Post on 10-Aug-2020
Ridurre drasticamente il colesterolo si traduce in beneficio clinico? Dall’IMPROVE-IT all’inibizione PCSK9
Dr Carlo SponzilliOspedale San Paolo Polo Universitario
ASST Santi Paolo Carlo - Milano
Chen Z et al., BMJ 1991; 303:276–282
Dati dello studio Shanghai, condotto in 9021 soggetti cinesi con un follow-up di 8–13 anni
Il numero delle morti per cardiopatia ischemica in ciascuno dei gruppi di colesterolo basale è indicato da una linea verticale che rappresenta una deviazione standard
Ris
chio
rel
ativ
o d
i m
ort
ali
tà C
HD
2.00
1.00
0.50
0.25
139 147 155 162 170 178 186
Colesterolo totale medio (mg/dl)
£136 159-178 137-158 ³179 Col. totale basale (mg/dl)
Lo studio Shanghai
4
9 12
18
Studi con statine in prevenzione secondaria: riduzione eventi e C-LDL “on trial”
30
25
20
15
10
5
0
30 50 70 90 100 130 150 170 190 210
4S-P
LIPID-P
CARE-P
CARE-S
LIPID-S
4S-S
HPS-P
HPS-S
PROVE-IT-AT
PROVE-IT-PR
Even
ti C
HD
(%
)
Colesterolo LDL (mg/dL)
Y = 0.1629x – 4.6776
R2 = 0.9029
p < 0.0001
Gli eventi sembrano
azzerarsi per un
C-LDL di 30 mg/dL
O’Keefe et al, JACC, 2004.
IMPROVE-IT
PCSK9 ?
TNT 10TNT 80
A2Z 20 A2Z 80
Risk Pattern for Subsequent CV Events Over a
Range of LDL-C Values1
CV = cardiovascular; CHD = coronary heart disease; MS = metabolic syndrome; IFG = impaired fasting glucose; CVD = CV disease. 1. Robinson JG et al. Am J Cardiol. 2006;98:1405–1408.
CHD + Diabetes
CHD + MS or IFG
CHD – No MS or IFG
Diabetes – No CVD
No Diabetes – No CVD
0 20 40 60 80 100 120 140 160 180 200 LDL, mg/dL
0
10
20
30
40
50
60
70
80
Card
iov
as
cu
lar
Ev
en
t R
ate
, %
Kenichi Tsujita et al J Am Coll Cardiol 2015;66:495–507)
SJ Nicholls et al JAMA. 2016;316(22):2373-2384.
Post Hoc Analysis Examining the Relationship Between Achieved LDL-C Level and Change in Percent Atheroma Volume (GLACOV)
Niacina e statine
AIM – HIGH 2012
Atheroma
Liver
Blood
CholesterolPool (Micelles)
NPC1L1 RemnantReceptors
LDL Receptor
Expression
Cholesterol
HMG-CoA
CMR
CM
Statins
Ezetimibe
X
X
2
1 Reduction of hepatic cholesterol
2 Increased LDL receptor expression
3 Increased clearance of plasma LDL-C
Together, ezetimibe in combination
with a statin provides:
LDL-C
NPC1L1 = Niemann-Pick C1-like 1; HMG-CoA = 3-hydroxy-3-methylglutaryl acetyl coenzyme A; CMR = chylomicron remnant.
1. Grigore L et al. Vas Health Risk Manag. 2008;4:267–278.
1 Cholesterol Pool
3
Ezetimibe and Statins Have Complementary
Mechanisms of Action1
LDL-C LDL-C LDL-C
20%
30-45%
STATIN
+As high as
60%
10%
20%
30%
40%
50%
ME
AN
LD
L-C
LO
WE
RIN
G2,3
synthesis absorptionsynthesis
absorptionsynthesis
absorption
As high as 60% LDL-C lowering via dual inhibition
1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.
CH
AN
GE
OF
SY
NT
HE
SIS
AN
D A
BS
OR
PT
ION
MA
RK
ER
S1
Inhibition of
absorption
Dual inhibition
Statin + EZETROL
Inhibition of synthesis
EZETIMIBE
Primary Endpoint — I TT
Simva — 34.7% 2742 events
EZ/Simva — 32.7% 2572 events
HR 0.936 CI (0.887, 0.988)
p=0.016
Cardiovascular death, MI, documented unstable angina requiring
rehospitalization, coronary revascularization (≥30 days), or stroke
7-year event rates
NNT= 50
Simva — 22.2% 1704 events
EZ/Simva — 20.4% 1544 events
HR 0.90 CI (0.84, 0.97)
p=0.003
NNT= 56
CV Death, Non-fatal MI , or Non-fatal Stroke
7-year event rates
First, Additional, and Total Primary Endpoint Events During Follow-Up by Randomization Group
Reduction in Total Cardiovascular Events
With Ezetimibe/Simvastatin Post-Acute Coronary
Syndrome:
The IMPROVE-IT Trial
Bohula, E.A. et al. J Am Coll Cardiol. 2017;69(8):911–21.
