Preoperative cardiovascular assessment as an opportunity to (re)affirm the 2019 ESC/EAS guidelines recommended LDL-C goal

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
A Ioannidis ◽  
V Giakoumi ◽  
A Pechlevanis ◽  
M Paraskelidou
Keyword(s):  
Lipid Lowering ◽  
Risk Category ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
City Hospital ◽  
The Novel ◽  
Observation Study ◽  
Pcsk9 Inhibitor ◽  
Cardiovascular Assessment ◽  
Risk Categories

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The novel 2019 ESC/EAS Guidelines on lipids recommend a more intensive reduction on LDL-C across CV risk categories in comparison with the 2016 edition. Purpose This cross-sectional observation study aimed to assess whether patients on lipid lowering therapy were aware of the new set LDL-C goals and if they achieved them. Methods Patients, taking at the time any statin, attending the preoperative CV assessment outpatient clinic at a city hospital in northern Greece were invited to participate. Results In total 625 eligible patients (45.1% female) were enrolled during 2020 (mean age 67 ± 9 years old). Mean duration of statin prescription was about 10 years (9.7 ± 7 years). About two thirds of the patients (402, 64.3%) had established atherosclerotic cardiovascular disease (ASCVD) and the rest were allocated into CV risk categories: low (24, 10.8%), medium (135, 60.5%), high (59, 26.5%) and very high (5, 2.2%). The estimated 10-year risk of CV death was calculated using SCORE. The majority (552, 88.3%) of the patients reported lab tests at least biannually. The majority of the participants (556, 89.0%) were taking a statin as monotherapy of either low (17, 2.7%), medium (237, 37.9%) or high (302, 48.3%) potency. One tenth (65, 10.4%) were prescribed a combination of ezetimibe with a medium or high potency statin. Lastly, only four patients (0.6%) were prescribed a PCSK9 inhibitor. Less than a quarter of the participants (143, 22.9%) had achieved the recommended LDL-C levels. Approximately, one out of six patients with established ASCVD had a LDL-C lower than 55mg/dL (68, 16.9%), while only one out of three primary prevention patients (75, 33.6%) had reached the LDL-C levels recommended for their allocated risk category. As expected, the higher the potency of the statin, the higher the percentage of patients reaching the goal. Moreover, twelve out of the sixty five the patients (18.5%) on ezetimibe combination therapy achieved the LDL-C goal. Lastly, three of the four patients (75.0%) on a PCSK9 inhibitor had attained the desired LDL-C level. No information could be collected regarding why patients not reaching the goal were not offered a statin of higher potency and/or dosing, a combination with ezetimibe or a PCSK9 inhibitor, accordingly. Disturbingly enough, none of the patient was aware that the LDL-C goals recommended by scientific societies had been lowered in 2019, although 94 patients (15.0%) could recall discussing LDL-C goals with their physician. The majority of the patients (427, 93.0%) reported that they would like to know the recommended (personal) LDL-C goals. Conclusions Greek patients taking statins were overall unaware of the novel set LDL-C goals. Hardly acceptable attainment of the LDL-C goal was observed. The preoperative assessment visit can be used to monitor the guidelines implementation. Further research is warranted to assess the barriers that obstruct a satisfactory goal achievement. Abstract Figure. Patients achieving LDL-C goal

scholarly journals Attainment of the 2019 ESC/EAS recommended LDL-C goal in Greek patients with established atherosclerotic cardiovascular disease

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
A Ioannidis ◽  
A Pechlevanis ◽  
M Paraskelidou
Keyword(s):  
Cardiovascular Disease ◽  
Phone Call ◽  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
The Novel ◽  
High Potency ◽  
Northern Greece ◽  
Observation Study ◽  
Pcsk9 Inhibitor

