The Use of Subclinical Atherosclerosis Imaging to Guide Preventive Cardiology Management.

PURPOSE OF THE REVIEW: Clinical atherosclerotic cardiovascular disease (ASCVD) requires years to manifest, providing a window of opportunity for preventive cardiovascular management. Subclinical atherosclerosis imaging leverages this long latency period to estimate and improve future ASCVD risk. RECENT FINDINGS: Coronary artery calcium (CAC) scoring has the most robust data in the detection of subclinical atherosclerosis. CAC scan significantly enhances cardiovascular risk stratification in addition to traditional risk models. Coronary computed tomography angiography data show similar strengths in subclinical atherosclerosis detection in addition to plaque morphology characterization with inherent limitations. Carotid intima-media thickness and ankle-brachial index are other modalities whose predictive value becomes incremental when added to the aforementioned modalities. When added to traditional risk models, subclinical atherosclerosis imaging modalities personalize future ASCVD risk stratification and assist in the initiation and rate of intensification of preventive therapies. Emerging imaging techniques exist but further research is required for primetime clinical use.

Advanced lipid testing: when, why, and in whom?

Atherosclerotic cardiovascular disease is a leading cause of morbidity and mortality in developed countries. The management of blood cholesterol with the use of statin drugs in at-risk patients is a pillar of medical therapy for the primary and secondary prevention of cardiovascular disease. Although the standard lipid panel is adequate to accurately assess cardiovascular disease risk in most patients, there are some situations in which conventional cholesterol testing does not fully identify cardiovascular risk or reflect disease progression. A number of advanced lipid tests can assist the clinician when assessing a patient's cardiovascular disease risk, including measurement of low-density lipoprotein particle number.

Post-Acute Coronary Syndrome Disparities in Guideline-Directed Lipid Therapy and Insufficient Achievement of Optimal Low-Density Lipoprotein.

Lipid-lowering therapies are an established cornerstone of secondary prevention. For patients with clinical atherosclerotic cardiovascular disease, guidelines provide a class I recommendation for high-intensity statins. Furthermore, patients with low-density lipoprotein cholesterol (LDL-c) levels >70 mg/100 ml are considered at a higher risk for recurrent cardiovascular events. Previous trends in guideline-directed lipid therapy (GDLT) for secondary prevention have noted insufficiencies. In this study, we aimed to explore GDLT-prescribing patterns and assess subsequent effects on outcomes through LDL-c reduction. We used a cross-sectional study across a large, multisite university hospital system. Electronic medical records were queried for all admitted patients diagnosed with acute coronary syndrome. Data were collected for age, gender, race, and prescribed lipid medication at discharge and 1 year after discharge. Chi-square analysis was performed to assess the statistical differences in prescription rates and achieved optimal LDL-c levels. A total of 3,386 patients were studied with 2/3 of the population identified as non-Hispanic White men. Men were prescribed GDLT at a statistically significant higher rate than women, and subsequently, men were found to achieve optimal LDL-c at a statistically significant higher rate. Interestingly, Black and Hispanic patients were prescribed GDLT at the highest rates; however, these patients achieved optimal LDL-c levels at the lowest rates (significance only met for Black patients). East Indian patients achieved optimal LDL-c levels at the lowest rate among all racial groups, despite having average GDLT prescription rates. White and Asian groups achieved optimal LDL-c levels at the highest rates, with average GDLT prescription rates. Among all patients, those who achieved LDL-c levels <70 mg/100 ml were prescribed GDLT at a statistically higher rate than those who did not achieve LDL- c levels <70 mg/100 ml. We found distinct disparities in both GDLT-prescribing rates and achievement of optimal LDL-c levels for patients presenting with clinical atherosclerotic cardiovascular disease. Our findings may help delineate patients who should be considered at a higher risk for recurrent major adverse cardiovascular events. We also found an interesting paradox between GDLT-prescribing patterns and achievement of optimal LDL-c levels among certain racial groups. However, among all patients who achieved LDL-c levels <70 mg/100 ml, the majority were prescribed GDLT, supporting the efficacy of statins. Prescribing GDLT does not reliably achieve optimal LDL-c levels across genders and racial groups for unclear reasons. Our study adds to the growing body of knowledge assessing the complexity in secondary cardiovascular prevention.

Comparative Effects of Low-Dose Rosuvastatin, Placebo, and Dietary Supplements on Lipids and Inflammatory Biomarkers.

BACKGROUND: Supplements are commonly used by individuals with indications for lipid-lowering therapy, but evidence of their effectiveness to lower low-density lipoprotein cholesterol (LDL-C) is lacking, particularly when compared with statins. OBJECTIVES: The trial objective was to compare the efficacy of a low-dose statin with placebo and 6 common supplements in impacting lipid and inflammatory biomarkers. METHODS: This was a single-center, prospective, randomized, single-blind clinical trial among adults with no history of atherosclerotic cardiovascular disease (ASCVD), an LDL-C of 70 to 189 mg/dL, and an increased 10-year risk of ASCVD. Participants were randomized to rosuvastatin 5 mg daily, placebo, fish oil, cinnamon, garlic, turmeric, plant sterols, or red yeast rice. The primary endpoint was the percent change in LDL-C from baseline for rosuvastatin 5 mg daily compared with placebo and each supplement after 28 days. The primary endpoint was evaluated in a hierarchical fashion with rosuvastatin first compared with placebo, then each supplement in a prespecified order using analysis of covariance. RESULTS: A total of 190 participants completed the study. The percent LDL-C reduction with rosuvastatin was greater than all supplements and placebo (P < 0.001). The difference in LDL-C reduction with rosuvastatin compared with placebo was -35.2% (95% CI: -41.3% to -29.1%; P < 0.001). None of the dietary supplements demonstrated a significant decrease in LDL-C compared with placebo. Adverse event rates were similar across study groups. CONCLUSIONS: Among individuals with increased 10-year risk for ASCVD, rosuvastatin 5 mg daily lowered LDL-C significantly more than placebo, fish oil, cinnamon, garlic, turmeric, plant sterols, and red yeast rice. (Supplements, Placebo, or Rosuvastatin Study [SPORT]; NCT04846231).

