背景:2021年加拿大心血管学会(CCS)指南建议对动脉粥样硬化性心血管疾病(ASCVD)患者强化低密度脂蛋白胆固醇(LDL-C)降低。对于最大耐受他汀类药物高于LDL-C阈值的患者,建议添加依泽替米贝和/或原蛋白转化酶枯草杆菌蛋白酶/kexin9型抑制剂(PCSK9i)。这种以人口为基础的,真实世界研究检查了服用他汀类药物且LDL-C水平高于当前指南阈值的ASCVD患者的心血管(CV)事件.
方法:使用艾伯塔省的行政健康数据,加拿大,我们确定了心肌梗死(MI)的患者,缺血性卒中(IS),或在2010年4月1日至2016年3月31日期间服用他汀类药物的LDL-C>1.8mmol/L的外周动脉疾病。探索性亚组包括非常高风险的ASCVD患者,这些患者被证明从CCS指南确定的PCSK9i强化中获得最大益处。包括患有急性冠脉综合征(ACS)或近期MI的患者。个体和复合CV事件的频率和发生率(主要结果:MI,IS,不稳定型心绞痛住院,冠状动脉血运重建,心血管死亡;次要结果:MI,IS,CV死亡)是在随访期间计算的。
结果:该研究包括32,984例患者,平均(标准差)随访40.8(21.0)个月。总的来说,17.7%和15.6%经历了主要和次要结果,分别,每100名患者年的比率为5.58和4.83,分别。CV死亡和MI是最常见的事件。患有复发性MI和糖尿病共病的亚组表现出更高的CV事件发生率(23.6%和22.2%有主要结局,分别)。在ACS或近期MI患者中,CV事件发生率明显较高(49.4%和54.0%为主要结局,分别)。
结论:这项现实世界的研究证实,他汀类药物治疗的ASCVD和LDL-C水平高于阈值的高危患者有相当高的CV事件复发发生率。这些发现加强了在高危患者中强化降脂治疗的机会,以降低CV风险。
BACKGROUND: The 2021 Canadian Cardiovascular Society (CCS)
guidelines recommend intensive low-density lipoprotein cholesterol (LDL-C) reduction for patients with atherosclerotic cardiovascular disease (ASCVD). For patients above LDL-C threshold on maximally tolerated statins, adding ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) is recommended. This population-based, real-world study examined cardiovascular (CV) events in patients with ASCVD who are on statins and above current
guideline threshold LDL-C levels.
METHODS: Using administrative health data in Alberta, Canada, we identified patients with myocardial infarction (MI), ischemic stroke (IS), or peripheral artery disease with LDL-C > 1.8 mmol/L on statins between April 1, 2010 and March 31, 2016. Exploratory subgroups included very high-risk patients with ASCVD shown to derive the most benefit from PCSK9i intensification as identified by the CCS
guidelines, including those with acute coronary syndrome (ACS) or recent MI. Frequencies and rates of individual and composite CV events (primary outcome: MI, IS, hospitalization for unstable angina, coronary revascularization, cardiovascular death; secondary outcome: MI, IS, CV death) were calculated over follow-up.
RESULTS: The study included 32,984 patients with a mean (standard deviation) follow-up of 40.8 (21.0) months. Overall, 17.7% and 15.6% experienced a primary and secondary outcome, respectively, with rates of 5.58 and 4.83 per 100 patient-years, respectively. CV death and MI were the most common events. Subgroups with recurrent MI and comorbid diabetes exhibited higher CV event rates (23.6% and 22.2% had a primary outcome, respectively). Rates of CV events were notably high in patients with ACS or recent MI (49.4% and 54.0% had a primary outcome, respectively).
CONCLUSIONS: This real-world study confirms that statin-treated high-risk patients with ASCVD and above-threshold LDL-C levels have substantial incidence of recurrent CV events. These findings reinforce the opportunity for lipid-lowering therapy intensification in high-risk patients to levels below
guideline-recommended threshold in order to reduce CV risk.