Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study

• Published in: European heart journal Vol. 41; no. 40; pp. 3900 - 3909
• Main Authors: Allahyari, Ali, Jernberg, Tomas, Hagström, Emil, Leosdottir, Margrét, Lundman, Pia, Ueda, Peter
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 2020
• Subjects: Adolescent; Adult; Aged; Anticholesteremic Agents - therapeutic use; Atherosclerosis; Cardiac and Cardiovascular Systems; Cardiology; Clinical Medicine; Clinical Research; Dyslipidemias - drug therapy; Dyslipidemias - epidemiology; ESC/EAS guidelines; Ezetimibe; Ezetimibe - therapeutic use; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use; Kardiologi; Klinisk medicin; LDL cholesterol target; Medical and Health Sciences; Medicin och hälsovetenskap; Middle Aged; Myocardial Infarction - drug therapy; PCSK9 inhibitors; Percutaneous Coronary Intervention; Proprotein Convertase 9 - antagonists & inhibitors; Statins; Treatment goals; Young Adult; Treatment goals; PCSK9 inhibitors; LDL cholesterol target; ESC/EAS guidelines; Statins; Ezetimibe
• ISSN: 0195-668X; 1522-9645; 1522-9645
• DOI: 10.1093/eurheartj/ehaa034

Abstract
Aims
To estimate the proportion of patients with a recent myocardial infarction (MI) who would be eligible for additional lipid-lowering therapy according to the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias, and to simulate the effects of expanded lipid-lowering therapy on attainment of the low-density lipoprotein cholesterol (LDL-C) target as recommended by the guidelines.
Methods and results
Using the nationwide SWEDEHEART register, we included 25 466 patients who had attended a follow-up visit 6–10 weeks after an MI event, 2013–17. While most patients (86.6%) were receiving high-intensity statins, 82.9% of the patients would be eligible for expanded lipid-lowering therapy, as they had not attained the target of an LDL-C level of <1.4 mmol and a ≥50% LDL-C level reduction. When maximized use of high-intensity statins followed by add-on therapy with ezetimibe was simulated using a Monte Carlo model, the LDL-C target was reached in 19.9% using high-intensity statin monotherapy and in another 28.5% with high-intensity statins and ezetimibe, while 50.7% would still be eligible for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. When use of alirocumab or evolocumab was simulated in those who were eligible for PCSK9 inhibitors, around 90% of all patients attained the LDL-C target.
Conclusion 
Our study suggests that, even with maximized use of high-intensity statins and ezetimibe, around half of patients with MI would be eligible for treatment with PCSK9 inhibitors according to the 2019 ESC/EAS guidelines. Considering the current cost of PCSK9 inhibitors, the financial implications of the new guidelines may be substantial.