VESL Wall, Issue #4, June 2021
Issue #4, June 2021

This month on the VESL Wall, we cover practical ASCVD risk reduction in the South Asian population, dive into the apoB debate, and evaluate lipid testing and therapy post-ACS in the Alberta population. See all issues of the VESL Wall at veslcommunity.org/the-vesl-wall.
 

Dr. Samer Mansour walks us through the VESL Wall Issue #4 in this 10-minute video >> Video Summary VESL Wall Issue #4
 
 
Expert consensus on ASCVD in the US South Asian population

This expert consensus document from the National Lipid Association provides a review of the risk and management of ASCVD in the US South Asian (SAUS) population. South  Asians have some of the highest rates of coronary heart disease in the world, and the SAUS population has a 4-fold higher risk of CVD than the general US population, with one in three dying of CVD before the age of 65. The increased CV risk for SAUS is derived from a high prevalence of classical and contributory risk factors, non-biological risk factors, and likely other biologic factors not yet understood. SA ancestry is considered a risk enhancing factor for clinician-patient discussion according to the ACC and AHA guidelines, and patients should be aggressively screened early for modifiable risk factors. Social and policy initiatives are needed to address the significant risk of ASCVD in the SA population.

The article provides very practical guidance on how to achieve a heart-healthy South Asian diet and culturally appropriate exercise guidance. South Asians appear to have similar responses as non-Hispanic White populations to statin therapy. There is less data on ezetimibe and PCSK9-inhibitors in SA populations, however smaller studies have demonstrated comparable safety and efficacy.

Read more: [Sosido Link] Kalra D, Vijayaraghavan K MD, Sikand G, et al. Prevention of atherosclerotic cardiovascular disease in South Asians in the US: A clinical perspective from the National Lipid Association [published online ahead of print, 2021 Mar 29]. J Clin Lipidol. 2021;S1933-2874(21)00058-1. doi:10.1016/j.jacl.2021.03.007
 

ApoB as a clinical marker of CV and to evaluate lipid-lowering therapy

Sniderman and colleagues review the evidence for apolipoprotein B (apoB) following the 2019 ESC guidelines statement that apoB was a more accurate clinical marker of CV risk and a better guide for evaluating lipid-lowering therapy. Discordance analyses have demonstrated that the number of apoB particles is a better predictor of CV risk than either LDL-C or non-HDL-C measurements. Additionally, apoB measurement is standardized, whereas LDL-C and non-HDL-C measurements can be affected by sample matrix effects of atypical lipoproteins, meaning results from one laboratory my differ from another laboratory.

They also provide support for using apoB in assessing the effectiveness of lipid-lowering therapy. As both LDL and VLDL are atherogenic, measuring only LDL-C does not fully assess the reduction in cardiovascular risk. This can explain some of the differentiated results between statins, which lower both LDL and VLDL, while fibrates mainly lower VLDL. The authors suggest routine measurement of apoB in clinical practice.

Read more: [Sosido Link] Sniderman A, Langlois M, Cobbaert C. Update on apolipoprotein B [published online ahead of print, 2021 Apr 16]. Curr Opin Lipidol. 2021; 10.1097/MOL.0000000000000754. doi:10.1097/MOL.0000000000000754
 

Canadian population-based analysis of lipid testing and therapy post-acute coronary syndrome
 
Adding to previous registry-based studies, Sarak et al investigated a large population-based cohort of patients from Alberta with incident acute coronary syndrome. They evaluated lipid testing performed in hospital or within 90 days of discharge in order to estimate the proportion of patients eligible for PCSK9i therapy and the expected benefits of treatment.

27,979 patients with a first ACS between 2012 and 2018 were included in the analysis. The median age was 64 years, and 70.7% of patients were male. Lipid testing within 90 days post discharge was not conducted in 13.4% of patients. Of those tested, 77.5% had at least one lipid value above the guideline threshold. Lipid testing in hospital was associated with over two-fold higher rates of initiation or escalation of statin therapy (adjusted OR, 2.13 [95% CI, 1.97–2.30).

Using the inclusion criteria for the ODYSSEY outcomes trial, 39.6% of the tested cohort would be eligible for PCSK9i use. In this group, the data indicate there were 190 CV deaths, 622 nonfatal myocardial infarctions, 134 ischemic strokes and 285 episodes of unstable angina resulting in hospitalization. Applying the 15% relative risk reduction observed in the ODYSSEY and FOURIER trials indicates that 184 cardiovascular events could have been prevented over 3.4 years. Addressing the care gaps post-ACS can likely reduce mortality and morbidity.

Read more: [Sosido Link] Sarak B, Savu A, Kaul P, et al. Lipid Testing, Lipid-Modifying Therapy, and PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9)  Inhibitor Eligibility in 27 979 Patients With Incident Acute Coronary Syndrome. Circ Cardiovasc Qual Outcomes. 2021;14(4):e006646.  doi:10.1161/ CIRCOUTCOMES.120.006646


Summary

South Asian ancestry is considered a risk-enhancing factor for clinician-patient discussion according to the ACC and AHA guidelines. Patients should be screened early and provided with culturally appropriate lifestyle guidance. Routine apoB measurement should be considered for clinical practice, while the relative roles of triglyceride-rich VLDL and cholesterol-rich LDL particles in ASCVD probably requires further study. In Alberta, lipid testing was not conducted in 13% of patients discharged for ACS between 2012 and 2018. Of those who were tested, nearly 40% would be eligible for PCSK9i treatment.
 

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