Low-density Lipoprotein Cholesterol Treatment Goals Research Articles

Drug intervention as an emerging concept for secondary prevention in patients with coronary disease.

Non-culprit lesion-related coronary events are a significant concern in patients with coronary artery disease (CAD) undergoing coronary intervention. Since several studies using intra-coronary imaging modalities have reported a high prevalence of vulnerable plaques in non-culprit lesions at the initial coronary event, the immediate stabilization of these plaques by intensive pharmacological regimens may contribute to the reduction in the adverse events. Although current treatment guidelines recommend the titration of statin and other drugs to attain the treatment goal of low-density lipoprotein cholesterol (LDL-C) level in patients with CAD, the early prescription of strong LDL-C lowering drugs with more intensive regimen may further reduce the incidence of recurrent cardiovascular events. In fact, several studies with intensive regimen have demonstrated a higher percentage of patients with the attainment of LDL-C treatment goal in the early phase following discharge. In addition to many imaging studies showing plaque stabilization by LDL-C lowering drugs, several recent reports have shown the efficacy of early statin and proprotein convertase subtilisin/kexin type 9 inhibitors on the immediate stabilization of non-culprit coronary plaques. To raise awareness regarding this important concept of immediate plaque stabilization and subsequent reduction in the incidence of recurrent coronary events, the term 'Drug Intervention' has been introduced and gradually applied in the clinical field, although a clear definition is lacking. The main target of this concept is patients with acute coronary syndrome as a higher prevalence of vulnerable plaques in non-culprit lesions in addition to the worse clinical outcomes has been reported in recent imaging studies. In this article, we discuss the backgrounds and the concept of drug intervention.

Atherogenic lipid profile in patients with acute coronary syndrome

Abstract Background Adverse atherogenic lipid profile is associated with an increased risk of major adverse cardiac events in patients with acute coronary syndrome (ACS). Objective To evaluate the control status of atherogenic lipid profile among ACS patients within 12 months after discharge. Methods We retrospectively analyzed the data from the multi-center iHeart program. Twenty tertiary hospitals in China were included. Natural language processing technique was used to extract real-world data from electronic health records (EHRs). Patients with a diagnosis of ACS from January 2014 to December 2021 during index hospitalization and having at least one medical record after discharge within 12 months were enrolled. Measurements of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non–high-density lipoprotein cholesterol (non-HDL-C), triglycerides (TGs), apolipoprotein B (ApoB), lipoprotein (a) (Lp[a]) at baseline and follow-up were collected and analyzed. Remnant cholesterol (RC) was calculated as TC minus HDL-C minus LDL-C. The treatment goal of LDL-C was defined as <1.8 mmol/L according to the guideline. An even lower LDL-C goal of <1.4 mmol/L was recommended in specific patients at extremely high risk with concomitant diabetes or ischemic cerebral vascular diseases. Results Among the 3956 patients, the mean age was 72 (12) years, and 64.8% were men. Diabetes was common (22.7%). There were 1612 (40.7%) patients with unstable angina, 391(9.9%) patients with non-ST-elevation myocardial infarction, 1146 (29.0%) patients with ST-elevation myocardial infarction, and 807 (20.4%) patients with undetermined ACS category. At baseline, the mean values for TC, LDL-C, HDL-C, non-HDL-C, ApoB, and RC were 4.61 (1.26) mmol/L, 2.83 (0.98) mmol/L, 1.12 (0.30) mmol/L, 3.38 (0.75) mmol/L, 96 (34) mg/dL, and 0.65 (0.56) mmol/L, respectively. The median values for TGs and Lp(a) were 1.44 mmol/L [1.06, 2.00] and 27.22 mg/dL [12.34, 39.2], respectively. The rate of lipid-lowering treatment was 94.8% (statins 93.1%, PCSK9 inhibitors 0.4%). The levels of TC, TGs, LDL-C, HDL-C, non-HDL-C, and ApoB were significantly decreased (P < 0.001) within 12 months. Median Lp(a) was 19.52 mg/dL [8.73, 39.08] (P = 0.117). Mean RC was 0.69 (1.10) mmol/L (P < 0.001). Overall, the proportion of patients achieving the LDL-C level of <1.8 mmol/L at baseline increased from 13.42% to 36.6% during follow-up. In patients with concomitant diabetes or ischemic cerebral vascular diseases, the rate of LDL-C <1.4 mmol/L was 17.79% and 17.52%, respectively. Conclusion Only 1/3 of patients had LDL-C <1.8mmol/L within 12 months after ACS. Despite the high treatment rate of statins, Lp(a) level had no change beyond the reduction in LDL-C. Elevated remnant cholesterol may be a critical contributor to residual risk. Novel therapeutics targeting the whole atherogenic lipid profile will be warranted to improve cardiovascular outcomes.LDL-C control rate within 12 months

