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Lipid lowering in PAD patients

Commented by Christine Espinola-Klein; section Peripheral Arterial Disease

ESC Working Groups
Prevention


Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease: Insights From the FOURIER Trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk); Bonaca MP et al

Patients with peripheral artery disease (PAD) are at very high risk for cardiovascular events, therefore lipid lowering has a high level of recommendation in the current ESC guidelines “Peripheral artery diseases” [1]. In particular, statins are recommended to improve cardiovascular prognosis and clinical symptoms of intermittent claudication (IA recommendation). 

In the Fourier (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) study evolocumab reduced low-density lipoprotein cholesterol and cardiovascular events in patients with atherosclerotic disease [2, 3]. In the subgroup of patients with PAD of lower extremities MALE (major adverse limb events) have also been reduced in the treatment arm [3]. Recently the results from the ODYSSEY outcomes study have been published [4]. Patients were randomized to alirocumab or placebo after an acute coronary syndrome. Alirocumab significantly reduced a composite endpoint of cardiovascular death, myocardial infarction, stroke, or unstable angina requiring hospitalization. In the current subgroup analysis prognosis was improved especially in patients with additional atherosclerosis in the carotid or peripheral arteries [5].

In contrast to guideline recommendations and current publications, PAD patients are still undertreated concerning lipid lowering therapy. Two major studies show that compared to patients with coronary artery disease only a minority of PAD patients are treated with high intense statins such as atorvastatin or rosuvastatin [6, 7]. In fact, treatment with high intensive statins reduced mortality and amputation rate in PAD patients compared with patients treated with simvastatin [7].

In conclusion, patients with PAD have a large improvement from intensive lipid lovering therapy using stains and PCSK9 inhibitors. In clinical practice there is an urgent need for more consequent treatment of these high risk patients.

 

References


  1. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC/ESVS Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017 Aug 26. doi: 10.1093/eurheartj/ ehx095.
  2. Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med. 2017; 376: 1713-1722.
  3. Bonaca MP, Nault P, Giugliano RP, et al. Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease: Insights From the FOURIER Trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk). 2018; 137: 338-350.
  4. Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome. N Engl J Med. 2018; 379: 2097-2107.
  5. Jukema JW, Szarek M, Zijlstra LE,et al. Patients with Recent Acute Coronary Syndrome and Polyvascular Disease Derive Large Absolute Benefit from Alirocumab: ODYSSEY OUTCOMES Trial. J Am Coll Cardiol. 2019 Mar 12. pii: S0735-1097(19)33921-X. doi: 10.1016/j.jacc.2019. 03.013.
  6. März W, Dippel FW, Theobald K, et al. Utilization of lipid-modifying therapy and low-density lipoprotein cholesterol goal attainment in patients at high and very-high cardiovascular risk: Real-world evidence from Germany. 2018 Jan;268:99-107.
  7. Arya S, Khakharia A, Binney ZO, et al. Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease. Circulation. 2018; 137:1435–1446.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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