Stable Coronary Artery Disease, An LDL “Vaccine,” and Anti-i
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The hotly anticipated results of a major trial should help to resolve a common clinical question: should patients with significant but stable coronary artery disease begin treatment with medication and lifestyle changes alone or will undergoing an invasive procedure, like stent placement or bypass surgery, along with medical therapy produce better outcomes?

Starting with optimal medical therapy alone was just as effective as also undergoing cardiac catheterization and revascularization in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. With 5179 participants in 37 countries, the National Heart, Lung, and Blood Institute–funded study is the largest head-to-head trial to compare an invasive or conservative strategy for patients with stable ischemic heart disease.

Over a median of 3.3 years, having an initial invasive procedure on top of optimal medical therapy did not reduce the risk of the primary end point—a composite of cardiovascular death, myocardial infarction (MI), resuscitated cardiac arrest, or hospitalization for unstable angina or heart failure. The more aggressive approach also didn’t cut down on a composite of cardiovascular deaths or MIs. The results were largely similar in a group of 777 patients with ischemia and advanced chronic kidney disease.

The procedures did, however, benefit patients with frequent angina. Those with daily, weekly, or monthly angina symptoms had significant, durable improvements in symptom control and quality of life not observed among those without the chest pain.

A Cholesterol-Lowering “Vaccine”

Most people with atherosclerotic cardiovascular disease (ASCVD) treated with statins don’t achieve target low-density lipoprotein cholesterol (LDL-C) levels. To move the needle, expert groups now recommend the addition of daily ezetimibe or once- or twice-monthly injections of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for some patients. In addition, the US Food and Drug Administration in February approved the ATP-citrate lyase inhibitor bempedoic acid (Nexletol) as a daily pill to lower elevated LDL-C levels in those with maximally tolerated statin therapy.

Targeting Inflammation

Despite evidence that inflammation contributes to atherosclerosis, no medications targeting the process are approved for cardiovascular disease.

Investigators are therefore interested in repurposing existing drugs for the task. In the recent Colchicine Cardiovascular Outcomes Trial (COLCOT), the generic anti-inflammatory typically used for gout and pericarditis lowered the risk of ischemic cardiovascular events among patients with a recent heart attack.

Source: https://jamanetwork.com/journals/jama/fullarticle/2763421
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