‘Striking’ Benefit of Lipid Lowering in Primary Prevention

Dr Steve Nissen

SAN DIEGO – A brand new evaluation of a large-scale trial of a novel lipid-lowering agent has proven a very giant discount in cardiovascular occasions within the major prevention inhabitants enrolled within the examine, two thirds of whom additionally had kind 2 diabetes, resulting in requires extra consideration to be paid to this group of sufferers.

The principle outcomes of the CLEAR Outcomes trial of bempedoic acid (Nexletol, Esperion) in a blended secondary and first prevention inhabitants illiberal to statins, reported on the American Faculty of Cardiology/World Congress of Cardiology 2023 assembly, confirmed a 13% relative threat discount in the principle major endpoint, a composite of cardiovascular dying, myocardial infarction (MI), stroke, or coronary revascularization.

This new evaluation of the 4206 high-risk major prevention sufferers within the examine — 67% of whom additionally had kind 2 diabetes — has proven a 30% relative threat discount in the identical endpoint.   

Different key endpoints have been diminished to an identical and even larger extent, with the composite of cardiovascular dying/stroke/MI displaying a 36% relative threat discount, and a 39% relative threat discount for cardiovascular dying and MI individually.

“These outcomes are frankly placing,” lead investigator Steve Nissen, MD, instructed Medscape Medical Information

“These are actually giant reductions. These outcomes are telling us that high-risk major prevention sufferers, though their absolute occasion charge is decrease than secondary prevention sufferers, can have very spectacular relative threat reductions in main cardiovascular occasions with lipid-lowering remedy,” he stated.

However Nissen, who’s chief tutorial officer on the Coronary heart Vascular & Thoracic Institute at Cleveland Clinic, Ohio, identified that this inhabitants of sufferers just isn’t nicely handled. 

“That is the issue: lower than half of high-risk major prevention sufferers within the US, and in nearly each different developed nation, are receiving cholesterol-lowering medicine. These sufferers are inclined to get ignored,” he burdened. 

Requested what recommendation he would give to clinicians primarily based on the present findings, Nissen stated: “If a affected person is at excessive threat of creating heart problems, significantly these with [type 2] diabetes, they should go on a lipid-lowering drug.” 

“If sufferers can tolerate a statin then that must be the primary selection. We all know statins work, and they’re now cheap. They’re probably to offer the very same profit as we’ve proven on this examine with bempedoic acid, as the 2 drug courses work by very comparable mechanisms. But when sufferers cannot tolerate a statin, then deal with them with bempedoic acid. The underside line is that these sufferers simply have to be handled,” he stated.

Wake-Up Name

He stated these new outcomes are a “wake-up name for the medical neighborhood that we have to pay much more consideration to high-risk major prevention sufferers.”

Nissen doesn’t imagine the impact is restricted to bempedoic acid; relatively, it’s extra probably an impact of reducing low-density lipoprotein ldl cholesterol (LDL-C) ranges. 

“This message just isn’t about bempedoic acid, specifically. We’ve seen comparable findings in historic research with the statins, however that appears to have been forgotten. The message is about reducing LDL in sufferers who’re at excessive threat of getting a primary cardiovascular occasion. We have to establish sufferers at excessive threat for a primary cardiac occasion and get them on a cholesterol-lowering drug — and typically that will likely be a statin.”

Nissen introduced the new evaluation from the CLEAR OUTCOMES trial right here on the American Diabetes Affiliation (ADA) 83rd Scientific Classes on June 24. It was concurrently printed on-line within the Journal of the American Medical Affiliation (JAMA).

He identified that enormous trials of lipid-lowering remedy within the major prevention inhabitants haven’t been accomplished for a few years. 

“All of the modern trials with lipid-lowering remedy have solely included secondary prevention sufferers and so they usually enroll sufferers after an acute coronary syndrome occasion.

“However for the CLEAR OUTCOMES trial, we included a major quantity of major prevention sufferers — these with threat components equivalent to [type 2] diabetes and hypertension who’re thought-about to be at excessive threat of creating heart problems,” he defined.

CLEAR OUTCOMES was a masked, randomized, trial that enrolled 13,970 statin-intolerant sufferers. The new evaluation included 4206 of these sufferers with threat components for coronary heart illness however with out a prior cardiovascular occasion — the first prevention group. The imply age of those members was 68 years, 67% had diabetes, and 59% have been girls.

Therapy with bempedoic acid confirmed a 22% discount in LDL-C in contrast with placebo, with a discount of 30.2 mg/dL from a imply baseline of 142.5 mg/dL. Excessive-sensitivity C-reactive protein (CRP) ranges have been additionally diminished by 0.56 mg/L (21.5%), from a median baseline of two.4 mg/L.

