European recommendations on therapy of dyslipidemias – 2016 Lipid-lowering therapy in patients with acute coronary syndrome and percutaneous coronary interventions

The EAS/ESC recommendations 2016 for therapy of dyslipidemia evidence that statin therapy retains its key positions. When determining a very high cardiovascular risk level in a patient the ChLDL should be reduced to lower than 1.8 mmol/l regardless of the age and gender. In ACS high-intensity statin therapy should be prescribed in the absence of contraindications and risk of complications immediately after admission or within 1–4 days regardless of the initial level of ChLDL. High-intensity statin therapy means prescribing of atorvastatin 40–80 mg or rosuvastatin at a dose of 20–40 mg/day. In PCI in patients with stable angina or ACS without ST-segment elevation the strategy of high dose of statin prior to the procedure is used. The treatment goal is the achievement of the target level of ChLDL or decrease from the original one by 50%. Re-determination of the ChLDL level is recommended after 4–6 weeks of treatment. If the maximum tolerated doses of statin therapy is insufficiently effective it’s possible to add the second drug: ezetimibe or PCSK9 inhibitor. Adding omega-3 polyunsaturated fatty acids currently cannot be recommended in clinical practice of patient treatment after ACS and percutaneous coronary interventions. A clinical example of treatment of the patient with coronary and brachiocephalic arteries atherosclerosis aimed at PCI is provided. 

1. Росстат 2016. www.gks.ru.

2. 2013 ESC guidelines on the management of stable coronary artery disease. The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J, 2013, 34: 2949-3003.

3. Cholesterol Treatment Trialists’ (CTT) Collaboration, Fulcher J, O’Connell R, Voysey M, et al. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174,000 participants in 27 randomised trials. Lancet, 2015, 385: 1397-1405.

4. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Eur Heart J, 2016, 37: 2999- 3058.

5. Weng TC, Yang YH, Lin SJ, Tai SH. A systematic review and meta-analysis on the therapeutic equivalence of statins. J Clin Pharm Ther, 2010, 35: 139-151.

6. Boekholdt SM, Hovingh GK, Mora S, et al. Very low levels of atherogenic lipoproteins and the risk for cardiovascular events: a meta-analysis of statin trials. J Am Coll Cardiol, 2014, 64: 485-494.

7. Chasman DI, Giulianini F, MacFadyen J et al. Genetic determinants of statin-induced low-den￾sity lipoprotein cholesterol reduction: JUPITER trial. Circ Cardiovasc Genet, 2012, 5: 257-264.

8. Schwartz GG, Olsson AG, Ezekowitz MD et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA, 2001, 285: 1711-1718.

9. de Lemos JA, Blazing MA, Wiviott SD, et al. Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. JAMA, 2004, 292: 1307-1316.

10. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol, 2005, 46: 1405-1410.

11. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. doi:10.1093/eurheartj/ehv320.

12. Baigent C, Blackwell L, Emberson J et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet, 2010, 376: 1670-1681.

13. LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med, 2005, 352: 1425-1435

14. Stone NJ, Robinson JG, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 2014, 63: 2889-2934.

15. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med, 2015, 372: 2387-2397.

16. Robinson JG, Farnier M, Krempf M et al. Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. N Engl J Med, 2015, 372: 1489-1499.

17. Sabatine MS, Giugliano RP, Wiviott SD et al. Efficacy and safety of evolocumab in reducing lipids and cardiovascular events. N Engl J Med, 2015, 727: 1500-1509.

18. Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA, 2012, 308: 1024-1033.

19. Di Sciascio G, Patti G, Pasceri V et al. Efficacy of atorvastatin reload in patients on chronic statin therapy undergoing percutaneous coronary intervention: results of the ARMYDA-RECAPTURE (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) Randomized Trial. J Am Coll Cardiol, 2009, 54: 558-565.

20. Patti G, Cannon CP, Murphy SA, et al. Clinical benefit of statin pretreatment in patients undergoing percutaneous coronary intervention: a collaborative patient-level meta-analysis of 13 randomized studies. Circulation, 2011, 123: 1622-1632.

21. Briguori C, Visconti G, Focaccio A et al. Novel approaches for preventing or limiting events (Naples) II trial: impact of a single high loading dose of atorvastatin on periprocedural myocardial infarction. J Am Coll Cardiol, 2009, 54: 2157-2163.

22. Kim JS, Kim J, Choi D et al. Efficacy of high-dose atorvastatin loading before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the STATIN STEMI trial. JACC Cardiovasc Interv, 2010, 3: 332-339.

23. Gandhi S, Mosleh W, Abdel-Qadir H, Farkouh ME. Statins and contrast-induced acute kidney injury with coronary angiography. Am J Med, 2014, 127: 987-1000.