Moderate Statin Research Articles

Comparison of statin plus ezetimibe with double-dose statin on lipid profiles and inflammation markers

BackgroundAchievement of low-density lipoprotein cholesterol (LDL-C) goal is the most important for the patients with atherosclerotic cardiovascular diseases (ASCVD) who received lipid-lowering therapy. It is unclear that whether combination of ezetimibe with statin is superior to double-dose of statin regarding both of the lipid-lowering efficacy and improvement of inflammation in Chinese patients with ASCVD. Therefore, this study was performed to compare the effects of these two regimes on lipid profiles and inflammation markers.MethodsIn this randomized control study, ninety eight patients with ASCVD, who were naïve to statins or other lipid-lowering agents, were enrolled into the study, and randomly assigned into two groups, A40 group (atorvastatin 40 mg/d, n = 50), A20E10 group (atorvastatin 20 mg/d combined with ezetimibe 10 mg/d, n = 48).The patients were followed up at week 4 and week 12 after treatment. The lipid profiles and oxidative low-density lipoprotein cholesterol (ox-LDL) were measured at the end of study.ResultsThere were no differences in clinical characteristics including lipid, ox-LDL and hypersensitive C reactive protein (Hs-CRP) among groups at baseline. However, the average level of LDL-C was lower in group A20E10 than that in group A40 significantly (1.59 ± 0.44 mmol/L vs 1.99 ± 0.56 mmol/L, p = 0.001) during follow-up at week 12 after treatment. Importantly, the higher rate of achievement of LDL-C goal was attained at group of combination statin with ezetimibe (79.2% in group A20E10 vs 50.0% in group A40, p = 0.016). The difference of the level of ox-LDL between both the groups after 12 weeks treatment had not statistical significance (3.63 ± 1.13 U/L in group A20E10 vs 4.14 ± 1.32 U/L in group A40, p = 0.077).Similarly, the level of Hs-CRP between both the groups after treatment was not significantly different (p > 0.05).ConclusionsIn this randomized study, the data showed that a combination of moderate statin and ezetimibe achieved more reduction of LDL-C compared to the double-dose statin but similar impact on inflammation markers.

Pharmacist documentation of gaps in care identified during diabetes coaching

Objectives1) To identify the number of gaps, type of gaps, and contributing factors to gaps in diabetes care reported by pharmacists in the Diabetes Gaps in Care Portal (Gaps Portal). 2) To understand how pharmacists used the Gaps Portal and the implications for quality diabetes care. DesignThe Alliance for Patient Medication Safety developed an online Gaps Portal as a tool for pharmacists to identify and document gaps in care when managing patients with diabetes. SettingPharmacists from across the United States in community pharmacy and ambulatory care settings who were engaged in diabetes coaching activities participated. Main outcome measuresPharmacists entered gaps in diabetes care into the Gaps Portal from April 2016 to June 2017. Descriptive statistics were used to determine the type and number of gaps and contributing factors. A qualitative analysis of pharmacist interviews was conducted to identify themes related to pharmacist perceptions of the portal. ResultsTen pharmacists entered 528 gaps in diabetes care (n = 469; 565 encounters). The most common category of gaps in diabetes care was drug therapy (n = 420/528; 79.6%). Of the drug therapy gaps reported, the most common gap occurred in patients with or at risk for atherosclerotic cardiovascular disease and not on a high-intensity statin (122/420), followed by those not on a moderate statin (106/420). Themes focused on during interviews included integration of diabetes coaching and documentation, impact of Gaps Portal on workflow, and prioritization of gaps. ConclusionPharmacists most commonly identified drug therapy gaps, predominantly pertaining to statin use, which coincides with a change in the guidelines for statin use in diabetics. Telephone interviews indicated that the Gaps Portal template served as a useful checklist to identify gaps in care during diabetes coaching activities and that the Gaps Portal was useful for reporting and monitoring purposes.

