In Brief | Cardiovascular Diseases |
Intensive LDL Cholesterol Lowering in ASCVD: Alternative Strategies and Outcomes
Time to read: 03: 23
Time to listen: 08:51
Originally Published: 20 December 2024
Sourced: JAMA Cardiology
Type of article: In Brief
MedED Catalogue Reference: MIBC006
Category: Cardiovascular Disease
Cross Reference: Gerontology
Keywords: cardiovascular diseases, statins, LDL, cholesterol
An alternative LDL-lowering strategy may be as effective as high-intensity statins in reducing cardiovascular events in ASCVD patients
This is a review of original research published in JAMA Cardiology,20 December 2024. This article does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information.
Intensive low-density lipoprotein (LDL) cholesterol lowering is recommended for high- and very high-risk atherosclerotic cardiovascular disease (ASCVD) patients. High-intensity statins are the first-line treatment in these patients; however, concerns regarding long-term safety and patient adherence remain.
Combining moderate-intensity statins with cholesterol absorption inhibitors such as ezetimibe has been proposed as an alternative approach to reduce statin-related adverse effects while maintaining effective LDL-lowering.
Prior to this study, most clinical trials comparing alternative LDL-lowering strategies with high-intensity statins primarily focused on efficacy, with limited data on adverse effects. This study, published in JAMA Cardiology, sought to address this unmet clinical need.
To compare the long-term efficacy and safety of an alternative LDL cholesterol–lowering strategy versus a high-intensity statin strategy in patients with ASCVD.
Study Methodology
The moderate-intensity statin plus ezetimibe combination in RACING and the treat-to-target LDL-C strategy in LODESTAR were classified as alternative LDL-lowering strategies.
Individual patient data from both trials were pooled and analysed using a 1-stage approach, allowing for a more precise comparison between alternative strategies and standard high-intensity statin therapy.
Findings
Data from 8,180 patients with ASCVD (mean age 64.5 years; 26.7% female, 73.3% male) were analysed.
This individual patient data meta-analysis suggests that an alternative LDL cholesterol-lowering strategy is non-inferior to high-intensity statin therapy in reducing 3-year cardiovascular events and mortality in ASCVD patients.
Additionally, the alternative strategy was associated with lower LDL cholesterol levels, reduced risk of new-onset diabetes, and improved treatment tolerance. These findings support the consideration of alternative LDL-lowering strategies as a viable option in ASCVD management, particularly for patients at risk of statin-related adverse effects.
Conclusion
The researchers conclude these findings support the consideration of alternative LDL-lowering strategies as a viable option in ASCVD management. The study demonstrated comparable efficacy in relation to the primary outcomes, with an associated reduction in LDL cholesterol levels and a lowered risk of developing new-onset diabetes or drug-intolerance.
Importance of this study for South Africa
Dyslipidaemia is a key modifiable risk factor for atherosclerotic cardiovascular disease. In South Africa, there is limited data on LDL-C goal attainment in patients at very high cardiovascular risk who are on the maximum tolerated statin therapy, with or without ezetimibe.
A 2020 study found that increasing the statin dose to its registered maximum and adding ezetimibe helped an additional 34.5% of patients reach their LDL-C target. These findings align with recent evidence suggesting that this approach may offer a cost-effective alternative, lowering LDL cholesterol levels while also reducing the risk of new-onset diabetes and treatment intolerance.3
Additional References
1. Kim, B. K., Hong, S. J., Lee, Y. J., Hong, S. J., Yun, K. H., Hong, B. K., Heo, J. H., Rha, S. W., Cho, Y. H., Lee, S. J., Ahn, C. M., Kim, J. S., Ko, Y. G., Choi, D., Jang, Y., Hong, M. K., & RACING investigators (2022). Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial. Lancet (London, England), 400(10349), 380–390. https://doi.org/10.1016/S0140-6736(22)00916-3
2. Lee, Y. J., Hong, S. J., Kang, W. C., Hong, B. K., Lee, J. Y., Lee, J. B., Cho, H. J., Yoon, J., Lee, S. J., Ahn, C. M., Kim, J. S., Kim, B. K., Ko, Y. G., Choi, D., Jang, Y., Hong, M. K., & LODESTAR investigators (2023). Rosuvastatin versus atorvastatin treatment in adults with coronary artery disease: secondary analysis of the randomised LODESTAR trial. BMJ (Clinical research ed.), 383, e075837. https://doi.org/10.1136/bmj-2023-075837
3. Blom DJ, Ranjith N, Joshi P, Naidoo P, van Tonder A, Musa MG, Joshi S, Leisegang R, Trokis JS, Makan H, Raal FJ. The therapeutic management of South African dyslipidaemic patients at very high cardiovascular risk (CARDIO TRACK): a cross-sectional study. Cardiovasc J Afr. 2020 Sep/Oct;31(5):245-251. doi: 10.5830/CVJA-2020-010. PMID: 33151240; PMCID: PMC8762769.
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