Low-density Lipoprotein Cholesterol Control Research Articles

Gender differences and hypercholesterolemia: real-world evidence from the study WECARE (Women Effective CArdiovascular Risk Evaluation)

Introduction: The therapeutic control of LDL-cholesterol is essential in cardiovascular prevention, as recommended by the recent guidelines. Objective: To evaluate gender differences in terms of demographic and clinical characteristics, treatment pattern, treatment adherence and healthcare costs in patients on lipid-lowering therapy, stratified by cardiovascular risk in the Italian real clinical practice. Methods: An observational analysis was conducted on the administrative databases of healthcare institutions, covering about 6.1 million health-assisted subjects. After inclusion of all patients on lipid-lowering therapy between January 2017 and June 2020, the population was investigated in the period before the first prescription of a lipid-lowering drug and followed-up for at least 12 months. Clinical and demographic variables were compared after stratification by gender and by cardiovascular risk (very high/high/other risk). The main outcome measures were treatment adherence and direct healthcare costs during follow-up. Results: Of the 684,829 patients with high/very high cardiovascular risk, 337,394 were men and 347,435 women, aged on average 69.3 years and 72.1 years, respectively (p < 0.001). Men were characterised by a worse comorbidity profile. Regardless of cardiovascular risk, female subjects were associated with larger utilisation of low-potency statins and lower adherence (p < 0.001). The annual healthcare costs per patient during follow-up were higher in men than in women (p < 0.001). Conclusions: The results highlighted larger utilisation of low-potency statins, a lower adherence and a milder comorbidity profile in women, the latter feasibly explaining the reduced healthcare costs compared to men.

Associations and attributable burden between risk factors and all-cause and cause-specific mortality at different ages in patients with hypertension.

It remains unclear the age-specific associations of risk factors with deaths and mortality burden attributable across age. In a territory-wide retrospective cohort, 1,012,228 adults with hypertension were identified. Comorbidities including diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), heart failure, and cancer, and risk factors including current smoking and suboptimal control of blood pressure (BP), glucose and low-density lipoprotein cholesterol were defined. Associations of comorbidities/risk factors with all-cause and cause-specific mortality across age groups (18-54, 55-64, 65-74, and ≥75 years) were assessed. Population attributable fractions were also quantified. During a median follow-up of 10.7 years, 244,268 (24.1%) patients died, with pneumonia (7.2%), cancer (5.1%), and CVD (4.2%) being the leading causes. Despite increasing deaths with age, relative risk of mortality related to comorbidities/risk factors decreased with age; similar patterns were found for cause-specific mortality. The assessed risk factors accounted for 24.0% (95% CI 22.5%, 25.4%) deaths, with highest proportion in the youngest group (33.5% [28.1%, 38.5%] in 18-54 years vs 19.4% [17.0%, 21.6%] in ≥75 years). For mortality burden, CKD was the overall leading risk factor (12.7% [12.4%, 12.9%]) with higher proportions in older patients (11.1-13.1% in ≥65 years), while diabetes was the leading risk factor in younger patients (15.9-13.5% in 18-54 years). The association of comorbidities or risk factors with mortality is stronger in younger patients with hypertension, despite lower absolute mortality in young patients than in the elderly. Leading risk factors differed across age, highlighting the importance of targeted and precise risk management.

Prescription of lipid-lowering therapy, LDLc control, and risk of MACE in patients after ST-elevation myocardial infarction in Mexico

