Author: Dr Tim Glenie
Having recently attended the American Heart Association meeting, it was interesting to see the many exciting advances in cardiovascular therapies either on the horizon or recently entered in clinical practice. The striking thing was the ongoing focus on the longstanding known modifiable risk factors.
The BPROAD Trial
The BPROAD trial was presented and simultaneously published in the New England Journal of Medicine. This involved 12,821 patients with type II Diabetes and hypertension who were at increased risk of cardiovascular disease. Randomisation was to either a systolic BP less than 120mmHg or systolic BP less than 140mmHg, with follow up to 5 years. The primary outcomes measured were major adverse cardiovascular events. The trial demonstrated significantly lower outcomes with more intensive BP control (hazard ratio 0.79, p value <0.001). This is in agreement with the previously published SPRINT trial in non diabetic patients and is the first adequately powered trial to address a BP target in this high risk group of patient. It supports intensive BP lowering to less than 120mmHg.
New Approaches to Managing Hyperlipidaemia
There were multiple trials presented looking at novel agents to manage hyperlipidaemia. These involved phase one trials for agents targeting LPa, oral PCSK9 inhibitors and discussion around incliseran for lipid lowering. It was highlighted that these new agents are all in addition to maximal tolerated statin therapies. There was recognition of the fact that we still have much to do to fully utilise the current available and relatively inexpensive therapies.
Cholesterol Management Guidelines
This is highlighted by the 2022 AHA/ACC expert consensus decision pathway published in the JACC. If there is an intervention performed to lower cholesterol it is recommended that repeat lipid profiles be performed between 4-12 weeks post intervention. In the setting of secondary prevention post an ACS event (or at high risk of future events) it is of key importance to introduce maximally tolerated statin dosing aiming for AT LEAST a 50% reduction in LDL level and targeting an LDL level of <1.4mmol/l. In New Zealand this can be attempted initially with 80mg of atorvastatin. If this is not possible due to adverse effects, the patient will now be eligible for PHARMAC funded rosuvastatin. If this does not achieve the LDL target then ezetimide can be added.
The Role of Non-Statin Therapies
There are now multiple non Statin therapies with limited availability in New Zealand and often with high associated patient cost. It is important to realise that the data with these medications all rely on the use of statins and often ezetimide as the baseline therapy. The other interesting comment in the paper is that a zero calcium score should NOT be regarded as a reason to omit statin therapies in a patient who is at high cardiovascular risk otherwise.