Role of Statins in Glucose Homeostasis and Insulin Resistance

Statins are widely used for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), and, under the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol treatment guidelines, more individuals are eligible for statin therapy. In this review, we summarize evidence for a mild increase in serum glucose and increased incidence of diabetes associated with statins, the hypothesized mechanisms by which statins may impair glucose homeostasis, the risk of diabetes associated with particular statins, and the net effect on ASCVD risk. As emphasized by the ACC/AHA guideline group and other experts, the risk-reducing benefits of statin therapy generally outweigh the mild rise in glucose levels or new diagnoses of diabetes. As such, an appropriate balancing of benefits and risks is critical in clinical practice as clinicians engage patients in shared decision making. Moreover, when discussing statins and risk of diabetes, this is a prime opportunity for clinicians to provide further counseling on the central importance of weight loss and adhering to a healthy lifestyle in glucose homeostasis and diabetes prevention.     

Prevention of Cardiovascular Disease: Highlights for the Clinician of the 2013 American College of Cardiology/American Heart Association Guidelines

Prevention of cardiovascular disease, undoubtedly an emphasis of clinical care in 2014, will provide both opportunities and challenges to patients and their healthcare providers. The recently‐released ACC/AHA guidelines on assessment of cardiovascular risk, lifestyle management to reduce cardiovascular risk, management of overweight and obesity, and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk, have introduced new concepts and revised prior conventional strategies. New to risk assessment are the Pooled Cohort Equations, targeting the expanded concept of atherosclerotic cardiovascular disease (ASCVD) and focusing not solely on mortality but as well on major nonfatal events. The lifestyle management focuses on diet and physical activity for lipid and blood pressure control. The cholesterol guideline identifies four high‐risk groups with the greatest benefits from statin therapy: preexisting ASCVD, primary LDL‐C elevations ≥190 mm/dl, those 45–75 years with diabetes and LDL‐C 70–189 mm/dl without clinical ASCVD, and those 40–75 years without clinical ASCVD with an LDL‐C 70–189 mg/dl with a 7.5% or greater 10‐year ASCVD risk. Eliminated are arbitrary LDL‐C treatment targets, with individual patient risk status guiding who should take statins and the appropriate intensity of statin drugs. Patient‐physician discussions of individual benefits and risks are paramount. Management of high blood pressure remains controversial, with two different expert panels offering varying treatment targets; there is general agreement on a <140/90 mmHg goal, but substantial disagreement on blood pressure targets for older adults. Clinicians and their patients deserve a well‐researched concensus document.     

Lipid management beyond the guidelines

The 2018 AHA/ACC cholesterol guideline builds on the 2013 ACC/AHA cholesterol guideline statin recommendations to provide more detailed recommendations for the use of nonstatin therapy risk stratification for primary prevention statin use. New information has become available after the development of the 2018 AHA/ACC cholesterol guideline that can further inform clinical practice. Proprotein convertase subtilisin kexin type-9 (PCSK9) monoclonal antibodies are now a reasonable or even good value following over 60% reductions in their acquisition price, and the identification of high risk patient groups most likely to benefit from further low-density lipoprotein cholesterol (LDL-C) lowering. Meta-analyses and clinical trial data now show that patients with LDL-C ≥ 100 mg/dl are more likely to experience progressively greater reductions in the risk of cardiovascular and total mortality and coronary heart disease events for progressively higher LDL-C levels. Icosapent ethyl, a highly concentrated form of modified EPA has been shown to reduce cardiovascular events in high risk patients with moderate hypertriglyceridemia on statin therapy. Comparisons with other statin guidelines revealed that statin initiation for those with ≥7.5% 10-year atherosclerotic cardiovascular disease (ASCVD) risk is the most effective strategy for reducing the most ASCVD events for the proportion of the population treated. Data from younger populations finally became available for coronary artery calcium (CAC) scoring (mean age of 51 years) which confirmed the value of CAC > 0 for identifying individuals at increased ASCVD risk most likely to benefit from statin initiation. This analysis also found that statins could keep CAC = 0 in those with risk factors. Epidemiologic pooling studies now clearly show that LDL-C and non-high-density lipoprotein cholesterol levels in young adulthood confer excess risk for ASCVD later in life. Accumulating data support earlier risk factor intervention trials as the next research priority.     

2013 ACC/AHA Guideline Recommends Fixed-Dose Strategies Instead of Targeted Goals to Lower Blood Cholesterol

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines recently issued the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. This new guideline endorses a paradigm shift in strategies for reducing atherosclerotic cardiovascular disease (ASCVD) events by lowering blood cholesterol. Whereas previous guidelines focused on therapy to decrease low-density lipoprotein and non–high-density lipoprotein cholesterol to specific target levels, the new guideline instead proposes implementation of cholesterol-lowering treatment using evidenced-based intensity of statin therapy without such targets. The guideline also provides a new risk estimator for primary prevention decisions, including stroke outcomes and data on African Americans, which will significantly increase the number of patients recommended for outcome-related benefits of cholesterol-lowering therapy. The first section of this paper reviews the process by which the task force developed the new evidence-based guideline, the major findings and recommendations, and their implications. The second section primarily focuses on the question of how much low-density lipoprotein cholesterol should be lowered and on additional considerations in risk assessment.     