Intensive Versus Moderate Statin Therapy Discontinuation in Patients With Acute Ischemic Stroke or Transient Ischemic Attack

PurposeThe differences of discontinuation risk between intensive and mild-to-moderate statin therapy in patients with acute ischemic stroke is not clear. This study aimed to clarify whether intensive statin therapy resulted in a significant increase in discontinuation early after discharge. MethodsThis multicenter registry study enrolled consecutive hospitalized patients with ischemic stroke or transient ischemic attack. All the patients were prescribed statin therapy at discharge. Intensity of statin therapy was defined according to the 2013 American College of Cardiology/American Heart Association guideline on the treatment of blood cholesterol. A logistic regression model was used to analyze the association between statin therapy intensity and discontinuation. FindingsThis study included 505 patients, of whom 64 and 441 received intensive and moderate statin therapy, respectively (mean follow-up, approximately 6 months). The rates of discontinuation of intensive and moderate statin therapy were 31.3% and 10.7% (P < 0.001), respectively. Variables with significant differences between the intensive and moderate statin therapy groups were included in the adjusted logistic regression model. Intensive statin therapy significantly increased discontinuation risk by 273.0% (odds ratio = 3.730; 95% CI, 2.013–6.911; P < .001) compared with moderate statin therapy. The result was consistent in most subgroups, except for patients with National Institutes of Health Stroke Scale scores ≥4. ImplicationsIn stroke secondary prevention, intensive statin therapy may significantly increase the risk of early discontinuation compared with moderate statin therapy. Future clinical trials that involve a comparison between intensive and moderate statin therapy for stroke secondary prevention should address the differences in discontinuation between these 2 groups.

Guideline-directed statin intensification in patients with new or worsening symptoms of peripheral artery disease.

The ACC/AHA cholesterol guidelines recommend patients with peripheral artery disease (PAD) be treated with a moderate to high-intensity statin. The extent to which patients with new or worsening PAD symptoms are offered guideline therapy is unknown. There is significant variability in rate of guideline-directed statin intensification across clinical practices. In the PORTRAIT registry, patterns of statin therapy were assessed in 1144 patients at 16 PAD specialty clinics between June 2011 and December 2015 before and after an evaluation for new or worsening claudication symptoms. We documented whether patients were treated with a guideline statin as well as the incidence of statin intensification. Statin intensification was defined as transitioning from no statin or low-intensity statin to moderate or high-intensity statin treatment. Patient factors associated with intensification were examined. Site and provider-level variation in intensification was summarized using an adjusted median odds ratio (aMOR). Among 1144 patients, 810 (70.8%) were initially on guideline therapy compared to 334 (29.2%) that were not. In the latter, 103 (30.8%) received intensification following evaluation. Patients with typical symptoms displayed greater odds of intensification (OR 3.74; 95% CI: 1.23-11.41) while older patients had lower odds of intensification (OR 0.60/decade; 95% CI: 0.41-0.88). Site variability for statin intensification was observed across sites (aMOR = 3.15; 95% CI 1.22-9.60, [P = 0.02]) but not providers (aMOR = 1.89; 95% CI 1.00-3.90, [P = 0.14]). Most patients evaluated at a PAD specialty clinic for new or worsening claudication symptoms arrived on guideline statin therapy. Only 31% not receiving appropriate therapy underwent statin intensification. These findings highlight an important opportunity to optimize medical therapy for patients with PAD.

Statin intensity and postoperative mortality following open repair of intact abdominal aortic aneurysm.

BackgroundThere is a lack of evidence for the association between intensive statin therapy and outcomes following vascular surgery. The aim of this study was to evaluate the association between perioperative statin intensity and in‐hospital mortality following open abdominal aortic aneurysm (AAA) repair.MethodsPatients undergoing open AAA repair between 2009 and 2015 were identified from the Premier Healthcare Database. Statin use was classified into low, moderate and high intensity, based on American College of Cardiology/American Heart Association guidelines. Supratherapeutic intensity was defined as doses higher than the recommended guidelines. Multivariable logistic regression analyses were undertaken to assess the association between statin intensity and postoperative major adverse events and in‐hospital mortality.ResultsOf 6497 patients undergoing open AAA repair, 3217 (49·5 per cent) received perioperative statin. Statin users were more likely to present with three or more co‐morbidities than non‐users (26·5 versus 21·8 per cent; P < 0·001). Unadjusted postoperative mortality was significantly lower in statin users (2·6 versus 6·3 per cent; P < 0·001); however, there was no difference in the risk of developing major adverse events. Multivariable analysis showed that statin use was associated with lower odds of death (odds ratio 0·41, 95 per cent c.i. 0·31 to 0·54). Moderate, high and supratherapeutic statin intensities were not associated with lower odds of death or major adverse events compared with low‐intensity statin therapy.ConclusionStatin use is associated with lower odds of death in hospital following open AAA repair. High‐intensity statins were not associated with lower morbidity or mortality.

