5130Association between degree of LDL-cholesterol decrease after a myocardial infarction and mortality - a nationwide cohort study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Schubert ◽  
B Lindahl ◽  
H Melhus ◽  
H Renlund ◽  
M Leosdottir ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Lower Risk ◽  
Ldl Cholesterol ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Index Event ◽  
Risk Of Death ◽  
Lowering Therapy ◽  
Statin Use

Abstract Background In clinical trials, patients with myocardial infarction (MI) and elevated LDL-cholesterol (LDL-C) benefit the most from lipid lowering therapy, and more intensive LDL-C lowering therapy is associated with better prognosis. Purpose To investigate the association between degree of LDL-C lowering and prognosis in MI patients from a large real-world setting. Methods Patients admitted with an MI between 2006 and 2016 and registered in the Swedish MI-registry (SWEDEHEART) were followed until 2018. The difference in LDL-C between the MI hospitalization and a 6–10 week follow-up was measured. In multivariable Cox regression analysis adjusting for clinical risk factors (eg. age, diabetes, prior cardiovascular disease), the association between LDL-C change, mortality and recurrent MI was assessed using restricted cubic splines. Further, the patients were stratified according to quartile decrease in LDL-C from MI hospitalization to the follow-up. Results A total of 44,148 patients (median age: 64) had an LDL-C measured during the MI hospitalization and at follow-up. Of these, 9,905 (22.4%) had ongoing statin treatment prior to admission. The median LDL-C at the MI hospitalization was 2.96 (interquartile range 2.23, 3.74) mmol/L and the median decrease in LDL-C was 1.17 (0.37, 1.86) mmol/L. During a median follow-up of 3.9 years, 3,342 patients died and 3,210 had an MI. Patients with the highest quartile of LDL-C decrease (1.86 mmol/L) from index event to follow-up, had a lower risk of mortality, hazard ratio (HR) 0.59 (95% confidence interval [CI] 0.44–0.80) compared to those with the lowest quartile of LDL-C decrease (0.37 mmol/L) (figure). For MI, the corresponding HR was 0.83 (95% CI 0.68–1.02). Ongoing statin-use prior to admission did not alter the effect of LDL-C decrease and outcome in the analysis. Conclusions In this large nationwide cohort of MI patients, a gradually lower risk of death was observed in patients with larger decrease in LDL-C from index event to follow-up, regardless of statin use prior to admission. The same trend was observed for recurrent MI, although not reaching statistical significance. This confirms previous findings that efforts should be made to lower LDL-C after MI.

P5325A possible paradoxical association between LDL-cholesterol in myocardial infarction patients and relation to major adverse outcomes - a 10-year nationwide cohort study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Schubert ◽  
B Lindahl ◽  
H Melhus ◽  
H Renlund ◽  
M Leosdottir ◽  
...  
Keyword(s):  
Risk Factors ◽  
Myocardial Infarction ◽  
Statin Therapy ◽  
Ldl Cholesterol ◽  
Lipid Lowering ◽  
World Population ◽  
Lipid Lowering Therapy ◽  
Cox Regression Analysis ◽  
Risk Of Death