Abstract Funding Acknowledgements None. Background/Introduction Optimal control of low-density lipoprotein cholesterol (LDLc) has been demonstrated to reduce cardiovascular event rates after ST-elevation myocardial infarction (STEMI). However, real-world data shows that a low proportion of patients achieve LDLc targets. Furthermore, the association of LDLc levels and major cardiovascular adverse events (MACE) in post-STEMI patients is limited in developing countries. Purpose In this study, we aimed to assess the prescription patterns of lipid-lowering therapies, LDLc control, and their impact on the risk of MACE after STEMI in Mexico. Methods We conducted a prospective observational study of patients with STEMI. LDLc levels and prescriptions of lipid-lowering therapy were assessed during the first scheduled visit following STEMI hospital discharge. LDLc control was determined in accordance with the 2023 European Society of Cardiology Acute Coronary Syndrome Guidelines, which recommend achieving LDLc levels below 55 mg/dL for secondary prevention. Patients were categorized as controlled (if LDLc <55 mg/dL) and not controlled (if LDLc >55 mg/dL) and were followed for a median of 4.5 years to evaluate the rate of MACE, including cardiovascular death, cardiogenic shock, recurrent MI, and heart failure. Results We included 447 patients with a mean age of 57.87 (± 10.5 years), predominantly male (84.5%). Hypertension (43.8%), smoking (41.1%), type 2 diabetes mellitus (33.5%), obesity (26.6%), and dyslipidemia (21.4%) were highly prevalent. The median LDLc level in the total population was 65.4 mg/dL (IQR 49.2- 87.7). Among these, 34% (152) were considered controlled, while 66% (295) were not. Baseline clinical characteristics did not significantly differ among the groups. Prescription of high-intensity statins reached 94.7%, and ezetimibe and PCSK-9i were used in 1.8% and 0.4% of cases, respectively. We observed no statistically significant difference (Hazard ratio: 1.03, 95% confidence interval 0.74-1.73) in the rate of MACE based on LDLc control (Fig.1). The risk of MACE was also not different based on the use of high-intensity statins. Conclusions In this real-world study of patients post-STEMI, LDLc control was achieved in just one-third of the population. While the prescription of high-intensity statins was high, combination therapy was low. We did not observe a statistically significant association with an increased long-term risk of MACE; however, we noted a higher rate of events compared with other series.

Real-world evidence evaluation of LDL-C among hospitalized patients: a population-based observational study in the timeframe 2021-2022

Aims. European registries and retrospective cohorts highlighted the lack of low-density lipoprotein-cholesterol (LDL-C) goal achievement in many very high-risk patients. Hospitalized patients are often frail, and frailty is associated with all-cause mortality and cardiovascular mortality. Aim of this study is to evaluate LDL-C levels in a Real-World setting of inpatients, identify cardiovascular risk categories and highlight treatment gaps in the implementation of LDL-C control. Methods. This retrospective, observational study included all the adult patients admitted at an Italian hospital between 2021-2022 and with LDL-C values available during hospitalization. Disease-related real-world data were collected from Hospital Information Systems using automated data extraction strategies and through the implementation of a patient-centered data repository (the Dyslipidemia Data Mart). Assessment of cardiovascular risk profiles, LDL-C target achievement according to the 2019 ESC/EAS guidelines and lipid-lowering therapies (LLT) use were performed. Results. 13,834 patients were included: 17.15%, 13.72%, 16.82% and 49.76% were low (L), moderate (M), high (H) and very high-risk (VH) patients, respectively. The percentage of in-target patients was progressively lower moving towards worse categories (78.79% in L, 58.38% in M, 33.3% in H and 21.37% in VH). Among LLT treated patients in VH category, in-target are 28.48%; 47.6.% in H, 69.12% in M and 68.47% in L. The impact of monotherapies and combination therapies on target achievement was also analyzed. Conclusions. This study depicts LDL-C control among an entire population of inpatients, highlighting relevant gaps especially in VH category. Future efforts must aim to reduce the cardiovascular risk of these subjects.

Temporal trends and racial/ethnic- and sex-differences in LDL cholesterol control among US adults with self-reported atherosclerotic cardiovascular disease

ObjectiveCurrent guidelines for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend targeting a low-density lipoprotein cholesterol (LDL-C) of < 70 mg/dL. However, temporal trends and racial/ethnic- and sex-differences in achievement of LDL-C targets are not well described. We assessed trends and racial/ethnic- and sex-differences in achievement of LDL-C < 70 mg/dL using data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 to 2017-March 2020. MethodsWe combined NHANES cycles into 4 periods: 2005–2008, 2009–2012, 2013–2016, and 2017-March 2020 and included participants ≥ 40 years with self-reported ASCVD. We estimated LDL-C < 70 mg/dL prevalence over time and further stratified by sex and race/ethnicity. We used multivariable logistic regression adjusted for social determinants of health and clinical covariates to model LDL-C target attainment. ResultsAmong 1,826 NHANES participants representing 7,161,221 US adults with self-reported ASCVD (59.6% ≥ 65 years, 56.4% male, 74.8% White), LDL-C target attainment increased from 19.0% (95% CI, 15.3%-23.3%) in 2005–2008 to 26.3% (95% CI, 20.4%-33.1%) in 2017-March 2020 (P = 0.012 for trend). Achievement of LDL-C < 70 mg/dL significantly rose among men from19.5% (95% CI, 15.1%-24.8%) to 29.4% (95% CI, 20.7%-29.9%) without significant change in women (from 18.3% [95% CI, 13.6%-24.2%] to 22.5% [95% CI, 13.0%-35.9%]; P = 0.241 for trend). Improvement in LDL-C target attainment was similar among White, Black, and Hispanic individuals (∼5–7% increase) and was greatest among individuals of other (non-White, Hispanic, or Black) race/ethnicity (23.1% increase). In our multivariable analysis, comorbid diabetes and ages 65–75 and > 75 years were associated with LDL-C target attainment. ConclusionLDL-C control modestly improved between 2005 and 2008 and 2017-March 2020; however, only ∼1/4 of individuals met guideline-directed LDL-C treatment targets by 2017-March 2020. Women had lower LDL-C control and lesser magnitude of improvement in LDL-C control than men, highlighting a need for targeted interventions to improve lipid-lowering therapy utilization in this population.

