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Background Dyslipidemia International Study II (DYSIS II)‐China was conducted to determine the low‐density lipoprotein cholesterol (LDL‐C) goal (<1.8 mmol/L) attainment rate in patients with post‐acute coronary syndrome (ACS). Hypothesis Compliance with treatment guideline recommendations improves the LDL‐C goal attainment rate in post‐ACS patients. Methods This multicenter prospective observational study conducted at 28 tertiary hospitals determined the LDL‐C goal attainment rates at admission and 6‐month follow‐up in patients on lipid‐lowering treatment (LLT) for ≥3 months and those not on LLT (LLT‐naive or off LLT for ≥3 months) at admission. Predictors of goal attainment at 6 months were identified using multivariate logistic regression. Results The LDL‐C goal attainment rate at admission in 1102/1103 enrolled patients was 17.1%; it was 41.2% among 752 patients with available lipid results at 6 months. The distance to goal was 0.7 mmol/L at 6 months. Statin monotherapy was the most prescribed LLT. Only 7.7% of patients were receiving statin + ezetimibe and 8.4% of patients were receiving an atorvastatin‐equivalent dose of ≥40 mg/day at 6 months. Being male (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.6) and undergoing percutaneous coronary intervention during index hospitalization (OR 1.5, 95% CI 1.1 to 2.1) were the independent predictors for LDL‐C goal attainment. Conclusions This real‐world DYSIS II study in China reports a low LDL‐C goal attainment rate in post‐ACS patients even after 6 months of LLT. Lack of intensification of statin therapy and underutilization of combinations suggest gaps between real‐world treatment practices and guideline recommendations.

Background Dyslipidemia remains the major cause of atherosclerotic cardiovascular disease (ASCVD). Lipid management in patients with increased cardiovascular (CV) risk needs improvement across Europe, and data gaps are noticeable at the country level. Hypothesis We described the current treatment landscape in Belgium, hypothesizing that lipid management in patients with ASCVD remains inadequate and aiming to understand the reasons. Methods Using data from an anonymized primary care database in Belgium derived from 494 750 individuals, we identified those with any CV risk factor between November 2019 and October 2022 and described the clinical features of patients with ASCVD. The main outcomes were the proportion of patients (i) receiving lipid‐lowering therapies (LLTs), (ii) per low‐density lipoprotein cholesterol (LDL‐C) threshold, stratified per LLT, (iii) reaching the 2021 ESC recommended LDL‐C goals, and (iv) LDL‐C reduction per type of LLT was also determined. Results Among 40 888 patients with very high CV risk, 24 859 had established ASCVD. Most patients with ASCVD were either receiving monotherapy (59.6%) or had no documented LLT (25.1%). Further, 64.2% of those with no documented LLT exhibited LDL‐C levels ≥ 100 mg/dL. Among common treatment options, one of the greatest improvements in LDL‐C levels was achieved with combination therapy of statin and ezetimibe, reducing LDL‐C levels by 41.5% (p < 0.0001). Yet, in this group, 24.8% of patients had still LDL‐C levels ≥ 100 mg/dL and only 20.7% were at goal. Conclusion Our study emphasizes the importance of developing strategies to help patients achieve their LDL‐C goals, with a focus on supporting the implementation of combination LLT in routine clinical practice. Practitioner Points Approximately 25% of patients with ASCVD had no documented LLT (although 64.2% of them exhibited LDL‐C levels ≥ 100 mg/dL), ~60% received monotherapy, and only 15.3% received combination LLT. The greatest improvements in LDL‐C levels were achieved with high‐intensity statin plus ezetimibe. Yet, ~25% of patients receiving statin plus ezetimibe had LDL‐C levels ≥ 100 mg/dL, and only 20.7% were at goal (2021 ESC guidelines). Altogether, the results emphasize the importance of developing strategies to help patients achieve their LDL‐C goals, with a focus on supporting the implementation of combination LLT in routine clinical practice.