Differences in treatment strategies for LDL-cholesterol reduction in a university lipid clinic vs. standard care apart from the use of PCSK9 inhibitors

Lipid-lowering therapy (LLT) in patients with cardiovascular disease (CVD) is insufficient despite clear guideline recommendations. Lipid clinics have specialized in patients with dyslipidemia, but the magnitude and reduction of low-density lipoprotein cholesterol (LDL-C) in lipid clinics has not yet been studied in depth. To assess LDL-C reduction in very high-risk CVD patients achieved in a lipid clinic through different forms of LLT in comparison to standard care without the initiation of PSCK9 inhibitors. Data from 96 lipid clinic patients were analyzed retrospectively and compared to 84 standard care patients. Very high-risk patients were defined according to the European Society of Cardiology (ESC). Different combinations of LLT focusing on statins and ezetimibe were investigated. Achievement of LDL-C treatment goals according to ESC guidelines as well as LDL-C reduction were assessed. Baseline and follow-up data of 180 very high-risk CVD patients (mean age 67.7 (±9.8) y; 60.6% male) were used. Achievement of the LDL-C goal in lipid clinic patients increased significantly from 14.6% at baseline to 41.7% at the latest visit (p<0.001) while standard care patients improved from 21.4% to 33.3% (p=0.08). The largest relative LDL-C reduction via an adjustment in LLT was achieved by initiation of high-intensity statins (50.8 ± 4.9%, n=5, p < 0.05). Treatment in a lipid clinic leads to a superior LDL-C goal achievement in very high-risk CVD patients as compared to standard care with the highest reduction under LLT with high-intensity statins and ezetimibe. Referral algorithms have to be established for high-risk patients.

Lipid lowering effects and safety of evolocumab in Chinese patients at very high cardiovascular risk: a single-center study.

Lipid lowering effects and safety of evolocumab in Chinese patients at very high cardiovascular risk: a single-center study.

Cardiovascular Outcomes according to Comorbidities and Low-Density Lipoprotein Cholesterol in Korean People with Type 2 Diabetes Mellitus.

There are no clear data to support the cardiovascular (CV) risk categories and low-density lipoprotein cholesterol (LDL-C) treatment goals in Korean people with type 2 diabetes mellitus (T2DM). We evaluated the incidence of cardiovascular disease (CVD) according to comorbidities and suggested LDL-C treatment goals in Korean people with T2DM in nationwide cohort data. Using the Korean National Health Insurance Service database, 248,002 people aged 30 to 90 years with T2DM who underwent routine health check-ups during 2009 were included. Subjects with previous CVD were excluded from the study. The primary outcome was incident CVD, defined as a composite of myocardial infarction and ischemic stroke during the follow-up period from 2009 to 2018. The mean age of the study participants was 59.6±10.9 years, and median follow-up period was 9.3 years. CVD incidence increased in the order of DM duration of 5 years or more (12.04/1,000 person-years), hypertension (HT) (12.27/1,000 personyears), three or more CV risk factors (14.10/1,000 person-years), and chronic kidney disease (18.28/1,000 person-years). The risk of incident CVD increased linearly from an LDL-C level of ≥70 mg/dL in most patients with T2DM. In T2DM patients without HT or with a DM duration of less than 5 years, the CVD incidence increased from LDL-C level of ≥100 mg/dL. For primary prevention of CVD in Korean adults with T2DM, it can be helpful to lower LDL-C targets when there are chronic kidney disease, HT, a long duration of diabetes mellitus, or three or more CV risk factors.

