Secondary Cardiovascular Prevention Research Articles

Effect of Nuts on Anthropometric and Glycemic Indexes and Blood Pressure in Secondary Cardiovascular Prevention: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Nut-enriched diets have a positive impact on cardiovascular risk factors, such as body mass, blood pressure, and fasting blood glucose. However, studies in individuals undergoing secondary cardiovascular prevention show controversial results. This systematic review with meta-analysis assessed the effect of nut supplementation on anthropometric, glycemic, and blood pressure indices in patients with atherosclerotic cardiovascular disease, as well as the frequency of adverse events. Six databases were used for the search-PubMed, Cochrane Library, EMBASE, BVS (Biblioteca Virtual da Saude), Web of Science, and ClinicalTrials.gov-until February 2023, with no language restrictions. The Cochrane Handbook for Systematic Reviews of Interventions methodology and the PICOS (Population, Intervention, Comparison, Outcome, Setting/design) strategy were used. Seven independent reviewers were involved in data extraction and resolution of disagreements. Certainty of the evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. From 5187 records identified, 6 publications containing data referring to 5 randomized clinical trials (n = 436) were included in the final analyses. The nuts evaluated were almonds, pecans, Brazil nuts, and mixed nuts, with portions that varied between 5 g and 85 g (median: 30 g/day). The intervention period varied between 6 and 12 weeks. The nuts had no effect on fasting glucose and anthropometric indices, although the certainty of the evidence for most of these outcomes was low or very low. They also had no effect on systolic (mean difference [MD]: -1.16 mmHg [95% CI, -5.68 to 3.35], I2 = 0%-moderate certainty of evidence) or diastolic (MD: 0.10 mmHg [95% CI, -2.30 to 2.51], I2 = 0%-high certainty of evidence) blood pressure. It was not possible to aggregate data on adverse events. Nut supplementation had no effect on blood pressure, fasting glucose, or anthropometric profile in the context of atherosclerotic cardiovascular disease. PROSPERO registration no. CRD42020163456.

Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention.

The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.

ANMCO Scientific statement on combination therapies and polypill in secondary prevention

The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an ANMCO scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socioeconomic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.

Polypill Strategy in Secondary Cardiovascular Prevention.

The polypill strategy, originally developed to improve medication adherence, has demonstrated efficacy in improving baseline systolic blood pressures and cholesterol levels in multiple clinical trials. However, the long-term clinical impact of improved major cardiovascular events (MACE) outcomes by the polypill remains uncertain. Recent trials with long-term follow-up, which included minority groups and people with low socioeconomic status, have shown non-inferiority with no difference in adverse effects rates for the secondary prevention of MACE. Although the polypill strategy was initially introduced to improve adherence to guideline-directed medical therapy (GDMT) for cardiovascular complications, the strategy has surpassed standard medical treatment for secondary prevention of MACE outcomes. Studies also showed improved medication compliance in underserved populations.

Primary and Secondary Cardiovascular and Kidney Prevention With Canagliflozin: Insights From the CANVAS Program and CREDENCE Trial.

This study evaluated the effects of canagliflozin in patients with type 2 diabetes with and without prevalent cardiovascular disease (secondary and primary prevention). This was a pooled participant-level analysis of the CANVAS (Canagliflozin Cardiovascular Assessment Study) Program and CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) trial. The CANVAS Program included participants with type 2 diabetes at elevated cardiovascular risk, whereas the CREDENCE trial included participants with type 2 diabetes and albuminuric chronic kidney disease. Hazard ratios (HRs) with interaction terms were obtained from Cox regression models to estimate relative risk reduction with canagliflozin versus placebo across the primary and secondary prevention groups. We analyzed 5616 (38.9%) and 8804 (61.1%) individuals in the primary and secondary prevention subgroups, respectively. Primary versus secondary prevention participants were on average younger (62.2 versus 63.8 years of age) and more often women (42% versus 31%). Canagliflozin reduced the risk of major adverse cardiovascular events (HR, 0.84 [95% CI, 0.76-0.94]) consistently across primary and secondary prevention subgroups (Pinteraction=0.86). Similarly, no treatment effect heterogeneity was observed with canagliflozin for hospitalization for heart failure, cardiovascular death, end-stage kidney disease, or all-cause mortality (all Pinteraction>0.5). Canagliflozin reduced cardiovascular and kidney outcomes with no statistical evidence of heterogeneity for the treatment effect across the primary and secondary prevention subgroups in the CANVAS Program and CREDENCE trial. Although studies on the optimal implementation of canagliflozin within these populations are warranted, these results reinforce canagliflozin's role in cardiorenal prevention and treatment in individuals with type 2 diabetes. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01032629, NCT01989754, NCT02065791.