Rosuvastatin-Based Lipid-Lowering Therapy for the Control of LDL Cholesterol in Patients at High Vascular Risk.

Vascular diseases are the leading cause of death in Spain. Hypercholesterolemia is not only a cardiovascular risk factor, but also underlies the etiopathogenesis of atherosclerosis. Therefore, reducing LDL cholesterol (LDL-C) to the goals recommended by clinical practice guidelines, is essential to decrease the risk of vascular complications. Despite this, current LDL-C control is scarce, even in subjects with high and very high risk. This is mainly due to an insufficient intensification of lipid-lowering treatment. In this context, it is essential to prescribe the appropriate therapy, adjusted to patient's needs based on their LDL-C and their vascular risk. Rosuvastatin, alone or in combination with ezetimibe, provides intensive LDL-C reductions (up to 50-55% and 60-75%, respectively), with a low risk of side effects and in an efficient manner, in patients both without and with established atherosclerotic vascular disease.

Patterns and gaps in guideline-directed statin use for atherosclerotic cardiovascular disease by race and ethnicity

ObjectiveThere remain disparities by race and ethnicity in atherosclerotic cardiovascular disease (ASCVD). Statins reduce low-density lipoprotein cholesterol (LDL-c) and improve ASCVD outcomes. ASCVD treatment patterns across disaggregated race and ethnicity groups are incompletely understood. We aimed to evaluate statin use and LDL-c control for ASCVD by race and ethnicity. MethodsFrom an electronic health record (EHR)-based cohort from a multisite Northern California health system, we included adults with an ASCVD diagnosis from 2010 to 2021 and at least 2 primary care visits, stratified by race and ethnicity (Non-Hispanic White [NHW], Non-Hispanic Black [Black], Hispanic, and Asian). Hispanic (Mexican, Puerto Rican, Other) and Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other) groups were disaggregated. Primary outcomes were 1-year post-ASCVD statin use (prescription) and LDL-c control (at least one value <70 mg/dL). Adjusted odds ratios (ORs) were estimated using logistic regression. ResultsOf 133,158 patients, there were 89,944 NHW, 6,294 Black, 12,478 (9.4 %) Hispanic and 13,179 (9.9 %) Asian patients. At 1 year after incident ASCVD, there was suboptimal statin use (any statins <60 %, high-intensity <25 %) and LDL-c control (<30 %) across groups, with lowest proportions in Black patients for statin use (46.7 %, any statin) and LDL-c control (10.7 %, OR 0.89 (0.81–0.97), referent NHW). Disaggregation of Asian and Hispanic groups unmasked within-group heterogeneity. ConclusionsIn patients with incident ASCVD, we describe suboptimal and heterogenous 1-year post-ASCVD guideline-directed statin use and 1-year post-ASCVD LDL-c control across disaggregated race and ethnicity groups. Findings may improve understanding of ASCVD treatment disparities and guide implementation.

Contemporary lipid-lowering management and risk of cardiovascular events in homozygous familial hypercholesterolaemia: insights from the Italian LIPIGEN Registry.

