| Part 1 Comparison of Low-Density Lipoprotein Cholesterol(LDL-C)Goal Achievement in the Patients With Coronary Heart Disease(CHD)With Different Renal FunctionBackground:The incidence and cardiovascular mortality of atherosclerotic cardiovascular diseases(ASCVD)increased significantly in chronic kidney disease(CKD)population compared with that in normal renal function population.Previous studies have shown that patients with renal impairment have a low application rate of lipid-lowering drugs and a low rate of achieving the goal of low-density lipoprotein cholesterol(LDL-C).Objective:To investigate whether lipid-lowering strategies and lipid goal attainment in CHD patients with renal impairment are different from those in CHD patients without renal impairment,and whether renal function status is an independent influencing factor for clinicians to apply lipid-lowering strategies and lipid goal attainment in CHD patients.Methods:This study was a single-center real-world study involving 933 patients with CHD who were admitted to the Cardiometabolic Center of Fuwai Hospital from September 2020 to March 2022.According to glomerular filtration rate(eGFR),the patients were divided into two groups:the group with impaired renal function(eGFR<60ml/min/1.73m2,n=125)and the control group without impaired renal function(eGFR≥60ml/min/1.73m2,n=808).Lipid-lowering strategies and lipid levels were followed-up at 3 months after discharge.Chi-square test was used to analyze whether there was any difference in lipid-lowering strategies adopted by clinicians for patients with different renal function,and Logistic regression was performed to analyze whether impaired renal function was an independent influencing factor for LDL-C goal attainment in patients with CHD.Results:The rate LDL-C goal achievement of impaired renal funcation group was significantly lower than that in control group(24.00%vs.35.52%,P=0.02).Based on medication usage,there are two strategies for lipid-lowering therapies(LLTs):highintensity LLTs and moderate-intensity LLTs(combination therapy and PCSK9 inhibitor monotherapy are considered high-intensity LLTs,while other medications are considered moderate-intensity LLTs).There was no significant difference in the proportion of high-intensity LLT between the two groups(82.50%vs.85.60%,P=0.40).In the total enrolled patients,the rate of LDL-C goal-achievement increased with the intensity of LLT(Moderate-intensity LLT vs.High-intensity LLT without preprotein invertase subtilin 9/kexin9(PCSK9)monoclonal antibody vs.Highintensity LLT with PCSK9 monoclonal antibody:22.50%vs.37.70%vs.60.00%,P<0.005).Multivariate logistic regression analysis showed that renal impairment(eGFR<60ml/min/1.73m2)was an independent factor influencing the rate of LDL-C goal achievement in patients with CHD(OR 1.81,95%CI 1.15-2.87,P=0.01).In addition,combined LLT was an independent protective factor for LDL-C the rate of goal achievement compared with statins monotherapy(statins combined with ezetimibe vs.statins monotherapy:OR 0.42,95%CI 0.3-0.6,P<0.001;statins and/or ezetimibe combined with PCSK9 monoclonal antibody vs.statins monotherapy:OR 0.15,95%CI 0.07-0.32,P<0.001).Conclusion:Impaired renal function is an independent factor affecting LDL-C goal achievement in patients with CHD.High-intensity LLT including PCSK9 monoclonal antibody can significantly improve the rate of LDL-C goal achievement in CHD patients.LDL-C is not easy to achieve goal level in CHD patients with renal impairment,so high-intensity LLT is suggested to be initiated as soon as possible,especially high-intensity LLT including PCSK9 monoclonal antibody,which can significantly improve the rate of LDL-C goal achievement.Further research is needed about the evidence of cardiovascular benefit from high-intensity lipid-lowering therapy in CHD patients with renal impairment.Part 2 Comparison of Low-Density Lipoprotein Cholesterol(LDL-C)Goal Achievement in the Patients With Coronary Heart Disease(CHD)With or Without Prior StrokeBackground:Few studies have been conducted on lipid-lowering strategies and lipid goal achievement in CHD patients with prior stroke.Whether high-intensity lipidlowering therapy(LLT)is associated with an increased risk of hemorrhagic stroke in CHD patients with prior stroke remains controversial.Objective:To investigate whether lipid-lowering strategies and lipid goal achievement in CHD patients complicated with prior stroke are different from those in CHD patients without stroke,and whether stroke is an independent influencing factor for clinicians to apply lipid-lowering strategies and lipid goal attainment in CHD patients.Method:This is a single-center real-world study.1620 CHD patients admitted to the Cardiovmetabolic Center of Fuwai Hospital from September 2020 to March 2022 were divided into two groups according to prior stroke or not:the stroke group(n=145)and the control group,non-stroke group(n=1475).Lipid-lowering strategies and lipid levels were followed up at 3-12 months after discharge.Chi-square test was used to analyze whether there was any difference in lipid-lowering strategies adopted by clinicians in CHD patients with or without stroke,Logistic regression was performed to analyze whether prior stroke was an independent factor influencing LDL-C goal attainment.Differences of the incidence of major adverse cardiovascular events(MACEs,including composite end points of all-cause death,nonfatal myocardial infarction,revascularization,rehospitalization due to unstable angina and nonfatal stroke)and hemorrhagic stroke was also compared between the two groups.Results:In the mean follow-up period with 8.55±3.13 months after discharge,there was no significant difference in the rate of LDL-C goal achievement between the stroke group and the control group(36.41%vs.36.55%,P=0.99).LLT was divided into moderate intensity LLT(LDL-C reduction<50%)and high-intensity LLT(≥50%reduction in LDL-C).There was no significant difference in the proportion of highintensity LLT between the stroke group and control group(80.00%vs.77.10%,P=0.36).In the total enrolled patients,the rate of LDL-C goal achievement increased with the intensity of LLT(moderate-intensity LLT vs.high-intensity LLT without PCSK9 monoclonal antibody vs.high-intensity LLT with PCSK9 monoclonal antibody:27.30%vs.39.26%vs.68.57%,P<0.005).For non-stroke patients,the rate of LDL-C goal achievement also increased with the intensity of LLT(moderateintensity LLT vs.high-intensity LLT without PCSK9 monoclonal antibody vs.highintensity LLT with PCSK9 monoclonal antibody 28.10%vs.38.71%vs.73.33%,P<0.005).Univariate Logistic regression analysis showed that stroke had no significant effect on the rate of LDL-C goal achievement in patients with CHD(OR 0.92,95%CI 0.65-1.31,P=0.64).After multivariate Logistic regression analysis,the results showed that stroke had no significant effect on the rate of LDL-C compliance in CHD patients(OR 0.90,95%CI 0.62-1.30,P=0.56).In the mean follow-up period of 8.55±3.13 months after discharge,the incidence of major adverse cardiovascular events(MACEs)in the total enrolled patients was 2.04%(2.76%in the stroke group vs.1.97%in control group,P=0.52).Only one patient in total enrolled patients experienced a hemorrhagic stroke.During the follow-up period,there was no significant difference about MACEs between the stroke group and the control group when LDL-C levels were<1.4mmol/L(1.70%vs.0.2%,P=0.88).Additionally,in the subgroup with LDL-C levels<1.4mmol/L,no patients experienced hemorrhagic stroke.Conclusions:In the real world,prior stroke does not change the lipid lowering strategy of clinicians for CHD patients,nor does it affect the rate of LDL-C goal achievement in CHD patients.High-intensity LLT containing PCSK9 monoclonal antibody can significantly improve the rate of LDL-C goal achievement.The same high-intensity LLT did not increase the risk of hemorrhagic stroke in CHD patients with prior stroke compared with CHD patients without stroke. |
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