The Egyptian Association of Vascular Biology and Atherosclerosis (EAVA) Perspectives on the Usage of Inclisiran.

BACKGROUND: Elevation of low-density lipoprotein cholesterol (LDL-c) is still a hugely unmet need in the reduction of atherosclerotic cardiovascular disease. In the published CardioRisk project in Egypt, up to 71% of female participants had dyslipidemia. Control of LDL-c levels and thus improvement of hyperlipidemia is quite often very difficult. With the introduction of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, the decrease of significant cardiac adverse events, the patient control rate, and the death rate have all been improved. Inhibition of the formation of PCSK9 through inclisiran, which is a novel method of reducing LDL-c and is only given twice per year, seems alluring. After revision of published data, we analyzed the potential advantages of the use of inclisiran. CONCLUSION: The Egyptian Association for Vascular Biology and Atherosclerosis (EAVA) analyzed the data necessary for obtaining clear indications for the usage of inclisiran. We propose the addition of inclisiran to statins with or without ezetimibe for patients with documented atherosclerotic cardiovascular disease (ASCVD) or similar risk, familial hypercholesterolemia (FH) with another major risk factor, and very high and high risk diabetes mellitus, who did not reach LDL-c goals and/or with true statin intolerance. Inclisiran is also recommended as upfront therapy, with triple combination, in extreme risk subjects such as those with post acute coronary syndromes (ACS).

Egyptian Atherosclerosis and Vascular Biology Association Consensus on the Use of Sodium Glucose Cotransporter-2 Inhibitors in Heart Failure with Reduced Ejection Fraction.

Heart failure (HF) is a common cause of cardiovascular mortality and morbidity. Despite advances in treatment, the prognosis remains poor. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors decrease HF events by 27-39% in high-risk patients with type 2 diabetes mellitus (T2DM). Moreover, the DAPA-HF and EMPEROR-Reduced studies randomized patients with HF with reduced ejection fraction (HFrEF) with or without diabetes mellitus to receive guideline-directed medical therapy versus guideline-directed medical therapy plus an SGLT-2 inhibitor. Both studies showed the benefits of SGLT-2 inhibitors. In addition, SGLT-2 inhibitors have shown improvement according to the EMPEROR-Preserved study of HF with preserved ejection fraction (HFpEF). Therefore, a panel of cardiology experts from the Egyptian Atherosclerosis and Vascular Biology Association (EAVA) revised the literature for SGLT-2 inhibitors in HF, along with the recommended indications and contraindications, and this article presents their consensus on the topic. The panel concluded that SGLT-2 inhibitors have significantly benefited patients with chronic HFrEF, as indicated through the DAPA-HF and EMPEROR-Reduced trials. The panel recommended early use of dapagliflozin 10 mg or empagliflozin 10 mg in patients with symptomatic chronic HFrEF, whether diabetic or non-diabetic, to ameliorate HF hospitalization rate, mortality, symptoms, and decline in renal function.

Egyptian Association of Vascular Biology and Atherosclerosis (EAVA) consensus on the usage of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.

BACKGROUND: The current expert view of the PCSK9 inhibitors' use in Egypt is still ambiguous. MAIN BODY: Hyperlipidemia is an important, if not the most important, risk factor for the occurrence of atherosclerosis worldwide. Egypt is the most populous country in the Middle East and North Africa and has > 15% of the cardiovascular deaths in the region. The burden of dyslipidemia as seen in the recently published CardioRisk project conducted throughout Egypt shows a high prevalence of dyslipidemia as a risk factor that is still reaching up to 71% in female participants. Reaching the targets for LDL lowering, and thus control of hyperlipidemia, is quite often very difficult especially with the update of the last ESC guidelines. With the advent of PCSK9 inhibitors, the control rate of patients, reduction of cardiac major adverse events, and mortality have been improved. However, Egypt is not considered a rich country on the grounds of annual income, and this raises a concern on which patients would benefit from these expensive medications. Revising the randomized control trials, we analyzed the data that would enable us to control LDL in those patients, at risk, to obtain simple clear indications for the use of these rather expensive medications. CONCLUSION: We recommend the use of PCSK9 inhibitors in addition to statins ± ezetimibe in patients with ASCVD, by definition at very high risk; patients with ASCVD at very high risk who do not tolerate appropriate doses of at least three statins; and familial hypercholesterolaemia patients with clinically diagnosed ASCVD, at very high cardiovascular risk.

Multi-slice CT coronary angiography assessment of remodeling index in patients with low- to intermediate-risk stable angina.