The availability of novel lipid-lowering therapies (LLTs) has remarkably changed the clinical management of homozygous familial hypercholesterolaemia (HoFH). The impact of these advances was evaluated in a cohort of 139 HoFH patients followed in a real-world clinical setting. The clinical characteristics of 139 HoFH patients, along with information about LLTs and low-density lipoprotein cholesterol (LDL-C) levels at baseline and after a median follow-up of 5 years, were retrospectively retrieved from the records of patients enrolled in the LIPid transport disorders Italian GEnetic Network-Familial Hypercholesterolaemia (LIPIGEN-FH) Registry. The annual rates of major atherosclerotic cardiovascular events (MACE-plus) during follow-up were compared before and after baseline. Additionally, the lifelong survival free from MACE-plus was compared with that of the historical LIPIGEN HoFH cohort. At baseline, LDL-C level was 332 ± 138 mg/dL. During follow-up, the potency of LLTs was enhanced and, at the last visit, 15.8% of patients were taking quadruple therapy. Consistently, LDL-C decreased to an average value of 124 mg/dL corresponding to a 58.3% reduction (Pt < 0.001), with the lowest value (∼90 mg/dL) reached in patients receiving proprotein convertase subtilisin/kexin type 9 inhibitors and lomitapide and/or evinacumab as add-on therapies. The average annual MACE-plus rate in the 5-year follow-up was significantly lower than that observed during the 5 years before baseline visit (21.7 vs. 56.5 per 1000 patients/year; P = 0.0016). Our findings indicate that the combination of novel and conventional LLTs significantly improved LDL-C control with a signal of better cardiovascular prognosis in HoFH patients. Overall, these results advocate the use of intensive, multidrug LLTs to effectively manage HoFH.

Study of Lipid-Modifying Therapy Use and Risk Factor Management in Patients With Dyslipidemia in Duhok City/Kurdistan Region, Iraq.

Introduction Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality globally, according to the World Health Organization. Research from the Middle East indicates that cardiovascular disease-related deaths in the region are among the highest worldwide. Multiple risk factors contribute to ASCVD. Elevated low-density lipoprotein cholesterol (LDL-C), often associated with hyperlipidemia, plays a pivotal role. The reduction of LDL cholesterol through statins has been extensively studied over the years and has demonstrated a significant decrease in rates of cardiovascular disease, particularly in high- and very high-risk groups. Study design This cross-sectional study enrolled 503 adult patients undergoing lipid-lowering therapy for primary and secondary prevention of ASCVD at the Azadi General & Teaching Hospital in Duhok City, Iraq. Data were collected from January 2, 2023, to October 31, 2023. The sample size was carefully determined to ensure a precise estimation of the primary outcome measure. Results Of the 503 patients aged 21-89 years, 315 (62.2%) were women. Among the 145 (28.8%) with ASCVD, 127 (87.5%)had coronary artery disease. Only 150 (29.8%) were on a high-intensity statin, compared to 293 (58.25%) on a moderate-intensity statin. In total, 155 (30.8%) attained LDL-C control (p<0.0001). Among the 207 with very high cardiovascular disease risk, only 10 (4.83%) achieved an LDL-C level below 55 mg/dl. Conclusion This study revealed inadequate management of LDL-C levels across various participant categories, particularly those classified as having high cardiovascular disease risk. Control of other risk factors (e.g., hypertension, diabetes, and metabolic syndrome) was overall very poor. Most participants were overweight or obese.

Evolocumab-Based LDL-C Management in High and Very High Cardiovascular Risk Patients in German Clinical Practice: The HEYMANS Study.

Low-density lipoprotein cholesterol (LDL-C) is among the most important modifiable risk factors for cardiovascular disease. In very high-risk patients, the European Society of Cardiology/European Atherosclerosis Society guidelines recommend attaining LDL-C < 55mg/dL. In the German cohort of the observational HEYMANS study, we aimed to describe the clinical characteristics and LDL-C control among patients initiating evolocumab. Data was collected between 09/2016 and 05/2021 for ≤ 6months before (retrospectively) and ≤ 30months after evolocumab initiation (prospectively). Patient characteristics, lipid-lowering therapy (LLT), lipid values, evolocumab use, and safety were collected. Of 380 enrolled patients, 93% received evolocumab in secondary prevention and 69% had a history of statin intolerance. At study baseline, 49% did not receive any statins and LDL-C was very high (145mg/dL). Use of evolocumab decreased LDL-C by a median of 53% within 3months and remained stable thereafter, despite mainly unchanged background LLT. Overall, 59% attained an LDL-C level < 55mg/dL (69% with, 49% without LLT). Persistence to evolocumab was 90.6% in months 1-12 and 93.5% in months 13-30. Adverse drug reactions were reported in 8% of patients. Data from the German HEYMANS cohort corroborate previous reports on evolocumab effectiveness and safety in clinical practice. Evolocumab initiation was associated with a rapid and sustained LDL-C reduction. Persistence with evolocumab was high. Our finding that patients receiving an evolocumab/LLT combination are more likely to attain the LDL-C goal than those receiving evolocumab alone corroborates previous data showing the importance of using highly intensive therapy. Graphical abstract available for this article. ClinicalTrials.gov Identifier NCT02770131 (registration date 27 April 2016).

