A Lipid-Laden Conference
HOPE-3 – The Effect of Blood Pressure and Cholesterol on Lowering Cognition presented by Jackie Bosch.
As part of the Heart Outcomes Prevention Evaluation-3 (HOPE-3) trial that assessed prevention of CV events with blood pressure and cholesterol lowering medications in intermediate risk patients, originally presented in April at the ACC Scientific Sessions, a subset of the patients underwent additional cognitive and functional assessments. The hope was that improvements in blood pressure and cholesterol control would slow cognitive decline. Of the 12,705 participants in HOPE-3, there were 3,086 older than 70 years of age, with 2,361 completing baseline questionnaires. Of the 2,142 participants living at the end of the study who had done baseline testing, 1,626 completed the final assessment. Despite improvements in blood pressure and cholesterol (using rosuvastatin) there was no difference from placebo treated participants in the decline in processing speed (primary outcome) over 5.6 years. While a negative trial, which may speak to the need for intervention starting at earlier age or for longer periods of time, this study did have a significant silver lining – the absence of signals implicating rosuvastatin in advancing cognitive decline.
In late February of 2012 the FDA released a safety communication with important changes to safety labels of statins. Here, while doing away with routine LFT monitoring for patients on statin therapy, they alerted patients to “memory loss and confusion” related to these medications. This study is a strong addition to the available evidence from observational trials showing a lack of evidence for this assertion and will certainly be reassuring to our patients as we discuss the risks and benefits of initiating statin therapy.
Robert Levy Memorial Lecture: Genetic Risk, Healthy Lifestyle Adherence and Coronary Artery Disease presented by Sekar Kathiresan.
When it comes to primary prevention, there remains an intense debate about exactly which patients should be recommended statin therapy. Currently our toolbox includes imperfect risk calculators based on clinical factors (age, sex, ethnicity, blood pressure, lipids etc). However, it is widely appreciated now that a significant risk for coronary artery disease (CAD) is imparted by the A’s, C’s, G’s and T’s of our DNA. Genome wide association studies have identified over 50 risk alleles associated with an increased risk for CAD. These risks alleles can be used to determine a genetic risk score (a few of which have been developed at this point) that has been shown to be predictive of adverse cardiovascular events in several independent studies. Using genotype information and adverse cardiovascular event data taken from four prior studies – in all accounting for 55,685 patients – Dr. Kathiresan’s group asked if adherence to optimal lifestyle factors (active, non-smoking, non-obese, consuming a healthy diet) offset any of the genetic risk for CAD as assessed by a genetic risk score. Indeed, in each of the populations studied, adherence to a favorable lifestyle significantly reduced adverse cardiovascular events for patients across all categories of genetic risk. Importantly, for patients with the highest genetic risk of CAD, a favorable lifestyle reduced adverse events by nearly half (HR 0.54, 0.47 – 0.63). It remains to be determined if the knowledge of one’s genetic risk score will provide motivation for positive changes in lifestyle modification on a prospective basis (with a small study presented at the posted sessions suggesting not) but our ability to further hone our atherosclerotic risk assessments based on genetic information to more appropriately counsel our patients will certainly be standard soon.
Trends in Statin Use in the U.S. Population – presented by Joseph A. Salami & Khurram Nasir
This poster and simultaneous publication in JAMA-Cardiology examined the publicly available data from Medical Expenditure Panel Survey from 2002-2013 to estimate statin utilization and costs. Strikingly, while statin use has increased substantially in adults over 40 years of age – 27.2% in 2012-2013 compared to 17.9% in 2002-2003 – there remains an inadequate use of any statins in patients with known atherosclerotic cardiovascular disease – 57.1% in 2012-2013 and 49.4% in 2002-2003. The good news is that more of our patients are using generic statins with an overall decreasing cost for these medications. However, the brand-name statins still account for more than half of the total statin costs in 2012-2013.
Effect of Evolocumab on Progression of Coronary Atherosclerosis in Statin-Treated Patients (GLAGOV Trial) presented by Steven Nissen.
Although we’ll have to wait for clinical outcomes data to be presented at a future sessions, PCSK9 inhibitors continued to garner great attention in New Orleans. Steven Nisson reported the results of the GLAGOV Trial on Tuesday showing regression of atherosclerotic plaque volume as assessed via intravascular ultrasound in patients receiving evolocumab on top of statin therapy. Though, the picture is not so simple given that 35% of the patients on evolocumab had plaque progression. More impressive are the LDL’s of 20.
Evan Muse, MD, PhD, MCTI
Assistant Professor, Scripps Translational Science Institute, La Jolla, Calif.
Evan Muse is an Assistant Professor at the Scripps Translational Science Institute and Cardiologist at The Scripps Clinic in La Jolla, California. His research mines the transition zone of digital medicine, genomics and atherosclerosis. Join him on Twitter @EvanMuse