Adequacy of Fatty Acids Consumption Among Individuals in Secondary Cardiovascular Prevention.

Adhering to a diet adequate in macronutrients is crucial for the secondary prevention of cardiovascular diseases. To assess the prevalence of adherence to recommendations for the consumption of dietary fatty acids for the prevention and treatment of cardiovascular diseases and to estimate whether the presence of certain cardiovascular risk factors would be associated with adherence. Cross-sectional study using baseline data from 2,358 participants included in the "Brazilian Cardioprotective Nutritional Program Trial". Dietary intake and cardiovascular risk factors were assessed. Adequate intake of polyunsaturated fatty acids (PUFA) was considered as ≥10% of total daily energy intake; for monounsaturated fatty acids (MUFA), 20%; and for saturated fatty acids (SFA), <7% according to the Brazilian Society of Cardiology. A significance level of 5% was considered in the statistical analysis. No participant adhered to all recommendations simultaneously, and more than half (1,482 [62.9%]) did not adhere to any recommendation. Adherence exclusively to the SFA recommendation was the most prevalent, fulfilled by 659 (28%) participants, followed by adherence exclusively to the PUFA (178 [7.6%]) and MUFA (5 [0.2%]) recommendations. There was no association between the number of comorbidities and adherence to nutritional recommendations (p = 0.269). Participants from the Brazilian Northeast region showed a higher proportion of adherence to SFA consumption recommendations (38.42%) and lower adherence to PUFA intake (3.52%) (p <0.001) compared to other regions. Among the evaluated sample, there was low adherence to nutritional recommendations for dietary fatty acid consumption.

EE615 A Cost-Effectiveness Analysis of the CNIC-Polypill Strategy, Compared to Usual Care, in Secondary Cardiovascular Prevention from a Spanish Perspective Using Data from the Secure Trial

EE615 A Cost-Effectiveness Analysis of the CNIC-Polypill Strategy, Compared to Usual Care, in Secondary Cardiovascular Prevention from a Spanish Perspective Using Data from the Secure Trial

Abstract 13778: Effects of Omega-3 Fatty Acid Supplementation on Revascularization and Major Cardiovascular Events: A Systematic Review and Meta-Analysis

Background: Benefits of omega-3 administration in preventing cardiovascular (CV) events are controversial. In particular, while statins have been associated with significant reduction of revascularizations (Revasc), effects of omega-3 on Revasc are unclear. Aim: To metanalyze evidence on the effect of omega-3 administration on incident Revasc and CV events (myocardial infarction [MI], stroke, heart failure [HF], CV death). Methods: We searched MEDLINE, Embase, Scopus, Web-of-Science and Cochrane Library for randomized controlled trials (RCTs) with ≥500 participants comparing the effects of omega-3 formulations [decosahexanoic acid+eicosapentaenoic acid (DHA+EPA) or EPA alone] versus placebo. Results: Seventeen RCTs with participants (both primary and secondary CV prevention) randomized to DHA+EPA (n=52,498) or EPA alone (n=13,415) and controls (n=65,771) were included. Follow-up ranged from 4.5 months to 7.4 years. Significant heterogeneity emerged among studies (Figure). Overall, compared to controls omega-3 supplementation was associated with reduced risk of Revasc (Figure) and MI [0.89, 95% CI 0.80-0.98; p heter =0.04; I 2 =45%; p=0.02] with no significant effect on stroke, HF, and CV death. Reduced risk of Revasc was still observed when most (≥60%) participants were already on statins (Figure). Compared to DHA+EPA, EPA alone was associated with a greater reduced risk of Revasc (Figure) and stroke [0.72, 95% CI 0.55-0.95], with no significant effect on HF and CV death. No significant differences were observed for DHA+EPA dose ≤0.9g/day vs &gt;0.9g/day, or EPA alone ≤0.7 g/day vs &gt;0.7 g/day. Conclusions: Omega-3 supplementation resulted in reduced risk of Revascularization, unaffected by background statin use. Use of EPA alone appeared to be associated with even greater benefits. Further studies are needed to clarify the role of omega-3 supplementation in preventing hard CV events

