Matthew J. Budoff, MD

 We’ve covered a lot of stuff, so we should end this discussion. I’d like to thank everybody for being active in participating and showing your knowledge, which is immense. Can you give us a closing statement? Paul?

 I don’t know if it’s a closing statement, but because there was a great deal of discussion about LDL [low-density lipoprotein] lowering, targets, and goals, I want to remind everyone about 2 groups of patients who, in my opinion, need particular attention to LDL lowering but aren’t getting it. One is the patient with diabetic dyslipidemia, or metabolic syndrome, whose triglycerides are elevated and HDL [high-density lipoproteins] is low. For those patients, as we heard a few times, when their triglyceride levels exceed 90 mg/dL, their LDL becomes more atherogenic. When the triglycerides are 130 or 140 mg/dL, they’re more atherogenic. Yet we use the same LDL targets for those patients if they have much more atherogenic LDL.

I suggest that we overtreat, in a sense—or treat much more aggressively—patients who have high triglycerides, low HDL, insulin resistance, and metabolic syndrome to LDL levels lower than we might think in traditional bracketing of LDL, because their LDL is much more atherogenic. If I have an LDL goal of 70 mg/dL for such a patient, I will say that this atherogenic profile is an LDL of 85 or 90 mg/dL, but I’m going to drive it down lower.

The second group of patients where we need to be more aggressive in lowering LDL are those with elevated LP(a) [lipoprotein (a)], which I measure frequently and is 1 of the hottest topics. We have no agents that effectively lower it very much. The only treatment for this is aggressive lowering of LDL. In the presence of an elevated LP(a), my LDL goal is even lower than the guidelines. Not so much in the second group, but in the first patient group with the diabetic dyslipidemia, I will use an APOB to guide me much more than a LDL because that tells me more about total particle size and atherogenic burden.

 A couple of comments getting back to duration. I like to think of it like pack-years of smoking. We have LDL years about durations. We need to get lower for longer. I want to emphasize the burden in women, because women continue to be undertreated for cholesterol and don’t have less achievement of guideline-directed recommendations compared with men. Also FH [familial hypercholesterolemia] is in 1 of 250 individuals. It’s very common, but people aren’t looking for it. Women in particular are undertreated, especially during their reproductive years. We do women a disservice because there’s no female advantage with FH. The onset of ASCVD [atherosclerotic cardiovascular disease] is the same in men and women. We cannot miss FH, and we must ensure that we’re treating our female patients appropriately.

 Don’t forget the mammogram of the heart. We can do a coronary calcium scan and find early heart disease like we use mammography to find early breast cancer.

 By the way, they’ve shown that in mammography, some classification, you can predict heart disease too.

 Breast or arterial calcification may also be a good predictor. The mammogram of the mammogram might be the mammogram of the heart. Identifying this disease early will help us. Remember, you can’t make an asymptomatic person feel better. You have to convince them that they need to be on these therapies. Even with slight adverse effects, patients taking a pill every day feel worse sometimes. If they feel compelled to be treated for high cholesterol because they also have atherosclerosis, that’s going to make your life a lot easier and your discussion with the patients a lot shorter to get them to comply with these therapies that we’re advocating.

 The biggest causes of premature pain, suffering, and death in our society are cardiovascular disease and cancer. We know how to prevent cardiovascular disease. If we implement these things, we could prevent 80% of this. A very simple aspect is that all the guidelines and the intensity of therapy are dependent upon the risk of the patient. What is the risk of that individual short and long term? Then we can reduce it. There are many things to do, but treating lipids is the easiest. Of all these things that we’ve talked about, it’s hard to change lifestyle and diet. But by controlling someone’s lipids with a little extra effort and attention in the modification of our approach, we can get people to very low levels and at least make a big part of reduction of their risk.

 We hope that we all agree and that we look at the goal, as Erin said. We can use combination therapy, and we can get them to go early on; the earlier, the better. With that, I’d like to thank you for watching this 

. If you enjoyed the content, please subscribe to the e-newsletter to receive more information about other great content sessions like this 1 in your in-box. Thank you. I appreciate you being with us.

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Drs Paul S. Jellinger, Erin D. Michos, Matthew J. Budoff, Christie Ballantyne, and Yehuda Handelsman share closing thoughts and advice for the management of ASCVD and hypercholesterolemia.

Future Directions for the Treatment of ASCVD and Hypercholesterolemia

 Christie, you mentioned the pipeline. What do we have emerging as new therapies in the pipeline?

