Use Of Lipid-lowering Therapy Research Articles

Dyslipidaemia in patients with chronic kidney disease - a neglected cardiovascular risk factor.

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD). In addition, CKD itself is a coronary artery disease equivalent due to its atherogenic potential. Despite the role of CKD in ASCVD and recommendations to control lipid levels aggressively, landmark lipid studies have often excluded patients with advanced CKD. Furthermore, there is a scarcity of data on the use and efficacy of lipid-lowering therapy (LLT) in those with CKD in South Africa (SA). To determine the prevalence and control of dyslipidaemia in a cohort of SA patients with CKD. A retrospective, cross-sectional observational study of 250 patients with CKD attending the Charlotte Maxeke Johannesburg Academic Hospital renal clinic from 1 July 2019 to 31 July 2020 was carried out. Lipograms, the use of LLT and achievement of target lipid levels were examined. The median (interquartile range) age of this cohort was 58 (46 - 69) years; 50.4% were males and 64.4% black African. Dyslipidaemia was prevalent in 83.6% (n=209) of patients. A total of 169 (67.6%) patients were on LLT, and of these only 28 (16.6%) achieved the recommended low-density lipoprotein cholesterol (LDL-C) target. Of those not on LLT, 51 (63%) were eligible for LLT and almost all were classified as either very high risk (64.2%) or high risk (28.4%) for ASCVD. Of those on LLT, all were on statin therapy, of which simvastatin at a mean dose of 20 mg daily was the most commonly prescribed LLT. This cohort comprised a large proportion of patients classified as high or very high risk for ASCVD. Despite this, the use of LLT was inadequate, and <20% of patients were at target LDL-C levels. These data suggest a greater need for awareness of initiating LLT to achieve recommended target LDL-C levels in patients with CKD.

Changing perceptions about the role of combination therapy with statin and fibrate in patients with hypertriglyceridemia

The article discusses the modern therapeutic approach to lowering blood triglyceride levels. The need to consider indications for the use of lipid-lowering therapy in patients with hypertriglyceridemia is caused by the emergence of new evidence-based information. The article describes how elevated blood TG levels are associated with the risk of developing cardiovascular (CV) complications, as well as pancreatitis. The mechanisms of TG metabolism that may regulate the relationship between elevated blood TG levels and the risk of developing CV complications are considered. The findings of large randomized clinical trials, including recent ones, which laid the foundation for the current clinical guidelines for the use of drugs to lower triglycerides levels, are discussed. Indications for fibrate therapy in patients with elevated blood TG levels in various clinical situations are considered. The article emphasizes that the icosapent ethyl ester drug is not currently available in the Russian Federation. According to the latest versions of international guidelines, it is considered a first-line drug to reduce the risk of developing CV complications in patients with an established diagnosis of CVD (i.e. for the purpose of secondary prevention). In this context, the significance of fenofibrate as a drug to lower blood triglyceride levels, specifically in secondary prevention of CV complications, can remain quite high in our country. The appearance of a rosuvastatin and fenofibrate combination drug on the pharmaceutical market of the Russian Federation will increase adherence to the therapy, if a fibrate is required to be added to statin therapy.

Patients who suffer a first atherosclerotic cardiovascular event while taking statins are often far off of lipid targets

Background and aimsDespite considerable evidence that lipid-lowering therapies (LLTs) afford clinical benefit, the control of low-density lipoprotein cholesterol (LDL-C) is suboptimal, and available LLTs are underused, especially in patients at high and very high cardiovascular (CV) risk. This study assesses the real-world LDL-C target attainment rate in patients on LLT before experiencing a first major acute cardiovascular event (MACE). Methods and resultsThe HEARTBEAT was a retrospective, multicentre observational study. From March to June 2021 a total of 334 patients on LLT who had a first MACE while being on statins were included in the study. Of these patients, 83.2 % had a high (40.7 %) or very high CV risk (29.0 %) prior to MACE. Overall, 87.5 % and 89.7 % of the patients at high and very high CV risk, respectively, failed to reach the LDL-C target. Regarding LLTs, only 11.8 % and 19.6 % of the patients at high and very high risk had received high-intensity LLTs prior to MACE. It was estimated that if these patients had reached their recommended LDL-C targets, the risk of MACE may have been reduced by a median of 24.5 % and 23.2 % in patients at high and very high risk respectively. ConclusionsPatients who suffer a first MACE while on statin therapy often were at high/very high CV risk. Despite their risk, LDL-levels and being on statins they are undertreated, and too far from lipid targets. A proper use of high-intensity LLTs led to an increase attainment of LDL targets and lower CV events.