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The novel 2019 ESC/EAS Guidelines on lipids recommend a more intensive reduction on LDL-C for patients with established atherosclerotic cardiovascular disease (ASCVD) in comparison with the 2016 edition. Purpose This cross-sectional observation study aims to assess whether patients on lipid lowering therapy, as a secondary prevention measure, are aware of the new set goals and if they achieved them. Methods Patients with known ASCVD, taking currently any statin, visiting the Emergency Department of a tertiary hospital in northern Greece were invited to participate by answering a short questionnaire followed by a phone call to provide the exact lab results or other details. Data were analyzed with the SPSS software version 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA) Results In total 459 eligible patients (37.9% female) were enrolled from January to October 2020 (mean age 68 ± 12 years old). Mean duration of statin prescription was about 11 years (11.2 ± 6 years). The majority (431, 93.9%) of the patients reported lab tests yearly. The majority of the participants (406, 88.5%) were taking a statin as monotherapy of either low (11, 2.4%), medium (174, 37.9%) or high (221, 48.1%) potency. One tenth (50, 10.9%) were prescribed a combination of ezetimibe with a medium or high potency statin. Lastly, only three patients (0.7%) were prescribed a PCSK9 inhibitor. Approximately, one out of six patients had a LDL-C lower than 55mg/dL (78, 17.0%). As expected, the higher the potency of the statin, the higher the percentage of patients reaching the goal: low (1 of 11 patients, 9.1%), medium (21 of 174 patients, 12.1%) and high potency (45 of 221 patients, 20.4%). Moreover, nine out of the fifty the patients (18.0%) on ezetimibe combination therapy achieved the LDL-C goal. Lastly, two of the three patients (66.7%) on a PCSK9 inhibitor had attained the desired LDL-C level. No information could be collected regarding why patients not reaching the goal were not offered a statin of higher potency and/or dosing, a combination with ezetimibe or a PCSK9 inhibitor, accordingly. Disturbingly enough, none of the patient was aware that the LDL-C goals recommended by scientific societies had been lowered in 2019, although 71 patients (15.5%) could recall discussing LDL-C goals with their physician, even though none of the patients recalled the limit of 55mg/dL. The majority of the patients (427, 93.0%) reported that they would like to know their personal LDL-C goal. Conclusions Greek patients with established ASCVD taking statins are overall unaware of the novel set LDL-C goals. Hardly acceptable attainment of the LDL-C goal was observed. Further research is warranted to assess the barriers that obstruct a satisfactory goal achievement. Abstract Figure. Patients achieving LDL-C goal

scholarly journals Patient"s awareness of recommended LDL-C goals in primary prevention and observed achievement

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
A Ioannidis ◽  
A Pechlevanis ◽  
M Paraskelidou ◽  
D Lakias
Keyword(s):  
Primary Prevention ◽  
Risk Score ◽  
Lipid Lowering ◽  
Moderate Intensity ◽  
Lipid Lowering Therapy ◽  
The Novel ◽  
Pcsk9 Inhibitor ◽  
Prevention Measure ◽  
Very High ◽  
Risk Categories

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The novel 2019 ESC/EAS Guidelines on lipids recommend more intensive reduction on LDL-C across CV risk categories in comparison with the 2016 edition. Purpose This cross-sectional observation study aims to assess whether patients on lipid lowering therapy, as a primary prevention measure, are aware of the new set goals and if they achieved them. Methods Patients, taking currently any statin as a primary prevention measure, visiting the Emergency Department of a tertiary hospital in northern Greece were invited to participate by answering a short questionnaire followed by a phone call to provide the exact lab results or other details. Results In total 412 eligible patients (54.1% female) were enrolled from January to October 2020 (mean age 61 ± 13 years old). Mean duration of statin prescription was about 8 years (7.8 ± 5 years). The majority (381, 92.5%) of patients reported lab tests yearly while most of them (394, 95.6%) were being followed up in outpatient clinics or private offices. Patients were allocated into CV categories: low (48, 11.7%), medium (239, 58.0%), high (108, 26.2%) and very high (17, 4.1%). The estimated 10-year risk of CV death was calculated using SCORE. Almost two thirds of the patients (282, 68.4%) were taking moderate intensity statins (as monotherapy) while one out of ten (45, 10.9%) was taking a statin plus ezetimibe combination. No patient was prescribed a PCSK9 inhibitor. Only two out of five (171, 41.5%) patients reached the LDL-C goal, though differences were noted between risk categories with almost half of the low and medium CV risk patients achieving the desired LDL-L level: low (23, 47.9%), medium (124, 51.9%), high (21, 19.4%) and very high (3, 17.6%). No significant difference was observed in terms of potency of statin. As expected, patients taking a statin and ezetimibe combination achieved lower LDL-C levels, with almost two thirds (31 out of 45 patients, 68.9%) reaching the goal. No information could be collected regarding why patients not reaching the goal were not offered a statin of higher potency and/or dosing, a combination with ezetimibe or a PCSK9 inhibitor. Disturbingly enough, none of the patient was aware that the LDL-C goals recommended by scientific societies had been lowered in 2019, while only 29 patients (7.0%) could recall discussing LDL-C goals with their physician. Moreover, merely three patients could remember the calculation of any CV risk score. The majority of the patients (379, 92.0%) reported that they would like to know their personal CV risk score and their LDL-C goal. Conclusions Greek primary prevention patients taking statins are overall unaware of the novel set LDL-C goals and it seems that they have not been offered a total CV risk score assessment. Hardly acceptable attainment of LDL-C goals was observed. Further research is warranted to assess the barriers that obstruct a satisfactory goal achievement. Abstract Figure.