PCV4 - Long-Term Efficacy Of Lower Intensity Statin Therapy In Chinese Acute Coronary Syndrome Patients

Studies indicate that lower statin doses achieve lipid improvements in Asian patients comparable with higher doses in Caucasians. We aim to evaluate the correlation between lower statin doses and long-term clinical outcome. We analysed consecutive 2,553 patients (mean age 70.0 ± 13.4 years, 67.6% male) admitted with ACS between August 2010 and July 2014 to 3 hospitals in Hong Kong for a mean follow-up of 30 ± 17 months. There was no change in statin dosage or type. Statin therapy was divided into high (simvastatin (SIM) 80mg, atorvastatin (ATO) 40-80mg, rosuvastatin (ROS) 20-40mg); moderate (SIM 20-40mg, ATO 10-20mg, ROS 5-10mg) and low (SIM 10mg) intensity groups and compared. Outcome measures included achievement of LDL level <1.8mmol/L, all-cause mortality and major adverse cardiac events (MACE). Overall, 80.7% (n=2,059) of patients were discharged and remained on the same statin dose of which 6.2%, 62.6% and 31.2% were of high, moderate and low intensity, respectively. Simvastatin (mean dose 20.3mg) was used in 88.2% of cases. Patients with baseline LDL level ≥2.6mmol/L compared to LDL <1.8mmol/L were more likely to be prescribed moderate (68.7% vs. 50.6%) and high (7.4% vs. 4.9%) intensity statin (p<0.01). Achievement of LDL level <1.8mmol/L at follow-up was suboptimal in all groups (low intensity statin 38.1% vs. moderate 40.2% vs. high 50.0%, p=0.07). Neither LDL level at baseline nor follow-up were predictors of MACE at follow-up. Independent predictors of MACE included moderate statin intensity (odds ratio (OR) 0.60, 95%CI 0.44-0.84), STEMI (OR 0.64, 95%CI 0.48-0.86), percutaneous coronary intervention (OR 0.65, 95%CI 0.52-0.82), diabetes mellitus (OR 1.44, 1.15-1.82) and age≥65 years (OR 2.07, 1.59-2.71), all p<0.01. High intensity statin therapy was rarely prescribed in Chinese patients presenting with ACS irrespective of baseline LDL level. Moderate intensity statin therapy was an independent predictor of improved long-term clinical outcomes.

Lipid Lowering Therapy for Acute Coronary Syndrome and Coronary Artery Disease: Highlights of the 2017 Taiwan Lipid Guidelines for High Risk Patients.

Intensive lipid lowering therapy is important in patients with acute coronary syndrome (ACS) and stable coronary artery disease (CAD). The 2017 Taiwan Lipid Guidelines for High Risk Patients was recently published. The guideline suggests that low-density lipoprotein cholesterol (LDL-C) should be the primary target, and that the treatment goal of LDL-C is < 70 mg/dL for patients with ACS or stable CAD. A lower target of < 55 mg/dL is appropriate for patients with ACS and diabetes mellitus. Non-high-density lipoprotein cholesterol (non-HDL-C) < 100 mg/dL can be considered as the secondary target after achieving the LDL-C goal for patients with a triglyceride level > 200 mg/dL. Statins are usually the first-line therapy. Moderate or high intensity statins are preferred, and up-titration to the highest recommended and tolerable dose to reach the target is necessary. Combination therapy with statins and other lipid-lowering drugs can also be considered. We hope the clinical outcomes of patients with ACS or CAD can be improved in Taiwan through the implementation of the guideline recommendations.

Intensive versus moderate statin therapy and early graft occlusion after coronary bypass surgery: The Aggressive Cholesterol Therapy to Inhibit Vein Graft Events randomized clinical trial