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

Effect of lipid-lowering therapy on platelet reactivity in patients treated with and without antiplatelet therapy.

Circulating lipoproteins may interact with platelets, increasing platelet sensitivity to aggregating agonists and their tendency towards activation and thrombus formation. In particular, patients with hypercholesterolemia exhibit a higher degree of platelet reactivity compared to normolipidemic. Moreover, accruing evidence report that lipid-lowering therapies can reduce thrombus formation, particularly in the absence of concomitant antiplatelet therapy. However, the underlying biological mechanism(s) explaining these clinical observations are not completely understood. Baseline platelet reactivity and high on-treatment platelet reactivity while on antiplatelet therapy (e.g., aspirin and clopidogrel) are associated with poor clinical outcomes. Therefore, strategies to reduce baseline platelet reactivity or improve the pharmacodynamic profile of antiplatelet therapies are an unmet clinical need. The potential use of lipid-lowering therapies for optimizing platelet reactivity provides several advantages as there is strong evidence that reducing circulating lipoproteins can improve clinical outcomes, and they may avoid the need for potent antiplatelet therapies that, although more effective, are associated with increased bleeding risk. This review will provide a systematic overview of the effects of lipid-lowering therapy on platelet reactivity in patients treated with and without antiplatelet therapy. We will focus on the potential biological mechanism(s) of action and the effect of statins, ezetimibe, proprotein convertase subtilisin/kexin 9 inhibitors, omega-3 fatty acids, and recombinant high-density lipoprotein on platelet reactivity. Ultimately, we will assess the current gaps in the literature and future perspective in the field.

Hypercholesterolaemia control in Spain: The same situation with different regional realities

Introduction and objectivesThe cardiovascular prevention strategy by autonomous communities can be variable since the competences in health are transferred. The objective of the study was to determine the degree of dyslipidaemia control and the lipid-lowering pharmacological therapy used in patients at high/very high cardiovascular risk (CVR) by autonomous communities. MethodsObservational, cross-sectional, descriptive study based on a consensus methodology. Information on the clinical practice of 145 health areas belonging to 17 Spanish autonomous communities was collected through face-to-face meetings and questionnaires administered to the 435 participating physicians. Furthermore, aggregate non-identifiable data were compiled from 10 consecutive dyslipidaemic patients that each participant had recently visited. ResultsOf the 4,010 patients collected, 649 (16%) had high and 2,458 (61%) very high CVR. The distribution of the 3,107 high/very high CVR patients was balanced across regions, but there were inter-regional differences (P < 0.0001) in the achievement of target LDL-C<70 and <55 mg/dL, respectively. High-intensity statins in monotherapy or in combination with ezetimibe and/or PCSK9 inhibitors were used in 44, 21 and 4% of high CVR patients, while in those at very high CVR it rose to 38, 45 and 6%, respectively. The use of these lipid-lowering therapies at national level was significantly different between regions (P = 0.0079). ConclusionsEven though the distribution of patients at high/very high CVR was similar between autonomous communities, inter-territorial differences were identified in the degree of achievement of LDL cholesterol therapeutic goal and use of lipid-lowering therapy.

Gaps in Guideline-Based Lipid-Lowering Therapy for Secondary Prevention in the United States: A Retrospective Cohort Study of 322 153 Patients.

Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period. LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use. We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year. Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD.