Referral to hepatologists or a second-line examination requirement is common in patients with type 2 diabetes mellitus

Background and aimsTo estimate the number of patients who required a referral to hepatologists following the 2016 EASL–EASD–EASO guideline and a second-line vibration controlled transient elastography (VCTE) examination following the 2021 EASL guideline according to obesity, glycated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) control status in patients with type 2 diabetes mellitus (T2DM). Methods and resultsA total of 2515 T2DM patients who were hospitalized were cross-sectionally assessed. When we applied the 2016 EASL–EASD–EASO guideline, 26.8 %–46.4 % (depending on the scores used for diagnosing fibrosis) of T2DM patients needed a referral to hepatologists. When we applied the 2021 EASL guideline, a VCTE examination was required in 10.9 %–35 % (depending on the scores used for diagnosing fibrosis) of T2DM patients. The referral rates and the VCTE requirement were even higher in patients who were obese and/or had poor HbA1c, BP, and/or LDL-C control. ConclusionsApplication of the screening guidelines would lead to a referral to hepatologists or a second-line VCTE examination requirement for a substantial number of T2DM patients, regardless of obesity and metabolic goal attainment status.

Impact of Guideline-Directed Management Strategies for Low-Density Lipoprotein Cholesterol Control in Patients Who Underwent Percutaneous Coronary Intervention

Background/ObjectiveThere are little direct comparative evidences of strategies between more than 50% and absolute target goal of LDL-C level less than 55mg/dL for the patients underwent percutaneous coronary intervention (PCI). The purpose of this study is to investigate the clinical impact of different strategies between two in patients underwent PCI. MethodsA total of 3,104 patients with prior PCI were retrospectively enrolled from 2014 to 2020 at Yeungnam University Medical Center. The study population was stratified into two groups based on whether LDL-C level were less than 55 mg/dL at one-year mark or not. Furthermore, the 50% reduction rate of LDL-C was also categorized based on whether it had decreased by 50% or more from the initial LDL-C level at the one-year mark. The primary endpoint was 3-year major adverse cardiovascular events (MACE) which was defined as a composite of cardiovascular death, nonfatal myocardial infarction, target-lesion revascularization, hospitalization for heart failure, or non-fatal stroke. ResultsThere was no significant difference between the LDL < 55 mg/dL group and the LDL ≥ 55 mg/dL group in the risk of MACE (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.81–1.38; P = 0.690) after propensity score matching. However, the group that achieved ≥ 50% reduction of LDL-C from baseline LDL-C level showed a significant reduction in the occurrence of MACE in the subgroup of LDL-C level ≥ 55 mg/dL (HR, 0.41; 95% CI, 0.19-0.89; P= 0.025), compared to the group with < 50% reduction of LDL-C. Among all patients, the achievement rate of target LDL-C < 55 mg/dL and more than 50% reduction from baseline was 17.2%. ConclusionGuideline directed management strategy of more than 50% reduction of LDL-C from the baseline will be needed to reduce the incidence of MACE in PCI treated patients with LDL-C ≥ 55 mg/dL and additional efforts to increase target-goal achievement rate of LDL-C are warranted.

LOGAN-CV: A Prospective Study of a Multifaceted Intervention Targeting United States Clinicians to Improve Guideline-Based Management of Lipid-Lowering Therapy.

