The Lancet is pleased to announce that the following papers will be published ahead of the European Society of Cardiology Congress 2014, taking place in Barcelona, Spain, from 30 August to 3 September 2014. This includes a special Series of three papers on lipids and cardiovascular disease.
Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data by Dr Johan Sundström et al
This study investigated whether the success of blood pressure-lowering drugs is dependent on baseline cardiovascular risk, and whether this could be used to inform treatment decisions for blood pressure-lowering therapy. The researchers found that lowering blood pressure provides similar relative protection at all levels of baseline cardiovascular risk, but progressively greater absolute risk reductions as baseline risk increases. These results support the use of predicted baseline cardiovascular disease risk equations to direct blood pressure-lowering treatment decisions.
Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials by Professor Matthew A Cavender et al
Bivalirudin and heparin are both options to use as an anticoagulant in patients undergoing percutaneous coronary intervention (PCI) for ischaemic heart disease. This study pooled data from close to 34 000 patients across 16 trials that compared a bivalirudin-based with a heparin-based anticoagulation regimen on ischaemic and bleeding outcomes. The researchers found that compared with a heparin-based regimen, a bivalirudin-based regimen increases the risk of myocardial infarction (heart attack) and stent thrombosis, but decreases the risk of bleeding; however, the magnitude of the reduction depending on concomitant glycoprotein IIb/ IIIa inhibitor use (a type of antithrombotic medication). They go on to recommend that physicians should weigh the trade-off between ischaemic and bleeding events when choosing between different anticoagulant regimens.
Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial by Professor Gerhard Hindricks et al
An increasing number of patients with heart failure receive implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation defibrillators (CRT-Ds) to monitor and control heart rhythm. Early detection of worsening heart failure, or factors that predispose to worsening heart failure by ICDs or CRT-Ds, might enable pre-emptive intervention and improve outcomes, but the evidence is weak. This study investigated this possibility and found that daily, implant-based telemonitoring using ICDs or CRT-Ds can improve clinical outcomes significantly for patients with heart failure.
Lipids and cardiovascular disease 1 - LDL cholesterol: controversies and future therapeutic directions by Professor Paul M Ridker
Lifelong exposure to raised concentrations of LDL cholesterol increases cardiovascular event rates, and the use of statin therapy as an adjunct to diet, exercise, and smoking cessation has proven highly effective in reducing the population burden associated with hyperlipidaemia. Yet, despite consistent biological, genetic, and epidemiological data, and evidence from randomised trials, there is controversy among national guidelines and clinical practice with regard to LDL cholesterol, its measurement, the usefulness of population-based screening, the net benefit-to-risk ratio for different LDL-lowering drugs, the benefit of treatment targets, and whether aggressive lowering of LDL is safe.
Several novel therapies have been introduced for the treatment of people with genetic defects that result in loss of function within the LDL receptor, a major determinant of inherited hyperlipidaemias. Moreover, the usefulness of monoclonal antibodies that extend the LDL-receptor lifecycle (and thus result in substantial lowering of LDL cholesterol below the levels achieved with statins alone) is being assessed in phase 3 trials that will enrol more than 60 000 at-risk patients worldwide. These trials represent an exceptionally rapid translation of genetic observations into clinical practice and will address core questions of how low LDL cholesterol can be safely reduced, whether the mechanism of LDL-cholesterol lowering matters, and whether ever more aggressive lipid-lowering provides a safe, long-term mechanism to prevent atherothrombotic complications.
Lipids and cardiovascular disease 2 - HDL and cardiovascular disease by Dr Daniel J Rader et al
The cholesterol contained within HDL-C is inversely associated with risk of coronary heart disease and is a key component of predicting cardiovascular risk. However, despite its properties that are consistent with protecting against the formation of atherosclerosis, the causal relation between HDL and atherosclerosis is uncertain.
Human genetics and failed clinical trials have created scepticism about the HDL hypothesis. Nevertheless, drugs that raise HDL-C concentrations, cholesteryl ester transfer protein inhibitors, are in late-stage clinical development, and other approaches that promote HDL function, including reverse cholesterol transport, are in early-stage clinical development. The final chapters regarding the effect of HDL-targeted therapeutic interventions on coronary heart disease events remain to be written.
Lipids and cardiovascular disease 3 - Triglycerides and cardiovascular disease by Professor Børge G Nordestgaard et al
After the introduction of statins, clinical emphasis first focussed on LDL cholesterol-lowering, then on the potential for raising HDL cholesterol, with less focus on lowering triglycerides. However, the understanding from genetic studies and negative results from randomised trials that low HDL cholesterol might not cause cardiovascular disease as originally thought has generated renewed interest in raised concentrations of triglycerides. This renewed interest has also been driven by epidemiological and genetic evidence supporting raised triglycerides, remnant cholesterol, or triglyceride-rich lipoproteins as an additional cause of cardiovascular disease and all-cause mortality. Although randomised trials showing cardiovascular benefit of triglyceride reduction are scarce, new triglyceride-lowering drugs are being developed, and large-scale trials have been initiated that will hopefully provide conclusive evidence as to whether lowering triglycerides reduces the risk of cardiovascular disease.