Hypercholesterolemia and cardiovascular risk

Pharmacological reduction of LDL-cholesterol (LDL-C) is a major treatment strategy in limiting atherosclerotic cardiovascular (ASCVD) risk. Statins remain the primary therapeutic cornerstone in ASCVD prevention. Furthermore, ezetimibe, bempedoic acid, and PCSK9 inhibition have recently also shown to reduce cardiovascular risk. Unfortunately, a treatment gap remains between guideline-recommended LDL-C goals and what is achieved in real-world practice. An important reason for this is the limited use of novel and effective non-statin lipid-lowering therapies. In order to achieve LDL-C treatment goals and, ultimately, reduction of cardiovascular events, a combination lipid-lowering therapy needs to be considered as the standard of care for patients at very high cardiovascular risk.

Risk Factors for Vulnerable Plaque Detected Using Near-Infrared Spectroscopy in Patients Receiving Statin Therapy with No History of Coronary Artery Disease.

Residual risk of atherosclerosis remains high despite the use of lipid-lowering therapy with statins. Near-infrared spectroscopy intravascular ultrasound imaging (NIRS-IVUS) can identify vulnerable plaque via the detection of lipid-rich plaque. This study aimed to reveal the clinical characteristics of patients with vulnerable plaque despite statin therapy.NIRS-IVUS was used to determine the maximum 4 mm Lipid Core Burden Index (MaxLCBI4 mm) values of 38 de novo culprit lesions from 32 patients with acute coronary syndrome (53%) (mean age: 73.1 ± 13.1 years) who underwent percutaneous coronary intervention after a minimum 6 months of statin therapy for primary prevention. A patient with vulnerable plaque was defined as an individual presenting at least 1 target lesion with a vulnerable plaque (MaxLCBI4 mm > 400). Overall, the average low-density lipoprotein cholesterol (LDL-C) level was 95.5 ± 27.2 mg/dL. Patients in the vulnerable plaque group were younger and had higher LDL-C, triglycerides, and non-high-density lipoprotein cholesterol (HDL-C) levels than those in the non-vulnerable plaque group. The MaxLCBI4 mm was positively correlated with LDL-C (P = 0.0002), triglycerides (P = 0.0003), and non-HDL-C (P = 0.0001). In multivariate analysis, all 3 treatable lipid components failed to show an independent relationship with the patients with vulnerable plaque. Using receiver-operating characteristics curve analysis, the cutoff points for LDL-C, triglycerides, and non-HDL-C were determined to be 78 mg/dL, 108 mg/dL, and 111 mg/dL, respectively, at MaxLCBI4 mm > 400. In conclusion, this study supports a more comprehensive and aggressive lipid-lowering therapy for the primary prevention of coronary artery disease.

Guideline-Directed Low-Density Lipoprotein Cholesterol Management After Acute Ischemic Stroke: Findings from a National Health Care Service

Patients with ischemic stroke are at high risk for future cardiovascular events and should be treated intensively with lipid-modifying agents. Combination lipid-lowering therapies are often needed to achieve updated guideline-directed treatment goals. However, real-world data on intensification of lipid-lowering therapies and attainment of low-density lipoprotein cholesterol (LDL-C) targets early after ischemic stroke are limited. We extracted data from the largest healthcare provider in Israel on patients hospitalized with acute ischemic stroke between January 2020 and February 2022. Included were 3,027 patients surviving ≥1 year after stroke, with documented LDL-C levels and lipid-lowering medications at 2 time periods (0 to 3months and 6 to 12months after discharge). Participants were classified according to preexisting stroke and/or coronary artery disease. The use of combination lipid-lowering therapy (ezetimibe and/or proprotein convertase subtilisin/kexin type 9 [monoclonal antibodies] inhibitor plus statin) in the study population increased between the 2 timepoints from 3.6% to 5.1%, reaching 10.5% in those with previous coronary artery disease and stroke. LDL-C levels <70 and <55mg/100ml were attained by 42.3% and 22.9% of patients early after hospitalization, and in 49.5% and 27.1% during 6 to 12months after hospitalization, respectively. Attainment of guideline-recommended LDL-C goals was higher in patients treated with combination lipid-lowering therapies and in those with preexisting cardiovascular disease. In conclusion, despite the advances in drug development and the availability of several mechanisms to lower cholesterol levels, the attainment of guideline-recommended LDL-C targets after acute ischemic stroke is suboptimal. Intensification of treatment with combination lipid-lowering therapies after hospitalization is uncommonly performed in clinical practice, even in those with preexisting cardiovascular disease.

