Vol 9, No 1 (2024)
Review article
Published online: 2024-01-18

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Strategy of lipid-lowering treatment in patients with acute coronary syndrome. The ELECTRA-SIRIO 2 investigators’ viewpoint

Jacek Kubica12, Maciej Banach34, Piotr Adamski1, Andrzej Budaj5, Piotr Buszman67, Salvatore Di Somma89, Rahima Gabulova1011, Robert Gajda12, Paul A. Gurbel13, Agata Kosobucka-Ozdoba14, Jacek Konarski2, Aldona Kubica14, Przemysław Magielski15, Piotr Niezgoda1, Małgorzata Ostrowska1, Maciej Piasecki1, Uzeyir Rahimov16, Udaya Tantry13, Julia M. Umińska1718, Eliano P. Navarese19
Medical Research Journal 2024;9(1):90-95.

Abstract

A linear reduction in cardiovascular adverse events has been shown even when LDL-C reduction surpassed
recommended treatment goals, thus postulating ‘the lower, the better for longer’ as a therapeutic strategy in
patients with acute coronary syndrome (ACS). It was linked with more and more data on dual lipid lowering
therapy (LLT) with statin and ezetimibe that showed to be associated with additional reduction of inflammatory
markers as compared with statin alone. Thus, we recommend dual LLT consisted of high dose of potent statin
and ezetimibe to be applied from the very beginning of hospitalization in all ACS patients.
We recommended further increase the education of patients and improve the standards of care by physicians/
cardiologists with the discharge letter recently suggested by the Polish Cardiac Society and Polish Lipid Association
added to the standardized discharge letter. At the first follow-up study visit, achievement of the therapeutic
LDL-C target should be assessed. Patients who did not achieve and are not expected to achieve this target,
and those who have been diagnosed with statin intolerance should be referred to a lipidological consultation.
Lipoprotein (a) [Lp(a)] has pro-inflammatory and pro-atherosclerotic properties. Concentration of Lp(a) is
predominantly determined by genetics (> 90%), more than any other lipoprotein. Elevated concentration of
Lp(a) is associated with increased risk of atherosclerotic cardiovascular disease, aortic stenosis, cardiovascular
and all-cause mortality. Therefore, Lp(a) should be assessed once during hospitalization in patients
with ASC. Patients with Lp(a) > 50 mg/dL (> 125 nmol/L) should be referred to a lipidological consultation.
These recommendations regarding LLT apply to patients enrolled in to the ELECTRA-SIRIO 2 trial, however,
we encourage to consider them for treatment of other patients with ACS.

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References

  1. Kubica J, Adamski P, Buszko K, et al. Rationale and Design of the Effectiveness of LowEr maintenanCe dose of TicagRelor early After myocardial infarction (ELECTRA) pilot study. Eur Heart J Cardiovasc Pharmacother. 2018; 4(3): 152–157.
  2. Kubica J, Adamski P, Buszko K, et al. Platelet inhibition with standard vs. lower maintenance dose of ticagrelor early after myocardial infarction (ELECTRA): a randomized, open-label, active-controlled pharmacodynamic and pharmacokinetic study. Eur Heart J Cardiovasc Pharmacother. 2019; 5(3): 139–148.
  3. Kubica J, Adamski P, Niezgoda P, et al. A new approach to ticagrelor-based de-escalation of antiplatelet therapy after acute coronary syndrome. A rationale for a randomized, double-blind, placebo-controlled, investigator-initiated, multicenter clinical study. Cardiol J. 2021; 28(4): 607–614.
  4. Kubica J, Adamski P, Gorog D, et al. Low-dose ticagrelor with or without acetylsalicylic acid in patients with acute coronary syndrome: Rationale and design of the ELECTRA-SIRIO 2 trial. Cardiology Journal. 2022; 29(1): 148–153.
  5. Vrablik M, Seifert B, Parkhomenko A, et al. Lipid-lowering therapy use in primary and secondary care in Central and Eastern Europe: DA VINCI observational study. Atherosclerosis. 2021; 334: 66–75.
  6. Ratajczak J, Kubica A, Michalski P, et al. Determinants of Lipid Parameters in Patients without Diagnosed Cardiovascular Disease-Results of the Polish Arm of the EUROASPIRE V Survey. J Clin Med. 2023; 12(7).