Abstract Background Cardiovascular disease (CVD) risk increases with the level of LDL-cholesterol (LDL-C), and LDL-C lowering treatment improves prognosis. Less is known about LDL-C levels at myocardial infarction (MI) admission and long-term prognosis. Purpose To investigate admission LDL-C levels in relation to mortality, recurrent MI and baseline characteristics. Methods Patients admitted with an MI in Sweden and recorded in the MI-registry (SWEDEHEART) 2006–2016 were included and followed until 2018. Associations between baseline LDL-C, mortality and MI were assessed with Cox regression analysis, adjusting for risk factors (eg. age, diabetes, prior CV events) and lipid lowering therapy. Results Of 126,669 patients (median age: 70) admitted with MI, 26.2% (n=32,883) had ongoing statin therapy, and the median LDL-C was 2.96 (interquartile range 2.23, 3.74) mmol/L. During median follow-up of 4.2 years, 31,024 died and 17,896 had an MI (table). Patients with higher LDL-C were younger, had substantially fewer comorbidities such as diabetes and prior CVD (p<0.001). In this analysis there was an interaction with ongoing statin-use (p=0.0025). When dividing patients by LDL-C into quartiles, statin naive in the highest LDL-C quartile (3.95 mmol/L) had a lower risk of death compared to patients in the lowest quartile (2.62 mmol/L) HR 0.86 (95% CI 0.83–0.90). For patients with ongoing statin, the risk was also lower with higher LDL-C (2.84 mmol/L) compared to lower LDL-C (1.72 mmol/L) HR 0.88 (95% CI 0.81–0.96). No association was observed between LDL-C and recurrent MI. Table 1. Event rate for mortality and myocardial infarction (MI) by LDL quartile groups Q1 Q2 Q3 Q4 LDL-C (mmol/L) Statin naive <2.62 2.62–3.26 3.26–3.95 >3.95 Ongoing <1.72 1.72–2.21 2.21–2.84 >2.84 Mortality Statin naive 0.074 (6553) 0.049 (4596) 0.037 (3706) 0.030 (2949) Ongoing 0.10 (3297) 0.075 (2769) 0.062 (2462) 0.055 (2157) MI Statin naive 0.034 (2808) 0.026 (2292) 0.024 (2269) 0.023 (2094) Ongoing 0.064 (1796) 0.055 (1792) 0.048 (1694) 0.044 (1557) Event/year (n of events) stratified by statin treatment at index event. Conclusions In this real-world population with over 126,000 patients and 10 years of follow-up, higher LDL-C at the time of the MI was associated with a markedly better prognosis in patients with and without prior statin therapy. This paradox may, despite adjustment, be caused by a substantially lower CVD baseline risk in patients with higher LDL-C pertaining to a lower burden of risk factors, younger age, and fewer prior CVD events as well as a highly treatable risk factor.

P5015Efficacy of lipid lowering therapy beyond statins to prevent cardiovascular events: A meta-analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I Dykun ◽  
R Mincu ◽  
M Totzeck ◽  
T Rassaf ◽  
A A Mahabadi
Keyword(s):  
Myocardial Infarction ◽  
Relative Risk ◽  
Statin Therapy ◽  
Risk Reduction ◽  
Cardiovascular Events ◽  
Ldl Cholesterol ◽  
Meta Analysis ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Lowering Therapy

Abstract Background Lipid lowering therapy is a key cornerstone in secondary prevention of patients with coronary artery disease. However, only a minority of patients with statin therapy reach LDL thresholds as suggested by the ESC. Ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors allow for reduction in LDL-cholesterol in addition to statin therapy. Purpose To perform a meta-analysis of existing trials, evaluating how lipid lowering therapy beyond statins impacts cardiovascular outcome. Methods We performed a systematic search using the Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies, evaluating the impact of an intensified lipid lowering therapy via ezetimibe or PCSK-9 inhibitor in addition to statin therapy compared to statin therapy alone. Manuscript and congress presentations, published until 1st of November 2018, were included. We made our search specific and sensitive using Medical Subject Headings terms and free text and considered studies published in English language. Search terms used were “ezetimibe”, “evolocumab”, “alirocumab”, or “bococizumab” and “cardiovascular events”. Results A total of 100,610 patients from 9 randomized controlled trials (IMPROVE-IT, FOURIER, ODYSSEY Outcomes, SIPRE I, SPIRE II, ODYSSEY LONG TERM, OSLER-1 and OSLER-2, HIJ-PROPER) were included. Treatment with ezetimibe or a PCSK-9 inhibitor was associated with a 18% risk reduction in cardiovascular events (OR [95% CI]: 0.82 [0.75–0.89]). Effect sizes were similar for myocardial infarction (0.84 [0.76–0.92]) and even more pronounced for ischemic stroke (0.77 [0.67–0.83]). In contrast, all-cause mortality was not improved by the intensified lipid lowering therapy (0.94 [0.85–1.05]). No relevant heterogeneity and inconsistency between groups was present in all analyses (detailed data not shown). Comparing efficacy of LDL-reduction and relative risk redaction of cardiovascular events, a linear relationship was observed (figure). Figure 1. Correlation of reduction of LDL-cholesterol at one year with relative risk reduction (95% confidence interval) of cardiovascular events in included trials. Conclusion Intensified LDL-lowering therapy with ezetimibe or PCSK-9 inhibitors, in addition to statins, reduces the risk of myocardial infarction and stroke, however, does not impact overall mortality. There is a linear relationship between LDL reduction and cardiovascular risk reduction, confirming the beneficial effects of LDL lowering therapy beyond statins in secondary prevention.