 There’s the whole field of PCSK9. You mentioned cholesterin and siRNA [small interfering RNA] every 6 months. There’s also oral PCSK9. Those data were presented at the AHA [American Heart Association Scientific Sessions], giving over 60% reduction. There’s some cool technology: cyclic peptide and enhanced susceptibility with it. We’ve got the LP(a) [lipoprotein (a)], ASO [antisense oligonucleotide], and siRNA. The HORIZON trial is fully recruited. The siRNA is in the pipeline. ANGPTL3 is still alive. There are some data at this meeting that ASO doesn’t work, but siRNA is cruising along.

 That’s the ASO. It hasn’t been presented, but the program is over.

 LFTs [liver function tests] have increased—liver fat—significantly. It reduced LDL [low-density lipoprotein] and A-Fib [atrial fibrillation] and everything, but there was a significant increase in hepatic fat.

 In the dose responses, it didn’t work the way it was expected. It was surprising, but there will be another siRNA on LP(a) presented at this meeting. It looks exciting. You mentioned anti-inflammatory. There’s a trial, CKD [chronic kidney disease], anti–IL-6 with it. There are other programs that target the inflammasome. They’re earlier stage with it. There’s even a CRISPR gene editing that’s going to be phase 1 this year.

 There’s a lot of cool stuff going on. How will it all pan out? I don’t know, but there are going to be even more things.

 Anything emerging that you’re involved in?

 Christie mentioned several things I’m excited about. I have many patients with elevated lipoprotein(a). I check it a lot now, especially in patients who don’t seem to have the LDL response with statins. We don’t have a lot of good therapy for those patients. PCSK9 has some effects. Pelacaren is the agent. With the ASO against we can lower lipoprotein(a) by about 90%. The question is how much does that translate to reduction in events? We’ll see that with the HORIZON trial.

Getting back to patients with FH [familial hypercholesterolemia], we have evolocumab and an ANGPTL3 inhibitor for homozygous FH. Because its mechanism is independent of the LDL receptor, this is for extremely high-risk patients. There are some other agents in that population as well.

 We mentioned ANGPTL3, but the APL-C3s are moving along nicely. There’s an ASO and an siRNA. They’re extremely effective for high triglycerides, even working with FCS [familial chylomicronemia syndrome]. The prior 1 had some adverse effects on platelets, and we’re not seeing that anymore. We’ll have other things in the future. Even for that group that’s still hard to treat, we’ll have something for them.

 The GLP-1, GIP dual inhibition for diabetes may have some cardiovascular benefits. There may be a tolerability issue. We’ll have to see how that pans out, but those large trials are ongoing as well. We’ve seen this great interaction between GLP-1 receptor agonists and cardiovascular event reduction, so this might extend that even further.

 Don’t forget, maybe the hardest and most disappointing 1 over the last 30 years has been the increase in obesity. We’ve got outcomes trials in the pipeline with semaglutide, and these data are very impressive.

 The data remind us of the fenfluramine-phentermine of the time, of the 15% to 20% weight reduction. I’m applauding them for willing to take outcome trial, which everybody was fearful to do in this early disease group of people. It will be superior, I have no doubt.

 We have this outcome trial for patients who are obese or overweight, who don’t have diabetes, looking at GLP-1 receptor agonists and subcutaneous. There’s also cardiovascular outcome trial that’s powered to be a trial for an oral semaglutide, because the prior trial was not. That is another potential option.

 GLP-1 is in the studies. What do you guys think of this revival of CETP inhibitor?

 People forget that the…study, was short of reduction in events, all driven by LDL. But they had low LDLs to go in. When they had the long-term follow-up, curves were still growing apart. This new CETP inhibitor is very effective for lowering LDL. We know that CETP inhibitors don’t work by raising HDL [high-density lipoprotein]; those studies are done. But could this be an easy way to lower LDL another 50%? We’ll see. There are also other approaches toward PCSK9 besides the ones that I mentioned. There’s a scaffolding approach, where some data showed about a 70% reduction instead of doing the monoclonal.

Experts in endocrinology and cardiology review novel agents in the pipeline for the management of hypercholesterolemia and ASCVD.

Emerging Agents for Treatment of Hypercholesterolemia and ASCVD

 Erin, what kind of patients would you use this kind of combination with bempedoic acid?