scholarly journals The impact of the revised ESC Dyslipidaemia Guidelines on lipid-lowering therapy: simulating the need for PCSK9 inhibition in a contemporary ASCVD cohort

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Blaum ◽  
F.J Brunner ◽  
F Kroeger ◽  
J Braetz ◽  
B Bay ◽  
...  
Keyword(s):  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitors ◽  
Treatment Target ◽  
Pcsk9 Inhibitor ◽  
Lowering Therapy ◽  
Artery Disease ◽  
Pcsk9 Inhibition ◽  
The Impact

Abstract Introduction The recently updated ESC guidelines on the management of dyslipidaemias recommend a more intense LDL-cholesterol (LDL-C) reduction. For patients with atherosclerotic cardiovascular disease (ASCVD) the LDL-C goal has been revised to ≤55 mg/dl with a concomitant class IA upgrade for cost intensive PCSK9 inhibitors. Purpose We aim to quantify the need for PCSK9 inhibitors to achieve the revised LDL-C target compared to former ESC recommendations in ASCVD patients Methods We included all patients with ASCVD (angiographically documented coronary artery disease, history of peripheral artery disease or stroke) from an observational cohort study ongoing since 2015. A simulation treatment algorithm adding sequentially a high intensity statin, ezetimibe and a PCSK9 inhibitor in case of a missed treatment target was applied with consideration of both partial and total statin intolerance. The need for PCSK9 inhibitors was calculated for 3 recommendations: 1. LDL-C treatment target ≤55 mg/dl (ESC 2019 Guidelines), 2. LDL-C treatment target ≤70 mg/dl (ESC 2016 Guidelines) and 3. risk-based use of PCSK9 inhibitors restricted to patients with a residual LDL-C >140 mg/dl or >100 mg/dl with clinical/angiographic risk factors (ESC consensus update 2017). Results We included 1936 patients (mean age 69 years, 74% male). Median LDL-C at inclusion was 86 mg/dl, with 60% of patients taking lipid lowering medication (55% statin only, 4% statin + ezetimibe, 1% ezetimibe only). Table 1 shows the distribution of medications required to meet recommendations 1–3. After simulated stepwise intensification of lipid lowering therapy 99% of patients achieved the revised LDL-C target of ≤55 mg/dl, with a need of 23.5% for a PCSK9 inhibitor. For the former LDL-C target of ≤70 mg/dl the need for PCSK9 inhibitors was 10.5%. Restricting the use of PCSK9 inhibitors to the highest risk patients according to the ESC 2017 consensus statement reduced the need for PCSK9 inhibition to only 1.4% with slightly fewer patients achieving their LDL-C target (78% for ≤55 mg/dl and 91% for ≤70 mg/dl respectively). Conclusion The revised LDL-C treatment goals substantially increase the projected need for PCSK9 inhibitors with an unclear health economic impact. Identification of ASCVD patients with a reasonable benefit/cost-ratio of PCSK9 inhibition remains to be investigated urgently. Funding Acknowledgement Type of funding source: None

Effect of evolocumab on acute arterial events across all vascular territories : results from the FOURIER trial

2021 ◽  
Author(s):  
Kazuma Oyama ◽  
Robert P Giugliano ◽  
Minao Tang ◽  
Marc P Bonaca ◽  
Jeffrey L Saver ◽  
...  
Keyword(s):  
Statin Therapy ◽  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Limb Ischaemia ◽  
Lipid Lowering Therapy ◽  
Peripheral Vascular ◽  
Pcsk9 Inhibitor ◽  
Acute Limb Ischaemia ◽  
The Impact ◽  
Over Time