scholarly journals Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease

2021 ◽  
Vol 8 (9) ◽  
pp. 105
Author(s):  
Thomas Wittlinger ◽  
Bernhard Schwaab ◽  
Heinz Völler ◽  
Christa Bongarth ◽  
Viktoria Heinze ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Coronary Heart Disease ◽  
Ldl Cholesterol ◽  
Lipid Lowering ◽  
Diabetic Patients ◽  
Lipid Lowering Therapy ◽  
Cholesterol Levels ◽  
Lowering Therapy ◽  
Patients With Diabetes

Background: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. Design: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. Methods: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. Results: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m2 vs. 27.8 ± 4.2 kg/m2, p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). Conclusion: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

scholarly journals Coronary lesion complexity in patients with heterozygous familial hypercholesterolemia hospitalized for acute myocardial infarction: data from the RICO survey

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Hermann Yao ◽  
Michel Farnier ◽  
Laura Tribouillard ◽  
Frédéric Chague ◽  
Philippe Brunel ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Risk ◽  
Ldl Cholesterol ◽  
Statin Treatment ◽  
Lipid Lowering ◽  
Syntax Score ◽  
Lipid Lowering Therapy ◽  
Lipid Clinic ◽  
Acute Mi ◽  
Artery Disease

Abstract Background Although patients with familial heterozygous hypercholesterolemia (FH) have a high risk of early myocardial infarction (MI), the coronary artery disease (CAD) burden in FH patients with acute MI remains to be investigated. Methods The data for all consecutive patients hospitalized in 2012–2019 for an acute MI and who underwent coronary angiography were collected from a multicenter database (RICO database). FH (n = 120) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥ 6). We compared the angiographic features of MI patients with and without FH (score 0–2) (n = 234) after matching for age, sex, and diabetes (1:2). Results Although LDL-cholesterol was high (208 [174–239] mg/dl), less than half of FH patients had chronic statin treatment. When compared with non-FH patients, FH increased the extent of CAD (as assessed by SYNTAX score; P = 0.005), and was associated with more frequent multivessel disease (P = 0.004), multiple complex lesions (P = 0.022) and significant stenosis location on left circumflex and right coronary arteries. Moreover, FH patients had more multiple lesions, with an increased rate of bifurcation lesions or calcifications (P = 0.021 and P = 0.036, respectively). In multivariate analysis, LDL-cholesterol levels (OR 1.948; 95% CI 1.090–3.480, P = 0.024) remained an independent estimator of anatomical complexity of coronary lesions, in addition to age (OR 1.035; 95% CI 1.014–1.057, P = 0.001). Conclusions FH patients with acute MI had more severe CAD, characterized by complex anatomical features that are mainly dependent on the LDL-cholesterol burden. Our findings reinforce the need for more aggressive preventive strategies in these high-risk patients, and for intensive lipid-lowering therapy as secondary prevention.

scholarly journals The importance of highly effective lipid-lowering therapy with atorvastatin in the normalization of the autonomic regulation of heart rate in patients with STEMI

