Control of Low-Density Lipoprotein Cholesterol in Secondary Prevention of Coronary Artery Disease in Real-Life Practice: The DAUSSET Study in French Cardiologists

Introduction: Patients with established coronary artery disease (CAD) are at very high risk for cardiovascular events. Methods: The DAUSSET study is a national, multicenter, non-interventional study that included very high-risk CAD patients followed by French cardiologists. It aimed to describe real-life clinical practices for low-density lipoprotein (LDL) cholesterol control in the secondary prevention of CAD. Results: A total of 912 patients (mean age, 65.4 years; men, 76.1%; myocardial infarction, 69.4%; first episode, 80.1%) were analyzed. The LDL cholesterol goal was 70 mg/dL in most cases (84.9%). The LDL cholesterol goal <70 mg/dL was achieved in 41.7% of patients. Of the 894 (98.0%) patients who received lipid-lowering therapy, 81.2% had been treated more intensively after the cardiac event, 27.0% had been treated less intensively and 13.1% had been maintained. Participating cardiologists were very satisfied or satisfied with treatment response in 72.6% of patients. Moderate satisfaction or dissatisfaction with lipid-lowering therapy was related to not achieving objectives (100%), treatment inefficacy (53.7%), treatment intolerance (23.4%) and poor adherence (12.3%). Conclusion: These real-world results show that lipid control in very high-risk patients remains insufficient. More than half of the patients did not achieve the LDL cholesterol goal. Prevention of cardiovascular events in these very high-risk patients could be further improved by better education and more intensive lipid-lowering therapy.

Trends in Apolipoprotein B, Non-High-Density Lipoprotein Cholesterol, Low-Density Lipoprotein Cholesterol, and Hemoglobin A1C Among US Adults with Diagnosed Diabetes, 2005-2018

Background: The control of blood glucose and athero­genic cholesterol particle concentrations is fundamental for patients with diabetes. The objective of this study was to examine trends in levels of apolipoprotein B (apo B), non-high-density lipoprotein (non-HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and hemoglobin A1c (A1C) and changes in the proportion of patients who achieved their glycemic and lipid goals between 2005 and 2018.Methods: We conducted a serial cross-sectional analysis of the US nationally representative data from the National Health and Nutrition Examination Surveys form 2005 through 2018. Results: In total, 5536 adults aged 20 years or older with diabetes were included (weighted mean age, 60.2 years; female, 50.1%). Among all adults with diabetes, the age-adjusted mean apo B levels did not decrease significantly from 2005 to 2016 (P =0.077). The age-adjusted mean non-HDL cholesterol levels reduced significantly (P =0.004) from 2005 to 2018. In 2017-2018, 55.3% of patients achieved the A1C goal of <7% and 43.8% achieved the non-HDL cholesterol goal of <130 mg/dl. In 2015-2016, 47.3% achieved the apo B goal of <90 mg/dL, 57.2% achieved the LDL cholesterol goal of <100 mg/dl, while 30.6% achieved all four glycemic and lipid goals. The success rates for achieving the goals of apo B, non-HDL cholesterol, and LDL cholesterol were higher in older compared with younger subjects, while white patients exhibited better glycemic control than Mexican Americans and non-Hispanic black patients.Conclusion: Among adults with diabetes, there was a significant reduction in non-HDL cholesterol level while there was no change in levels of apo B, LDL cholesterol or A1C over the past decade. Nevertheless, large percentages of adults with diabetes continue to have higher levels of apo B, non-HDL cholesterol, LDL cholesterol, and A1C.

Effectiveness and Tolerability of Alternative Statin Dosing in Daily Statin Intolerant Patients in the Era of PCSK9 Inhibitors

Background: Intolerance to the daily use of statins can be dealt with by the use of Proprotein Catylase Subtilisin Kexin Type 9 (PCSK9) inhibitors. Alternative statin dosing has previously been utilized in patients with statin intolerance. Methods: Since the introduction of PCSK9 inhibitors for clinical use in 2015, we evaluated the effectiveness of alternative statin dosing in patients with daily statin intolerance defined as the inability to tolerate the daily use of any dose of statin. Alternative statin dosing was defined as weekly, twice weekly, or every other day atorvastatin or rosuvastatin. From our lipid clinic population of 505 patients with primary hypercholesterolemia (71% with atherosclerotic cardiovascular disease), 338 (67%) had daily statin intolerance. Alternative statin dosing was agreed to by 122 patients of these 338. At the time of this analysis, 87 patients (59% with atherosclerotic cardiovascular disease) could be assessed concerning the effectiveness of alternative statin dosing to achieve their LDL-cholesterol goal. Results: Of the 87 patients undergoing alternative statin dosing with or without ezetimibe, 30 (34%) achieved their goal. An additional 22 patients had a >30% reduction in LDL-cholesterol with oral therapy alone. Twenty-nine of the 87 patients later received PCSK9 inhibition with 27 achieving either their goal or a >30% reduction in LDL cholesterol. The baseline LDL-cholesterol of those achieving their goal LDLcholesterol with alternative statin dosing (154 + 40 mg/dL) could not be distinguished (p=0.79) from those who later required PCSK9 inhibition to achieve their goal (157 + 41 mg/dL). Intolerance to alternative statin dosing was seen in 24 of the 87 (28%) patients. Conclusion: In conclusion, prior to initiating PCSK9 inhibition in patients with daily statin intolerance, a trial of alternative statin dosing should be attempted. The success of alternative statin dosing cannot be predicted by the baseline level of LDL-cholesterol.