  7. Laskowska E, Michalski P, Pietrzykowski Ł, et al. Implementation of therapeutic recommendations in high cardiovascular-risk patients. The Polish population of EUROASPIRE V survey. Medical Research Journal. 2021; 6(3): 230–236.
  8. Kubica A, Pietrzykowski Ł, Michalski P, et al. The occurrence of cardiovascular risk factors and functioning in chronic illness in the Polish population of EUROASPIRE V. Cardiol J. 2022 [Epub ahead of print].
  9. Jankowski P, Kosior DA, Sowa P, et al. Secondary prevention of coronary artery disease in Poland. Results from the POLASPIRE survey. Cardiol J. 2020; 27(5): 533–540.
  10. Haberka M, Jankowski P, Kosior DA, et al. Treatment goal attainment for secondary prevention in coronary patients with or without diabetes mellitus - Polish multicenter study POLASPIRE. Arch Med Sci. 2023; 19(2): 305–312.
  11. Byrne RA, Rossello X, Coughlan JJ, et al. ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023; 44(38): 3720–3826.
  12. Banach M, Penson PE, Vrablik M, et al. ACS EuroPath Central & South European Countries Project. Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP). Pharmacol Res. 2021; 166: 105499.
  13. Lewek J, Niedziela J, Desperak P, et al. Intensive Statin Therapy Versus Upfront Combination Therapy of Statin and Ezetimibe in Patients With Acute Coronary Syndrome: A Propensity Score Matching Analysis Based on the PL-ACS Data. J Am Heart Assoc. 2023; 12(18): e030414.
  14. Cannon CP, Blazing MA, Giugliano RP, et al. IMPROVE-IT Investigators. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med. 2015; 372(25): 2387–2397.
  15. Ference BA, Ginsberg HN, Graham I, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017; 38(32): 2459–2472.
  16. Navarese EP, Kowalewski M, Andreotti F, et al. Meta-analysis of time-related benefits of statin therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Am J Cardiol. 2014; 113(10): 1753–1764.
  17. Krychtiuk KA, Ahrens I, Drexel H, et al. Acute LDL-C reduction post ACS: strike early and strike strong: from evidence to clinical practice. A clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), in collaboration with the European Association of Preventive Cardiology (EAPC) and the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. Eur Heart J Acute Cardiovasc Care. 2022; 11(12): 939–949.
  18. Navarese EP, Robinson JG, Kowalewski M, et al. Association Between Baseline LDL-C Level and Total and Cardiovascular Mortality After LDL-C Lowering: A Systematic Review and Meta-analysis. JAMA. 2018; 319(15): 1566–1579.
  19. Navarese EP, Brouwer MA, Kubica J. Long-Term Outcomes Following Coronary Revascularizations in Diabetes Mellitus: The Emerging Role of LDL-C Thresholds. J Am Coll Cardiol. 2020; 76(19): 2208–2211.
  20. Navarese EP, Kolodziejczak M, Schulze V, et al. Effects of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies in Adults With Hypercholesterolemia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015; 163(1): 40–51.
  21. Adamski P, Adamska U, Ostrowska M, et al. New directions for pharmacotherapy in the treatment of acute coronary syndrome. Expert Opin Pharmacother. 2016; 17(17): 2291–2306.
  22. Banach M, Reiner Z, Cicero AFG, et al. 2022: the year in cardiovascular disease - the year of upfront lipid lowering combination therapy. Arch Med Sci. 2022; 18(6): 1429–1434.
  23. Obońska K, Kasprzak M, Sikora J, et al. The impact of the time of drug administration on the effectiveness of combined treatment of hypercholesterolemia with Rosuvastatin and Ezetimibe (RosEze): study protocol for a randomized controlled trial. Trials. 2017; 18(1): 316.
  24. Obońska K, Kasprzak M, Tymosiak K, et al. Low dose of ROSuvastatin in combination with EZEtimibe effectively and permanently reduce low density lipoprotein cholesterol concentration independently of timing of administration (ROSEZE): A randomized, crossover study - preliminary results. Cardiol J. 2021; 28(1): 58–66.
  25. Schiele F, Sabouret P, Puymirat E, et al. French expert group proposal for lipid-lowering therapy in the first 3 months after acute myocardial infarction. Panminerva Med. 2023; 65(4): 521–526.