Evaluation of Social Isolation Trajectories and Incident Cardiovascular Disease Among Middle-Aged and Older Adults in China: National Cohort Study.

Although the association between social isolation and the risk of subsequent cardiovascular disease (CVD) is well documented, most studies have only assessed social isolation at a single time point, and few studies have considered the association using repeatedly measured social isolation. This study aimed to examine the association between social isolation trajectories and incident CVD in a large cohort of middle-aged and older adults. This study used data from 4 waves (wave 1, wave 2, wave 3, and wave 4) of the China Health and Retirement Longitudinal Study. We defined the exposure period as from June 2011 to September 2015 (from wave 1 to wave 3) and the follow-up period as from September 2015 to March 2019 (wave 4). On the basis of the inclusion and exclusion criteria, our final analytic sample included 8422 individuals who had no CVD in the China Health and Retirement Longitudinal Study in waves 1 to 3 and were fully followed up in wave 4. Social isolation was ascertained using an extensively used questionnaire at 3 consecutive, biennial time points from waves 1 to 3, and individuals were assigned to 3 predefined social isolation trajectories based on their scores at each wave (consistently low, fluctuating, and consistently high). Incident CVD included self-reported physician-diagnosed heart disease and stroke combined. Cox proportional hazard models estimated the associations of social isolation trajectories with risks of incident CVD, adjusting for demographics, health behaviors, and health conditions. Of the 8422 participants (mean age 59.76, SD 10.33 years at baseline), 4219 (50.09%) were male. Most of the participants (5267/8422, 62.54%) had consistently low social isolation over time and 16.62% (1400/8422) of the participants had consistently high social isolation over the exposure period. During the 4-year follow-up, 746 incident CVDs occurred (heart disease: 450 cases and stroke: 336 cases). Compared with individuals with consistently low social isolation, those with fluctuating social isolation (adjusted hazard ratio 1.27, 95% CI 1.01-1.59) and consistently high social isolation (adjusted hazard ratio 1.45, 95% CI 1.13-1.85) had higher risks for incident CVD after adjusting for demographics (ie, age, sex, residence, and educational level), health behaviors (ie, smoking status and drinking status), and health conditions (ie, BMI; history of diabetes, hypertension, dyslipidemia, chronic kidney disease; use of diabetes medications, hypertension medications, and lipid-lowering therapy; and depressive symptoms scores). In this cohort study, middle-aged and older adults with fluctuating and consistently high social isolation exposure had higher risks of the onset of CVD than those without the exposure. The findings suggest that routine social isolation screenings and efforts to improve social connectedness merit increased attention for preventing CVD among middle-aged and older adults.

Association of COVID-19 outcomes with diabetes in the Veneto region (north-east italy): Epidemiological insights for the endemic phase?

Background and aimsDiabetes mellitus is a prevalent chronic disease in patients who die of COVID-19. The aim of this study was to investigate the clinical and metabolic characteristics of diabetic patients with COVID-19 during the pre-vaccination phase. Methods and resultsA retrospective cohort study was conducted from February 2020 to February 2021 to examine the clinical and metabolic profiles of unvaccinated diabetic patients affected by COVID-19. Data were collected from claim databases, hospital discharge records, and clinical records within a healthcare district located in northeastern Italy with a population of 936,000. Potential prognostic indicators including sex, age, Body Mass Index (BMI), duration and type of diabetes, metabolic control, and the use of antidiabetic, antihypertensive, lipid-lowering, and antiplatelet therapies were investigated. For hospitalized patients, additional variables were recorded, such as length of hospital stay, blood pressure at admission, comorbidities, D-dimer levels, blood glucose (BG), in-hospital insulin and corticosteroid therapies, requirement for mechanical ventilation (i.e., orotracheal or tracheostomy), admission to the Intensive Care Unit (ICU), and mortality. Diabetic patients hospitalized for COVID-19 with a poorer prognosis were characterized by advanced age, longer diabetes duration, hypertension, higher usage of sulfonylureas, and lower usage of dietotherapy alone, metformin, Glucagon-Like Peptide-1 Receptor agonists (GLP1-Ra), and Renin-Angiotensin-Aldosterone System inhibitors (RAAS-i). ConclusionConsidering the potential for COVID-19 to become endemic, special care should be taken in managing older diabetic patients’ treatments.

