Lower LDL confers fewer events in patients with CHD, diabetes eligible for PCI, CABG
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Lower LDL levels were associated with fewer adverse events among patients with CHD and type 2 diabetes eligible for PCI or CABG, according to results published in the Journal of the American College of Cardiology.
Michael E. Farkouh, MD, MSc, professor and vice chair of research in the department of medicine at the University of Toronto, Peter Munk Chair in Multinational Clinical Trials at the Peter Munk Cardiac Center and director of the Heart and Stroke Richard Lewar Center of Excellence in Cardiovascular Research, and colleagues conducted a patient-level pooled analysis of 3 randomized clinical trials, BARI 2D, COURAGE and FREEDOM.
The analysis included 4,050 adult patients (mean age, 63 years; 27% women) with CHD and type 2 diabetes enrolled between 1999 and 2010. In the clinical trials, patients were randomly assigned to optimal medical therapy vs. PCI and optimal medical therapy (COURAGE), PCI and optimal medical therapy vs. CABG and optimal medical therapy (FREEDOM) or optimal medical therapy vs. PCI and optimal medical therapy or CABG and optimal medical therapy (BARI 2D). Patients were categorized according to LDL levels at 1 year following randomization and followed for a median of 3.9 years.
The primary endpoint was the 4-year rate of MACCE including all-cause mortality, nonfatal MI or nonfatal stroke.
Lower LDL reduced risk
Researchers observed a higher 4-year cumulative risk for MACCE in patients who had LDL > 100 mg/dL at 1 year compared with those with LDL < 70 mg/dL or 70 to < 100 mg/dL at 1 year (P = .016). Compared with patients who had optimal medical therapy alone, those who had PCI experienced a reduction in MACCE if LDL at 1 year was < 70 mg/dL (HR = 0.61; 95% CI, 0.4-0.91), but not if 1-year LDL was higher. Patients with CABG showed an association with improved outcomes across all 1-year LDL strata. Those with 1-year LDL > 70 mg/dL who underwent CABG had significantly lower rates of MACCE compared with those who underwent PCI.
According to Farkouh, optimizing LDL levels introduces the hypothesis that the gap between CABG, PCI and medical therapy can be closed if patients with diabetes and CAD undergoing PCI achieve lower LDL levels.
“Patients with diabetes and CAD who achieve optimal LDL levels appear to benefit from PCI over medical therapy alone,” Farkouh told Healio. “This should be studied further. This suggests that we should target patients undergoing revascularization for LDL < 70 mg/dL and use this as a quality metric for centers.”
Personalized medicine implications
“The findings of the present study are relevant for clinical practice and may pave the way toward the generation of novel personalized medicine models that can optimize care of patients with [type 2 diabetes],” Eliano P. Navarese, MD, PhD, interventional cardiology and cardiovascular medicine researcher in the department of cardiology and internal medicine at Nicolaus Copernicus University, Skodowskiej-Curie, Poland, and colleagues wrote in a related editorial.
According to the editorial, these results support the idea of individualized treatment strategies accounting for patients’ LDL level to estimate clinical outcomes and expected treatment effects following therapeutic interventions. These findings will integrate the treatment effects from coronary revascularization and lipid-lowering interventions with baseline and 1-year LDL thresholds.
“This research is a much welcomed deeper foray into this important area and should increase the pace of future investigations to further unravel the so-far neglected association among LDL thresholds, outcome and expected treatment effects in all high-risk subjects,” Navarese and colleagues wrote.
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