Effect of Passive Choice and Active Choice Interventions in the Electronic Health Record to Cardiologists on Statin Prescribing: A Cluster Randomized Clinical Trial.

Importance: Statin therapy is underused for many patients who could benefit. Objective: To evaluate the effect of passive choice and active choice interventions in the electronic health record (EHR) to promote guideline-directed statin therapy. Design, Setting, and Participants: Three-arm randomized clinical trial with a 6-month preintervention period and 6-month intervention. Randomization conducted at the cardiologist level at 16 cardiology practices in Pennsylvania and New Jersey. The study included 82 cardiologists and 11 693 patients. Data were analyzed between May 8, 2019, and January 9, 2020. Interventions: In passive choice, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In active choice, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy. Cardiologists in the control group were informed of the trial but received no other interventions. Main Outcomes and Measures: Primary outcome was statin therapy at optimal dose based on clinical guidelines. Secondary outcome was statin therapy at any dose. Results: The sample comprised 11 693 patients with a mean (SD) age of 63.8 (9.1) years; 58% were male (n = 6749 of 11 693), 66% were White (n = 7683 of 11 693), and 24% were Black (n = 2824 of 11 693). The mean (SD) 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was 15.4 (10.0); 68% had an ASVCD clinical diagnosis. Baseline statin prescribing rates at the optimal dose were 40.3% in the control arm, 39.1% in the passive choice arm, and 41.2% in the active choice arm. In adjusted analyses, the change in statin prescribing rates at optimal dose over time was not significantly different from control for passive choice (adjusted difference in percentage points, 0.2; 95% CI, -2.9 to 2.8; P = .86) or active choice (adjusted difference in percentage points, 2.4; 95% CI, -0.6 to 5.0; P = .08). In adjusted analyses of the subset of patients with clinical ASCVD, the active choice intervention resulted in a significant increase in statin prescribing at optimal dose relative to control (adjusted difference in percentage points, 3.8; 95% CI, 1.0-6.4; P = .008). No other subset analyses were significant. There were no significant changes in statin prescribing at any dose for either intervention. Conclusions and Relevance: The passive choice and active choice interventions did not change statin prescribing. In the subgroup of patients with clinical ASCVD, the active choice intervention led to a small increase in statin prescribing at the optimal dose, which could inform the design or targeting of future interventions. Trial Registration: ClinicalTrials.gov Identifier: NCT03271931.

Renin-angiotensin system and atherothrombotic disease: from genes to treatment.

The renin-angiotensin system plays a central role in the pathogenesis of cardiovascular disease. At the molecular and cellular levels, angiotensin II, the main effector peptide of the system, stimulates key components of atherosclerosis. Trials in animals and humans indicate that blocking renin-angiotensin system pathways decreases atherosclerotic plaque progression and ischemic events. This review provides a broad overview of the entire role of the renin-angiotensin system in atherothrombotic disease, ranging from molecular pathways to human genetics to the latest clinical trials.

Updated cholesterol guidelines and intensity of statin therapy.

BACKGROUND: In November 2013, the American College of Cardiology and the American Heart Association released new cholesterol guidelines. Implications of these new guidelines for statin prescription remain uncertain, particularly in individuals already on statin therapy. OBJECTIVE: Our objective was to examine the impact of the guidelines on the intensity of statin therapy at a large academic medical center. METHODS: We queried the electronic health record at the University of Pennsylvania Health System to evaluate current practice patterns at a large academic institution in patients already on statin therapy. RESULTS: Among 40,036 statin-treated patients, 47% of patients may warrant an intensification of statin therapy according to the updated national cholesterol guidelines. CONCLUSIONS: These findings highlight the magnitude of potential changes in statin prescription patterns favoring higher potency statin therapy, a sizable shift that parallels the predicted increase in statin initiation.

Noninvasive atherosclerosis imaging for predicting cardiovascular events and assessing therapeutic interventions.

Noninvasive assessment of atherosclerosis offers an opportunity to provide individual cardiovascular risk management and an opportunity to monitor the efficacy of therapy targeted toward atherosclerosis. The three imaging modalities that currently hold the most promise at the clinical and research levels are ultrasound for carotid intima-media thickness, computed tomography for coronary artery calcification, and magnetic resonance imaging for carotid and aortic plaque imaging. The following review describes the evidence that validates each technique as a surrogate marker of atherosclerosis, with an emphasis on cardiovascular events and the progression of disease. Both the particular strengths and limitations of each imaging modality are discussed.