Abstract Aims We assessed the impact of the proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor evolocumab on acute arterial events across all vascular territories, including coronary, cerebrovascular, and peripheral vascular beds, in patients with established atherosclerotic cardiovascular disease (ASCVD). Methods and results In the FOURIER trial, 27 564 patients with stable ASCVD on statin therapy were randomly assigned to evolocumab or placebo. Acute arterial events were a composite of acute coronary (coronary heart disease death, myocardial infarction, or urgent coronary revascularization), cerebrovascular (ischaemic stroke, transient ischaemic attack, or urgent cerebral revascularization), or peripheral vascular (acute limb ischaemia, major amputation, or urgent peripheral revascularization) events. Of the 2210 first acute arterial events, 74% were coronary, 22% were cerebrovascular, and 4% were peripheral vascular. Evolocumab reduced first acute arterial events by 19% (hazard ratio [HR] 0.81 [95% confidence interval 0.74–0.88]; P < 0.001), with significant individual reductions in acute coronary (HR 0.83 [0.75–0.91]), cerebrovascular (HR 0.77 [0.65–0.92]), and peripheral vascular (HR 0.58 [0.38–0.88]) events. There were 3437 total events (first plus recurrent), with evolocumab reducing total events by 24% (incidence rate ratio 0.76 [0.69–0.85]). The magnitude of reduction in acute arterial events with evolocumab numerically increased over time, with a 16% reduction (HR 0.84 [0.75–0.95]) in the first year followed by a 24% reduction (HR 0.76 [0.67–0.85]) thereafter. Conclusion The addition of the PCSK9 inhibitor evolocumab to statin therapy reduced acute arterial events across all vascular territories with a robust effect over time, indicating a pan-vascular impact of aggressive lipid-lowering therapy on these acute and clinically meaningful events. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01764633.

Abstract 15913: Two-year Results of the Getting to an Improved Understanding of Low-density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) Registry of Patients With Atherosclerotic Cardiovascular Disease (ASCVD)

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Christopher P Cannon ◽  
James A De Lemos ◽  
Christie M Ballantyne ◽  
Robert S Rosenson ◽  
Shushama Alam ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Statin Therapy ◽  
Treatment Guidelines ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitor ◽  
Statin Dose

Background: Atherosclerotic cardiovascular disease (ASCVD) treatment guidelines recommend intensive statin therapy and adding non-statin therapy if LDL-C ≥70 mg/dL. Methods: We designed the GOULD registry to assess lipid-lowering therapy (LLT) over time: At 120 U.S. centers, 5006 ASCVD patients on any (LLT) were enrolled in 1 of 3 cohorts: 1) currently on PCSK9 inhibitor (PCSK9i), 2) no PCSK9i and LDL-C ≥100 mg/dL, and 3) no PCSK9i and LDL-C 70-99 mg/dL. Results: Over the two years, only 16.8% had some type of LLT intensification, In the cohorts of patients with baseline LDL-C ≥ 100 and 70-99 mg/dL, LLT intensification was present in 21.9% and 14.3% respectively: statin dose was intensified in 6.1% and 6.1%, ezetimibe was added in 6.8% and 4.3% and PCSK9i was added in 6.3% and 2.2% respectively. Conversely, out of the total population, statins were discontinued in 246/4275 (5.8%), ezetimibe in 81/535 (15.1%), and PCSK9i in 47/544 (8.6%). At 24 months, 83.7% were on statin (43.4% high-intensity), with 14.2% on ezetimibe. Lipid panels were measured in 73% by 1 year and 84% by 2 years. Among Pts in the LDL-C ≥100 and 70-99 mg/dL cohorts, 18.6% and 30.4% achieved an LDL-C <70 mg/dL by 1 year, with little further change by 2 years: 21.3% and 33.5% respectively. In the PCSK9 cohort, 53.2% had LDL-C<70 mg/dl. Overall, only 31.7% had LDL-C <70 mg/dL at 2 years (an increase from 6.7% at baseline), while 25.0% had LDL-C >100 mg/dL. Conclusion: Of ASCVD patients with suboptimal LDL-C at baseline, even after 2 years of follow up, strikingly only 16% had LLT intensification, and thus most remained uncontrolled. Further intensive efforts are needed to achieve optimal LDL management in patients with ASCVD.

scholarly journals Lower is better: ezetimibe and PCSK9 inhibition join the mainstream of lipid‑lowering therapy

2016 ◽  
Vol 7 (1) ◽  
pp. 17-25
Author(s):  
Cezary Wójcik
Keyword(s):  
Statin Therapy ◽  
Heart Association ◽  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitors ◽  
Level Of Evidence ◽  
Cholesterol Guidelines ◽  
Pcsk9 Inhibition ◽  
Current Guidelines