Knowledge of HbA1c and LDL‐C treatment goals, subjective level of disease‐related information and information needs in patients with atherosclerotic cardiovascular disease

Risk factor control of diabetes mellitus (DM) and especially dyslipidemia remains unsatisfactory in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to analyze the knowledge of low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c) treatment goals, subjective level of information, and information needs in very high-risk patients with ASCVD. ASCVD patients (n = 210; 75 ± 9 years; 71.4% male; 89.5% coronary disease) with DM (96.7% type 2) completed a questionnaire assessing knowledge of HbA1c and LDL-C treatment goals and subjective level of information and information needs on disease-related topics of DM and ASCVD. Serum LDL-C and HbA1c were measured. HbA1c goal (<7.0% in 60.6%) was attained more frequently than LDL-C goal (<70 mg/dl in 39.9%; p < .01). Significantly more participants named the correct goal for HbA1c compared to LDL-C (52.9% vs. 2.4%; p < .01). Subjective levels of information were higher and information needs were lower for DM than for ASCVD (p < .01 for all topics). No associations of knowledge of treatment goals and level of information with the attainment of treatment goals for HbA1c and LDL-C were found. However, in multivariate regression, higher levels of education were associated with knowledge of treatment goals (HbA1c: odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.72, p = .04; LDL-C: OR 2.32, 95% CI 1.07-5.03; p = .03). In very high-risk patients with ASCVD, a deficit of knowledge of treatment goals to control dyslipidemia exists when compared to DM, patients felt significantly better informed for topics of DM than for ASCVD and display higher information needs for topics of ASCVD.

European Physician Survey Characterizing the Clinical Pathway and Treatment Patterns of Patients Post-Myocardial Infarction.

The 2019 European Society of Cardiology and European Atherosclerosis Society (2019 ESC/EAS) guidelines stress the importance of managing low-density lipoprotein cholesterol (LDL-C) after myocardial infarction (MI) to reduce the risk of cardiovascular events. Information on guideline implementation is limited. The aim of this survey was to describe current clinical practice regarding LDL-C management in the first year post-MI across Europe, improving understanding of the role of ESC/EAS guidelines on clinical practice. A qualitative web-based cross-sectional physician survey about the patient pathway and LDL-C management post-MI was conducted in 360 physicians from France, Italy, Germany, The Netherlands, Spain, and the UK (n = 60/country) between December 2019 and June 2020. Secondary and primary care physicians (SCPs/PCPs) described their experiences treating patients post-MI over the preceding 2months. Physicians reported that on average 90.7% of patients not prescribed lipid-lowering therapy (LLT) before an MI initiated LLT as inpatients; for patients already taking LLT, treatment was intensified for 64.7% of inpatients post-MI. SCPs reported prescribing higher-intensity statins and/or ezetimibe for between 72.3% (Italy) and 88.6% (UK) of patients post-MI. More than 80.0% of SCPs and 51.2% of PCPs stated that they would initiate a change in LLT immediately if patients did not achieve their LDL-C treatment goal by 12weeks post-MI; 82.0% of SCPs and 55.1% of PCPs reported referring to 2019 ESC/EAS guidelines for management of patients post-MI. Barriers to initiating PCSK9 inhibitors (PCSK9is) included prior prescription of a maximally tolerated dose of statin (49.4%) and/or ezetimibe (38.9%), requirement to reach threshold LDL-C levels (44.9%), and pre-authorization requirements (30.4%). Differences in clinical practice post-MI were reported across the countries surveyed, including divergence between 2019 ESC/EAS and local guidelines. Increased use of innovative medicines to achieve LDL-C goals should reduce risk of subsequent cardiovascular events in very high-risk patients post-MI.

Low-Density Lipoprotein Cholesterol Treatment Target Achievement in Patients with Myocardial Infarction, Percutaneous Coronary Intervention, or Stroke in Hong Kong.