  26. Banach M, Burchardt P, Chlebus K, et al. PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021. Arch Med Sci. 2021; 17(6): 1447–1547.
  27. Kosobucka A, Michalski P, Pietrzykowski Ł, et al. The impact of readiness to discharge from hospital on adherence to treatment in patients after myocardial infarction. Cardiol J. 2022; 29(4): 582–590.
  28. Pietrzykowski Ł, Kasprzak M, Michalski P, et al. The influence of patient expectations on adherence to treatment regimen after myocardial infarction. Patient Educ Couns. 2022; 105(2): 426–431.
  29. Kubica A, Obońska K, Fabiszak T, et al. Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials. Curr Med Res Opin. 2016; 32(8): 1441–1451.
  30. Pietrzykowski Ł, Michalski P, Kosobucka A, et al. Medication adherence and its determinants in patients after myocardial infarction. Sci Rep. 2020; 10(1): 12028.
  31. Kubica A. Adherence to medication in elderly patients. Medical Research Journal. 2023; 1(8): 93–94.
  32. Kubica A, Gruchała M, Jaguszewski M, et al. Adherence to treatment — a pivotal issue in long-term treatment of patients with cardiovascular diseases. An expert standpoint. Medical Research Journal. 2018; 2(4): 123–127.
  33. Pietrzykowski Ł, Kasprzak M, Michalski P, et al. Therapy Discontinuation after Myocardial Infarction. J Clin Med. 2020; 9(12).
  34. Kubica A, Pietrzykowski Ł. The therapeutic plan implementation in patients discharged from the hospital after myocardial infarction. Medical Research Journal. 2021; 6(2): 79–82.
  35. Kubica A, Obońska K, Kasprzak M, et al. Prediction of high risk of non-adherence to antiplatelet treatment. Kardiol Pol. 2016; 74(1): 61–67.
  36. Kubica, A.; Bączkowska, A. Rationale for motivational interventions as pivotal element of multilevel educational and motivational project (MEDMOTION). Folia Cardiologica. 2020; 15: 6–10.
  37. Kubica A, Adamski P, Bączkowska A, et al. The rationale for Multilevel Educational and Motivational Intervention in Patients after Myocardial Infarction (MEDMOTION) project is to support multicentre randomized clinical trial Evaluating Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome (ELECTRA – SIRIO 2). Medical Research Journal. 2020; 5(4): 244–249.
  38. Kubica A. Rationale of cardiopulmonary resuscitation training as an element of multilevel educational and motivational project (MEDMOTION). Disaster and Emergency Medicine Journal. 2020.
  39. Kubica A, Kasprzak M, Obońska K, et al. Impact of health education on adherence to clopidogrel and clinical effectiveness of antiplatelet treatment in patients after myocardial infarction. Medical Research Journal. 2016; 3(4): 154–159.
  40. Kubica A, Kasprzak M, Obońska K, et al. Discrepancies in assessment of adherence to antiplatelet treatment after myocardial infarction. Pharmacology. 2015; 95(1-2): 50–58.
  41. Zhao S, Zhao H, Wang L, et al. Education is critical for medication adherence in patients with coronary heart disease. Acta Cardiol. 2015; 70(2): 197–204.
  42. Kubica A. Problems of long-term antiplatelet therapy after coronary stent implantation. Advances in Interventional Cardiology. 2009; 5: 158–161.
  43. Kubica A, Kochman W, Bogdan M, et al. The influence of undergone percutaneous coronary interventions, and earlier hospitalizations with myocardial infarction on the level of knowledge and the effectiveness of health education in patients with myocardial infarction. Advances in Interventional Cardiology. 2009; 5: 25–30.
  44. Tang L, Patao C, Chuang J, et al. Cardiovascular risk factor control and adherence to recommended lifestyle and medical therapies in persons with coronary heart disease (from the National Health and Nutrition Examination Survey 2007-2010). Am J Cardiol. 2013; 112(8): 1126–1132.
  45. Kubica A, Kasprzak M, Siller-Matula J, et al. Time-related changes in determinants of antiplatelet effect of clopidogrel in patients after myocardial infarction. Eur J Pharmacol. 2014; 742: 47–54.
  46. Michalski P, Kasprzak M, Siedlaczek M, et al. The impact of knowledge and effectiveness of educational intervention on readiness for hospital discharge and adherence to therapeutic recommendations in patients with acute coronary syndrome. Medical Research Journal. 2020.