The focus of 2013 cholesterol guidelines to prevent atherosclerotic cardiovascular disease (ASCVD) released by American College of Cardiology (ACC) and American Heart Association (AHA) is the administration of high intensity statin therapy to specific four groups of patients, which were found to benefit the most from such therapy. They no longer promote achieving specific LDL-C goals with a combination therapy involving statins and other drugs, as advocated by the former ATP-III guidelines as well as current guidelines of European Atherosclerosis Society, International Atherosclerosis Society or National Lipid Association. Such approach has been dictated by the strict reliance on randomized controlled trials as the only acceptable level of evidence. However, since publication of the 2013 ACC/AHA guidelines, cardiovascular benefits of ezetimibe added to statin therapy have been established. Moreover, the advent of PCSK9 inhibitors, providing a powerful supplement and/or alternative to statin therapy, further complicates the therapeutic horizon in dyslipdiemias. It is very likely that a new set of ACC/AHA guidelines will be published in 2016, with a return of specific LDL-C and Non-HDL-C goals of therapy as well as integration of drugs other than statins. As the treatment of dyslipidemias becomes more complex, the need for the subspecialty of clinical lipidology to be officially recognized becomes more evident.

scholarly journals PCSK9 inhibitors for in-hospital treatment of patients with acute coronary syndrome and severe lipid metabolism disorders

2020 ◽  
Vol 25 (8) ◽  
pp. 4010
Author(s):  
O. L. Barbarash ◽  
N. V. Fedorova ◽  
D. Yu. Sedykh ◽  
O. V. Gruzdeva ◽  
O. N. Khryachkova ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Statin Therapy ◽  
Lipid Lowering ◽  
High Density Lipoproteins ◽  
Hospital Treatment ◽  
Lipid Lowering Therapy ◽  
Pcsk9 Inhibitor ◽  
Coronary Syndrome ◽  
Lowering Therapy ◽  
Baseline Values

Aim. To assess the efficacy and safety of PCSK9 inhibitor alirocumab as part of a combination lipid-lowering therapy in patients with acute coronary syndrome (ACS).Material and methods. This prospective, open-label, single-center activetreatment study included 13 patients hospitalized due to ACS. The main inclusion criterion was nonachievement of target low-density lipoprotein cholesterol (LDL-C) values (<1,4 mmol/L) with high-intensity statin therapy prior to ACS. During the first 30 days after ACS, all patients received therapy with atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day in combination with alirocumab 150 mg/ml (Praluent) administered by subcutaneous injection. Lipid and biochemical profiles were monitored. The first injection of the PCSK9 inhibitor was performed on days 3-5 of hospitalization, the second — after 2 weeks.Results. On admission, the median LDL-C was 4,3 [3,5;5,3] mmol/L. A day after administration, there was a decrease in LDL-C by 41,9% (median 2,5 [1,8;3,2] mmol/L; p=0,001) without a negative effect on high-density lipoproteins (HDL-C) (median 1,2 [0,8;1,4] mmol/L; p=0,270). Before the next injection, LDL-C decreased by another 8% (median 2,3 [1,1;4,1] mmol/L). A day after the second injection, a decrease in LDL-C from the baseline values was 69,8% (median 1,3 [0,7;1,5] mmol/L; p=0,010). Strengthening lipid-lowering therapy with a PCSK9 inhibitor within 30 days after ACS did not lead to clinical and biochemical deterioration.Conclusion. The use of subcutaneous 150-mg injections of alirocumab 2 times a week 30 days after ACS in patients who did not reach target LDL-C values with statin therapy, leads to a 69% decrease in LDL-C from baseline values and is safe.

scholarly journals Assessing Atherosclerotic Cardiovascular Disease Risk with Advanced Lipid Testing: State of the Science

2020 ◽  
Vol 15 ◽  
Author(s):  
Charles Amir German ◽  
Michael David Shapiro
Keyword(s):  
Cardiovascular Disease ◽  
Clinical Medicine ◽  
Plasma Lipids ◽  
Disease Risk ◽  
Cardiovascular Disease Risk ◽  
Lipid Lowering ◽  
Atherosclerotic Cardiovascular Disease ◽  
Lipid Lowering Therapy ◽  
Obesity And Diabetes ◽  
Lipid Panel

Cardiovascular disease is the number one cause of death and disability worldwide. While substantial gains have been made in reducing cardiovascular mortality, future projections suggest that we have reached a nadir and may be at an inflection point, given the rising tide of obesity and diabetes. Evaluation and management of plasma lipids is central to the prevention of atherosclerotic cardiovascular disease. Although the standard lipid panel represents a well-established platform to assess risk, this test alone can be insufficient and/or misleading. Advances in our understanding of atherosclerosis have led to the development of lipid-based biomarkers that help to discriminate the risk of cardiovascular disease when it is unclear. While these biomarkers provide novel information, their implementation into clinical medicine remains difficult given discrepancies in the literature, lack of assay standardisation, poor accessibility and high cost. However, additional measures of atherogenic lipoproteins or their surrogates may offer insight beyond the standard lipid panel, providing a more precise assessment of risk and more accurate assessment of lipid-lowering therapy.

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