BACKGROUND: Early identification of vulnerable plaques by remodeling index prior to rupture and development of acute event is of considerable importance especially by a reliable non-invasive method as CT coronary angiography (CTA), so we aim to evaluate coronary artery remodeling index in patients with low- to intermediate-risk stable angina by CTA. RESULTS: This single-center, cross-sectional, observational study included 150 patients with stable angina with normal resting ECG, negative markers, normal systolic function by 2D echocardiography (EF > 50%), and without regional wall motion abnormality at rest who were referred to MSCT evaluation of the coronary artery tree; the mean age was 56.8 ± 6.4 years, 83.3% had one-vessel disease, and 16.7% had two-vessel diseases. The mean remodeling index (RI) was 1.04 ± 0.28, 38% had significant positive remodeling, LAD was the most affected vessel (55.3), and proximal lesions were predominant in 48.5%; there was a statistically significant positive correlation between RI and cholesterol, triglyceride, LDL, duration of DM, HBA1c, and plaque burden (P < 0.001) and a statistically significant negative correlation with HDL (P < 0.001). Predictors of higher RI were positive family history, diabetes mellitus, low HDL, HBA1c, and plaque burden% (P < 0.001). Patients with remodeling index > 1.1 were diabetic, hypertensive, smoker, with longer duration of diabetes mellitus, higher HBA1c, cholesterol, triglyceride, LDL, plaque burden, wall lumen ratio, stenosis area, and lower HDL. CONCLUSION: CTA was able to detect the presence and extent of early, non-obstructive but significant coronary artery-positive remodeling in patients with low- to intermediate-risk stable angina patients. TRIAL REGISTRATION: NCT03963609 , 22 May 2019.

The pattern of risk-factor profile in Egyptian patients with acute coronary syndrome: phase II of the Egyptian cross-sectional CardioRisk project.

BACKGROUND: Egypt is the most populous country in the Middle East and North Africa and has more than 15% of the cardiovascular deaths in the region, but little is known about the prevalence of traditional risk factors and treatment strategies in acute coronary syndrome (ACS) patients across Egypt. METHODS: From November 2015 to August 2017, data were collected from 1 681 patients with ACS in 30 coronary care centres, covering 11 governorates across Egypt, spanning the Mediterranean coast, Nile Delta and Upper Egypt, with a focus on risk factors and management strategies. RESULTS: Women constituted 25% of the patients. Premature ACS was common, with 43% of men aged less than 55 years, and 67% of women under 65 years. Most men had ST-elevation myocardial infarction (STEMI) (49%), while a larger percentage of women had unstable angina and non-ST-elevation myocardial infarction (NSTEMI) (32% each; p < 0.001). Central obesity was present in 80% of men and 89% of women, with 32% of men and women having atherogenic dyslipidaemia. Current smoking was reported by 62% of men and by 72% of men under 55 years. A larger proportion of women had type 2 diabetes (53 vs 34% of men), hypertension (69 vs 49%), dyslipidaemia, and obesity (71 vs 41%) (p < 0.001 for all). There were no gender differences in most diagnostic and therapeutic procedures, but among STEMI patients, 51% of men underwent primary percutaneous coronary intervention compared to 46% of women (p = 0.064). CONCLUSIONS: Central obesity and smoking are extremely prevalent in Egypt, contributing to an increased burden of premature ACS, which warrants tailored prevention strategies. The recognised tendency worldwide to treat men more aggressively was less pronounced than expected.

Centralized Pan-Middle East Survey on the Under-Treatment of Hypercholesterolemia: Results from the CEPHEUS II Study in Egypt.

INTRODUCTION: As part of the CEPHEUS study, CEPHEUS I was conducted in 2010 and 2011 in Cairo and then the CEPHEUS II study was carried out in Alexandria and Delta Regions in Egypt between April 2014 and August 2015 to determine the proportion of dyslipidemic patients on lipid-lowering treatment reaching LDL-C treatment goals. METHODS: We conducted an open-label, observational, multicenter, cross-sectional survey where 90 investigators enrolled 1127 patients receiving lipid-lowering drugs for at least 3 months. After signing informed consent forms, the study questionnaires were completed by patients and investigators. Blood samples were taken for laboratory investigations. Patients with missing LDL-C data were excluded from the analysis and results from 896 patients were analyzed according to European Atherosclerosis Society and EAS/ESC 2011 guidelines. RESULTS: Out of 896 patients enrolled based on the risk stratification of EAS/ESC 2011 guidelines, 12.4% were classified as low risk, 20.0% as moderate risk, 2.5% as high risk, and 65.2% as very high risk. Achievement goals were 84.7, 44.7, 18.2, and 22.3% for low-risk, moderate-risk, high-risk, and very high risk patients, respectively, with an overall achievement goal of 34.4%. The study population included 50.2% diabetes, 64.4% hypertension, 54.9% metabolic syndrome, 32.2% family history of cardiovascular disease, 23.1% smokers, and 33.8% secondary prevention. Lipid-lowering agents were prescribed as a monotherapy to 90.1% and in combination in 9.9% with goal achievements of 34 and 38%, respectively (p > 0.05). Statins were prescribed to 86.9% of patients. The most frequent prescribed statins were rosuvastatin (47.1%) and atorvastatin (36.0%), followed by simvastatin (9.2%). Treatment goal was achieved in 34.2, 36.0, and 31.7% for rosuvastatin, atorvastatin, and simvastatin, respectively, with no significant difference in achievement goals (p > 0.05). CONCLUSIONS: Hypercholesterolemia is still not being effectively managed in many at-risk patients in Egypt. The majority of patients enrolled in the study were being actively treated with lipid-lowering medications yet the percentage goal achievement was less when compared to CEPHEUS results.