ObjectiveStatins prevent saphenous vein graft (SVG) disease and improve outcomes after coronary artery bypass graft surgery. However, the optimal postoperative statin dose remains unclear. The Aggressive Cholesterol Therapy to Inhibit Vein Graft Events trial was undertaken to evaluate whether early postoperative high-dose statin therapy reduces SVG occlusion compared with conventional moderate-dose therapy. MethodsIn this pilot, multicenter, double-blind randomized trial, 173 patients who had coronary artery bypass graft surgery with SVG were randomized to receive 10 mg or 80 mg atorvastatin daily for 1 year. The primary outcome was SVG occlusion at 1 year. Secondary outcomes were SVG stenosis and major adverse cardiovascular events. ResultsDuring trial enrollment, patients randomized to 80 mg atorvastatin achieved significantly lower low-density lipoprotein cholesterol levels (P < .00001). One-year graft assessment was performed in 145 patients (83.8%). The primary outcome, SVG occlusion at 1 year, did not significantly differ between the 2 groups (12.9% vs 11.4% for 10 mg atorvastatin vs 80 mg atorvastatin; P = .85). The incidence of vein graft stenosis also did not significantly differ between the groups (P = .54). However, there was a trend toward fewer patients developing vein graft disease (either occlusion or stenosis) in the 80 mg atorvastatin group (29.2% vs 19.2%, 10 mg atorvastatin vs 80 mg atorvastatin; P = .18). Freedom from major adverse cardiovascular events at 1 year was similar between the groups (P = .27). ConclusionsCompared with 10 mg atorvastatin, 80 mg atorvastatin did not significantly reduce vein graft occlusion 1 year after coronary artery bypass graft surgery in this pilot trial.

PDB4 - Risk of Diabetes Among Intensive and Moderate Dose Statin Users with Potential Modifying Effects of Treatment Duration

PDB4 - Risk of Diabetes Among Intensive and Moderate Dose Statin Users with Potential Modifying Effects of Treatment Duration

Impact of statin therapy on coronary plaque burden and composition assessed by coronary computed tomographic angiography: a systematic review and meta-analysis.

To clarify the potential role of coronary computed tomographic angiography (CCTA) in assessing the remodelling impact of statin therapy on plaque burden and compositions. A systematic literature review and meta-analysis were conducted to examine the effect of statin therapy on different plaque volumes assessed by serial CCTA. Twelve studies were included with a mean (±standard deviation) follow-up period of 14.5 ± 9.5 months. Data on plaque volume were pooled using weighted mean difference method. Available data on a total of 199 intensive statin therapy receivers, 404 moderate statin therapy receivers and 189 controls (mean age = 62 ± 5 years, male gender = 78%) were meta-analysed. Intensive statin therapy reduced total plaque volume (TPV) by -20.87 [95% confidence interval (CI) -31.17, -10.56; P < 0.001] mm3, while moderate statin therapy reduced it by -1.67 (95% CI -9.99, 6.65; P = 0.69) mm3. In contrast TPV increased significantly in controls by 14.96 (95% CI 5.28, 24.64; P = 0.002) mm3. Percents of mean volume regression were -3.6% and -0.7% in intensive and moderate statin receivers, respectively, vs. +5.8% progression in controls. Statin therapy decreased non-calcified plaque volume by -7.62 (95% CI -17.38, 2.13; P = 0.124) mm3 and low attenuation plaque volume by -5.84 (95% CI -8.02, -3.66; P < 0.001) mm3. In statin therapy receivers, calcified plaque volume increased by 11.83 (95% CI 3.37, 20.29; P = 0.006) mm3 and calcium signal intensity increased by 21.99 (95% CI 9.2, 34.8; P < 0.001) Hounsfield units. Initial studies demonstrated CCTA's possible role in evaluating the effect of statin therapy on plaque volume and composition. Further studies are warranted to delineate the mechanisms behind plaque changes.

Abstract MP16: Trends in Statin Utilization Among Adults With Severe Peripheral Artery Disease Including Critical Limb Ischemia in an Integrated Healthcare Delivery System