Treatment gaps in the implementation of LDL cholesterol control among high- and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study

European data pre-2019 suggest statin monotherapy is the most common approach to lipid management for preventing cardiovascular (CV) events, resulting in only one-fifth of high- and very high-risk patients achieving the 2019 ESC/EAS recommended low-density lipoprotein cholesterol (LDL-C) goals. Whether the treatment landscape has evolved, or gaps persist remains of interest. Baseline data are presented from SANTORINI, an observational, prospective study that documents the use of lipid-lowering therapies (LLTs) in patients ≥18 years at high or very high CV risk between 2020 and 2021 across primary and secondary care settings in 14 European countries. Of 9602 enrolled patients, 9044 with complete data were included (mean age: 65.3±10.9 years; 72.6% male). Physicians reported using 2019 ESC/EAS guidelines as a basis for CV risk classification in 52.0% (4706/9044) of patients (overall: high risk 29.2%; very high risk 70.8%). However, centrally re-assessed CV risk based on 2019 ESC/EAS guidelines suggested 6.5% (308/4706) and 91.0% (4284/4706) were high- and very high-risk patients, respectively. Overall, 21.8% of patients had no documented LLTs, 54.2% were receiving monotherapy and 24.0% combination LLT. Median (interquartile range [IQR]) LDL-C was 2.1 (1.6, 3.0) mmol/L (82 [60, 117] mg/dL), with 20.1% of patients achieving risk-based LDL-C goals as per the 2019 ESC/EAS guidelines. At the time of study enrolment, 80% of high- and very high-risk patients failed to achieve 2019 ESC/EAS guidelines LDL-C goals. Contributory factors may include CV risk underestimation and underutilization of combination therapies. Further efforts are needed to achieve current guideline-recommended LDL-C goals. ClinicalTrials.gov Identifier: NCT04271280. This study is funded by Daiichi Sankyo Europe GmbH, Munich, Germany.

Evolving Management of Low-Density Lipoprotein Cholesterol: A Personalized Approach to Preventing Atherosclerotic Cardiovascular Disease Across the Risk Continuum.

Management of elevated low-density lipoprotein cholesterol (LDL-C) is central to preventing atherosclerotic cardiovascular disease (ASCVD) and key to reducing the risk of ASCVD events. Current guidelines on the management of blood cholesterol recommend statins as first-line therapy for LDL-C reduction according to an individual's ASCVD risk and baseline LDL-C levels. The addition of nonstatin lipid-lowering therapy to statins to achieve intensive LDL-C lowering is recommended for patients at very high risk of ASCVD events, including patients with familial hypercholesterolemia who have not achieved adequate LDL-C lowering with statins alone. Despite guideline recommendations and clinical trial evidence to support the use of lipid-lowering therapies for ASCVD risk reduction, most patients at high or very high risk do not meet LDL-C thresholds. This review explores the challenges associated with LDL-C lowering in contemporary clinical practice and proposes a framework for rethinking the binary definition of ASCVD, shifting from "primary" versus "secondary" prevention to a "continuum of risk." The approach considers the role of plaque burden and progression in subclinical disease and emphasizes the importance of early risk assessment and treatment for preventing first cardiovascular events. Patients at high risk of ASCVD events who require significant LDL-C lowering should be considered for combination therapies comprising statin and nonstatin agents. Practical guidance for the pharmacological management of elevated LDL-C, both now and in the future, is provided.