The Brazilian Cardioprotective Nutritional (BALANCE) Program improves diet quality in patients with established cardiovascular disease: Results from a multicenter randomized controlled trial

Dietary modifications are essential strategies for cardiovascular disease prevention. However, studies are needed to investigate the diet quality of individuals undergoing secondary prevention in cardiology and who received dietary intervention based on cardiovascular disease management. We prospectively evaluated the diet quality in the Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial). We hypothesized that the BALANCE Program could improve patients’ dietary pattern according to different indices of diet quality such as the Dietary Inflammatory Index (DII); the dietary total antioxidant capacity; overall, healthful, and unhealthful Plant-Based Diet Index (PDI, hPDI, and uPDI, respectively); and modified Alternative Healthy Eating Index (mAHEI). This multicenter randomized, controlled trial included patients aged ≥45 years randomly assigned to either the experimental or control group. Data from 2185 participants at baseline and after 12, 24, 36, and 48 months showed that the intervention group (n = 1077) had lower mean values of DII and higher dietary total antioxidant capacity, PDI, hPDI, and mAHEI than the control group. The results also showed differences between the follow-up times for DII, hPDI, and uPDI (48 months vs baseline) and for PDI and mAHEI (24 months vs baseline), regardless of group. The interaction analysis demonstrated that the intervention group showed better results than the control group at 12, 24, 36, and 48 months for the DII and at months 12, 36, and 48 for the mAHEI. Our results provide prospective evidence that the BALANCE Program improved the diet quality in those in secondary cardiovascular prevention according to different indices, with the intervention group showing better results than the control group.

FRI085 Lipid Lowering Therapy Deficits In Secondary Cardiovascular Prevention In A Large Cohort From Eight Busy Clinics In Greece Over 12 Years

Abstract Disclosure: R.D. Paparodis: None. I. Androulakis: None. D.P. Askitis: None. I. Perogamvros: None. N. Angelopoulos: None. A. Rizoulis: None. S. Livadas: None. A. Boniakos: None. Background: The increasing availability of aggressive lipid lowering therapies (LLTs) worldwide is expected to produce a significant decline in cholesterol concentrations worldwide and a more successful attainment of LDL lowering goals (LLGs), especially in those who need them most: patients with established atherosclerotic cardiovascular disease (ASCVD). Aims: To assess the long-term changes in the rate of attainment of LGs according to the European Society of Cardiology Guidelines nationwide, with the use of different LLTs during 12 consecutive years. Methods: We reviewed the charts of all patients initially seen between 2010-2022 who returned for care follow up at our 8 busy Endocrinology clinics, located in 6 cities in Greece, between Sep-1-2022 and Nov-30-2022. We enrolled those with recorded diagnosis of ASCVD [coronary artery disease (CAD), peripheral arterial disease (PAD) or carotid stenosis &amp;gt;50% (CS)] prior to our initial visit. For the present work, we reviewed data on tobacco use, intake of LLTs, and LDL-cholesterol concentrations as recorded during our initial clinic visit. We excluded all patients referred to our clinics for lipids management. Data are presented as means ± standard deviation. Means are compared with Kruskal Wallis test and p&amp;lt;0.05 is deemed significant. Results: We enrolled n=890 consecutive patients, age 63.9 ± 11.4 years, n=339 were women (38.1%), n=529 (59.4%) had diabetes, n=672 (75.5%) had hypertensions and all had ≥1 forms of established ASCVD: n=630 with CAD, n=279 with CS and n=151 with PAD. Out of these, n=144 (16.2%) were on no LLTs, n=334 (37.5%) continued to smoke, n=381 (42.8%) were on guidelines-based appropriate LLT strategy, n=248 (27.9%) reached LLGs and n=318 (35.7%) fulfilled the year-specific guidelines requirements. Of note is, that this rate dropped to 2.4-20.4% in the years 2019-2022. The likelihood of achieving LDL goals was not statistically significantly different among patients with different forms of ASCVD (p=0.42). Overall, the mean LDL was 88.2 ± 32.1mg/dl, and was not different between patients with different forms of ASCVD (p=0.75). Mean LDL concentrations have only started to drop between 2020-2022 as compared to 2019 (p&amp;lt;0.001), but are not different compared to those seen in the years 2010-2018. The mean LDL dropped to 82.3 ± 30.5mg/dl in 2022 as compared to 102.2 ± 38.8mg/dl in 2019. Conclusions: Our study reveals a large care gap in patients with established ASCVD, which did not seem to improve significantly over the past 12 years, despite the excellent availability of aggressive LLT strategies in Greece. Intervention studies are urgently needed to enhance adherence to updated international guidelines and reduce the extremely high ASCVD risk in this fragile population. Presentation: Friday, June 16, 2023