Background Statins are lipid‐lowering drugs with favorable anti‐inflammatory effects. This study aimed to explore different statin‐based lipid‐lowering strategies to reduce high‐sensitivity C‐reactive protein (hs‐CRP). Hypothesis The hypothesis is that different statin‐based lipid‐lowering strategies might reduce hs‐CRP. Methods This retrospective study included 3653 patients who underwent percutaneous coronary intervention (PCI). Three statin‐based lipid‐lowering strategies were investigated, including different types of statins (atorvastatin vs. rosuvastatin), statin combined with ezetimibe therapy (vs. without), and intensive statin therapy (vs. regular). The hs‐CRP levels and blood lipid indicators were measured at baseline and after 1‐month lipid‐lowering therapy. Multivariable linear regression analysis and structural equation mode analysis were conducted to verify the association between different lipid‐lowering strategies, Δhs‐CRP (%) and ΔLDL‐C (%). Results Totally, 3653 patients were enrolled with an average age of 63.81 years. Multivariable linear regression demonstrated that statin combined with ezetimibe therapy was significantly associated with decreased Δhs‐CRP (%) (β = −0.253, 95% CI: [−0.501 to −0.005], p = 0.045). The increased ΔLDL‐C (%) was an independent predictor of elevated levels of Δhs‐CRP (%) (β = 0.487, 95% CI: [0.15−0.824], p = 0.005). Furthermore, structural equation model analysis proved that statin combined with ezetimibe therapy (β = −0.300, p < 0.001) and intensive statin therapy (β = −0.032, p = 0.043) had an indirect negative effect on Δhs‐CRP via ΔLDL‐C. Conclusions Compared with routine statin use, statin combined with ezetimibe therapy and intensive statin therapy could further reduce hs‐CRP levels. This study included stable coronary artery disease patients who underwent PCI and following treatment with statins. During treatment, hs‐CRP, LDL‐C, high‐density lipoprotein cholesterol, non‐HDL‐C, total cholesterol, and triglycerides were measured at baseline and 1 month of lipid‐lowering therapy. In conclusion, statin combined with ezetimibe therapy and intensive statin therapy could further reduce hs‐CRP levels by lowering LDL‐C levels.

Background Non‐statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non‐statin LLT remain incompletely described. Hypothesis The guideline‐recommended statin intensity remains underutilized in patients treated with and without non‐statin LLT. Methods The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non‐statin LLT. Results Among 7720 patients, 1930 (25.0%) were treated with a non‐statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline‐recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non‐statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non‐statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non‐statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again. Conclusions Non‐statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline‐recommended statin intensity. More work is needed to establish statins as first line therapy.

Background Familial hypercholesterolemia (FH), an autosomal dominant genetic disease with the elevated levels of low‐density lipoprotein (LDL) cholesterol (LDL‐C), increases the risk of coronary artery disease (CAD). The proprotein convertase subtilisin/kexin type 9 (PCSK9) gene is associated with FH. There is a positive relationship between circulating LDL‐C and PCSK9 levels, a potential CAD condition, without lipid‐lowering therapy (LLT); however, we do not know whether their correlation exists in FH patients under LLT. Methods This study compared the correlation of PCSK9 variants among patients with FH under LLT (n = 70; mean age, 53 years; male, 63%). LDLR, PCSK9 and APOB variants were analyzed using next‐generation sequencing. Results The LDL‐C and PCSK9 levels in patients with gain‐of‐function (GOF) variants of PCSK9 (n = 7) were mostly similar to those in patients with LDLR variants (n = 17) or variant‐negative patients (n = 46). A significant positive correlation was observed between LDL‐C and PCSK9 levels in patients with GOF variants of PCSK9 (r = 0.79, p = 0.04), but not in patients with LDLR variants or variant‐negative patients. Conclusion The LDL‐C‐PCSK9 correlation is suggested to be retained in FH patients with GOF variants of PCSK9 even under LLT, and these variants can be used as molecular markers for additional treatment with statins in FH patients. A significant positive correlation was observed between LDL‐C and PCSK9 levels in patients with gain‐of‐function variants of PCSK9, but not in patients with the other variants.

