. The predictors of ASCVD included in the model were age, smoking status, diabetes, systolic blood pressure, lipid profiles, urine protein, and lipid-lowering and blood pressure-lowering treatment. The K-CVD model had good discrimination and strong calibration in the validation dataset (time-dependent area under the curve=0.846; 95% confidence interval, 0.828 to 0.864; calibration χ2=4.73, goodness-of-fit p=0.32). Compared with our model, both FRS and PCE showed worse calibration, overestimating ASCVD risk in the Korean population. Through a nationwide cohort, we developed a model for 10-year ASCVD risk prediction in a contemporary Korean population. The K-CVD model showed excellent discrimination and calibration in Koreans. This population-based risk prediction tool would help to appropriately identify high-risk individuals and provide preventive interventions in the Korean population.

Clinical characteristics of adult and paediatric patients with familial hypercholesterolemia: A real-life cross-sectional study from the Turkish National Database

Background and aimsFamilial hypercholesterolemia (FH) is the most common cause of premature atherosclerotic cardiovascular disease (ASCVD). Türkiye is among the countries with the highest rate of ASCVD. However, no population-based study has been published so far on the prevalence of FH, demographic and clinical characteristics, burden of ASCVD, treatment compliance, and attainment of low-density lipoprotein cholesterol (LDL-C) targets. MethodsWe performed a study using the Turkish Ministry of Health's national electronic health records involving 83,063,515 citizens as of December 2021 dating back 2016. Adults fulfilling the diagnostic criteria of definite or probable FH according to the Dutch Lipid Network Criteria (DLNC), and children and adolescents fulfilling the criteria of probable FH according to the European Atherosclerosis Society (EAS) Consensus Panel report formed the study population (n = 157,790). The primary endpoint was the prevalence of FH. ResultsProbable or definite FH was detected in 0.63% (1 in 158) of the adults and 0.61% (1 in 164) of the total population. The proportion of adults with LDL-C levels >4.9 mmol/L (190 mg/dL) was 4.56% (1 in 22). The prevalence of FH among children and adolescents was 0.37% (1 in 270). Less than one-third of the children and adolescents, and two-thirds of young adults (aged 18–29) with FH were already diagnosed with dyslipidaemia. The proportion of adults and children and adolescents on lipid-lowering treatment (LLT) was 32.1% and 1.5%, respectively. The overall discontinuation rate of LLT was 65.8% among adults and 77.9% among children and adolescents. Almost no subjects on LLT were found to attain the target LDL-C levels. ConclusionsThis nationwide study showed a very high prevalence of FH in Türkiye. Patients with FH are diagnosed late and treated sub-optimally. Whether these findings may explain the high rates of premature ASCVD in Türkiye needs further investigation. These results denote the urgent need for country-wide initiatives for early diagnosis and effective management of FH patients.

Adherence to lipid lowering treatment in type 2 diabetics with dyslipidemia

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Managing lipid risk in acute coronary syndrome patients in the real world: results from the BEST consensus

The gap between the targets recommended by current guidelines and the lipid values observed in the real world among patients at very high or extreme cardiovascular risk has called into question the effectiveness of the stepwise lipid-lowering strategy. The BEST (Best Evidence with Ezetimibe/statin Treatment) project supported an expert panel of Italian cardiologists to investigate the different clinical-therapeutic pathways in the management of the residual lipid risk of post-acute coronary syndrome (ACS) patients at discharge and to analyze potential critical issues. Among the members of the panel, 37 cardiologists were selected to participate in a consensus process using the mini-Delphi technique. A 9-statement questionnaire, focusing on the early use of combination lipid-lowering therapies in post-ACS patients, was built up based on a previous survey that involved all members of the BEST project. For each proposed statement, participants anonymously expressed their personal level of disagreement/agreement, according to a 7-point Likert scale. The relative degree of agreement and consensus was calculated based on the median and the 25th percentile values and the interquartile range (IQR). The administration of the questionnaire was repeated twice: the second one after general discussion and analysis of the answers given in the first round in order to obtain as much consensus as possible. With the exception of a single item, the responses of the participants were in agreement with a broad consensus already at the first round with a median value of 6, a 25th percentile of 5 and an IQR of 2. This trend resulted more evident at the second round (median 7, 25th percentile 6, IQR 1). In particular, there was unanimous agreement (median 7, IQR 0-1) on the statements in favor of a lipid-lowering therapy that guarantees the achievement of the targets as much and as soon as possible by the systematic early utilization of the high-dose/intensity statin + ezetimibe combination and, when needed, PCSK9 inhibitors. The percentage of the experts who changed their responses between the first and second round was 39% overall, ranging from 16% to 69%. According to the mini-Delphi results, there is a broad agreement and consensus to manage the lipid risk in post-ACS patients by lipid-lowering treatments that guarantee an early and "robust" lipid reduction which can be achieved only by the systematic use of combination therapies.

