Optimal Cardiovascular Risk Reduction Research Articles

Management of Atherogenic Dyslipidemia in a Patient with LDL Discordance

<h3>Lead Author's Financial Disclosures</h3> Nothing to disclose. <h3>Study Funding</h3> None. <h3>Background/Synopsis</h3> We review a case of a 43-year-old male referred for optimal management of dyslipidemia and cardiovascular risk reduction. This is intended to highlight key features in diagnosis and management of atherogenic dyslipidemia in the setting of metabolic syndrome. <h3>Objective/Purpose</h3> To review a clinical scenario involving LDL discordance in a patient with atherogenic dyslipidemia and its impact on management. <h3>Methods</h3> Clinical management done at tertiary care lipid program. Advanced lipid testing including LDL particle number and size is ordered through Quest Diagnostics. <h3>Results</h3> A 43-year-old nonsmoker male with metabolic syndrome and recently diagnosed insulin dependent type 2 diabetes mellitus was referred to the lipid clinic for further evaluation. With subclinical atherosclerosis noted with calcium score of 6.6 at age 43 (50-75th percentile) and above-average carotid intimal medial thickness, he was treated with rosuvastatin 20 mg daily. Subsequently, he had a good response of ∼50% LDL reduction with LDL-c of 75 mg/dL. At this point, while most clinicians as well as guideline directed approach may suggest a sufficient management of his dyslipidemia, the advent of advanced lipid testing contrasts this dogma otherwise. LDL discordance noted based on higher-than-expected particle number strongly warrants further aggressive LDL lowering for optimal cardiovascular risk reduction in the setting of metabolic syndrome. <h3>Conclusions</h3> While calculated LDL cholesterol has been well established as a primary target of treatment to reduce cardiovascular risk, in patients with hypertriglyceridemia or metabolic syndrome, this may underestimate the true burden of atherogenic, cholesterol-carrying lipoproteins. Measurements of apoB or LDL particle number by NMR may more closely quantify the atherogenic lipoprotein load and thus prove to be better indices of cardiovascular disease risk than calculated LDL cholesterol or non-HDL cholesterol in such a population. In our clinical case, the patient may not be adequately treated based on a calculated LDL of 75 mg/dL on high intensity statin, however, an advanced lipid panel revealing LDL discordance suggests intensification and more aggressive LDL lowering for optimal cardiovascular risk reduction.

Experience with Azilsartan and Azilsartan Combined with Chlorthalidone in a Preventive Cardiology Center. Fighting the Therapeutic Inertia with a Program Based on Evidence, Personalization, and Empowerment

In patients with hypertension (HT), cardiovascular risk reduction is directly proportional to the reduction in blood pressure sustained over time. However, in “real life,” blood pressure control is often insufficient or not sustained over time to achieve optimal cardiovascular risk reduction. In this article, we comment on the multiple reasons which explain this common therapeutic failure. Also, in this article, we summarize the amazing basic and clinical phase III evidence of azilsartan (AZL) and azilsartan combined with chlortalidone (CLD), two excellent therapeutic options for HT control. With such evidence as scientific background, we communicate our results with almost 300 HT patients treated with azilsartan and azilsartan/chlortalidone in "real life." In brief, our findings were the following: a) In HT patients with blood pressure (BP) &lt;150/90 mmHg, AZL 40 mg as monotherapy provides practically 100% success to achieve a target BP &lt;140/90 and &lt;130/80 mmHg, in a subpopulation that we have called “hyper-responders” b) In HT patients with BP &lt;150/90 mmHg (naive or with another treatment failure), AZL/CLD 40/12.5 mg provides practically 100% success to achieve a target BP &lt;140/90 mmHg and 90% to achieve a target BP &lt;130/80 mmHg; c) In HT patients with BP &gt;150/90 mmHg (generally with another treatment failure), AZL/CLD 80/12.5 mg gives women a success rate greater than 60% to achieve a target BP &lt;140/90 mmHg and greater than 50% to achieve a target BP &lt;130/80 mmHg. The success rates were higher in men, greater than 75% to achieve a target BP &lt;140/90 mmHg and greater than 60% to achieve a target BP &lt;130/80 mmHg. In both cases, the use of amlodipine (2.5, 5, or 10 mg) made it possible to achieve a target BP &lt;140/90 mmHg in 100% of the cases and &lt;130/80 mmHg in 80% of the cases. Finally, according to our results, we propose a simple three-step strategy based on evidence, personalization, and empowerment which allows reaching a target BP &lt;140/90 mmHg in more than 90% of cases and a target BP &lt;130/80 mmHg in more than 75% of cases in 4 to 12 weeks.