Nissen instructed a press briefing on the ADA assembly that he believes “it is the mixture of LDL reducing and discount in CRP which may have been the driving force [for the effects we saw in the trial]. Actually, bempedoic acid lowers each.”

And he famous the latest US approval of a brand new low dose of colchicine 0.5 mg (Lodoco, Agepha Pharma) with a broad indication to be used in atherosclerotic heart problems (ASCVD), which represents a very new method to remedy, particularly concentrating on irritation as a driver of atherosclerosis.

Bempedoic acid is a prodrug that works alongside the identical pathways as statins however doesn’t trigger muscle ache, which makes many individuals illiberal to statins. Bempedoic acid was first authorized by the US Meals and Drug Administration in 2020 for the remedy of adults with heterozygous familial hypercholesterolemia or established ASCVD who require further LDL-C reducing.

Better Profit in Major Prevention?

On this major prevention group, remedy with bempedoic acid for 40 months was related to a major threat discount for the first endpoint — a composite of cardiovascular dying, nonfatal MI, nonfatal stroke, or coronary revascularization — which occurred in 5.3% of the remedy group versus 7.6% within the placebo group (adjusted hazard ratio (HR), 0.70; P = .002). This represents a 30% relative threat discount in main cardiovascular occasions.

Different key secondary endpoints additionally confirmed spectacular reductions.

The speed of the composite endpoint of cardiovascular dying, MI, or stroke was 6.4% within the placebo group and 4.0% with bempedoic acid (HR, 0.64; P < .001); MI occurred in 2.2% versus 1.4% (HR, 0.61), cardiovascular dying in 3.1% versus 1.8% (HR, 0.61), and all-cause mortality in 5.2% versus 3.6% (HR, 0.73), respectively.

Adversarial results with bempedoic acid included a better incidence of gout (2.6% vs 2.0%), cholelithiasis (2.5% vs 1.1%), and will increase in serum creatinine, uric acid, and hepatic enzyme ranges.

Nissen believes these outcomes recommend that there could also be a larger good thing about lipid reducing in high-risk major prevention sufferers than within the secondary prevention inhabitants.

“It could appear paradoxical, however there may be truly some historical past that this can be the case,” he stated.

He pointed out that the JUPITER trial of rosuvastatin in 2008 was the final main major prevention trial of a lipid-lowering agent, which was stopped early with a 44% discount of the first endpoint.

He famous that one of many arguments in opposition to using statins in major prevention is the assumption that absolute threat reductions are fairly modest.

“However on this evaluation, we discovered an absolute threat discount of two.3% for the first endpoint. That is a quantity wanted to deal with to forestall 1 occasion of 43. That is fairly good,” he commented.

Attempting to clarify why there could also be extra profit within the major prevention inhabitants, Nissen recommended that these sufferers might have extra susceptible plaques.

“I feel high-risk major prevention sufferers in all probability have a number of lipid-laden plaque — some individuals name it ‘susceptible’ plaque. These are softer, cholesterol-laden plaque. We all know that remedy with cholesterol-lowering medicine causes these plaques to shrink. The lipid core is delipidated and the plaque stabilizes,” he defined.

“It could be that in secondary prevention sufferers to some extent the horse is already out of the barn — they’ve superior illness. However major prevention sufferers might have plaques which are extra amenable to modification by ldl cholesterol reducing.”

He admitted that the thought is barely hypothesis. “However that could be a potential clarification for our observations.”

Editorial Cautious

In an accompanying editorial, additionally printed in JAMA, Dhruv S. Kazi, MD, Beth Israel Deaconess Medical Middle, Boston, Massachusetts, says the findings have to be interpreted with warning as they arrive from certainly one of many subgroup analyses of a bigger trial.

Kazi additionally factors out that the intervention and management survival curves separate straight away, on the primary day of follow-up, whereas the true impact of lipid-lowering remedy for major prevention can be anticipated to have a considerably delayed onset, an commentary he says helps the argument that this can be a likelihood discovering.

Kazi additionally reminds clinicians that bempedoic acid shouldn’t be thought to be an alternative to statins, which ought to stay the first-line remedy for major prevention.

“For now, obtainable proof means that though bempedoic acid just isn’t an ideal substitute for a statin, it’s a cheap therapeutic selection for major prevention of ASCVD occasions in high-risk, statin-intolerant sufferers,” he concludes.

ADA 2023. Offered June 24, 2023.

JAMA. Revealed on-line June 24, 203. Full textual content, Editorial

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