Dr Martin Mpe, an interventional cardiologist from South Africa was the keynote speaker at the webinar hosted by Zydus on 8 October. Dr Mpe underscored the pressing need for tailored strategies aimed at preventing recurrent CV events in patients already diagnosed with established ASCVD.
The burden of recurrent CV events remains significant. Each year, ~35 million individuals experience acute coronary syndromes or cerebrovascular events. Alarmingly, 20%-40% of these cases involve patients with a prior history of CVD.
Moreover, the five-year recurrence rate among patients with known CV conditions is around 30%, a statistic that starkly contrasts with rates seen in individuals without such histories. This highlights the importance of implementing effective secondary prevention measures to mitigate these risks.
Dr Mpe strongly emphasised that employing effective secondary prevention strategies can lead to a remarkable 75%-80% reduction in recurrent CV events through the application of evidence-based therapies. Key components of these strategies include the use of aspirin, angiotensin-converting enzyme inhibitors, statins, and beta-blockers, coupled with essential lifestyle modifications such as smoking cessation and adherence to a healthy diet.
Notably, pharmacological treatments can dramatically decrease the risk of subsequent CV events, with statins alone reducing event rates to an impressive 3%. This compelling evidence underscores the necessity for comprehensive and personalised management strategies that can enhance patient outcomes and improve quality of life while simultaneously reducing healthcare costs.
Effective management of dyslipidaemia pivotal in preventing CVD
Effective management of dyslipidaemia plays a pivotal role in the secondary prevention of CVD. The 2021 European Atherosclerosis Society guidelines provide clear recommendations for managing dyslipidaemia.
Essential lifestyle modifications should be prioritised, alongside maintaining blood pressure (BP) <140mmHg, ideally aiming for levels <130mmHg. A critical goal is achieving a minimum 50% reduction in low-density lipoprotein (LDL) cholesterol, targeting levels <1.8mmol/l.
High-intensity statin therapy is integral to this process, with the aim of reaching specified LDL cholesterol goals. In cases where these targets are not met with statin therapy alone, alternative treatments, such as ezetimibe or PCSK9 inhibitors, should be considered.
The relationship between LDL cholesterol reduction and the risk of CVD is well established. Research shows that every 1% decrease in LDL cholesterol corresponds to a one per cent reduction in risk. Effective statin therapy has been shown to lower all-cause mortality by 19% and CVD-related mortality by 27% per cent. However, adherence to statin therapy remains a significant hurdle, with only ~50% of eligible patients receiving these medications and even fewer being prescribed high-intensity statins.
To enhance adherence, Dr Mpe proposed practical strategies to improve the implementation of guidelines and consequently patient outcomes. The five R framework, which encompasses the right information, person, format, channels, and timing, serves as a useful tool for addressing adherence challenges.
Dr Mpe also noted the adverse consequences of discontinuing statin therapy, highlighting that the rate of CV events significantly increases for those who cease taking statins compared to those who maintain their treatment.
The discussion also briefly explored alternative lipid-lowering therapies. Ezetimibe, for instance, inhibits the absorption of dietary cholesterol, leading to an increase in low-density lipoprotein receptor expression and a consequent reduction in LDL cholesterol levels by ~20%.
Bempedoic acid, a newer non-statin option, inhibits an enzyme in the cholesterol biosynthesis pathway, resulting in a reduction in low-density lipoprotein levels ranging from 17%-21%. PCSK9 inhibitors work by preventing the destruction of low-density lipoprotein receptors, thereby increasing low-density lipoprotein clearance and lowering levels by 43% to 64%. Clinical trials have demonstrated that these inhibitors can yield a 15% risk reduction in settings focused on secondary prevention.
Another novel approach, inclisiran, utilises small interfering RNA technology to inhibit the production of PCSK9, achieving similar effects as PCSK9 inhibitors, with reductions in low-density lipoprotein cholesterol of ~50%.
Combination therapy is often necessary to attain optimal reductions in LDL cholesterol, particularly in high-risk patients who do not achieve targets through monotherapy.
Dr Mpe noted that while he typically prescribes high-dose statins, a small proportion of patients may require additional therapies, such as ezetimibe or PCSK9 inhibitors. These patients are often managed by lipid specialists due to the complexity and cost associated with these medications.
In conclusion, lipid-lowering therapy is foundational for treating patients with established atherosclerotic cardiovascular disease, with statins serving as the cornerstone for secondary prevention efforts. Recent discussions have raised concerns regarding the safety of statins, revealing that many reported side effects are likely attributable to nocebo effects, with adverse event rates comparable to placebo in pivotal studies. Emerging lipid-lowering therapies offer additional options for reducing low-density lipoprotein levels beyond the capabilities of statins, thus further decreasing residual risk. The future of dyslipidemia management will hinge on evolving evidence and improving access to these therapies, ultimately aiming to enhance the secondary prevention of cardiovascular disease. The session underscored the complexities inherent in managing dyslipidemia, particularly for patients experiencing statin intolerance, and reiterated the need for personalised treatment approaches.
To watch a replay of the webinar and earn your CPD point, please click here.