Elevated concentrations of low-density lipoprotein cholesterol (LDL-C) are an important cause of recurrent cardiovascular events. This study aimed to describe the distribution and achieved concentrations of LDL-C among patients with myocardial infarction (MI), percutaneous coronary intervention (PCI), stroke, or transient ischaemic attack (TIA) in Hong Kong. Patients with a lipid test from a public hospital were identified from the Clinical Database and Analysis Reporting System of the Hong Kong Hospital Authority. Among patients with an inpatient hospitalization for MI, PCI, stroke or TIA, between 2003 to 2016, the distribution of LDL-C levels and the number (%) of patients achieving an absolute concentration of LDL-C 1.8 mmol/L at baseline (in-hospital) and during 12 months after hospital discharge were described. A total of 18417 patients were included (mean [SD] age, 70.0 [12.9] years; male, 60.3%), of which 3637 had MI, 4096 had PCI, and 10684 had stroke or TIA. At hospital discharge 12082 (65.6%) patients were prescribed statins, 690 (3.7%) were prescribed nonstatins, and 1849 (10.0%) achieved an LDL-C 1.8 mmol/L. Overall, 5654 (30.7%) patients did not have LDL-C result available within 12 months of discharge (MI, 605 [16.6%]; PCI, 432 [10.5%]; stroke or TIA, 4617 [43.2%]). Among the overall cohort, 4591 (24.9%) patients achieved an LDL-C 1.8 mmol/L during 12 months of follow-up (MI, 1288 [35.4%]; PCI, 1542 [37.6%]; stroke or TIA, 1761 [16.5%]). Improvements in achieved LDL-C were observed over time with a mean LDL-C 2.64 (0.92) mmol/L and 20.0% of patients achieving an LDL-C 1.8 mmol/L in 2003 as compared with a mean LDL-C 1.86 (0.70) mmol/L and 53.9% of patients achieving an LDL-C 1.8 mmol/L in 2016. In this single centre cohort study from Hong Kong, nearly half of patients with MI, PCI, or stroke in 2016 appear to qualify for intensification of lipid-modifying drug treatment in order to achieve a treatment goal of LDL-C 1.8 mmol/L. Further research is required in Hong Kong to assess contemporary management of LDL-C in a larger group of patients with established atherosclerotic cardiovascular disease.

New data of the treatment with bempedoic acid in clinical routine

Background and Aims : Bempedoic acid, an inhibitor of ATP citrate lyase, reduces low-density lipoprotein cholesterol (LDL-C) and since 2020 has become an additional treatment option to reach the LDL-C treatment goal. The aim of this analysis is to provide new data of side effects and efficacy of bempedoic acid in a “real-world” cohort.

Achievement of ESC/EAS LDL-C treatment goals after an acute coronary syndrome with statin and alirocumab.

European guidelines set low-density lipoprotein cholesterol (LDL-C) treatment goals &lt;1.4 mmol/L after acute coronary syndrome (ACS), and &lt;1.0 mmol/L for patients with recurrent cardiovascular events ≤2 years. Many ACS patients do not achieve these goals on statin alone. We examined actual goal achievement with alirocumab and projected achievement with ezetimibe, either added to optimized statin therapy. The ODYSSEY OUTCOMES trial (NCT01663402) compared alirocumab with placebo in 18 924 patients with recent ACS and hyperlipidaemia despite high-intensity or maximum-tolerated statin therapy. This subanalysis comprised 17 589 patients with LDL-C ≥1.4 mmol/L at baseline who did not receive ezetimibe treatment. High-intensity statin treatment was used in 88.8%. Median (interquartile range) baseline LDL-C was 2.3 (1.9-2.7) mmol/L. With alirocumab, 94.6% of patients achieved LDL-C &lt;1.4 mmol/L at ≥1 post-baseline measurement vs. 17.3% with placebo. Among 2236 patients with a previous cardiovascular event within 2 years (before the qualifying ACS), 85.2% vs. 3.5%, respectively, achieved LDL-C &lt;1.0 mmol/L. Among patients not treated with ezetimibe, we projected that its use would have achieved LDL-C &lt;1.4 and &lt;1.0 mmol/L in 10.6 and 0%, respectively, at baseline (assuming 18 ± 3% reduction of LDL-C). Among patients with recent ACS and LDL-C ≥1.4 mmol/L despite optimized statin therapy, the addition of alirocumab allowed 94.6% to achieve the 2019 European guideline LDL-C goal &lt;1.4 mmol/L, and 85.2% of those with recurrent cardiovascular events to achieve &lt;1.0 mmol/L. In contrast, the addition of ezetimibe to optimized statin therapy was projected to achieve LDL-C &lt;1.4 mmol/L in only 10.6% of patients at baseline.