Adherence to CPAP Treatment and the Risk of Recurrent Cardiovascular Events

The effect of continuous positive airway pressure (CPAP) on secondary cardiovascular disease prevention is highly debated. To assess the effect of CPAP treatment for obstructive sleep apnea (OSA) on the risk of adverse cardiovascular events in randomized clinical trials. PubMed (MEDLINE), EMBASE, Current Controlled Trials: metaRegister of Controlled Trials, ISRCTN Registry, European Union clinical trials database, CENTRAL (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov databases were systematically searched through June 22, 2023. For qualitative and individual participant data (IPD) meta-analysis, randomized clinical trials addressing the therapeutic effect of CPAP on cardiovascular outcomes and mortality in adults with cardiovascular disease and OSA were included. Two reviewers independently screened records, evaluated potentially eligible primary studies in full text, extracted data, and cross-checked errors. IPD were requested from authors of the selected studies (SAVE [NCT00738179], ISAACC [NCT01335087], and RICCADSA [NCT00519597]). One-stage and 2-stage IPD meta-analyses were completed to estimate the effect of CPAP treatment on risk of recurrent major adverse cardiac and cerebrovascular events (MACCEs) using mixed-effect Cox regression models. Additionally, an on-treatment analysis with marginal structural Cox models using inverse probability of treatment weighting was fitted to assess the effect of good adherence to CPAP (≥4 hours per day). A total of 4186 individual participants were evaluated (82.1% men; mean [SD] body mass index, 28.9 [4.5]; mean [SD] age, 61.2 [8.7] years; mean [SD] apnea-hypopnea index, 31.2 [17] events per hour; 71% with hypertension; 50.1% receiving CPAP [mean {SD} adherence, 3.1 {2.4} hours per day]; 49.9% not receiving CPAP [usual care], mean [SD] follow-up, 3.25 [1.8] years). The main outcome was defined as the first MACCE, which was similar for the CPAP and no CPAP groups (hazard ratio, 1.01 [95% CI, 0.87-1.17]). However, an on-treatment analysis by marginal structural model revealed a reduced risk of MACCEs associated with good adherence to CPAP (hazard ratio, 0.69 [95% CI, 0.52-0.92]). Adherence to CPAP was associated with a reduced MACCE recurrence risk, suggesting that treatment adherence is a key factor in secondary cardiovascular prevention in patients with OSA.

Quality of care for secondary cardiovascular disease prevention in 2009–2017: population-wide cohort study of antiplatelet therapy use in Scotland

BackgroundAntiplatelet therapy (APT) can substantially reduce the risk of further vascular events in individuals with established atherosclerotic cardiovascular disease (ASCVD). However, knowledge regarding the extent and determinants of APT use...

Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population.

Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy. To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients. We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses. Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor. A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Statins and risk of type 2 diabetes: mechanism and clinical implications.

Statins are widely used to prevent cardiovascular disease events. Cardiovascular diseases and type 2 diabetes are tightly connected since type 2 diabetes is a major risk factor for cardiovascular diseases. Additionally, cardiovascular diseases often precede the development of type 2 diabetes. These two diseases have common genetic and environmental antecedents. Statins are effective in the lowering of cardiovascular disease events. However, they have also important side effects, including an increased risk of type 2 diabetes. The first study reporting an association of statin treatment with the risk of type 2 diabetes was the WOSCOPS trial (West of Scotland Coronary Prevention Study) in 2001. Other primary and secondary cardiovascular disease prevention studies as well as population-based studies have confirmed original findings. The purpose of our review is to examine and summarize the most important findings of these studies as well as to describe the mechanisms how statins increase the risk of type 2 diabetes.

Global eligibility and cost effectiveness of icosapent ethyl in primary and secondary cardiovascular prevention.