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety blood cholesterol guidelines recommend clinicians consider adding non-statin therapy for patients with very high-risk (VHR) atherosclerotic cardiovascular disease (ASCVD) and low-density lipoprotein cholesterol (LDL-C) ≥ 70mg/dl while receiving maximally tolerated statins. However, according to a recent study, only 17.1% of patients with established ASCVD received appropriate lipid-lowering therapy (LLT) intensification. Here, we describe the design of a prospective, 12-month study (LOGAN-CV) evaluating a multifaceted site-level intervention to enhance clinicians' adherence to guidelines to improve LDL-C levels for patients with VHR ASCVD. Clinicians from up to ten research sites are eligible if they care for adult patients with ASCVD. Interventions include educational modules, a cloud-based performance platform providing clinicians a tailored summary of their LDL-C management performance, newsletters, periodic peer-to-peer calls, and pre- and post-intervention surveys evaluating knowledge, attitudes, and beliefs around LDL-C management, with additional interventions for clinicians demonstrating a lower readiness to make treatment decisions based on guideline recommendations. Patients with VHR ASCVD, defined as having recent myocardial infarction and LDL-C ≥ 70mg/dl despite statin treatment, will be included in the study. Patient data will be collected from electronic medical records from baseline (clinician enrollment) through the 12-month intervention. The study started in October 2022, with anticipated completion in March 2024. The change in proportion of patients with LDL-C < 70mg/dl achieved at any time during the 12-month intervention (primary); LLT intensification, changes in guideline-aligned LDL-C testing and LLT titration over 12months, and change in overall clinicians' knowledge, attitudes, and beliefsare key outcomes of interest. The LOGAN-CV study addresses a critical unmet need in LDL-C control in patients with VHR ASCVD and evaluates the effect of a multifaceted intervention targeting clinicians to improve their adherence to guidelines and consequently improve clinical outcomes for patients.

Lipid-lowering therapy and LDL-C control for primary prevention in persons with diabetes across 90 health systems in the United States

ObjectiveNational guidelines recommend statin therapy for patients with type 2 diabetes. We assessed the extent of moderate- to high-intensity statin therapy utilization in community practice. MethodsWe evaluated lipid-lowering therapy (LLT) and low-density lipoprotein cholesterol (LDL-C) levels at baseline and 1-year follow-up in patients aged 40–75 years with type 2 diabetes but without atherosclerotic cardiovascular disease (ASCVD), across 90 health systems in the United States participating in an electronic health record–derived dataset, Cerner Real-World Data. Multivariable logistic regression was used to evaluate factors associated with utilization of moderate- to high-intensity statin. ResultsWe identified 241,232 patients with type 2 diabetes (58.1 % on moderate- to high-intensity statin, 7.0 % on low-intensity statin, and 34.9 % on no statin). Predictors of moderate- to high-intensity statin therapy included retinopathy (adjusted odds ratio [aOR], 1.26; 95 % confidence interval [CI], 1.15–1.38), hypertension (aOR, 1.52; 95 % CI, 1.43–1.61), and stage 3 chronic kidney disease (aOR, 1.14; 95 % CI, 1.07–1.21). Women (aOR, 0.85; 95 % CI, 0.82–0.87), and those with rheumatoid arthritis (aOR, 0.79; 95 % CI, 0.71–0.87), psoriasis (aOR, 0.85; 95 % CI, 0.75–0.96), and hepatitis C (aOR, 0.40; 95 % CI, 0.39–0.46), had reduced odds of moderate- to high-intensity statin treatment. Utilization of ezetimibe was rare (2.0 %). LDL-C control was suboptimal at baseline (37.0 % and 27.9 % had LDL-C ≥100 mg/dL and <70 mg/dL, respectively). At 1-year follow-up, the rate of moderate- to high-intensity statin therapy utilization was 65.3 %. ConclusionIncreased efforts are needed to improve LDL-C control and LLT use for primary prevention of ASCVD in adults with type 2 diabetes, in particular among women and those with risk-enhancing inflammatory conditions.

Real vs perceived LDL cholesterol control in clinical practice in Spain: Which factors are related to real control?