Advances in reducing cardiovascular risk in the management of patients with type 2 diabetes mellitus

Treatment intended to lower cardiovascular (CV) risk in patients with diabetes has always been a primary goal of diabetes treatment. Due to the subdued effects of reducing hemoglobin A1c (HbA1c) on macrovascular complications, controlling other CV risk factors such as hypertension and hyperlipidemia instead of hyperglycemia has been the mainstay treatment to improve CV outcome in patients with type 2 diabetes mellitus (T2DM) until recent years. This review is intended to summarize and compare the results from the available cardiovascular outcome trials (CVOTs) for the two classes of glucose lowering drug: sodium-glucose co-transporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA). The results including the EMPA-REG, CANVAS program and DECLARE-TIMI 58 trials for SGLT2i, and the ELIXA, LEADER, SUSTAIN-6, EXSCEL and HARMONY trials for GLP-1 RA were summarized. The potential mechanisms of these CV beneficial effects and the optimal CV risk reduction treatment in patients with T2DM based on patient risk stratification and evidence from these CVOTs in real-world setting were discussed.

Design and rationale for the Patient and Provider Assessment of Lipid Management (PALM) registry

Despite improvements in diagnosis and treatment, the prevalence of hyperlipidemia among adults in the United States remains high. Data are limited on treatment patterns and patient perceptions of cardiovascular disease risk since the release of new lipid guidelines. The objectives of the PALM registry are to assess contemporary patterns of lipid-lowering therapy use among adults receiving care in a nationally representative cohort of community clinics, determine consistency of treatment with varying lipid guidelines, identify factors affecting use of lipid-lowering therapy including patient-reported statin intolerance, and assess patient and provider knowledge of cardiovascular risk reduction goals. The PALM registry will enroll 7,500 patients likely to be considered for lipid-lowering therapy from 175 cardiology, primary care, and endocrinology practices across the United States. In this cross-sectional, observational registry, a novel tablet-based platform will be used to collect patient-reported knowledge, attitudes, and beliefs regarding cardiovascular risk reduction and lipid management. Chart abstraction and core laboratory lipid levels will describe current lipid management. Provider surveys will assess perception of current lipid-lowering goals and barriers to optimal cardiovascular risk reduction. The PALM registry will allow for better understanding of current practice patterns, patient experiences, and patient and provider attitudes toward cholesterol management for cardiovascular disease risk reduction. These data can be used to better understand gaps in care and design targeted interventions to improve uptake of lipid-lowering therapies for cardiovascular risk reduction.

Do patients with chronic kidney disease get optimal cardiovascular risk reduction?

Cardiovascular events are the major cause of death in chronic kidney disease (CKD). Individuals with CKD have a substantially greater risk of cardiovascular disease compared with the general population but have largely been excluded from clinical trials. This review highlights the complex pathogenesis of cardiovascular disease, discusses the evidence for cardiovascular risk reduction and assesses the achievement of cardiovascular treatment targets in CKD. There is evidence to support both blood pressure and cholesterol reduction in the CKD population. The risk of bleeding with antiplatelet drugs is high in CKD and these should be used with caution. Although there has been recent interest in targeting nonclassical cardiovascular risk factors in CKD, few trials have demonstrated any significant reduction in cardiovascular risk. Smoking cessation remains important but is poorly studied in CKD with many dialysis patients still smoking. The pathogenesis of cardiovascular disease in CKD differs subtly from that of non-CKD patients. As renal function declines, the role and impact of treating classical risk factors may change and diminish. However, hypertension, hypercholesterolaemia and smoking cessation management should be optimized and may require multiple agents and approaches, particularly as CKD advances. Treatment of hypertension would appear to be one management area in which performance is less than ideal. Future work should focus on new management strategies and drug combinations that tackle the classical risk factors as well as better designed longitudinal and randomized control trials of nonclassical risk factors. Patients with CKD should be included in all cardiovascular intervention studies, given their poor outcomes without interventions.

AB0906 Prevalence and characteristics of coronary disease and cardiovascular risk factors in a cohort of patients with spondyloarthropathies and biologic therapy

BackgroundWe performed a descriptive study of our patients with spondyloarthropathies (SpA) in biologic therapy attending to the presence of coronary disease and cardiovascular risk factors.MethodsPatients with spondyloarthropathies and anti-TNF treatment...

Telemedicine cardiovascular risk reduction in Veterans

Patients with co-occurrence of hypertension, hyperlipidemia, and diabetes have an increased risk of cardiovascular disease (CVD) events. Comprehensive programs addressing both tailored patient self-management and pharmacotherapy are needed to address barriers to optimal cardiovascular risk reduction. We are examining a Clinical pharmacy specialist-, telephone-administered intervention, relying on home monitoring, with a goal of providing tailored medication and behavioral intervention to Veterans with CVD risk. Randomized controlled trial including patients with hypertension (blood pressure >150/100 mm Hg) or elevated low density liporotein (>130 mg/dL). Longitudinal changes in CVD risk profile and improvement in health behaviors over time will be examined. Given the national prevalence of CVD and the dismal rates of risk factor control, intensive but easily disseminated interventions are required to treat this epidemic. This study will be an important step in testing the effectiveness of a behavioral and medication intervention to improve CVD control among Veterans.

Provider and Systems Factors in Diabetes Quality of Care

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

How do we achieve optimal cardiovascular risk reduction?