 I have an interest in women's health, and I get to see many patients who have statin intolerance. They're over-referred to my clinic, so I see a much greater percentage than may be in the general population. As we've discussed, for all these reasons, bempedoic acid is a great agent for patients that can't tolerate a higher intensity statin, and I think about it in those patients. It's encouraging about the CRP [C-reactive protein] reduction. It doesn't seem to worsen glycemia, or to have new onset diabetes, many patients are worried about that regarding statins. They read about statins, and they think it's going to cause diabetes, but I try to reassure them that those statins don't take someone who's normal glycemic and make them diabetic; it's usually people that are on the pathway there, that already have some insulin resistance, prediabetes, elevated BMI, that are more likely to have that new onset diabetes, but patients are worried about that. Bempedoic acid is a good agent for this. The label right now is for patients who have ASCVD [atherosclerotic cardiovascular disease] or FH, familial hypercholesterolemia, who need further reduction in their LDL [low-density lipoprotein] despite being on the maximally tolerated statin in conjunction with diet and lifestyle. For some patients, the maximally tolerated is zero statin. I use it in statin-intolerant patients, even though that doesn't say that currently in the label, because that is their maximal dose, zero.

 That's a really important point in terms of, if you want to use combination therapies, sometimes the drugs require prior authorization. The way you write that note is - the words maximally tolerated statin, having a recent lipid profile. Those are the keys for success. Interestingly, when we did this multigrade analysis to see who the individuals are who got over 30% reduction, women were more likely to have a better response. You don't know until you try it, but in general, women are more likely to have statin intolerance and have a good response to this agent.

 It's very interesting that you're saying that. I mentioned colesevelam when I was involved in some of the trials, and we found something similar. About 50% of the people had reduction of 30 to 40% and more, while another group was just 10% and nothing more. A study out of Sweden several years ago about statins showed that up to 20% of the people did not respond to statin. We know that many of them did not take them, but there is a variability with which we approach population-based results, and it's different than individual results. You must remember that, even when we write guidelines.

 That's a thing that comes up. We have the agents now where you can—and we've got things in the pipeline too—manage people's lipids incredibly effective. We have the fellows rotating in our clinic. If you look at these LDLs, you're getting 20, 30, which was unthinkable when I was starting. We can do it, but it's not being done, and that's what's so frustrating. You can argue we're not doing as well with our risk factors, and that's true. We're not doing well with blood pressure and obesity, but we have better and better tools to do it.

 And the lipids are the easiest of all of them.

 Matt, in your practice, how do you use bempedoic acid? How much of it do you use, by itself and in combination, choice of mono or the combination with ezetimibe? How is it in your practice?

 I have a lot of patients, who are either statin intolerant or unable to take a full 80 milligrams of atorvastatin, and I like to use the combination pill. I don't see a downside to it, ezetimibe is well tolerated, and bempedoic acid is well tolerated. Now you're getting 38, maybe 40%, LDL reduction on top of a statin. That's quite a bit, so I use it frequently. You must be careful about how you write it, it requires a little bit of finesse to get approved because it's a new drug, but I think the results are clear. The patients seem to have minimal side effects and I avoid those patients who have prior tendon ruptures as my primary thing or uric acids that are very high. But if the uric acid is well-controlled, and they're already on allopurinol or something else, I don't worry about that at all.

 I like the way you said that. The answer may be even clearer after.

Erin D. Michos, MD, MHS, leads a discussion on selecting the appropriate patient populations for the use of bempedoic acid when managing atherosclerotic cardiovascular disease (ASCVD) and hypercholesterolemia.

ASCVD and Hypercholesterolemia: Patient Selection for Bempedoic Acid

 Christie, can you explain why we don't see with bempedoic acid that muscle impact? You said it's kind of the same line, just higher up on how we…

 It's a pro drug, it gets converted to the active drug in the liver. That enzyme for conversion, that's an issue in terms of muscle. Bempedoic acid is a new agent that many people have not used. There is the issue of uric acid, it gets excreted by the kidney, so there's a transporter that can be competing with uric acid. If someone has hyperuricemia, that would be a relative contraindication, although you could see what happens. If they had gout and were treated with allopurinol, it's not an issue. If you looked at the study, if uric acid levels were normal, then people did not end up with gout, but if they were high -

 You said the study, but let’s describe the studies because not everybody is familiar.

 There was a large phase 3 program, the CLEAR program. They were monotherapy combination therapies. We've looked at this in terms of the safety aspects. With hyperuricemia, there's a slight increase that 1 to 2 % of people could get elevations of uric acid that might lead to gout. That can be avoided simply by measuring it at baseline, and if it's low, you don't have to worry, but if it's borderline or high, then you should repeat it. There was also an increased numerical imbalance of tendon rupture. If someone has a history of tendon rupture, tendinopathy, or something else, then this is probably not the right agent for that patient. Those were very rare, they were infrequent, but those are the 2 that I think for consideration.

 The mono trials were CLEAR Harmony and CLEAR Wisdom. The combo trial was 53, something like that. Do you want to touch on the efficacy?

