Estrategias para el control de la dislipemia en pacientes con cardiopatía isquémica

Estrategias para el control de la dislipemia en
pacientes con cardiopatía isquémica Dr. José Ramón González-Juanatey
Alteraciones del Metabolismo de los
Lípidos en Cardiología.
Mas allá de LDL y Cardiopatía Isquémica
José R. González Juanatey
Hospital Clínico Universitario. IDIS, CIBERCV
Santiago de Compostela
Conflict of interest:
Research grants and honoraria from (research committees, clinical trials, personal,
Institutional)
Astra-Zeneca, Bayer, Boehringer Ingelheim, Lilly / Daiichi-Sankyo, Ferrer, MSD,
Novartis, Pfizer, Sanofi, Servier, Amgen

1. La Organización del
Proceso Asistencial de
Cardiopatía Isquémica en
tiempos de COVID

Khera A, et al. Am J Prev Cardiol 2020. https://doi.org/10.1016/j.ajpc.2020.100009
COVID-19
Challenges in Medicine

La Transición de Cuidados en Pacientes Hospitalizados.
Barreras y Oportunidades.
El caso del “Síndrome Coronario Agudo”
1er AÑO AÑOS SG. →
Tratamiento Médico
Revascularización
Miocárdica
Prevención Secundaria
Transición de Cuidados
SCA (Hospitalización)
SCA
Hospital
Comorbilidades
Seguimiento Cardiológico
Prevención Secundaria (Comunitaria / Hospital)
Otros
Especialistas
Programas Rehabilitación
4-7 días
Cardiólogo
(Hospital,
Comunitario)
AP
Otros
Especialistas
Paciente
Gestores
Proceso
del Alta
Hospitalari
a y
Transición
de
Cuidados
2
Implicación
de
Pacientes y
Cuidadores
7
Pérdida de
la
Continuidad
Asistencial
6
Optimización
Diagnóstica y
Terapéutica.
Estratificación
del Riesgo
1
Integración
de la
Rehabilitac
Cardíaca
4
Evaluación
de
Objetivos
Tratamiento
3
Optimización
Diagnóstica y
Terapéutica.
Estratificación
del Riesgo
1
Proceso del
Alta
Hospitalaria
y Transición
de Cuidados
2

Alta Hospitalaria:
- Informe Estructurado
- Plan Transición de Cuidados
- Cita Teleconsulta Centro de
Salud
Teleconsulta Precoz Centro Salud:
- Enfermería/Medicina
- Síntomas/Signos
- Refuerzo Recomendaciones
- Ajuste y Cumplimentación
Terapéutica
- Cita Analítica Control
Teleconsulta Centro Salud:
- Resultados Analítica
- Evaluación clínica
- Ajuste y Cumplimentación
Terapéutica
- Cita Teleconsulta
Teleconsulta Centro Salud/Cardiología:
- Enfermería/Medicina
- Síntomas/Signos
- Refuerzo Recomendaciones
- Ajuste y Cumplimentación Terapéutica, fin doble
antiagregación
- Revisión Analítica y ECG
- Transición Programa Síndromes Coronarios Crónicos
Dia 0
Dia 7-15
Semana 10-12
Meses 12-14
HOSPITALIZACIÓN EXTENDIDA

LA RUTA DEL PACIENTE CON
CARDIOPATÍA ISQUÉMICA
1 2
3
4
5
HI statin + Ez
HI statin + Ez
2020 : 76%
2020 PCSK9i
Statin intolerants
/ pre-Tx
week 10-12:
LDL < 70 mg/dl: 65%
LDL < 55 mg/dl: 47%
iPCSK9 – 5%

2. Lípidos y
ateroesclerosis; mas allá
del LDL-c

EFFECT OF LOWER SBP AND LDL ON LIFETIME RISK OF CV DISEASE
LIFETIME EXPOSURE TO THE COMBINATION OF 39 MG/DL LOWER LDL-C AND 10 MMHG LOWER SBP
WAS ASSOCIATED WITH AN 80% LOWER LIFETIME RISK OF CV DISEASE AND 68% LOWER LIFETIME
RISK OF CV DEATH
Ference BA, et al.JAMA 2019.

Hypertension
Accelerate
Coronary
Atherosclerosis
Normal BP High BP

Associations
Between HDL
Particles and
Ischemic
Events
Compared with HDL-C, HDL-P
was consistently associated
with MI and ischemic stroke
in the overall population.
Differential associations of
both HDL-C and HDL-P for MI
by Black ethnicity suggest
that atherosclerotic
cardiovascular disease risk
may differ by vascular domain
and ethnicity.
Singh K, et al. Circulation 2020; 142: 657-669.
HDL-P
(unadjusted for HDL-C)
HDL-P
adjusted for HDL-C)

. APOB CONTAINING LIPOPROTEINS (NOT TOO
LARGE)
. CHYLOMICRON-REMNANTS (REMNANT CHOLESTEROL)
. VLDL-REMNANTS (REMNANT CHOLESTEROL)
. IDL (REMNANT CHOLESTEROL)
. LDL (LDL-CHOLESTEROL)
. LIPOPROTEIN (A) (LDL-CHOLESTEROL)
ELEVATED
WITH
ELEVATED TG
APPROXIMATE: APOB CONCENTRATION OR
NON-HDL CHOLESTEROL CONCENTRATION
Atherogenic Lipoproteins

Icosapent Ethyl on
Progression of
Coronary
Atherosclerosis in
Patients with
elevated TG on Statin
Therapy.
EVAPORATE Trial
Budoff MJ, et al. EHJ 2020; 41: 3925-3932.

Reduction in
Revascularization
with Icosapent
Ethyl.
Insights From
REDUCE-IT
Revascularization
Analyses
Peterson BE et al . Circulation 2021; 143: 33-44.