Icosapent ethyl (IPE) is a purified eicosapentaenoic acid-only omega-3 fatty acid that significantly reduced cardiovascular (CV) events in patients receiving statins with established cardiovascular disease (CVD) and those with diabetes and additional risk factors in the pivotal REDUCE-IT trial. Since the publication of REDUCE-IT, there has been global interest in determining IPE eligibility in different patient populations, the proportion of patients who may benefit from IPE, and cost effectiveness of IPE in primary and secondary prevention settings. The aim of this review is to summarize information from eligibility and cost effectiveness studies of IPE to date. A total of sixteen studies were reviewed, involving 2,068,111 patients in the primary or secondary prevention settings worldwide. Up to forty-five percent of patients were eligible for IPE, depending on the selection criteria used (ie, REDUCE-IT criteria, US Food and Drug Administration label, Health Canada label, practice guidelines) and the population studied. Overall, eight cost-effectiveness studies across the United States, Canada, Germany, Israel, and Australia were included in this review and findings indicated that IPE is particularly cost effective in patients with established CVD.

Machine Learning Applied to Cholesterol-Lowering Pharmacotherapy: Proof-of-Concept in High-Risk Patients Treated in Primary Care.

Objectives: Machine learning has potential to improve the management of lipid disorders. We explored the utility of machine learning in high-risk patients in primary care receiving cholesterol-lowering medications. Methods: Machine learning algorithms were created based on lipid management guidelines for England [National Institute for Health and Care Excellence (NICE) CG181] to reproduce the guidance with >95% accuracy. Natural language processing and therapy identification algorithms were applied to anonymized electronic records from six South London primary care general practices to extract medication information from free text fields. Results: Among a total of 48,226 adult patients, a subset of 5630 (mean ± standard deviation, age = 67 ± 13 years; male:female = 55:45) with a history of lipid-lowering therapy were identified. Additional major cardiometabolic comorbidities included type 2 diabetes in 13% (n = 724) and hypertension in 32% (n = 1791); all three risk factors were present in a further 28% (n = 1552). Of the 5630 patients, 4290 (76%) and 1349 (24%) were in primary and secondary cardiovascular disease prevention cohorts, respectively. Statin monotherapy was the most common current medication (82%, n = 4632). For patients receiving statin monotherapy, 71% (n = 3269) were on high-intensity therapy aligned with NICE guidance with rates being similar for the primary and secondary prevention cohorts. In the combined cohort, only 46% of patients who had been prescribed lipid-lowering therapy in the previous 12 months achieved the NICE treatment goal of >40% reduction in non-high-density lipoprotein cholesterol from baseline pretreatment levels. Based on the most recent data entry for patients not at goal the neural network recommended either increasing the dose of statin, adding complementary cholesterol-lowering medication, or obtaining an expert lipid opinion. Conclusions: Machine learning can be of value in (a) quantifying suboptimal lipid-lowering prescribing patterns, (b) identifying high-risk patients who could benefit from more intensive therapy, and (c) suggesting evidence-based therapeutic options.

The use of the CNIC-Polypill in real-life clinical practice: opportunities and challenges in patients at very high risk of atherosclerotic cardiovascular disease – expert panel meeting report

Although the cardiovascular (CV) polypill concept is not new and several guidelines state that a CV polypill should be considered an integral part of a comprehensive CV disease (CVD) prevention strategy, there are still some barriers to its implementation in the real-world setting, mainly in secondary CV prevention. As the CNIC-polypill is the only one approved for secondary CV prevention in patients with atherosclerotic CVD in 27 countries worldwide, a panel of four discussants and 30 participants from 18 countries conveyed in a virtual meeting on April 21, 2022, to discuss key clinical questions regarding the practical use of the CNIC-Polypill and barriers to its implementation.Data presented showed that, although the use of the CV polypill is not explicitly mentioned in the current 2021 European Society of Cardiology guidelines on CVD prevention, it may be used in any patient for secondary CVD prevention tolerating all their components to improve outcomes through different aspects. The favourable results of the Secondary Prevention of Cardiovascular Disease in the Elderly (SECURE) trial now reinforce this recommendation. The panellists presented algorithms on how to switch from any baseline regimen when starting treatment with the CNIC-polypill in different situations, including patients with hypertension, dyslipidaemia, and a previous CV event; at discharge after a cardiovascular event; in chronic ischemic conditions; and in cases of polypharmacy. The panellists and expert discussants did agree that available studies conducted so far with the CNIC-polypill demonstrate that it is as efficacious as the monocomponents, equipotent drugs, or other therapies; reduces the risk of experiencing recurrent major CV events; improves medication adherence; reduces health care costs and resources compared to patients treated with loose drugs; and the patients prefer it over the multipill strategy.In conclusion, the data presented by the participants provided the evidence behind the use of the CNIC-polypill to help fulfil the goal of encouraging its adoption by physicians.