Cholesterol-lowering drugs: Focus on Ezetimibe: Cholesterol-lowering drugs: Focus on ezetimibe

Ezetimibe is an intestinal cholesterol/sterol inhibitor. It is generally well-tolerated, and except for coadministration with cyclosporin (which increases concentration of both ezetimibe and cyclosporin), has limited drug interactions. Clinical trial data suggests that ezetimibe 10 mg orally once a day reduces low density lipoprotein cholesterol (LDL-C) levels about 15-25% as monotherapy or when added to statins, depending on the patient and individual clinical trial. Ezetimibe also reduces lipoprotein remnants. Due to its additive effects to statins, international lipid guidelines recommend ezetimibe as an option for patients who do not achieve LDL-C treatment goals with statins alone. The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) trial demonstrated that when added to statin therapy, ezetimibe incrementally lowered LDL-C levels and modestly improved cardiovascular outcomes. Ezetimibe is formulated as monotherapy, or as a fixed-dose combination with statins or bempedoic acid. Finally, ezetimibe is the only pharmacotherapy approved for treatment of beta-sitosterolemia, which is a rare autsomal recessive disorder resulting in enhanced intestinal cholesterol absorption, increased circulating sterols, and tendinous and cutaneous xanthomas, arthritis or arthralgia, and premature cardiovascular disease.

Statin treatment and LDL-cholesterol treatment goal attainment among individuals with familial hypercholesterolaemia in primary care

ObjectivesGuidance recommends statin treatment in familial hypercholesterolaemia (FH) to achieve at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C). We assessed statin prescribing rates and LDL-C treatment goal attainment...

Why Should We Measure Low-Density Lipoprotein Cholesterol Directly? Comparison of Low-Density Lipoprotein Cholesterol Assessment by Friedewald Estimation, and Direct Measurement

Intorduction: Plasma levels of low-density lipoprotein cholesterol (LDL-C) are an important biomarker for coronary artery disease. In clinical and research settings worldwide, levels LDL-C are often not measured and are estimated using the Friedewald equation (total cholesterol - HDL cholesterol - triglycerides)/5). Bias of either over or underestimation of LDL-C can be corrected by direct measurement of LDL-C. We assessed the precision of the Friedewald equation in a heterogonous patients population within a wide range of lipid levels. Methods: A sample of consecutive fasting lipid profiles was obtained from ambulatory and hospitalized patients at the Chaim Sheba Medical Center, Tel-Hashomer. LDL-C concentrations were directly measured (dir LDL-C) (Olympus, Ireland) and correspondingly calculated at by the Friedewald equation (calc LDL-C). Results: 32,245 samples were analyzed. In 93% of the samples, underestimation of plasma levels of LDL-C was observed using the Friedewald equation. In 11,054 patients (34.3%), the difference between dir LDL and calc LDL were over 10mg/dl. In 7,693 patients (23.8%), the difference between dir LDL and calc LDL were over 20mg/dl. The difference between dir LDL and calc LDL correlated with plasma TG levels, including TG levels within the normal range. The difference between cal LDL and dir LDL levels is inversely correlated to cholesterol plasma levels. Conclusions: Direct measurement of LDL-C is more precise than Friedewald’s formula and overcomes the inaccurateness, due to elevated TG levels or relatively low LDL-C levels, in the setting of a heterogeneous Israeli population. In the era of extremely low LDL-C treatment goals, our findings require consideration due to their clinical importance and direct measurement of plasma LDL-C should be implemented as underestimation of LDL levels may lead to inappropriate therapeutic decisions.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry.

Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients. We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia. Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P<.001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P=.06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages. In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

PCSK9 inhibition in clinical practice: Treatment patterns and attainment of lipid goals in a large health maintenance organization

BackgroundProprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) effectively reduce low-density lipoprotein cholesterol (LDL-C), improving cardiovascular outcomes in clinical trials when added to statin therapy. ObjectivesAs real-world evidence is lacking, we aimed to evaluate treatment and adherence patterns using PCSK9i in clinical practice. MethodsWe investigated 1600 patients initiating PCSK9i between January 2016 and December 2019 in a large health maintenance organization. Treatment discontinuation was defined as a gap ≥60 days between last days' supply of one prescription and the start of the next. Re-initiation rates as well as proportion of days covered (PDC) over 1-year period and attainment of lipid goals under PCSK9i, were analyzed. ResultsEvolocumab 140 mg was initiated by 50.7%, alirocumab 75 mg by 29.5% and 150 mg by 19.8%. Cumulative discontinuation rates were 28.1% after 6-months and 49.9% after 3-years. Overall, 58% of the patients that discontinued therapy have re-initiated PCSK9i (31% after 3-months from discontinuation). Mean PDC over 1-year of therapy was 56% ± 29, with PDC ≥80% evident in 29%. Of those with established cardiovascular disease (n = 991), 55% achieved LDL-C<70 mg/dL and 38% LDL-C<55 mg/dL. Attainment rates were lower in patients with PDC<80%, baseline LDL-C>190 mg/dL and in those not treated with concurrent statin therapy. ConclusionsIn real-world practice of patients treated by PCSK9i, high proportion of early treatment discontinuation was evident, with non-negligible re-initiation rates but overall low medication coverage over time. This have contributed to sub-optimal attainment of LDL-C treatment goals, particularly observed in patients with severe hypercholesterolemia, inadequate drug adherence, and those using PCSK9i as monotherapy.

Prevalence, treatment, and control of severe hyperlipidemia

ObjectiveTo identify the prevalence, treatment, and low-density lipoprotein cholesterol (LDL-C) control of individuals with LDL-C ≥190 ​mg/dL in contemporary clinical practice. MethodsWe included adults (age ≥18 years) with LDL-C ≥190 ​mg/dL, at least one LDL-C level drawn from 255 health systems participating in Cerner HealthFacts database (2000–2017, n ​= ​4,623,851), and a detailed examination within Duke University Health System (DUHS, 2015–2017, n ​= ​267,710). Factors associated with LDL-C control were evaluated using multivariable logistic regression modeling. ResultsThe cross-sectional prevalence of LDL-C ≥190 ​mg/dL was 3.0% in Cerner (n ​= ​139,539/4,623,851) and 2.9% at DUHS (n ​= ​7728/267,710); among these, rates of repeat LDL-C measurement within 13 months were low: 27.9% (n ​= ​38,960) in Cerner, 54.5% (n ​= ​4211) at DUHS. Of patients with follow-up LDL-C levels, 23.6% in Cerner had a 50% of greater reduction in LDL-C, 18.3% achieved an LDL-C <100 ​mg/dL and 2.7% ​< ​70 ​mg/dL. At DUHS, 28.4% had a 50% or greater reduction in LDL-C, 28.4% achieved an LDL-C ≤100 ​mg/dL and 4.4% achieved <70 ​mg/dL. Within DUHS, 71.6% with LDL-C ≥190 ​mg/dL were on any statin during follow-up, but only 28.5% were on a high-intensity statin. In multivariable modeling, seeing a cardiologist (Cerner odds ratio [OR] 1.56, confidence interval [CI] 1.33–1.83; DUHS OR 1.89, 95% CI 1.18–3.01) and having diabetes (Cerner OR 1.34 CI 1.23–1.46; DUHS OR 2.07, CI 1.62–2.65) increased odds of LDL-C control, defined as a ≥50% reduction in LDL-C (at Cerner) or initiation of high intensity statin (at DUHS). Prior atherosclerotic cardiovascular disease (OR 1.19, CI 1.07–1.33), hypertension (OR 1.10, CI 1.03–1.18), African American race (OR 0.79, CI 0.71–0.89), and government (vs. private) insurance (OR 0.90, CI 0.83–0.98) were associated with LDL-C control at Cerner. Female sex was associated with lower odds of appropriate therapy (OR 0.69, CI 0.59–0.81) at DUHS. ConclusionsApproximately 3% of United States adults have LDL-C ≥190 ​mg/dL. Among those with very high LDL-C, rates of repeat measurement within one year were low; of those retested, only about one-fourth met guideline-recommended LDL-C treatment goals.