Current international guidelines strongly recommend the use of high-intensity lipid-lowering therapy (LLT) after hospitalization for atherosclerotic cardiovascular disease (ASCVD) events. With this study, our aim was to evaluate LLT prescribing in a large Italian cohort of patients after discharge for an ASCVD event, exploring factors associated with a lower likelihood of receiving any LLT and high-intensity LLT. Individuals aged 18 years and older discharged for an ASCVD event in 2019–2020 were identified using hospital discharge abstracts from two local health units of the Campania region. LLT treatment patterns were analyzed in the 6 months after the index event. Logistic regression models were developed for estimating patient predictors of any LLT prescription and to compare high-intensity and low-to-moderate-intensity LLT. Results: A total of 8705 subjects were identified. In the 6 months post-discharge, 56.7% of patients were prescribed LLT and, of those, 48.7% were high-intensity LLT. Female sex, older age, and stroke/TIA or PAD conditions were associated with a higher likelihood of not receiving high-intensity LLT. Similar predictors were found for LLT prescriptions. LLT utilization and the specific use of high-intensity LLT remain low in patients with ASCVD, suggesting a substantial unmet need among these patients in the contemporary real-world setting.

IntroductionReduction of low-density lipoprotein C (LDL-C) slows progression of atherosclerosis and decreases risk of future cardiovascular events following acute coronary syndrome (ACS). However, notable differences exist between European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guidelines on lipid lowering goals. For patients diagnosed with ACS, NICE 2023 guidance recommends a target LDL-C level of 2.0 mmol/l or less, or non-HDL cholesterol level of 2.6 mmol/l or less. NICE also recommend full lipid profile evaluation on admission and 2–3 months after starting or changing treatment. ESC 2019 dyslipidaemia guidelines recommend high intensity statin therapy for a 50% reduction in LDL-C or LDL-C levels of <1.4 mmol/l in very high-risk patients. Failure to reach lipid targets should warrant consideration of novel lipid lowering therapies. We sought to determine the proportion of patients with ACS who achieved LDL-C goals by 3 months and to assess adherence to lipid profile monitoring recommendations. MethodsIn this retrospective cohort analysis, patients with confirmed ACS from 1st June 2022 to 31st May 2023 were identified from our local Myocardial Ischaemia National Audit Project (MINAP) dataset. Lipid profile, baseline demographic and medical therapy data were collected from our Trust online laboratory reporting system, healthcare summary records and correspondence. Data was analysed using GraphPad Prism and Microsoft Excel.ResultsOf the 343 patients included in the study, mean age was 67.9 years, 67.7% were male and 12.2% had previously diagnosed dyslipdiaemia (table 1). 72.9% met the NICE target, and 34.6% met the ESC target.During admission for ACS 12.0% of patients had a lipid profile taken and 31.2% had a lipid profile <3 months following discharge (table 2). 2.9% of patients had a lipid profile both during admission and <3 months of discharge. 88.8% of patients were discharged on a statin, 3.8% on combination or newer lipid lowering therapies, and 7.4% on no lipid lowering therapy at all. Of the 301 patients discharged on a statin, 18.6% reported an intolerance or side effect. 64.3% reduced their statin dose or were prescribed an alternative statin, 5.4% were started on Ezetimibe. 23.2% received no alternative lipid lowering therapy agent.ConclusionThis data demonstrates that NICE and ESC 3 month lipid targets are not being met in post ACS patients at our institution. Given the availability of new lipid lowering therapies, this study highlights that improvements in both serial lipid profile monitoring and prescription of novel therapies can be made to reduce risk of future cardiovascular events.Abstract 223 Table 1Baseline demographics Category n= 343 Mean age 67.9 years Male gender 67.7% (n= 232) Mean BMI 29.7 Mean eGFR (mL/min) 68.0 Current smoker 22.2% (n=76) Ex-smoker 37.9% (n=130) Diabetes 35.0% (n=120) Hypertension 38.8% (n=133) Hypercholesterolaemia 12.2% (n= 42) Abstract 223 Table 2Results Number of patients Lipid profile during admission for ACS (%) 41 (12) Lipid profile < 3 months of discharge (%) 107 (31.2) Lipid profile during admission + <3 months of discharge (%) 10 (2.9) Discharged on a statin (%) 301 (88.8) Discharged on combination therapy (%) 13 (3.8) Discharged on no lipid therapy at all (%) 25 (7.4) Reported statin intolerance or side effect (%) 56 (18.6) Patients who reported statin intolerance or side effect who received no alternative lipid lowering therapy agent (%) 13 (23.2) Conflict of InterestNone