Abstract Background/Introduction According to ESC Guidelines, low-density lipoprotein cholesterol (LDLc) reduction is essential for the control of dyslipidaemia. Frequently, the physicians’ perception of LDLc control in patients (pts) is higher than the actual control, potentially leading to a suboptimal management of these pts. Purpose To understand the impact of physicians’ perception on LDLc control using a multivariate analysis and identify other potential predictive factors in the management of pts with dyslipidaemia in Spain. Methods Cross-sectional and multicentre study that included 435 healthcare professionals (34% cardiologists, 28% General Practitioners [GPs], 24% internists, and 14% endocrinologists) from 145 healthcare areas in Spain. Qualitative and quantitative information related to the management of pts with dyslipidaemia in clinical practice was collected. Additionally, aggregated anonymized data of the last 10 pts with dyslipidaemia attended by each physician were collected. With these data, a multivariate analysis was performed to estimate the impact of different variables on real LDLc control, including: age, gender and speciality of the physician, category of prevention, presence of comorbidities, lipid-lowing therapy (LLT) used, and whether the physician accurately perceived the real LDLc control. Results 4,010 pts (8%, 13%, 16% and 61% with low, moderate, high, and very high CV risk) were included. Physicians’ perception was that 62% of the pts achieved LDLc goals, but in actual clinical practice only 31% of pts did (p&amp;lt;0.01) (Figure 1). In the multivariate analysis it was found that physicians’ age and gender had little to no effect on LDLc control of pts, while their speciality did: cardiologists were twice as likely to control patients with dyslipidaemia than GPs. Likewise, pts with comorbidities or on secondary prevention were statistically associated with lower chance of appropriate LDLc control. Regarding the treatment used, data showed that the proportion of pts achieving LDLc goals increased as higher potency LLT was used. Precisely, LLT was found to have an significant impact on LDLc control: when compared to low intensity statins, pts treated with the combination of statin + ezetimibe had twice as many chances of achieving LDLc goals, reaching up to almost 15 times more possibilities for pts using PCSK9i. Lastly, control perception also mattered, with physicians who accurately perceived the real control having a probability two times higher to control their pts than physicians with poor LDLc control perception. Conclusions In Spain, most pts with dyslipidemia do not achieve the recommended LDLc goals mainly because of an insufficient intensification of LLT. The multivariate analysis showed that both LLT intensity and physicians’ perception had a major effect on LDLc control. These data highlight the need to further intensify LLT and raise awareness among physicians of the importance of achieving LDLc targets.Perceived vs real LDLc control by riskMultivariate analysis results

Impact of team-based health information technology to improve low-density lipoprotein cholesterol goal attainment after acute coronary syndrome hospital discharge: a single-center experience

Abstract Objectives The reduction in circulating low-density lipoprotein cholesterol (LDL-C) is the primary aim of lipid-lowering therapies as a method of atherosclerotic cardiovascular disease risk reduction. Although guidelines recommended strictly control of low-density lipoprotein cholesterol (LDL-C) below 70 mg/dL by high-intensity statin therapy in patients with acute coronary syndrome (ACS), the LDL-C target goal is not often attained. Health information technology (HIT) with information integration, decision making algorithm, is being applied on chronic illness care. Purpose We aimed to perform a qualitative review of the impact of HIT interventions on lipid management and LDL-C goal attainment in patients after ACS hospital discharge. Method Consecutive ACS patients with dyslipidemia (LDL-C &amp;gt;100 mg/dL) at discharge between January 2018 and December 2021 in a tertiary medical center were retrospectively reviewed. The LDL-C &amp;lt;70 mg/dL is defined as target. The team-based approach quality improvement program that consisted of patient education and high-intensity statin initiation before discharge, outpatient clinics with periodic laboratory follow-up, titration of lipid-lowering agents, and system-level interventions that involve database monitoring and outreach by centralized care teams, was introduced in October 2018. Electronical medical records including the medications, laboratory data at discharge and within 1 year were compared, before and after initiation of HIT system. Result A total 2248 ACS patients were included. The LDL-C &amp;lt;70 mg/dL attainment rate (36.52%, 53.57%, 59.22%, 62.18% in 2018, 2019, 2020, and 2021) and medium serum LDL-C level (80.5 mg/dL, 68 mg/dL, 65 mg/dL, 64 mg/dL in 2018, 2019, 2020, and 2021) significantly improved within 6 months after initiation of the team-based integrated intervention with assisted by HIT (2018 as the reference, all p&amp;lt;0.001). The LDL-C goal attainment rate at 12-month kept increasing gradually (53.80%, 61.82%, 64.21%, in 2019, 2020, 2021, p= 0.019). Most of the population initiated with moderate-intensity statin in 2018 (76.24%, 20.92%, 10.95%, 6.41% in 2018, 2019, 2020, and 2021), then switched to a high-intensity statin after initiation of the program (0.57%, 63.67%, 72.41%, 84.44% in 2018, 2019, 2020, and 2021) (2018 as the reference, all p&amp;lt;0.001), while the adverse event rates including hepatotoxicity and rhabdomyolysis remained similarly low. Conclusion Our results confirmed that multifaceted intervention with HIT assisted multidisciplinary approach could substantially improve LDL-C goal attainment in post-ACS patients. There was a direct relationship between high-intensity statins and LDL-C goal attainment, without significant increase of adverse events.LDL-C goal attainment rate and levelLower lipid treatment and adverse event

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

Observational study of patients from a Lipid Unit on lipid-modifying therapy for primary and secondary prevention: ULFI Study