  47. Pietrzykowski Ł, Michalski P, Kosobucka A, et al. Knowledge about health and disease in obese patients after myocardial infarction. An observational study. Medical Research Journal. 2018; 2(4): 135–140.
  48. Michalski P, Kosobucka A, Pietrzykowski Ł, et al. Effectiveness of therapeutic education in patients with myocardial infarction. Medical Research Journal. 2018; 2(3): 89–96.
  49. Gianos E, Schoenthaler A, Guo Yu, et al. Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial. Am Heart J. 2018; 199: 37–43.
  50. Kubica A, Bączkowska A. Uzasadnienie interwencji motywacyjnych jako kluczowego elementu projektu wielopoziomowej edukacji i motywacji u pacjentów z zawałem serca (MEDMOTION). Folia Cardiologica. 2020; 15(1): 6–10.
  51. Hardcastle SJ, Taylor AH, Bailey MP, et al. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up. Int J Behav Nutr Phys Act. 2013; 10: 40.
  52. Kubica A. Self-reported questionnaires for a comprehensive assessment of patients after acute coronary syndrome. Medical Research Journal. 2019; 4(2): 106–109.
  53. Buszko K, Pietrzykowski Ł, Michalski P, et al. Validation of the Functioning in Chronic Illness Scale (FCIS). Medical Research Journal. 2018; 3(2): 63–69.
  54. Kubica A, Kosobucka A, Michalski P, et al. Self-reported questionnaires for assessment adherence to treatment in patients with cardiovascular diseases. Medical Research Journal. 2018; 2(4): 115–122.
  55. Buszko K, Obońska K, Michalski P, et al. The Adherence Scale in Chronic Diseases (ASCD). The power of knowledge: the key to successful patient — health care provider cooperation. Medical Research Journal. 2016; 1(1): 37–42.
  56. Kubica A, Kosobucka A, Michalski P, et al. The Adherence in Chronic Diseases Scale — a new tool to monitor implementation of a treatment plan. Folia Cardiologica 2017;12:19-26, DOI: 10. 5603/FC. ; 2016: 0000.
  57. Kosobucka A, Michalski P, Pietrzykowski Ł, et al. Adherence to treatment assessed with the Adherence in Chronic Diseases Scale in patients after myocardial infarction. Patient Prefer Adherence. 2018; 12: 333–340.
  58. Buszko K, Kosobucka A, Michalski P, et al. The readiness for hospital discharge of patients after acute myocardial infarction: a new self-reported questionnaire. Medical Research Journal. 2017; 2(1): 20–28.
  59. Kubica A, Kosobucka A, Fabiszak T, et al. Assessment of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention. Is there a place for newself-reported questionnaires? Curr Med Res Opin. 2019; 35(2): 341–349.
  60. Kubica A. The functioning in chronic illness –— a key determinant of treatment efficacy in patients with metabolic syndrome. Medical Research Journal. 2023; 8(4): 326–327.
  61. Kubica A, Kubica J. Functioning in chronic disease — a key factor determining adherence to heart failure treatment. Medical Research Journal. 2022; 7(4): 277–279.
  62. Mitkowski P, Witkowski A, Stępińska J, et al. Position of the Polish Cardiac Society on therapeutic targets for LDL cholesterol concentrations in secondary prevention of myocardial infarctions. Kardiol Pol. 2023; 81(7-8): 818–823.
  63. Banach M, Rizzo M, Toth PP, et al. Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel. Expert Opin Drug Saf. 2015; 14(6): 935–955.
  64. Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J. 2022; 43(39): 3925–3946.
  65. Catapano AL, Tokgözoğlu L, Banach M, et al. Lipid Clinics Network Group. Evaluation of lipoprotein(a) in the prevention and management of atherosclerotic cardiovascular disease: A survey among the Lipid Clinics Network. Atherosclerosis. 2023; 370: 5–11.
  66. Banach M, Penson PE. Statins and Lp(a): do not make perfect the enemy of excellent. Eur Heart J. 2020; 41(1): 190–191.
  67. Sathiyakumar V, Kapoor K, Jones SR, et al. Novel Therapeutic Targets for Managing Dyslipidemia. Trends Pharmacol Sci. 2018; 39(8): 733–747.