Dyslipidemia in patients with type 2 diabetes (DMT2) is one of the worst controlled worldwide, with only about 1/4 of patients being on the low-density lipoprotein cholesterol (LDL-C) target. There are many reasons of this, including physicians’ inertia, including diabetologists and cardiologists, therapy nonadherence, but also underusage and underdosing of lipid lowering drugs due to unsuitable cardiovascular (CV) risk stratification. In the last several years there is a big debate on the risk stratification of DMT2 patients, with the strong indications that all patients with diabetes should be at least at high cardiovascular disease (CVD) risk. Moreover, we have finally lipid lowering drugs, that not only allow for the effective reduction of LDL-C and do not increase the risk of new onset diabetes (NOD), and/or glucose impairment; in the opposite, some of them might effectively improve glucose control. One of the most interesting is pitavastatin, which is now available in Europe, with the best metabolic profile within statins (no risk of NOD, improvement of fasting blood glucose, HOMA-IR, HbA1c), bempedoic acid (with the potential for the reduction of NOD risk), innovative therapies—PCSK9 inhibitors and inclisiran with no DMT2 risk increase, and new forthcoming therapies, including apabetalone and obicetrapib—for the latter one with the possibility of even decreasing the number of patients diagnosed with prediabetes and DMT2. Altogether, nowadays we have possibility to individualize lipid lowering therapy in DMT2 patients and increase the number of patients on LDL-C goal without any risk of new onset diabetes and/or diabetes control worsening, and in consequence to reduce the risk of CVD complications due to progression of atherosclerosis in this patients’ group.

Purpose of the Review A significant number of patients fail to achieve target LDL cholesterol (LDL-C) levels. This review aims to explore why inclisiran, a novel class of LLT, should be considered a valuable addition to the current treatment options. Recent Findings Inclisiran is a small interfering RNA (siRNA) that targets PCSK9 synthesis specifically in the hepatocytes. The drug remains in circulation for less than 48 h, but its effect lasts for over six months. Two subcutaneous injections per year consistently lowers LDL-C by approximately 55% with a favorable safety profile. In combination with other LLTs, it can achieve LDL-C reductions of over 80%, supporting its role in high-intensity LLT strategies. Summary Inclisiran represents a novel class of LLT. Administered biannually, reduces baseline LDL-C levels by half. Additionally, it has a strong safety profile. Due to its pharmacokinetic properties, is likely to improve adherence to LLT and persistently maintain low LDL-C levels.

BackgroundA key aim in secondary prevention of acute coronary syndrome (ACS) is reduction in low density lipid cholesterol (LDL-C). All patients with established coronary artery disease (CAD) should be on appropriate therapy to achieve this. The purpose of this study is to evaluate the lipid levels of ACS patients and the efficacy of lipid lowering therapy in an outpatient clinic that reviews these patients following percutaneous coronary intervention (PCI).MethodA retrospective analysis was conducted on 105 consecutive patients who were admitted for treatment of ACS at our district general hospital, and successfully revascularised with PCI. They were reviewed at the nurse-led post-PCI clinic, with particular emphasis on the lipid- lowering drug therapy being utilised and assessment of LDL-C levels. A 4-month follow-up was performed, and a therapeutic goal was defined as LDL-C value below 1.4mmol/L according to the latest ESC guidelinesResultsData was collected from 105 patients. All patients reported good concordance with their medical therapy. 67 patients (63.8%) achieved an LDL-C of <1.4mmol/l on either a combination of statin and ezetimibe (n=44, 41.9%) or statin alone (n=23, 21.9%). 34 patients (32.4%) had an LDL >1.4 despite being on lipid lowering drugs (either in combination [n=14, 13.3%] or as monotherapy [n=5, 4.8%]). 4 patients were not on any treatment due to reported intolerance to both statin therapy and ezetimibe. Significantly higher proportion of patients on statin and ezetimibe (40%) achieved the target LDL compared to 29% with statin alone (p=0.023). The post PCI clinic helped to identify the potential candidates for inclisiran or PCSK9 inhibitors who did not achieve the target.ConclusionStatin and ezetimibe monotherapy may not be sufficient in reaching target LDL-C in ACS patients. Combination therapy was more effective in achieving LDL-C target than statin monotherapy. There should be consideration of lower thresholds for initiation of additional lipid lowering therapies in order to achieve appropriate LDL-C targets, such as Inclisiran/PCSK9 inhibitors.Conflict of InterestNil