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Application of ESC/EAS Dyslipidemia Guidelines to MI Patient Data
Study Questions:
What proportion of patients with a recent myocardial infarction (MI) would be eligible for additional lipid-lowering therapy based on 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines, and what would be the effect on attaining the recommended target low-density lipoprotein cholesterol (LDL-C) target?
Methods:
Using the nationwide SWEDEHEART register, 25,466 patients who had attended a follow-up visit 6–10 weeks after an MI event between 2013 and 2017 were eligible. 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 <1.4 mmol (<55 mg/dl) and a ≥50% reduction in LDL-C.
Results:
Mean age was 62.5 years with 75% men, and mean baseline LDL-C 123 mg/dl (± 46). 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.
Conclusions:
The 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.
Perspective:
The European guidelines suggest lifestyle modification and high-intensity statins in acute MI at discharge then titration with ezetimibe at 4-6 weeks followed by PCSK9 inhibitors later if target is not reached. The value of achieving very low levels of LDL-C by intensifying treatment at discharge will require a placebo-controlled trial. But there is clear evidence that early intervention with high-intensity statins as compared to lower dosing reduces subsequent event rates related to effect on LDL-C and inflammation. Considering how easily one can estimate the LDL-lowering agent(s) to achieve a target LDL-C of 50 mg/dl or lower, it makes sense to consider high-intensity statins plus ezetimibe in most patients and instituting PCSK9 antibody treatment prior to discharge when LDL-C would likely remain >50 mg/dl (e.g., heterozygous familial hypercholesterolemia and LDL-C >160 mg/dl). There are good safety data with evolocumab prior to discharge in patients with an acute coronary syndrome (Koskinas KC, et al., J Am Coll Cardiol 2019;74:2452-62).
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Primary Hyperlipidemia, Statins
Keywords: Acute Coronary Syndrome, Atherosclerosis, Cholesterol, LDL, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipoproteinemia Type II, Inflammation, Life Style, Myocardial Infarction, Patient Discharge, Primary Prevention, Proprotein Convertases, Subtilisins
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