 Yeah and just to go back quickly, because I think it's important to recognize and Christie talked about it being a pro drug. Statins are not a pro drug, they go into the liver and inhibit the liver, they go into the brain, that's the cognitive stuff, and they go into the muscle, which might cause real or perceived statin intolerance. Bempedoic acid can only be, that we know of, converted, and the only place this conversion enzyme exists is in the liver, so it can't go into the muscle. Muscle adverse reactions were comparable to placebo across all the trials that we've seen so far.

 Will not inhibit cholesterol synthesis in the muscle, with statins. The statin that had the greatest viability was cerivastatin, and we know what happened with cerivastatin, it had the greatest amount of myopathy. We have some data that the greater the viability of the statin, the more it goes in the muscle and the greater the chance of having muscle problems.

 We have the CLEAR combo study, that 053, renamed as CLEAR Combo, which added ezetimibe plus bempedoic acid into a combination, and now we’re seeing LDL [low-density lipoproteins] reductions closer to 40%, which is statin-esque. If you can't take a statin, that benefit might be greater because you're not dual inhibiting that pathway that Christie described.

 You mentioned, as monotherapy, so on top of a statin, it's about 18% reduction. Because both statins and bempedoic acid work on the same pathway, so not in combination with a statin, it's about 24% LDL reduction. In combination with ezetimibe, you're getting to 38% or 40% reduction.

 A comment about the well-known doubling of the statin dose and what resultant LDL, the 6% rule. I've seen many exceptions to that, it's absurd, that's a population-based study. Individual patients are extremely variable, so don't hesitate to double the statin dose. You may get a 20% reduction or you may get a 2%, depending on their LP(a) level. One of the nice clinical pearls that I've appreciated over the years is that patients whose LDL do not decrease on a statin probably have an elevated LP(a), and look for that there because that will not respond to statins. That will serve you well by doing that. Don't be timid about doubling the dose of statin and see what your individual patients will do. Secondly, in terms of the gout, the increased uric acid with bempedoic acid was 0.8%, it's very small.

 Overall, it's very small, it's only a concern if someone has a history of gout or a high uric acid. You make a really important point–we treat one patient at a time. That's the issue if you have someone who is not at their target. When you give a trial of an agent, be it ezetimibe, bempedoic acid, you get your effect within 4 weeks. You can even give samples. You can see, do they respond, here's the number, and you will see that some people have very big responses. Overall, people who are not on statins, over half got a 30% or more reduction. Someone who's been struggling with their lipids, when they see that, they are very pleased. That's the experience in my practice. We've had some people get 50% reductions, and you'll have some that get less. We treat one patient at a time, if someone responds well and they do that, then you've helped that patient.

 Part of the impact that we believe that statins have, is a pleiotropic effect. It's beyond the LDL reduction, the impact on inflammation, which we call pleiotropic effect. When we look at bempedoic acid, it has impact on inflammation. If a patient cannot be on a statin, and you put them on this combination drug, they still get some impact on inflammation, which I think is 4 on the pleiotropic effect. There's also slight reduction in glucose, it's not huge, but unlike what was said with statin, that can push sugars up and not be clear why it's happening; we don't see it with bempedoic acid in that kind of a combination. I don't know if you do it, but I have 2 patients on the combination of colesevelam with bempedoic acid, ezetimibe, and I have huge reductions in cholesterol, inflammation, and glucose. It's not difficult, it's easy to do and a statin is better if we can get them to take it.

 It's nice that we're seeing the opposite effect on diabetes. It will not be listed as a diabetes agent, but it was statistically significant. Less for new onset diabetes if you're on the bempedoic acid than if you're on placebo in these trials so far. CLEAR outcomes will be 14,000 patients and that will give us a much clearer look, but the signals are not there.

 Christie described it earlier, but CLEAR outcomes look at 14,000 patients who must be statin intolerant, and are randomized to bempedoic acid or placebo. I'm pretty sure it's going to finish this year, it's an event-driven trial. We're coming up on the very end of the study and hopefully we'll have some announcement later this year. I'm not sure if it'll be presented at AHA [American Heart Association] early next year.

 ACC [American Cardiology College] maybe? The thing that was impressive is, it didn't take that long to recruit.

 That will be the issue, is this happening in practice? All you get to see is when they recruit 14,000 people rapidly, it tells you something.

 There's a lot of people looking for something.

 It's very interesting because I was supposed to be part of the phase 3 trial, I ended up not being part of it because I could not recruit in my population, but today it probably would have been easier to recruit.

Christie Ballantyne, MD, leads a discussion on the use of bempedoic acid for the management of atherosclerotic cardiovascular disease (ASCVD) and hypercholesterolemia as seen in the CLEAR studies.

Matthew J. Budoff, MD

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