Current approaches to the treatment of patients with dyslipidemia in the real practice in the outpatient stage

Aim To evaluate the frequency and structure of lipid-lowering therapy and of achieving the goal of low-density lipoprotein cholesterol (LDL-C) in patients with very high cardiovascular risk (CVR) who were monitored at the outpatient stage.Material and methods A retrospective snapshot analysis was performed by continuous sampling method for 136 medical records of outpatient patients (71 men, 65 women) aged 42 to 91 years [median, 68 years; 25th and 75th percentiles (59; 78)].Results 134 (98,53 %) patients took statins; 8 (5.88 %) patients took a combination of statin and ezetimibe; 2 (1.47 %) patients took proprotein convertase subtilisin/kexin type 9 enzyme inhibitors (PCSK9): 2 (1.47 %) patients took evolocumab and 1 (0.74%) of 2 PCSK9-treated patients took a combination of PCSK9 inhibitor and statin. Atorvastatin at a dose of 20 (20; 40) mg as recommended at the hospital was the most frequently prescribed statin. 5 (3.68%) patients achieved the goal LDL-C of ≤1.4 mmol/l.Conclusion Statins prevail in the structure of lipid-lowering therapy in patients with very high CVR. The frequency of combination therapy (statin/ezetimibe, 5.88%; PCSK9 inhibitor/statin, 0.74%) and PCSK9 inhibitors was noted to be low. Only 3.68% of patients achieved the goal LDL-C during the lipid-lowering treatment.

Proposal for a diagnostic and therapeutic care pathway of the Piedmont Region on lipid-lowering and antithrombotic treatment in patients with peripheral arterial disease

The aim of this paper is to present the diagnostic and therapeutic care pathway on peripheral arterial disease, recently developed in the Piedmont Region, Italy. It proposes a combined approach between the cardiologist and vascular surgeon for optimizing the treatment of patients with peripheral artery disease, which includes the most recently approved antithrombotic and lipid-lowering drugs. The goal is to promote a greater awareness on peripheral vascular disease, in order to implement its treatment patterns and consequently to perform an effective secondary cardiovascular prevention.

Lipid-lowering treatment and LDL-C goal attainment in high and very high cardiovascular risk patients: Evidence from the SANTORINI study-The Italian experience

The SANTORINI study is an observational study that enrolled 9602 adult individuals at high or very high cardiovascular (CV) risk across Europe, aimed at providing information on the current status of the management of dyslipidaemias, in light of the most recent 2019 EAS/ESC guidelines. Italy participated in the study with 1977 patients, 1531 (77.4%) of whom were classified at very high CV risk and 446 (22.6%) at high CV risk. Overall, in the Italian population, 79.31% of the patients had a history of atherosclerotic cardiovascular disease (ASCVD). At enrolment, the mean level of LDL-C in the total population was 98.4 mg/dL. LDL-C levels were lower in the very high-risk group (94.6 mg/dL) than in the high-risk group (111.4 mg/dL). Considering the therapeutic goals recommended by the most recent 2019 ESC/EAS guidelines (LDL-C &lt;55 mg/dL or &lt;70 mg/dL respectively in very high or high-risk patients, respectively), only 20.3% of the overall study population achieved such goals (19.9% of very high-risk patients and 21.8% of high-risk patients). About one-third of the patients included in the study (32.6%) were not prescribed any therapy, one-third received statin monotherapy (34.4%), and only one-third (33%) were taking combination therapy; these percentages were comparable in the two risk subgroups. Based on the most recent 2019 ESC/EAS guidelines, the use of cholesterol-lowering therapies is not always optimal to achieve the therapeutic goals even in patients with very high CV risk. This means that about 80% of patients are far from the recommended therapeutic goals for their risk category.