Review of Clinical Practice Guidelines for the Management of LDL-Related Risk

Managing risk related to low-density lipoprotein (LDL) is vital in therapy for patients at risk for atherosclerotic cardiovascular disease (ASCVD) events given its important etiologic role in atherogenesis. Despite decades of research showing reduction of ASCVD risk with multiple approaches to lowering of LDL cholesterol, there continue to be significant gaps in care with inadequate numbers of patients receiving standard of care lipid-lowering therapy. Confusion regarding implementation of the multiple published clinical practice guidelines has been identified as one contributor to suboptimal management of LDL-related risk. This review summarizes the current guidelines for reduction of LDL-related cardiovascular risk provided by a number of major professional societies, which have broad applicability to diverse populations worldwide. Statements have varied in the process and methodology of development of recommendations, the grading system for level and strength of evidence, the inclusion or exclusion of expert opinion, the suggested ASCVD risk assessment tool, the lipoproteins recommended for risk assessment, and the lipoprotein targets of therapy. The similarities and differences among important guidelines in the United States and internationally are discussed, with recommendations for future strategies to improve consistency in approaches to LDL-related ASCVD risk and to reduce gaps in implementation of evidence-based therapies.     

Icosapent ethyl: Where will it fit into guideline-based medical therapy for high risk atherosclerotic cardiovascular disease?

Patients who are at high or very high risk for atherosclerotic cardiovascular disease (ASCVD) events derive the greatest benefit when clinicians prescribe evidence-based preventive therapies. The writing process used in the creation of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol employed a thorough evaluation of the highest quality evidence, and synthesis of this evidence into actionable recommendations for ASCVD risk reduction. Clinical trials supporting the addition of ezetimibe, PCSK9 inhibitors, or both to evidence-based statins provide the basis for the updated recommendations for the preventive care of these patients. The publication in late 2018 of a randomized controlled trial supporting the net ASCVD risk reduction benefit of adding icosapent ethyl to statins in selected hypertriglyceridemic patients with clinical ASCVD and/or type 2 diabetes with multiple additional risk markers provides the rationale for incorporation of icosapent ethyl therapy into future ASCVD preventive care regimens.     

2013 ACC/AHA Cholesterol Guideline for Reducing Cardiovascular Risk: What is so Controversial?

In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults. The guideline recommendations were developed from a rigorous systematic review of randomized, controlled trials (RCTs) and meta-analyses of RCTs that evaluated ASCVD outcomes. Major recommendations address a healthy lifestyle, identification of groups of patients most likely to experience a net benefit form statin therapy, appropriate intensity of statin therapy to reduce ASCVD, safety, decision-making in primary prevention, monitoring therapy, and appropriate use of nonstatin therapy. Areas of controversy are discussed.     

Coronary artery calcium scoring for individualized cardiovascular risk estimation in important patient subpopulations after the 2019 AHA/ACC primary prevention guidelines

The 2018 and 2019 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of so-called “risk-enhancing factors” in borderline to intermediate risk individuals. These include high-risk race/ethnicity (e.g. South Asian origin), chronic kidney disease, a family history of premature ASCVD, the metabolic syndrome, chronic inflammatory disorders (e.g. rheumatoid arthritis [RA], psoriasis, or chronic human immunodeficiency virus [HIV]), and conditions specific to women, among others. Studies suggest, however, that risk may be highly heterogeneous within these subgroups. The AHA/ACC guidelines also recommend consideration of coronary artery calcium (CAC) scoring for further risk assessment in borderline to intermediate risk individuals in whom management is uncertain. Although the combination of risk enhancing factors and CAC burden (together with Pooled Cohort estimates) may lead to more accurate ASCVD risk assessment, few publications have closely examined the interplay between risk enhancing factors and CAC scoring for personalized risk estimation. Our aim is to review the relevant literature in this area. Although further research is clearly needed, CAC assessment seems a highly valuable option to inform individualized ASCVD risk management in these important, often highly heterogeneous patient subgroups.     

The 2013 ACC/AHA cardiovascular prevention guidelines improve alignment of statin therapy with coronary atherosclerosis as detected by coronary computed tomography angiography

The recently released 2013 ACC/AHA guidelines for management of blood cholesterol have substantially increased the number of adults who are eligible for preventive statin therapy. We sought to determine whether eligibility for statin therapy as determined by the 2013 ACC/AHA guideline recommendation is better aligned with the actual presence of coronary artery disease (CAD) as detected by coronary CT angiography (CCTA) when compared to prior guidelines including the 2004 NCEP ATP III and 2011 ESC/EAS guidelines.     