Background: Studies have demonstrated benefit of statin therapy in patients with peripheral artery disease (PAD). However, use of statins in patients with PAD has been found to be suboptimal. We examined trends in statin use and discontinuation among adults with severe PAD including critical limb ischemia (CLI) from 2002-2015. Methods: Using electronic health record data from a large, integrated healthcare delivery system, we identified patients aged ≥40 yrs with incident severe PAD/CLI and 12 months of prior continuous coverage of health and drug benefits. Statin intensity was defined at first prescription fill. Discontinuation of statin therapy was defined as the first 90-day gap in treatment within 1 yr after diagnosis. Results: We identified 11,059 patients with incident severe PAD/CLI from 2002-2015. Mean (SD) age was 69 (11.3) yrs, 40% were female, 54% were White, 23% Hispanic, 16% Black and 4% Asian/Pacific Islander. Statin use in the yr before diagnosis increased from 50% in 2002 to 66% in 2015. Overall, 60% (n=6578) were on a statin in the yr before diagnosis. Of these patients, 18%, 54% and 28% were receiving high, moderate and low intensity statins, respectively. The proportion of patients on high intensity statins increased from 7.3% in 2002 to 41.9% in 2015 while the proportion on low intensity statins decreased (Figure). Of the 40% (n=4481) who were not on a statin in the yr before diagnosis, 13.5% (n=607) newly initiated statin therapy within 1 month after diagnosis. The proportion of patients with no statin use increased with increasing LDL-C, while the percentage with any statin use decreased (Figure). Following diagnosis of PAD/CLI, 13% discontinued statin therapy within 1 yr. Conclusions: Use of statins and high intensity statins increased from 2002-2015 among a population of patients with severe PAD including CLI. However, a substantial proportion remained untreated with statins, representing a significant treatment gap in this population at high risk for cardiovascular events and adverse limb outcomes.

Abstract P194: LDL-Cholesterol Reduction and Efficacy of Statin Intensity Over One Year in Veterans With the Familial Hypercholesterolemia Phenotype

Introduction: Severe elevations of LDL-Cholesterol (LDL-C) ≥190mg/dl in adults, representing the familial hypercholesterolemia (FH) phenotype, have been associated with increased risk of cardiovascular disease (CVD). The 2013 AHA/ACC guidelines recommend high intensity statin therapy to reduce LDL-C by ≥50%. We identified patients with FH phenotype in the Veterans Health Administration (VHA) who were statin-naive and determined the degree of LDL-C reduction over one year after statin initiation and the efficacy of statin intensity on ≥50% reduction. Methods: Patients receiving care at the VHA from 2002-2007, ≥21 years of age, with baseline LDL-C measurement of ≥190 mg/dl (LDL-C 0 ), and statin-naïve were included. Statin initiation was required within 90 days of LDL-C 0 , and a follow up level (LDL-C 1 ) had to be collected within one year ± 90 days. All participants were free of clinical CVD at baseline. Baseline characteristics were ascertained from patient charts. LDL-C reduction was defined as the difference between LDL-C 0 and LDL-C 1 . Multivariable logistic regression models, adjusted for age, sex, race, diabetes, kidney disease, hypertension, and hypertension treatment were constructed to determine the odds of goal LDL-C (≥50%) reduction by statin intensity. We defined statin intensity per the 2013 AHA/ACC guidelines. High intensity statins included Simvastatin 80mg, Atorvastatin 40-80mg, and Rosuvastatin 20-40mg. Results: We included 35,894 Veterans (Men: N= 33,049 (92.1%), Age=55±10 years; Women: N=2845 (7.9%), Age=50±11 years). The mean duration between LDL-C 0 and LDL-C 1 was 52±7 weeks. The population was predominantly white (78.1%). Mean LDL-C 0 was 210±22 mg/dl, triglycerides were 175±126 mg/dl. At baseline, 0.3% had kidney disease, 14.1% diabetes, and 52.8% hypertension. Mean absolute LDL-C reduction in the population was 70.2±41.9 mg/dl. A total of 6718 (18.7%) patients achieved an LDL-C reduction of ≥50%. Among these patients, 5.2% were on low, 62.2% were on moderate, and 32.6% were on high intensity statins. In multivariable-adjusted logistic regression models using moderate intensity statins as the comparator, high intensity therapy resulted in 97% higher odds of achieving goal LDL-C reduction (Odds ratio [OR]=1.97; 95% Confidence Interval [CI]=1.85-2.09), and low intensity statins resulted in 42% lower odds of achieving goal LDL-C reduction (OR= 0.58; 95%CI= 0.52-0.65). Conclusions: In a large veteran population with the FH phenotype, though there was a marked reduction in LDL-C with statin therapy, most patients did not achieve goal LDL-C reduction of ≥50%. This may be related to statin intensity, individual response to statin therapy, or lack of adherence to treatment. In multivariable-adjusted logistic regression models, patients on high intensity statins had 2-fold odds of goal LDL-C reduction compared to moderate intensity statins.