Atherothrombotic Risk Stratification and Ezetimibe for Secondary Risk Prevention
Effects of Ezetimibe by risk scores in IMPROVE-IT
JACC 2017
FOURIERPrimary Endpoint: Composite of CV Death, MI, Stroke, Hospitalization for UA, or
Coronary Revascularization
HR 0.85 (95% CI 0.79 to 0.92); P < 0.001
Sabatine MS, et al . NEJM 2017
6.0
10.7
14.6
5.3
9.1
12.6
No. at RiskPlacebo 13,780 13,278 12,825 11,871 7,610 3,690 686Evolocumab 13,784 13,351 12,939 12,070 7,771 3,746 689
Cu
mu
lati
ve I
ncid
en
ce (
%) Placebo
Evolocumab
0
2
4
6
8
10
12
14
16
0 6 1812 24 3630Months
15%
3.7
6.8
9.9
Fourier Key Secondary Endpoint: Composite of CV Death, MI, or Stroke
HR 0.80 (95% CI 0.73 to 0.88); P < 0.001
No. at RiskPlaceboEvolocumab
Cu
mu
lati
ve I
ncid
en
ce (
%) Placebo
Evolocumab
Months
0
2
4
6
8
9
10
11
0 6 1812 24 3630
1
3
5
7
13,780 13,449 13,142 12,288 7,944 3,893 73113,784 13,501 13,241 12,456 8,094 3,935 724
3.1
5.5
7.9
Sabatine MS, et al . NEJM 2017
20%
FOURIERAssociation of LDL-C Levels and CV Events
P<0.0001 Q4
Q3
Q2
Q1
Q4Q3
Q2
Q1
Placebo
Evolocumab
13%
12%
11%
10%
9%
8%
7%
6%
5%0 20 40 60 80 100 120
Achieved LDL Cholesterol (mg/dL)
Car
dio
vasc
ula
r D
eat
h, M
I, o
r St
roke
Sabatine MS, et al. American College of Cardiology – 66th Annual ScientificSession Late-Breaking Clinical Trial. Washington, D.C. March 17, 2017.
Patients divided by quartile of baseline LDL-C and by treatment arm
Landmark Analysis of Primary Endpoint
Year 1: RRR 12% > Year 1: RRR 19%
Longer duration of treatment and follow up suggests larger risk reduction
Evolocumab
Cu
mu
lati
ve
In
cid
en
ce
(%
)
0%
2%
4%
6%
8%
10%
0 90 180 270 360DaysNo. at Risk
Placebo 13780 13542 13282 13044 12834Evolocumab13784 13563 13358 13137 12950
Placebo
Hazard ratio 0.88
(95% CI, 0.80-0.97)
13524 12467 8080 3928 89113548 12598 8204 3942 888
0%
2%
4%
6%
8%
10%
360 540 720 900 1080
Cu
mu
lati
ve
In
cid
en
ce
(%
)
Days
Placebo
Evolocumab
Hazard ratio 0.81
(95% CI, 0.73-0.89)
Landmark analyses were performed in which patients who were alive and in follow-up at the start of the period of interest formed the group at risk.Sabatine MS, et al . NEJM. [published online ahead of print March 17, 2017]. doi: 10.1056/NEJMoa1615664 (Supplementary Figure S4)
Robinson, J.G. et al. J Am Coll Cardiol. 2016;68(22):2412–21.
Association Between the Magnitude of LDL-C Lowering and
Proportional Reduction in Major Cardiovascular Events
FourierLDL-C 9230 mg/dl (3.0 0,78 mmol/L)
ODYSSEY OUTCOMES – Study Design
*Dose titrated up to 150mg Q2W at Month 2 if LDL-C ≥50 mg/dL(1.29 mmol/L) at Month 1 visit.ClinicalTrials.gov. ODYSSEY OUTCOMES Study. http://clinicaltrials.gov/ct2/show/NCT01663402. Accessed May 14, 2015. Schwartz GG, et al. Am Heart J. 2014;168:682-689.e1.
24
Population
• Patients 4-52 weeks post-ACS
• Age ≥ 40
Lipid criteria at entry
• LDL-C ≥70 mg/dL [≥1.81 mmol/L] OR• ApoB ≥80 mg/dL [≥0.8 mmol/L] OR• Non-HDL-C ≥100 mg/dL [≥2.59
mmol/L]
Primary endpoint
• Composite of– CHD death
– Nonfatal MI
– Ischemic stroke
– High-risk UA requiring hospitalization
Double-Blind Treatment Period (64 Months)
n=9000
n=9000
R
Placebo SC
Run-in
Screeningvisit
Injectiontraining
visit
NCEP-ATPIII TLC diet or equivalent
Alirocumab 75 mg with potential ↑ to 150 mg Q2W SC* + placebo PO (single 1-mL injection using prefilled pen for self-administration)
Patients on maximum-tolerated potent statins
atorvastatin 40-80 mg or rosuvastatin 20-40 mg
OR statin intolerant
November 2015: 18,000-Patient ODYSSEY OUTCOMES Trial of Praluent® (alirocumab) Injection Fully Enrolled
CONFIDENTIAL
Robinson, J.G. et al. J Am Coll Cardiol. 2017;69(5):471–82.
Low-Density Lipoprotein Cholesterol Levels <25 mg/dl Following
Alirocumab Treatment: Associated Factors, Exposure, and Safety
Robinson, J.G. et al. J Am Coll Cardiol. 2016;68(22):2412–21.
Determining When to Add Nonstatin Therapy
ACC EXPERT CONSENSUS DECISION PATHWAY 2016
ACC EXPERT CONSENSUS DECISION PATHWAY 2016
ACC EXPERT CONSENSUS DECISION PATHWAY 2016
Recommendations for the pharmacological treatment of hypercholesterolaemia
2016 ESC/EAS Guidelines for the Management of Dyslipidaemias
• Il sogno di riuscire quasi ad azzerare gli eventicardiovascolari riducendo il Colesterolo LDL si staavverando
• L’associazione di più farmaci per ottenere la riduzione delle LDL si è dimostrata efficace e sicura
• Importante utilizzare le associazioni giuste con unaprogressione degli interventi identificando i pazienti amaggior rischio
• Il raggiungimento di valori anche molto bassi dicolesterolo LDL si è dimostrata efficace e sicura nelridurre ulteriormente gli eventi cardiovasculari
Conclusioni
Chiedo soprattutto che vengano unificate le
spine elettriche e le unità di misura