Early outcomes following integration of computed tomography (CT) coronary angiography service in an established cardiology practice in disease management

BackgroundComputed tomography coronary angiography (CTCA) is an established modality for the diagnosis and assessment of cardiovascular disease. However, price and space pressure have mostly necessitated outsourcing CTCA to external radiology providers. Advara HeartCare has recently integrated CT services within local clinical networks across Australia. This study examined the benefits of the presence (integrated) or absence (pre-integrated) of this “in-house” CTCA service in real-world clinical practice. MethodsDe-identified patient data from electronic medical records were used to create an Advara HeartCare CTCA database. Data analysis included clinical history, demographics, CTCA procedure, and 30-day outcomes post-CTCA from two age-matched cohorts: integrated (n ​= ​495) and pre-integrated (n ​= ​456). ResultsData capture was more comprehensive and standardised across the integrated cohort. There was a 21% increase in referrals for CTCA from cardiologists observed for the integration cohort vs. pre-integration [n ​= ​332 (72.8%) pre-integration vs. n ​= ​465 (93.9%) post-integration, p ​< ​0.0001] with a parallel increase in diagnostic assessments including blood tests [n ​= ​209 (45.8%) vs. n ​= ​387 (78.1%), respectively, p ​< ​0.0001]. The integrated cohort received lower total dose length product [Median 212 (interquartile range 136–418) mGy∗cm vs. 244 (141.5, 339.3) mGy∗cm, p ​= ​0.004] during the CTCA procedure. 30-days after CTCA scan, there was a significantly higher use of lipid-lowering therapies in the integrated cohort [n ​= ​133 (50.5%) vs. n ​= ​179 (60.6%), p ​= ​0.04], along with a significant decrease in the number of stress echocardiograms performed [n ​= ​14 (10.6%) vs. n ​= ​5 (11.6%), p ​= ​0.01]. ConclusionIntegrated CTCA has salient benefits in patient management, including increased pathology tests, statin usage, and decreased post-CTCA stress echocardiography utilisation. Our ongoing work will examine the effect of integration on cardiovascular outcomes.

Managing lipid risk in acute coronary syndrome patients in the real world: results from the BEST consensus

The gap between the targets recommended by current guidelines and the lipid values observed in the real world among patients at very high or extreme cardiovascular risk has called into question the effectiveness of the stepwise lipid-lowering strategy. The BEST (Best Evidence with Ezetimibe/statin Treatment) project supported an expert panel of Italian cardiologists to investigate the different clinical-therapeutic pathways in the management of the residual lipid risk of post-acute coronary syndrome (ACS) patients at discharge and to analyze potential critical issues. Among the members of the panel, 37 cardiologists were selected to participate in a consensus process using the mini-Delphi technique. A 9-statement questionnaire, focusing on the early use of combination lipid-lowering therapies in post-ACS patients, was built up based on a previous survey that involved all members of the BEST project. For each proposed statement, participants anonymously expressed their personal level of disagreement/agreement, according to a 7-point Likert scale. The relative degree of agreement and consensus was calculated based on the median and the 25th percentile values and the interquartile range (IQR). The administration of the questionnaire was repeated twice: the second one after general discussion and analysis of the answers given in the first round in order to obtain as much consensus as possible. With the exception of a single item, the responses of the participants were in agreement with a broad consensus already at the first round with a median value of 6, a 25th percentile of 5 and an IQR of 2. This trend resulted more evident at the second round (median 7, 25th percentile 6, IQR 1). In particular, there was unanimous agreement (median 7, IQR 0-1) on the statements in favor of a lipid-lowering therapy that guarantees the achievement of the targets as much and as soon as possible by the systematic early utilization of the high-dose/intensity statin + ezetimibe combination and, when needed, PCSK9 inhibitors. The percentage of the experts who changed their responses between the first and second round was 39% overall, ranging from 16% to 69%. According to the mini-Delphi results, there is a broad agreement and consensus to manage the lipid risk in post-ACS patients by lipid-lowering treatments that guarantee an early and "robust" lipid reduction which can be achieved only by the systematic use of combination therapies.