Abstract 014: Comparative Cost-Effectiveness of 10-Year Atherosclerotic Cardiovascular Disease Risk Equations Over 10 Years of Follow-up: The Multi-Ethnic Study of Atherosclerosis

Introduction: Uncertainty remains regarding the most efficient and cost-effective 10-year atherosclerotic cardiovascular disease (ASCVD) risk prediction tool for identifying moderate to high-risk patients for primary prevention statin treatment. Methods: We utilized the CVD Policy Model, a computer microsimulation model of ASCVD incidence, prevalence, mortality, and costs, to compare cost-effectiveness of statin treatment at varying 10-year predicted ASCVD risk thresholds for Framingham CVD (FRS-CVD), Reynolds Risk Score (RRS), and Pooled Cohorts Risk Equations over a 10-year time horizon in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. Cost effectiveness was assessed at predicted 10-year risk ≥ 20.0%, 15.0%, 10.0%, 7.5%, 5.0%, and 2.5%. We restricted the simulation cohort to participants aged 50 to 74 years who were not taking statins at baseline (n = 2,871). Moderate intensity statin treatment effectiveness was parameterized in the model as a 29% low-density lipoprotein cholesterol reduction. Total cost comprised statins ($100/year), side effect costs, and ASCVD event costs. Disability from treatment side effects and ASCVD events were included. Results: Average FRS-CVD, RRS, and Pooled Cohorts 10-year predicted ASCVD risks were 18.8%, 11.3%, 12.2%, for men and 8.9%, 4.3%, 6.6%, for women, respectively. At the same predicted risk, FRS-CVD consistently selected the most patients for treatment, and RRS the fewest ( Figure ). Compared with no treatment, treating patients with RRS ≥ 20% was cost saving in men. Subsequent risk threshold strategies with incremental cost effectiveness &lt;$75,000/quality-adjusted life-year (QALY) for men were: FRS-CVD ≥ 20% ($13,046), RRS ≥ 7.5% ($17,774), and RRS ≥ 5.0% ($19,891). For women, the non-dominated thresholds were: Pooled Cohorts ≥ 15% ($27,908) and Pooled Cohorts ≥ 7.5% ($72,377). Conclusions: At cost-effectiveness thresholds less than $75,000/QALY, RRS was the highest value tool for men while the Pooled Cohorts Risk Equations performed best for women.

Treatment patterns in hyperlipidaemia patients based on administrative claim databases in Japan

Background and aimsReal-world evidence on treatment of hyperlipidaemia (HLD) in Japan is limited. We aimed to describe treatment patterns, persistence with, and adherence to treatment in Japanese patients with HLD. MethodsRetrospective analyses of adult HLD patients receiving drug therapy in 2014–2015 were conducted using the Japan Medical Data Center (JMDC) and Medical Data Vision (MDV) databases. Depending on their HLD treatment history, individuals were categorised as untreated (UT) or previously treated (PT), and were followed for at least 12 months. Outcomes of interest included prescribing patterns of HLD drug classes, persistence with treatment at 12 months, and adherence to treatment. ResultsData for 49,582 and 53,865 patients from the JMDC and MDV databases, respectively, were analysed. First-line HLD prescriptions for UT patients were predominantly for moderate statins (JMDC: 75.9%, MDV: 77.0%). PT patients most commonly received combination therapy (JMDC: 43.9%, MDV: 52.6%). Approximately half of the UT patients discontinued treatment during observation. Within each cohort, persistence rates were lower in UT patients than in PT patients (JMDC: 45.0% vs. 77.5%; MDV: 51.9% vs. 85.3%). Adherence was ≥80% across almost all HLD drug classes, and was slightly lower in the JMDC cohort than MDV cohort. ConclusionsMost common prescriptions were moderate statins in UT patients and combination therapy in PT patients. The high discontinuation rate of HLD therapy in UT patients warrants further investigation and identification of methods to encourage and support long-term persistence.

Does spotty calcification attenuate the response of nonculprit plaque to statin therapy?: A serial optical coherence tomography study.

