EAS 2020 — Need for aggressive interventions as Europe fails to meet optimal lipid targets


  • Rashmi
  • Conference Reports
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Takeaway

  • DA VINCI study highlights a gap between the European Society of Cardiology/European Atherosclerosis Society guidelines and clinical practice for lipid management across Europe, with only 54% and 33% of patients achieving their 2016 and more stringent 2019 goals, respectively.
  • Moderate-intensity statin (MIS) monotherapy is still the most widely used lipid-lowering therapy (LLT) across Europe, which even post-optimization leads to low-density lipoprotein-cholesterol (LDL-C) levels above 2.0 mmol/L.
  • Prof Kausik Ray urges the need to change the clinical practice by increasing the usage of combination therapies with ezetimibe and/or proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i).

Why this matters

  • Recent guidelines recommend lowering LDL-C levels as low as possible for cardiovascular risk reduction, but translation in clinical practice needs evaluation.

Study design

  • A cross-sectional, multicenter study used data of 5888 patients receiving LLTs at primary prevention (PP; n=3000) and secondary prevention (SP; n=2888) centres across 18 European countries between June 2017 and November 2018.
  • Primary outcome: risk-based LDL-C goal achievement on stabilized LLTs.
  • Funding: Amgen.

Key results

  • Overall, 2794 patients had established atherosclerotic cardiovascular diseases (ASCVDs) in the SP cohort:
    • cerebral vascular disease: 41%;
    • peripheral artery disease: 37%;
    • coronary disease: 22%; and
    • other vascular diseases: 3%.
  • Predicted 10-year risk for cardiovascular events in 82% and 31% of patients with ASCVD was greater than 20% and 40%, respectively.
  • In the PP cohort, 67% of patients were in the moderate cardiovascular risk group, with 9%, 18% and 3% of patients in low-, high- and very high-risk groups, respectively.
  • Most frequently prescribed LLTs were MIS (52%) and high-intensity statin (28%) monotherapies, followed by ezetimibe combination therapy (9%), whereas PCSK9i combination was used only in 1% of patients.
  • Only 54% and 33% of patients achieved their 2016 and 2019 risk-based LDL-C goals, respectively.
  • In patients with established ASCVDs, the use of LLTs and goal attainment according to 2016 vs 2019 risk-based guidelines were as follows:
    • low-intensity statin monotherapy (2%): 19% vs 13%;
    • MIS monotherapy (44%): 36% vs 16%;
    • high-intensity statin monotherapy (38%): 45% vs 22%;
    • ezetimibe combination (9%): 54% vs 21%;
    • PCSK9i combination (1%): 67% vs 58%; and
    • other LLTs (6%): 15% vs 8%.
  • In PP cohort, MIS monotherapy led to highest LDL-C goal attainment in moderate-risk patients (2016 vs 2019: 81% vs 66%), but suboptimal control in high-risk (63% vs 29%) and very high-risk (23% vs 10%) patients.
  • Mean stabilized LDL-C levels in PP and SP patients were 2.40 mmol/L and 2.02 mmol/L, respectively.
  • Overall, MIS monotherapy yielded mean LDL-C levels of 2.31 mmol/L, and even after optimization with high-intensity statins, the mean levels just lowered to 2.18 mmol/L.

Limitations

  • Cross-sectional design.
  • Baseline LDL-C levels were not measured.
  • Physician choices, pre-treatment LDL-C levels and local prescription restrictions may have influenced outcomes.