Nine-year overview of dyslipidemia management in children with heterozygous familial hypercholesterolemia: a university hospital outpatient lipid clinic project in Northwestern Greece.

Background To assess the efficacy and safety of lipid-lowering treatment in children with heterozygous familial hypercholesterolemia (HeFH) aged ≤12 years attending a tertiary hospital-based outpatient lipid clinic. Methods Data in 318 children from the University Hospital of Ioannina (Northwestern Greece) Outpatient Lipid Clinic Project for Children and Adolescents with Dyslipidemia from March 2009 to December 2018 were analyzed. We assessed the efficacy and safety treatment alongside any possible predictors of the achievement of the treatment target. Results Of 318 children with hyperlipidemia, 72 were diagnosed having HeFH based on clinical criteria and genetic confirmation. Compared with non-familial hypercholesterolemia (non-FH) children, those with FH had a higher occurrence of positive family history of premature cardiovascular disease, and higher levels of total, low-density lipoprotein-cholesterol (LDL-C), apolipoprotein B (apoB) and lipoprotein (a) (Lp(a)). Treatment regimens included either atorvastatin 10-20 mg/day, rosuvastatin 5-10 mg/day, pitavastatin 2-4 mg/day monotherapy or in combination with ezetimibe. The treatment goal of LDL-C (<135 mg/dL, 3.5 mmol/L) was achieved in 69% of children treated. The achievement of the treatment targets correlated positively with male sex and inversely with the Dutch Lipid Clinic Network Score, baseline total, LDL-C and apoB levels. No clinically significant changes in liver or muscle-related laboratory tests were reported; no effect on growth or sexual maturation was noted. Conclusions This study confirms that lipid-lowering treatment in HeFH children initiated in the setting of a specialized tertiary hospital-based outpatient lipid clinic is efficacious and safe. Children of male sex and low baseline lipid values had a better achievement of treatment target.

PCSK9 inhibitors: The breakthrough lipid-lowering treatment at real-life setting – A 2-year regional lipid clinic experience

Aim: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been demonstrated to be safe and effective in low-density lipoprotein cholesterol (LDL-C) lowering and cardiovascular risk reduction. Data on clinical implementation of PCSK9 inhibitors in real life setting in Greece is limited. Thus, we report 2-year experience with PCSK9 inhibitors in clinical practice at a University Hospital Lipid Clinic. Patients and methods: This is a retrospective study of patients who were first prescribed a PCSK9 inhibitor during 2016-2018. Patients had either established cardiovascular disease (CVD) and/or familial hypercholesterolemia (FH) and LDL-C level &gt;100 mg/dL despite maximum tolerated high-intensity statin plus ezetimibe. Patient demographics, medical history, concomitant medications and laboratory results were documented during visits. Results: We included 37 patients (mean age 52 years, 56.8% males). Of patients, 28 (76%) had established CVD and 27 patients (74%) had FH. Concerning treatment, 33 patients (89%) were receiving high-intensity statin, while 35 patients (95%) were also on ezetimibe 10 mg. Addition of PCSK9 inhibitors (51% on evolocumab 140 mg per 2 weeks (Q2W), 22% on alirocumab 75 mg Q2W and 27% on alirocumab 150 mg Q2W) resulted in a reduction of total cholesterol by 42% and LDL-C by 59% after 2 months (p&lt;0.05). These reductions remained unchanged after 1 and 2 years on treatment. Thirty patients (81%) achieved LDL-C treatment goal following PCSK9i treatment. Four patients (11%) developed minor adverse effects. No treatment discontinuation was reported. Conclusion: In real-life setting addition of PCSK9 inhibitors to maximally tolerated lipid-lowering therapy resulted in reductions of LDL-C levels of the magnitude seen in clinical studies. These reductions were sustainable during a 2-year follow-up.