ObjectivesTo evaluate the achievement of low-density lipoprotein cholesterol (LDLc) goals established by the 2019 European Guidelines for the Management of Dyslipidemias and 2021 Cardiovascular Disease Prevention Guidelines, describe the lipid-lowering treatment received, analyze the achievement of goals according to the lipid-lowering treatment received and study the factors associated with therapeutic success. DesignObservational study that included 185 patients of both sexes aged 18 or over undergoing lipid-lowering treatment for primary or secondary prevention, attended at the Lipid Unit. Results62,1% of the patients had a very high cardiovascular risk (CVR) according to the 2019 guidelines, and 60,5% according to the 2021 guidelines. Of the total cases, 22,7% achieved adequate control of LDLc according to the 2019 guidelines and 20% according to the 2021 guidelines. 47,6% of the patients received very high intensity lipid-lowering treatment, and 14,1% received extremely high intensity lipid-lowering treatment. 76% of subjects with very high CVR on extremely high intensity lipid-lowering treatment achieved the therapeutic objectives of both guides. In the multivariate analysis, factors associated with therapeutic success were the presence of arteriosclerotic cardiovascular disease, the intensity of lipid-lowering treatment, diabetes mellitus, and low to moderate alcohol consumption. ConclusionsDyslipidemia control is improvable. High or extremely high intensity lipid-lowering treatments can contribute to optimizing control of patients with higher CVR.

Crucial safety issues on Janus kinase inhibitors in rheumatoid arthritis might be associated with the lack of LDL-cholesterol management: a reasoned literature analysis.

This point of view explores the safety concerns of Janus kinase inhibitors (JAK-Is), used in treating rheumatoid arthritis (RA) and other rheumatologic conditions. Increasing evidence shows that JAK-Is may elevate the risk of venous thromboembolism (VTE), especially pulmonary embolism. This fact has prompted the European Medicines Agency to advise cautious use of these drugs in patients over 65, smokers, and those at risk of cardiovascular issues or cancer. The paper analyses the evidence on the association between VTE risk and RA and whether different JAK-Is pose different risks. It also probes the link between VTE, lipids, and JAK inhibition, noting that JAK-Is can alter HDL and LDL levels. On the other hand, some evidence indicates that tighter LDL-cholesterol control could mitigate VTE risk, particularly pulmonary embolism. Moreover, data from trials show little attention to treating this main cardiovascular and VTE risk factor in rheumatological patients. Although the lipid paradox theory emphasizes the U-shaped relationship between LDL cholesterol and cardiovascular risk in patients with RA, uncontrolled levels of clinically relevant LDL cholesterol remain closely linked to cardiovascular and VTE risk. In conclusion, high-potency statins could help to manage the increased cardiovascular and VTE risk concomitant to JAK-Is treatment in rheumatologic patients without depriving them of the best therapeutic choice and, in addition, reducing the inherent risk associated with the disease.

Associations of advanced liver fibrosis with heart failure with preserved ejection fraction in type 2 diabetic patients according to obesity and metabolic goal achievement status.

Heart failure with preserved ejection fraction (HFpEF), a major cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM), is frequently coexisted with obesity, poor glycemic, blood pressure (BP), and/or lipid control. We aimed to investigate the associations of nonalcoholic fatty liver disease (NAFLD) and its advanced fibrosis with HFpEF according to obesity, glycated hemoglobin A1c (HbA1c), BP, and low-density lipoprotein cholesterol (LDL-C) goal achievement status in T2DM patients. A total of 2,418 T2DM patients who were hospitalized were cross-sectionally assessed. Liver fibrosis was evaluated by non-invasive biomarkers. Logistic regression analysis was used to evaluate the independent and combined associations of fibrosis status and diabetic care goal attainments with HFpEF risk. Simple steatosis was not associated with HFpEF risk compared with patients without steatosis, while advanced liver fibrosis was found to have significantly higher odds for HFpEF risk (odds ratio,1.59; 95% confidence interval, 1.22-2.08). Advanced fibrosis in NAFLD was significantly associated with an increased risk of HFpEF, regardless of obesity status, HbA1c, BP, and LDL-C goal achievement status. P values for the interactions between fibrosis status and HbA1c control status, fibrosis status and BP control status, fibrosis status and LDL-C control status, and fibrosis status and body mass index (BMI) status on HFpEF risk were 0.021, 0.13, 0.001, and 0.23, respectively. In patients with T2DM, advanced hepatic fibrosis was significantly associated with HFpEF risk, irrespective of obesity status, HbA1c, BP, and LDL-C goal attainment status. Further, HbA1c and LDL-C goal attainment status modified this association.