OBSERVATIONAL ASSOCIATION: 1.1-FOLD
GENETIC ASSOCIATION: 1.6-FOLD
PLASMA TG PER 1
MMOL/L (49 MG/DL)
REMNANT CH PER
0.39 MMOL/L (15
MG/DL)
AORTIC VALVE STENOSIS
TRIGLYCERIDE-RICH LIPOPROTEINS
Triglycerides and Remnant cholesterol associated
with risk of Aortic Valve Stenosis
CONCLUSION: TRIGLYCERIDE-RICK REMNANT LIPOPROTEINS ASSOCIATED
OBSERVATIONALLY AND GENETICALLY WITH AORTIC VALVE STENOSIS Kaltoft M et al. Eur Heart J
2020.

Odds ratio 1.52 (1.22 to 1.90)
per 0.98 mmol/L higher LDL cholesterol Nazarzadeh M, et al. EHJ 2020; 41: 3913-3920.
Plasma Lipids and the Risk
of Aortic Stenosis.
A Mendelian randomization study

FAMILIAR HYPERCHOLESTEROLEMIA ELEVATED LPA
BOTH
Association
between
Elevated Lpa
and FHC

Lpa lowering by alirocumab reduces CV events independent
of LDL lowering: ODYSSEY OUTCOMES Trial
Szarek M, et al. EHJ 2020; 41: 4245-4255.

PCSK9
enhances in
vivo
thrombosis, the
effects are
abolished by
Evolocumab
Qi Z et al . Circulation 2021; 143: 45-61.

PCSK9 activating
platelet CD36
aggravates
microvascular
obstruction and
Promotes MI
expansión post-MI
Qi Z et al . Circulation 2021; 143: 45-61.

3. Lípidos y cardiopatía
isquémica; mas allá de las
recomendaciones de las
Guías

Recommendations Class
*
Level
†
In all ACS patients without any contraindication or definite
history of intolerance, it is recommended that high-dose statin
therapy is initiated or continued as early as possible,
regardless of initial LDL-C values.
I A
Lipid levels should be re-evaluated 4-6 weeks after ACS to
determine whether a reduction of ≥ 50% from baseline and
goal levels of LDL-C <1.4 mmol/L (<55 mg/dL) have been
achieved. Safety issues need to be assessed at this time
and statin treatment doses adapted accordingly.
IIa C
If the LDL-C goal is not achieved after4-6 weeks with
the maximally tolerated statin dose, combination with
ezetimibeis recommended.
I B
If the LDL-C goal is not achievedafter 4-6 weeks despite
maximal tolerated statin therapy and ezetimibe, the addition
of a PCSK9 inhibitor is recommended
I B
In patients with confirmed statin intolerance or in patients in
whom a statin is contraindicated, ezetimibe should be IIa C
• Mach F, et al. Eur Heart J. 2019. doi:10.1093/eurheartj/ehz455. Epub ahead of print. • For LDL-C, 1 mmol/L = 38.67 mg/dL
STEMI, ST-elevation myocardial infarction.
‘as early
as
possible’
‘2-step
PCSK9’
ACS – routine
therapies: 2-step
lipid-lowering
therapy – ESC
Guidelines 2019

HIGHER LDL-C AFTER PCI WAS ASSOCIATED WITH A HIGHER RISK OF MACE
RATE OF MACE ADJUSTED RISK OF MACE
<70
70 TO 100
>100
LDL-C
and
Risk of
MACE
after
PCI

Adjusted HR and Incidence rates for MACE events by change in LDL-C 6-10
weeks after Acute Myocardial Infarction. Swedisheart Registry
HR for 1.85 vs 0.36 mmol/L LDL-C reduction: 0.77 (95% CI 0.70-0.84)
Schubert J, et al . EHJ 2020; (Ahead-of-print)

Efficacy of Alirocumab after ACS According to Achieved Level of LDL-c.
ODYSSEY OUTCOMES Trial
Schwartz GG et al . Circulation 2021; (Ahead-of-Print).

Efficacy of Alirocumab after ACS According to Achieved Level of LDL-c.
ODYSSEY OUTCOMES Trial
Schwartz GG et al . Circulation 2021; (Ahead-of-Print).
Alirocumab Group

Effects of
Evolocumab on
Complex
Coronary
Revascularization
Complex Revas CABG Complex PCI

Cordero A, …, González-Juanatey JR. Eur Heart J 2019;40(Suppl):679.
LDL-C IN PATIENTS WITH ACS. CHUS-CHUSJ REGISTRY

Attributable risk proportion of uncontrolled LDL-C on
recurrent acute coronary syndromes CHUS-CHUSJ Registry
Cordero A, …, González-Juanatey JR. Eur Heart J 2019;40(Suppl):679. ACS, acute coronary syndromes; ARP, attributable risk proportion; CHD, coronary heart disease; CHUS-
CHUSJ, Centre Hospitalier Universitaire Sainte-Justine; LDL-C, low-density lipoprotein cholesterol.
The ARP of uncontrolled LDL-C on recurrent ACS is 13.8%
1 in every 7 recurrent ACS could be prevented by accurate LDL-C control

THE MODERNS CONCEPT OF LIPID-LOWERING STRATEGIES
TO REDUCE CARDIOVASCULAR DISEASES. 2021
Concept change I: Start Early
Less “lipid-exposure leads to prevention of lesion formation”
Concept change II: Treat (much more) aggressively
From desirable target to “LDL-C elimination in the blood”
Concept change III: Use combination therapy
Statin + Ezetimibe (+/- PCSK9mAb) induced LDL-C lowering
reduces risk – Consider PCSK9mAb prior to hospital discharge

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