Lipid-lowering in ‘very high risk’ patients undergoing coronary artery bypass surgery and its projected reduction in risk for recurrent vascular events: A Monte Carlo stepwise simulation approach

Deo, S. et al. (2023) Lipid-lowering in ‘very high risk’ patients undergoing coronary artery bypass surgery and its projected reduction in risk for recurrent vascular events: A Monte Carlo stepwise simulation approach. Journal of Cardiovascular Pharmacology, 81(2), pp. 120-128. (doi: 10.1097/FJC.0000000000001374) (PMID:36315474)

Abstract

2018 AHA guidelines provide criteria to identify patients at very high-risk (VHR) for adverse vascular events and recommend an LDL-C level < 1.8 mmol/L. Data regarding the 10-year risk for adverse vascular events in CABG patients at VHR and the need for non-statin therapies in the VHR cohort are limited. We queried a national cohort of CABG patients to answer these questions. The projected reduction of LDL-C from stepwise escalation of lipid lowering therapy (LLT) was simulated; Monte Carlo methods were used to account for patient-level heterogeneity in treatment effects. Data on preoperative statin therapy and LDL-C levels were obtained. In the first scenario, all eligible patients not at target LDL-C received high intensity statins, followed by ezetimibe and then alirocumab; alternatively, bempedoic acid was also utilized. The 10-year risk for an adverse vascular event was estimated using a validated risk score. Potential risk reduction was estimated after simulating maximal LLT. Before CABG, 8,948/27,443 patients [(median LDL-C 85 mg/dl) were VHR. In the whole cohort, 31% were receiving high intensity statins. With stepwise LLT escalation, the proportion of patients at target were 60%, 78%, 86% and 97% after high intensity statins, ezetimibe, bempedoic acid and alirocumab respectively. The projected 10-year risk to suffer a vascular event reduced by 4.6%. A large proportion of CABG patients who are at VHR for vascular events fail to meet 2018 AHA LDL-C targets. A stepwise approach, particularly with the use of bempedoic acid, can significantly reduce the need for more expensive PCSK9 inhibitors.

• Item Type: Articles
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: McAllister, Professor David and Hawkins, Professor Neil and Pell, Professor Jill and Sattar, Professor Naveed and Deo, Salil
• Authors: Deo, S., Ueda, P., Sheikh, A. M., Altarabsheh, S., Elgudin, Y., Rubelowsky, J., Cmolik, B., Hawkins, N., McAllister, D., Ruel, M., Sattar, N., and Pell, J.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health; College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Health Economics and Health Technology Assessment; College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health
• Journal Name: Journal of Cardiovascular Pharmacology
• Publisher: Lippincott Williams & Wilkins
• ISSN: 0160-2446
• ISSN (Online): 1533-4023
• Published Online: 12 October 2022
• Copyright Holders: Copyright © 2022 Wolters Kluwer Health, Inc.
• First Published: First published in Journal of Cardiovascular Pharmacology 81(2): 120-128
• Publisher Policy: Reproduced in accordance with the publisher copyright policy