Optimizing coronary heart disease (CHD) risk reduction requires the application of clinical evidence to patient care, as well as the refinement of risk assessment. Clinical evidence indicates that most patients are not treated to optimal low-density lipoprotein (LDL) cholesterol goals. Despite the efficacy of statin therapy in reducing the incidence of CHD, many treated patients still experience CHD events. Targeting other lipid factors such as high-density lipoprotein cholesterol and triglycerides may augment the risk reduction achieved by lowering LDL cholesterol. Refined global risk assessment can lead to more accurate determinations of absolute risk and to the identification both of high-risk patients needing aggressive intervention and intermediate-risk patients who appear to be at low risk. Previous global risk assessment measures failed to identify a substantial proportion of primary prevention patients who would benefit from therapy. However, revised guidelines issued by the National Cholesterol Education Program introduce new criteria for more precise risk assessment and advocate use of the Framingham scoring system to calculate absolute risk. Although intensified treatment is recommended for high-risk patients, cost considerations may limit drug therapy for some lower-risk individuals.

Statin therapy for targeting cardiovascular risk in rheumatoid arthritis

Rheumatoid arthritis (RA), a prototypical immune-mediated inflammatory disease, is now definitely recognized to increase cardiovascular morbidity and mortality, irrespective of established classical risk factors. The chronic inflammatory state, a hallmark of RA, is increasingly considered to be a driving force for accelerated atherogenesis. Consequently, aggressive control of RA disease activity has been suggested to be instrumental for cardiovascular risk reduction. Currently, statins are the cornerstone of cardiovascular risk-reducing strategies. Apart from their lipid-lowering capacity, statins also exert immune-modulatory effects, which therefore may be of dual benefit in RA patients. Yet guidelines for optimal cardiovascular risk reduction in patients with RA are lacking, largely owing to the absence of randomized, clinical trial data. In this review, we focus on the pathophysiology and observational evidence of cardiovascular risk in RA, as well as the need to adjust currently employed cardiovascula...

The broadening landscape for hypertension management

Several lines of evidence show that office blood pressure (BP) reduction can substantially decrease the risk of major cardiovascular events in hypertensive patients. It is also increasingly recognized that home and 24-hour ambulatory BPs provide additional prognostic information, and there is evidence to suggest that BP lowering over the 24-hour period is crucial for optimal risk reduction. However, BP is often difficult to control, even under the near-optimal conditions of clinical trials. Ideally, antihypertensive therapy should aim to control both office and out-of-office (i.e., 24-hour) BPs, and multiple risk factors in order to provide optimal cardiovascular risk reduction. This approach usually necessitates the use of polypharmacy with an attendant increase in costs and the risk of adverse events. For these reasons, increasing attention is being devoted to drugs that exert beneficial, BP-independent effects on target-organ damage or reduce the incidence of conditions (such as diabetes and metabolic syndrome) that are associated with high cardiovascular risk. Several studies have consistently shown that the incidence of new-onset diabetes is lower with angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists than “older” drugs such as diuretics and beta-blockers. However, long-term studies examining target-organ protection may more fully illustrate the BP-independent benefits of specific antihypertensive agents.

Optimal care of cardiovascular disease and type 2 diabetes patients: Shared responsibilities between the cardiologist and diabetologist

Type 2 diabetes and cardiovascular disease are inextricably linked. Patients with type 2 diabetes are at increased risk of cardiovascular events and mortality. However, controlling blood glucose, which until recently had often been the focus of the diabetologist, is only one component of optimal cardiovascular risk reduction. Vascular protection of the patient with diabetes also includes management of hypertension and dyslipidaemia and lifestyle changes such as smoking cessation. Now both cardiologists and diabetologists need to optimise all components of vascular protection, including glycaemic control, in patients with diabetes. An elevated blood glucose is predictive of poor outcomes in patients with acute coronary syndromes, even if frank diabetes is not present. Early control of hyperglycaemia should be achieved: a strategy that results in improved outcomes. More than two-thirds of patients with coronary artery disease (CAD) have abnormal glucose regulation, which is a predictor of poor outcome. Therefore, the presence of diabetes (and/or glucose intolerance) should be routinely screened for in cardiac patients on admission to hospital. Early identification and treatment of CAD in patients with diabetes is important for optimal prevention of cardiovascular events. However, screening all diabetes patients for CAD is not feasible, and selection of patients for non-invasive cardiac testing remains a challenge for both the diabetologist and cardiologist. Optimal care of diabetic and cardiac patients requires a multidisciplinary team approach, with key roles for the cardiologist and diabetologist.

Rationale for Targeting Multiple Lipid Pathways for Optimal Cardiovascular Risk Reduction

Clinical trials of statin therapy have consistently demonstrated significant reductions in coronary artery disease (CAD) events, yet statin-treated patients remain at risk for CAD despite substantial reductions in low-density lipoprotein (LDL) cholesterol. Recent evidence from clinical trials supports reduction of LDL cholesterol to lower targets, and the updated treatment guidelines include optional, more aggressive LDL cholesterol goals for patients at very high and moderately high risk. Achievement of these lower goals will require enhanced treatment strategies. Targeting multiple lipid pathways can provide greater reductions in LDL cholesterol as well as improvements in other lipid parameters. Clinical trials are needed to determine which treatment strategies provide optimal cardiovascular risk reduction.