Page 4 - Reflections_dyslipidaemia_newsletter4_2023

REFLECTIONS
Dyslipidaemia
Dyslipidaemia Global Newsletter #4 2023

inhibition is a novel strategy that may be considered. than 20,000 patients comparing more with less intensive LDL-C
lowering after ischaemic stroke, more intensive LDL-C lowering
This consensus statement from the Association for Acute was associated with an increased risk of haemorrhagic stroke,
Dyslipidaemia
CardioVascular (ACVC), in collaboration with the European while the rate of recurrent stroke and MACE were reduced. But
Association of Preventive Cardiology (EAPC) and the European the number needed to treat to prevent a recurrent stroke within
Society of Cardiology (ESC) working group on cardiovascular four years was 90 and for preventing a MACE was 35, while
pharmacotherapy review the evidence to support this new the number needed to harm for a haemorrhagic stroke was
approach and focus on the hurdles and solutions to provide 242. Therefore, the benefits and risks of more intensive LDL-C
high-quality, evidence-based follow-up care in post-ACS lowering might be more favourable overall as compared to
patients. less intensive LDL-C, especially in patients with atherosclerotic
disease.
Most lipid-lowering drug studies have focused on the degree of
LDL-C lowering rather than the rapidity of lipid lowering. Time is The proposed lipid-lowering algorithm stratifies patients
of particular importance post-ACS when patients are at elevated to statin-naïve, patient on statin, or patient with suspected
risk of recurrent events. High-intensity statin treatment has been statin intolerance. For those that are statin-naïve, the authors
shown to reduce LDL-C by 50% and combination with ezetimibe recommend immediately initiating high-intensity LLT, preferably
reduces LDL-C by 65% from baseline. While the rapidity of before coronary angiography. For those currently on a statin,
LDL-C lowering has not been systematically assessed, the it is important to continue high-intensity statin therapy without
authors provide reported results at two weeks after therapy interruption or to escalate to a high-intensity statin. In addition,
initiation, where available. Maximal LDL-C lowering effects were the addition of ezetimibe early after ACS is reasonable. In
seen in the PCSK9-group which had LDL-C levels reduced by those patients with high-risk features, such as multivessel CAD,
50–60% after two weeks of treatment. polyvascular disease, or FH, the authors suggest consideration
of PCSK9i in the acute phase.
The concern that aggressive LDL-C lowering could promote
haemorrhagic stroke was not shown to be true in the The authors highlight that an ideal care pathway for suspected
prespecified ODYSSEY OUTCOMES analysis where the rate statin intolerance has yet to be established, especially in
of haemorrhagic stroke after ACS was almost negligible and not high-risk situations such as in the immediate phase post-ACS.
increased by the PCSK9 antibody alirocumab vs. placebo. In Several studies suggest that muscle symptoms may be due to
addition, in a recent meta-analysis including 11 trials with more a nocebo effect, and that a large percentage of patients were

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