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Barmenkova ◽  
E Dushina ◽  
N Burko ◽  
V Oleinikov
Keyword(s):  
Myocardial Infarction ◽  
Heart Rate ◽  
Troponin I ◽  
Cardiac Activity ◽  
Autonomic Regulation ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Lowering Therapy ◽  
Target Values ◽  
Highly Effective

Abstract Purpose To assess the importance of highly effective lipid-lowering therapy with atorvastatin in the normalization of the autonomic regulation of cardiac activity in patients with myocardial infarction with ST segment elevation (STEMI). Methods The study included 130 patients with STEMI aged 51.3±8.9 years, the majority of males (91%). Inclusion criteria: age from 35 to 70 years, STEMI confirmed by ECG and the level of biomarkers (troponin I, CK-MB), the presence of hemodynamically significant stenosis of a culprit artery according to coronary angiography provided that other coronary arteries are occluded no more than 50%, left main coronary artery - not more than 30%. Exclusion criteria: a history of myocardial infarction, CHF III-IV NYHA, bundle branch block, atrial fibrillation, artificial pacemaker. All patients took atorvastatin at a dose of 40–80 mg/day for 48 weeks after STEMI. As part of a further study at the 7th-9th day and 48 weeks after STEMI, 24-hour ECG monitoring was performed with the Astrocard system. The spectral parameters of heart rate variability (HRV) were evaluated: TotP (ms2), ULF (ms2), VLF (ms2), LF (ms2), HF (ms2), LF / HF. By the 48th week of treatment, patients were divided into groups depending on the achievement of the target level of low density lipoproteins (LDL) of less than 1.4 mmol / l or less than 50% of the initial values: 64 people who reached target values of LDL and formed the group of high-effective lipid-lowering therapy “H”, the group of low effective treatment “L” included 66 patients whose LDL did not meet the recommended level. The groups were matched by gender, age, and anthropometric data. Results In the “H” group, by the 48th week, a pronounced power amplification of all spectral components was obtained. The TotP parameter increased from 13021 (95% CI 10967; 15076) ms2 to 20988 (95% CI 17617; 24358) ms2 (p=0.0001); HF - from 164 (95% CI 105; 222) ms2 to 249 (95% CI 178; 321) ms2 (p=0.003). An increase in the low-frequency components of HRV was observed: an increase in ULF from 10695 (95% CI 8985; 12406) ms2 to 20401 (95% CI 15099; 25703) ms2 (p=0.0001), VLF - from 1473 (95% CI 1212; 1734) ms2 to 1734 (95% CI 1478; 1990) ms2 (p=0.01), LF - from 761 (95% CI 573; 949) ms2 to 909 (95% CI 736; 1082) ms2 (p=0.02). Against the background of an increase in all parameters of the frequency spectrum, the sympathovagal balance coefficient LF / HF decreased from 6.6 (95% CI 5.7; 7.6) to 5.2 (95% CI 4.3; 6.1) ( p=0.004). An analysis of the HRV indicators dynamics in the L group revealed an increase in only the total spectrum power - TotP from 12740 (95% CI 10947; 14533) ms2 to 20195 (95% CI 16619; 23770) ms2. Conclusions Highly effective therapy with atorvastatin in STEMI patients helps to normalize the parameters of the autonomic regulation of heart rate in the post-infarction period due to the increased effects of parasympathetic activity. Funding Acknowledgement Type of funding source: None

Abstract T P388: Statin Use is Linked to Lower Risk of Recurrent Vascular Events among Ischemic Stroke Patients with Atrial Fibrillation

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Meng Lee ◽  
Yi-Ling Wu ◽  
Jeffrey L Saver ◽  
Jiann-Der Lee ◽  
Hui-Hsuan Wang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Lower Risk ◽  
Recurrent Stroke ◽  
Stroke Patients ◽  
Antithrombotic Agent ◽  
Vascular Events ◽  
Index Stroke ◽  
Statin Use

