Future directions in CVD prevention
A comprehensive approach involving a combination of LDL-cholesterol (LDL-C) lowering and anti-inflammatory therapy may improve clinical outcomes for appropriately selected patients at risk of cardiovascular disease (CVD), according to Dr San-Hyun Kim of the Seoul National University in Korea.
“LDL-C is the primary target of treatment, and studies have shown that the lower the level, the greater the risk reduction,” said Kim. [N Engl J Med 2004;3501495-1504; N Engl J Med 2005;352:1425-1435] “While statins are the drugs of choice for dyslipidaemia management, non-statin therapies are safe and effective when added to statin therapy.”
Adding ezetimibe has achieved incremental LDL-C lowering with better clinical prognosis. [N Engl J Med 2015;372:2387-2397] More recently, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have demonstrated significant 60 percent reductions in LDL-C with about 15 percent reductions in major adverse cardiovascular events (MACE) in patients already on statin therapy. [N Engl J Med 2017;376:1713-1722; Steg PG, et al, ACC 2018]
“Targeting the inflammatory interleukin pathway offers additional atheroprotection, independent of lipid lowering,” he argued. “For example, canakinumab, which targets interleukin-1b, has shown a 15 percent reduction in MACE. This has been attributed to significant 35–40 percent reductions in high sensitivity C-reactive protein [hsCRP] and interleukin-6, without any change in LDL-C.” [N Engl J Med 2017;377:1119-1131]
Kim emphasized that appropriate therapy selection based on patients’ underlying risk factors is crucial for successful atheroprotection and CVD risk reduction.