News from the 90th EAS Congress, Milan Italy: Monday 23rd May, 2022
Global risk estimation is fundamental to preventive cardiology, enabling clinicians to prioritise treatment to those at highest risk. However, as discussed by Professor Ian Graham (Co-Chair of the ESC Cardiovascular Risk Collaboration, Trinity College, Dublin), current approaches to global risk estimation are not without limitations. The SCORE system integral to the 2019 ESC/EAS dyslipidaemia guidelines1 estimates the risk of a fatal event over a limited age range (40-65 years); the estimates are dominated by age and gender. Two new derivations of SCORE, SCORE 2 (relating to total cardiovascular events, recalibrated to 4 risk regions in Europe) and SCORE2 OP-(in which the age range is extended to 65-90 years) have been developed to address the limitations of SCORE. These two systems are incorporated in the 2021 ESC cardiovascular disease prevention guidelines,2 aiming to enhance the accuracy and sustainability of cardiovascular disease prevention in Europe. Evaluation of new approaches to true lifetime risk and to estimating treatment benefits, however, are still in progress.
Following on, Professor Brian A. Ference (University of Cambridge, UK) focused on what is new in prevention in apparently healthy people. Some of what is new to the guidelines is very good, notably inclusion of a definitive statement that low-density lipoprotein (LDL) is causal for atherosclerotic cardiovascular disease and that the benefit of lowering LDL depends on BOTH the magnitude and duration of exposure. However, other innovations are less favourable, including continued use of recommendations based on 10-year risk, or even considered worse (Table 1). Estimation of the expected lifetime benefit of treatment leaves much to be desired, as the method used reinforces the bias of current risk algorithms that treating LATER in life is BETTER than prevention by maintaining low levels of LDL and systolic blood pressure throughout life (which is evidently better).
| 2-step treatment-intensification approach to treating LDL-C |
| Recommended method to estimate lifetime risk systematically underestimates the effect of modifiable targets of treatment |
| Recommended method to estimate expected lifetime benefit of treatment |
In secondary prevention, there have been several innovations in dyslipidaemia management, as discussed by Professor Ulrich Laufs (Universitätsklinikum Leipzig, Germany). Reinforcing LDL-C as the priority for intervention, goals have been lowered in high- and very-high risk patients (with the additional goal of at least 50% reduction in plasma LDL-C levels). The guidelines also define an extremely high risk category (patients with a second vascular event within 2 years while taking maximally tolerated statin-based therapy) in whom the recommended LDL-C goal is<1.0 mmol/L (<40 mg/dL).1 Combination lipid-lowering therapy is now recommended as the first-line approach to managing very-high-risk patients, and in extremely high risk patients, the combination of statin/ezetimibe plus PCSK9-targeted therapy is recommended as the starting strategy.3 RNA-based therapies offer practical advantages; in the case of inclisiran, there is durable LDL-C lowering with a 6 monthly administration schedule following a loading dose.4
There is also recognition of lipid targets beyond LDL-C. Guidelines recommend that lipoprotein(a) [Lp(a)] should be measured at least once to identify those individuals with very high inherited Lp(a) concentration. In addition, there is a renewed focus on the management of elevated triglycerides, especially moderate levels, driven by the strength of evidence from epidemiologic and Mendelian randomization studies, as well results from REDUCE-IT with icosapent ethyl.5 Individualised combination lipid-modifying therapy is the future for dyslipidaemia management in high-risk patients.
Despite these ongoing innovations in dyslipidaemia management, however, implementation of guideline recommendations remains problematic. According to the DA VINCI study, an 18 country, observational study of patients prescribed lipid lowering therapy, only about one in five secondary prevention patients in Western Europe attain risk-based LDL-C goals, and even fewer in Central and Eastern Europe.6.7 According to Professor Michal Vrablik (Charles University, Prague, Czech Republic), failure to attain LDL-C goal is a multifaceted problem. Not only is physician inertia a contributing factor, but there are also well recognised issues with treatment adherence. For successful personalised management of cardiovascular risk, communication of risk is crucial, as is the use of pro-active strategies, intervening early to target all modifiable risk factors. LDL-C goal attainment is possible, with the use of guideline-recommended combination therapy; practical barriers warrant urgent action.
References
1. Mach F, Baigent C, Catapano AL, et al. Eur Heart J 2020;41:111-188.
2. Visseren FLJ, Mach F, Smulders YM, et al. Eur Heart J 2021;42:3227-3337.
3. Ray KK, Reeskamp LF, Laufs U, et al. Eur Heart J 2022;43:830-833.
4. Katzmann JL, Packard CJ, Chapman MJ, et al. J Am Coll Cardiol 2020;76:563-579.
5. Bhatt DL, Steg PG, Miller M, et al. N Engl J Med 2019;380:11-22.
6. Ray KK, Molemans B, Schoonen WM, et al. Eur J Prev Cardiol 2021;28:1279-1289.
7. Vrablik M, Seifert B, Parkhomenko A, et al. Atherosclerosis 2021, 334: 66-75.