Background: The efficacy of statin therapy in the prevention of recurrent stroke and major adverse cardiovascularevents (MACE) was clearly established by the SPARCL trial; but SPARCL excluded patients whose index stroke was due to a presumed cardioembolic mechanism. As such, it remains unclear whether statins are beneficial in cardioembolic stroke patients, particularly those with atrial fibrillation (AF). Objective: To evaluate the relationship between statin use and future vascular risk reduction among recent ischemic stroke patients with AF Methods: We analyzed the Taiwan National Health Insurance registry which comprises beneficiaries aged ≥ 18 years. Code ICD-9 was used to identify a primary hospitalization diagnosis of ischemic stroke and AF among subjects encountered between 2003 and 2009. Follow-up was from time of the index stroke to admission for recurrent stroke or myocardial infarction; withdrawal from the registry; and last medical claim before 1/1/2011. Patients were divided into 2 groups based on whether statin was prescribed (at least 30 days vs. never used) during the follow-up period. Patients were excluded if they did not take any antithrombotic agent within 30 days before an endpoint. Primary endpoint was MACE (composite of stroke and myocardial infarction) and a key secondary endpoint was any recurrent stroke. Multivariate-adjusted hazard ratio (HR) and 95% CI for the development of events were estimated using Cox models. Model was adjusted for baseline age, gender, hypertension, diabetes, prior stroke, prior myocardial infarction, hyperlipidemia, hospital level, and antithrombotic agent during follow-up. Results: Among 4455 eligible patients, mean age was 71 years and mean follow-up duration was 2.8 years.Compared to non-statin use, statin use was associated with a significantly lower occurrence of MACE (adjusted HR 0.84, 95% CI 0.72 to 0.99, P=0.04) and recurrent stroke (adjusted HR 0.82, 0.69 to 0.97, P=0.02). Statin use was also linked to lower ischemic stroke risk, but had neutral effects on intracranial hemorrhage and myocardial infarction. Conclusion: Among patients with an index ischemic stroke and AF, statin use is associated with a lower risk of recurrent vascular events including stroke.

scholarly journals Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study

2020 ◽  
Vol 41 (40) ◽  
pp. 3900-3909 ◽  
Author(s):  
Ali Allahyari ◽  
Tomas Jernberg ◽  
Emil Hagström ◽  
Margrét Leosdottir ◽  
Pia Lundman ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Intensity ◽  
Low Density Lipoprotein ◽  
Monte Carlo Model ◽  
Density Lipoprotein ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitors ◽  
Recent Myocardial Infarction ◽  
Lowering Therapy

Abstract Aims To estimate the proportion of patients with a recent myocardial infarction (MI) who would be eligible for additional lipid-lowering therapy according to the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias, and to simulate the effects of expanded lipid-lowering therapy on attainment of the low-density lipoprotein cholesterol (LDL-C) target as recommended by the guidelines. Methods and results Using the nationwide SWEDEHEART register, we included 25 466 patients who had attended a follow-up visit 6–10 weeks after an MI event, 2013–17. While most patients (86.6%) were receiving high-intensity statins, 82.9% of the patients would be eligible for expanded lipid-lowering therapy, as they had not attained the target of an LDL-C level of &lt;1.4 mmol and a ≥50% LDL-C level reduction. When maximized use of high-intensity statins followed by add-on therapy with ezetimibe was simulated using a Monte Carlo model, the LDL-C target was reached in 19.9% using high-intensity statin monotherapy and in another 28.5% with high-intensity statins and ezetimibe, while 50.7% would still be eligible for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. When use of alirocumab or evolocumab was simulated in those who were eligible for PCSK9 inhibitors, around 90% of all patients attained the LDL-C target. Conclusion  Our study suggests that, even with maximized use of high-intensity statins and ezetimibe, around half of patients with MI would be eligible for treatment with PCSK9 inhibitors according to the 2019 ESC/EAS guidelines. Considering the current cost of PCSK9 inhibitors, the financial implications of the new guidelines may be substantial.

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