The aim of this study was to determine if spotty calcification decreases the response of plaque progression to statin therapy. Previous studies showed that the presence of spotty calcification is a marker of vulnerable plaque. However, the relationship between spotty calcification and plaque progression is not clear. Ninety-six nonculprit lipid-rich plaques in 69 patients who received serial optical coherence tomography (OCT) imaging were included. Plaques were divided into three groups: spotty calcification (n=38), calcified (n=12) and noncalcified (n=46) plaques. Spotty calcification was identified by the presence of a lesion <4mm in length with an arc of calcification <90°. Changes in plaque characteristics and fibrous cap thickness (FCT) at 6 and 12months under statin therapy were analyzed by OCT. The increase of FCT was sustained from baseline to 6 and 12months in three groups: spotty calcification (62.8±20.9, 126.4±84.9, and 169.2±81.6μm, respectively; P<.001), calcified (59.8±17.0, 93.4±51.4, and 155.2±61.7μm, respectively; P<.001) and noncalcified (60.0±17.2, 125.5±62.1, and 161.0±80.5μm, respectively; P<.001). Intensive statin induced a greater change in FCT at 12months than moderate statin in the spotty calcification group (P=0.034). The mean lipid arc decreased significantly at 12months from baseline in the three groups (P=0.004, P=0.023, and P<.001, respectively). Statin therapy was effective for plaque stabilization in plaques with and without spotty calcification. Patients with spotty calcification benefitted more from intensive statin than from moderate statin therapy.

Effect of Pioglitazone in Combination with Moderate Dose Statin on Atherosclerotic Inflammation: Randomized Controlled Clinical Trial Using Serial FDG-PET/CT.

Background and ObjectivesNon-statin therapy plus lower intensity statin might be an alternative in patients with coronary artery disease (CAD). A recent data suggested an anti-inflammatory therapy can reduce recurrent cardiovascular events and pioglitazone is also an intriguing inflammatory-modulating agent. However, limited data exist on whether pioglitazone on top of statins further attenuates plaque inflammation.MethodsStatin-naïve patients with stable CAD and carotid plaques of ≥3 mm were randomly prescribed moderate dose atorvastatin (20 mg/day), or moderate dose atorvastatin plus pioglitazone (30 mg/day) for 3 months. The primary endpoint was the change in the arterial inflammation of the carotid artery measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) during 3 months.ResultsOf the 41 randomized patients, 33 underwent an evaluation by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT; 17 atorvastatin plus pioglitazone and 16 atorvastatin patients). The addition of pioglitazone significantly improved the insulin sensitivity and increased the high-density lipoprotein cholesterol after 3 months. Although a reduction in the (FDG) uptake by pioglitazone on top of atorvastatin in carotid arteries with plaque showed marginally statistical significance in the entire patient group (atorvastatin plus pioglitazone; −0.10±0.07 and atorvastatin −0.06±0.04, p=0.058), pioglitazone showed a further reduction of the fluorodeoxyglucose (FDG) uptake among patients who had a baseline FDG uptake above the median (atorvastatin plus pioglitazone; −0.14±0.04 and atorvastatin −0.03±0.03, p<0.001).ConclusionsPioglitazone demonstrated marginally significant anti-inflammatory effects in addition to moderate dose atorvastatin. This may have been due to the lack of power of the study. However, pioglitazone may have an anti-inflammatory effect in those patients with high plaque inflammation (Trial registry at ClinicalTrials.gov, NCT01341730).

Emerging evidence of moderate intensity statin therapy in high-risk primary and secondary prevention in Asian populations - Lessons from the EMPATHY and REAL-CAD studies

Emerging evidence of moderate intensity statin therapy in high-risk primary and secondary prevention in Asian populations - Lessons from the EMPATHY and REAL-CAD studies

Implications of GLAGOV study.

Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibition has emerged as a novel approach to lowering levels of low-density lipoprotein cholesterol (LDL-C). The impact of PCSK9 inhibition in statin-treated patients on coronary atherosclerosis had remained unknown. The GLAGOV trial compared the effect of the PCSK9 inhibitor, evolocumab, and placebo on progression of coronary atherosclerosis in patients treated with at least moderate intensity statin therapy. Predictable lowering of LDL-C with evolocumab (36.6 versus 93.0 mg/dl) associated with significant regression of coronary atherosclerosis. A direct relationship was observed between achieved LDL-C levels and disease progression. Addition of evolocumab to statin therapy produces incremental regression of plaque regression in patients with established coronary artery disease. This finding provides a biological rationale for the reported beneficial effects of evolocumab on cardiovascular events.

Evolocumab

Evolocumab

Treatment Patterns And Lack of Low-Density Lipoprotein Cholesterol (LDL-C) Goal Attainment Among High-Risk Patients Using High or Moderate Intensity Statin Therapy In Germany

Treatment Patterns And Lack of Low-Density Lipoprotein Cholesterol (LDL-C) Goal Attainment Among High-Risk Patients Using High or Moderate Intensity Statin Therapy In Germany