Established and Emerging Lipid-Lowering Drugs for Primary and Secondary Cardiovascular Prevention.

Despite treatment with statins, patients with elevated low-density lipoprotein cholesterol (LDL-C) and triglycerides remain at increased risk for adverse cardiovascular events. Consequently, novel pharmaceutical drugs have been developed to control and modify the composition of blood lipids to ultimately prevent fatal cardiovascular events in patients with dyslipidaemia. This article reviews established and emerging lipid-lowering drugs regarding their mechanism of action, development stage, ongoing clinical trials, side effects, effect on blood lipids and reduction in cardiovascular morbidity and mortality. We conducted a keyword search to identify studies on established and emerging lipid modifying drugs. Results were summarized in a narrative overview. Established pharmaceutical treatment options include the Niemann-Pick-C1 like-1 protein (NPC1L1) inhibitor ezetimibe, the protein convertase subtilisin-kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab, fibrates as peroxisome proliferator receptor alpha (PPAR-α) activators, and the omega-3 fatty acid icosapent ethyl. Statins are recommended as the first-line therapy for primary and secondary cardiovascular prevention in patients with hypercholesterinaemia and hypertriglyceridemia. For secondary prevention in hypercholesterinaemia, second-line options such as statin add-on or statin-intolerant treatments are ezetimibe, alirocumab and evolocumab. For secondary prevention in hypertriglyceridemia, second-line options such as statin add-on or statin-intolerant treatments are icosapent ethyl and fenofibrate. Robust data for these add-on therapeutics in primary cardiovascular prevention remains scarce. Recent biotechnological advances have led to the development of innovative small molecules (bempedoic acid, lomitapide, pemafibrate, docosapentaenoic and eicosapentaenoic acid), antibodies (evinacumab), antisense oligonucleotides (mipomersen, volanesorsen, pelcarsen, olezarsen), small interfering RNA (inclisiran, olpasiran), and gene therapies for patients with dyslipidemia. These molecules specifically target new cellular pathways, such as the adenosine triphosphate-citrate lyase (bempedoic acid), PCSK9 (inclisiran), angiopoietin-like 3 (ANGPTL3: evinacumab), microsomal triglyceride transfer protein (MTP: lomitapide), apolipoprotein B-100 (ApoB-100: mipomersen), apolipoprotein C-III (ApoC-III: volanesorsen, olezarsen), and lipoprotein (a) (Lp(a): pelcarsen, olpasiran). The authors are hopeful that the development of new treatment modalities alongside new therapeutic targets will further reduce patients' risk of adverse cardiovascular events. Apart from statins, data on new drugs' use in primary cardiovascular prevention remain scarce. For their swift adoption into clinical routine, these treatments must demonstrate safety and efficacy as well as cost-effectiveness in randomized cardiovascular outcome trials.

Adherence to the Mediterranean Diet in Preventing Major Cardiovascular Events in Patients with Ischemic Heart Disease: The EVA Study.

Adherence to healthy dietary patterns, such as the Mediterranean diet (Med-diet), is recommended for the maintenance of cardiovascular health. The determinants for adherence to Med-diet and its importance in secondary cardiovascular disease prevention are still unclear. The aim of the study was to evaluate the influence of sex- and psycho-socio-cultural (i.e., gender-related) factors on Med-diet adherence and its role in preventing major cardiovascular events (MACEs) in patients with ischemic heart disease (IHD). Med-diet adherence was evaluated among 503 consecutive adults with IHD. MACEs were collected during a long-term follow-up. Male Bem Sex-Role Inventory score (i.e., male personality traits) and physical functional capacity were associated with higher adherence, while cohabitation with a smoker and physical inactivity with poorer adherence. During a median follow-up of 22 months, 48 participants experienced MACEs (17.5%, 8.1%, and 3.9% of patients with low, medium, and high adherence, respectively; p = 0.016). At multivariate Cox--regression analysis, a greater adherence remained inversely associated with MACEs (HR: 0.49; 95% CI: 0.29-0.82; p = 0.006) after adjusting for confounding factors. The study suggests that gender-related factors have a role in maintaining a healthy dietary pattern. Improving Med-diet adherence may lower the risk of recurring cardiovascular events.

Lipid Goals Achievement in Secondary Cardiovascular Prevention: Predictors of Success in a Large Multicentre Cohort Study in Greece

Lipid Goals Achievement in Secondary Cardiovascular Prevention: Predictors of Success in a Large Multicentre Cohort Study in Greece