Control de la hipercolesterolemia en España: una misma situación con diferentes realidades autonómicas

Introduction and objectiveThe cardiovascular prevention strategy by autonomous communities can be variable since the competences in health are transferred. The objective of the study was to determine the degree of dyslipidaemia control and the lipid-lowering pharmacological therapy used in patients at high/very high cardiovascular risk (CVR) by autonomous communities. MethodsObservational, cross-sectional, descriptive study based on a consensus methodology. Information on the clinical practice of 145 health areas belonging to 17 Spanish autonomous communities was collected through face-to-face meetings and questionnaires administered to the 435 participating physicians. Furthermore, aggregate non-identifiable data were compiled from 10 consecutive dyslipidaemic patients that each participant had recently visited. ResultsOf the 4010 patients collected, 649 (16%) had high and 2458 (61%) very high CVR. The distribution of the 3107 high/very high CVR patients was balanced across regions, but there were inter-regional differences (P<.0001) in the achievement of target LDL-C <70 and <55mg/dL, respectively. High-intensity statins in monotherapy or in combination with ezetimibe and/or PCSK9 inhibitors were used in 44, 21 and 4% of high CVR patients, while in those at very high CVR it rose to 38, 45 and 6%, respectively. The use of these lipid-lowering therapies at national level was significantly different between regions (P=.0079). ConclusionsEven though the distribution of patients at high/very high CVR was similar between autonomous communities, inter-territorial differences were identified in the degree of achievement of LDL cholesterol therapeutic goal and use of lipid-lowering therapy.

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.

The Role of RNA Interference Therapeutics in Hypercholesterolemia and Implications for Practice

An estimated 80% of patients with dyslipidemia do not reach their targeted low-density lipoprotein-cholesterol goals. Despite the use of traditional lipid-lowering therapies, challenges exist in getting patients to goal. Long-acting RNA interference (RNAi) therapeutics represent the next generation of medication that can provide up to 50% reduction of low-density lipoprotein-cholesterol, with few adverse effects for patients who need additional therapy or are intolerant or nonadherent to statin therapy. Its twice-yearly dosing profile offers a treatment option that may help in overcoming treatment barriers. Nurse practitioners need to be knowledgeable about novel pharmacologic agents to treat high-risk populations not meeting treatment goals.

Modern possibilities of intensive treatment of dyslipidemia and gaps in its control: literature review

The article discusses modern approaches to screening for dyslipidemia and its control, target levels of low-density lipoproteins (LDL), initiation of lipid-lowering therapy depending on the total risk on the Systematic Coronary Risk Evaluation (SCORE) scale, considering the effects of age, gender, smoking, blood pressure, lipid levels, which are of crucial importance for selecting preventive and therapeutic strategies in patients with several risk factors. Different types of therapy for dyslipidemia are discussed as of monotherapy with statins and, in combination with ezetimibe, inhibitors of the enzyme proprotein convertase subtilisin-kexin type 9 (PCSK9). New lipid-lowering drugs are highlighted: bempedoic acid and inclisiran, a synthetic small interfering RNA (siRNA) conjugated with a hydrocarbon of three-antennary N-acetylgalactosamine, which activates the natural RNA interference mechanism to cleave the mRNA of the PCSK9 enzyme and prevent its translation into a protein molecule. This increases the number of receptors for LDL and reducing their amount in the blood. We present our results of assessing the use of lipid-lowering therapy and achievement of the target LDL value in very high-risk patients. Innovative biotechnological drugs based on human monoclonal antibodies or antisense oligonucleodins create additional opportunities for improving the treatment of statin-resistant forms of dyslipidemia in patients with a very high cardiovascular risk. The article aims to increase the level of knowledge about modern approaches to lipid-lowering therapy of general practitioners, cardiologists of the primary care settings and will be of interest to other specialists.