Suboptimal treatment of dyslipidemia in patients with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) patients often have dyslipidemia, and optimal treatment of dyslipidemia lowers the risk of cardiovascular disease and mortality. Our aim was to study the prescription of statin and low-density lipoprotein cholesterol treatment targets in NAFLD patients. Consecutive NAFLD patients attending five clinics in Asia were included in this study. The 10-year cardiovascular disease risk was calculated based on the Framingham Heart Study, and patients were categorized as moderate, high, or very high risk for cardiovascular disease on the basis of the American Association of Clinical Endocrinologist 2017 Guidelines. The low-density lipoprotein cholesterol treatment goal for each of the risk groups was 2.6, 2.6, and 1.8mmol/L, respectively. The data for 428 patients were analyzed (mean age 54.4±11.1years, 52.1% male). Dyslipidemia was seen in 60.5% (259/428), but only 43.2% (185/428) were on a statin. The percentage of patients who were at moderate, high, and very high risk for cardiovascular disease was 36.7% (157/428), 27.3% (117/428), and 36.0% (154/428), respectively. Among patients who were on a statin, 58.9% (109/185) did not achieve the treatment target. Among patients who were not on a statin, 74.1% (180/243) should be receiving statin therapy. The percentage of patients who were not treated to target or who should be on statin was highest among patients at very high risk for cardiovascular disease at 79.6% (78/98) or 94.6% (53/56), respectively. This study highlights the suboptimal treatment of dyslipidemia and calls for action to improve the treatment of dyslipidemia in NAFLD patients.

Effectiveness and prescription pattern of lipid-lowering therapy and its associated factors among patients with type 2 diabetes mellitus in Malaysian primary care settings.

BackgroundCardiovascular diseases (CVDs) are the main complication leading to morbidity and mortality among patients with type 2 diabetes mellitus (T2DM). There is a large amount of evidence to support the use of lipid-lowering therapy (LLT) for the prevention of CVD. This study aimed to assess the effectiveness and prescription quality of LLT among T2DM patients and to identify its associated factors.MethodsA multicenter cross-sectional study included 816 T2DM patients from four different primary care centers in Pahang, Malaysia. We involved LLT-eligible T2DM patients as per the national clinical practice guidelines (CPG). The assessment of therapy effectiveness focused on the attainment of target lipid measures stated in the CPG. Evaluation of the prescription quality was classified into appropriate, potentially inappropriate, and inappropriate, based on the compliance with guidelines and existence of potential safety concerns. Binomial logistic regression was employed to identify the predictors of LLT effectiveness and prescription quality.ResultsThe overall percentage of T2DM patients receiving statin therapy was 87.6% (715/816). Statin therapy was appropriately prescribed in 71.5% of the cases. About 17.5% of the LLT prescriptions have at least one significant drug interaction with co-prescribed medications. The achievement of the primary target of low-density lipoprotein cholesterol (LDL-C) levels was observed in only 37% of T2DM patients. The LLT indication and appropriateness of prescription were significantly associated with the attainment of LDL-C treatment goals. Primary prevention, Malay race, and hypertension were identified as predictors for appropriate prescribing of LLT among T2DM subjects.ConclusionThere is a need to enhance the quality of LLT prescribing in the primary care setting to cover all eligible high-risk patients and ensure patient safety. Strategies to improve the achievement of LDL-C goals among patients with T2DM, such as investigating the potential role of the combination therapy and high-intensity statin therapy, are required.