Most important advances in preventive cardiology during this past decade: Viewpoint from the American Society for Preventive Cardiology

The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol mangement focusing on the identification of “statin eligible groups” and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare. The availability of the sodium glucose transport protein-2 (SGLT2) inhibitors and glucagon-like peptide -1 receptor antagonists (GLP1-RA) for managing diabetes have shifted our focus in diabetes care beyond glucose lowering to addressing cardiovascular risk reduction. While many prior trials of fish oil therapy have failed to show benefit, the recent Reduction of Cardiovascular Events With EPA – Intervention Trial (REDUCE-IT) testing the efficacy of icosapent ethyl has shown dramatic benefit in further addressing residual atherosclerotic cardiovascular disease (ASCVD) risk beyond statin therapy not only in those with known ASCVD, but also in diabetic patients with multiple risk factors. The past decade also ushered in confirmation of the inflammation hypothesis of atherosclerosis with the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) using canakinumab, despite the fact the therapy was not approved by the Food and Drug Administration (FDA) for cardiovascular risk reduction. Also, to improve our understanding of heart disease in women, the emergence of novel concepts of ischemia or myocardial infarction in those with normal or nonobstructive atherosclerotic disease has been a major advance. Moreover, the past decade brought the emergence of proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy and the cardiovascular risk reduction benefits seen in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trials, providing further evidence-based therapy for additional reduction of ASCVD risk beyond statin therapy. The PCSK9 monoclonal antibodies have facilitated the attainment of LDL-C levels never previously thought possible. Finally with the mRNA interference therapy inclisiran in development, we may soon have a “vaccine-like” approach for addressing dyslipidemia and atherosclerosis.     

Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines

Purpose of review

In this review, we evaluate the coronary artery calcium (CAC) score as a biomarker for advanced atherosclerotic cardiovascular disease (ASCVD) risk assessment.

Recent findings

We summarize the evidence from multiple epidemiological studies, which show a clear advantage of CAC compared to traditional and non-traditional cardiovascular risk factors. We then compare the recommendations included in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and in the 2017 Society of Cardiovascular Computed Tomography (SCCT) guidelines for the use of CAC in ASCVD risk assessment, and examine the recent 2018 US Preventive Services Task Force (USPSTF) document. Finally, based on the currently available evidence, we provide constructive input for the upcoming ACC/AHA guidelines, regarding the population in whom CAC is most likely to be informative, the level of evidence that we believe should be assigned to CAC as an advanced ASCVD risk assessment tool, and the special populations in whom CAC might be beneficial for further risk assessment.

Summary

We support a pragmatic approach that combines the pooled cohort equations (PCE) for initial ASCVD risk stratification, followed by CAC for refining ASCVD risk assessment among a broad range of intermediate risk patients and other special groups.

     

Primary prevention with statins in cardiovascular diseases: A Saudi Arabian perspective

Cardiovascular disease (CVD) constitutes one of the major causes of deaths and disabilities, globally claiming 17.3 million lives a year. Incidence of CVD is expected to rise to 25 million by 2030, and Saudi Arabia, already witnessing a rapid rise in CVDs, is no exception. Statins are the drugs of choice in established CVDs. In the recent past, evidence was increasingly suggesting benefits in primary prevention. But over the last decade Saudi Arabia has a witnessed significant rise in CVD-related deaths. Smoking, high-fat, low-fiber dietary intake, lack of exercise, sedentary life, high blood cholesterol and glucose levels were reported as frequent CVD-risk factors among Saudis, who may therefore be considered for primary prevention with statin. The prevalence of dyslipidemia, in particular, indicates that treatment should be directed at reducing the disorder with lipid-modifying agents and therapeutic lifestyle changes.The recent American College of Cardiology (ACC)/American Heart Association (AHA) guidelines has reported lowering the low-density lipoprotein cholesterol (LDL-C) target levels, prescribed by the 2011 European Society of Cardiology (ESC)/the European Atherosclerosis Society (EAS). The new ACC/AHA guidelines have overemphasized the use of statin while ignoring lipid targets, and have recommended primary prevention with moderate-intensity statin to individuals with diabetes aged 40–75 years and with LDL-C 70–189 mg/dL. Treatment with statin was based on estimated 10-year atherosclerotic-CVD (ASCVD) risk in individuals aged 40–75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD or diabetes. Adoption of the recent ACC/AHA guidelines will lead to inclusion of a large population for primary prevention with statins, and would cause over treatment to some who actually would not need statin therapy but instead should have been recommended lifestyle modifications. Furthermore, adoption of this guideline may potentially increase the incidences of statin intolerance and side-effects. On the other hand, the most widely used lipid management guideline, the 2011 ESC/EAC guidelines, targets lipid levels at different stages of disease activity before recommending statins. Hence, the 2011 ESC/EAC still offers a holistic and pragmatic approach to treating lipid abnormalities in CVD. Therefore, it is the 2011 ESC/EAC guidelines, and not the recent ACC/AHA guidelines, that should be adopted to draw guidance on primary prevention of CVD in Saudi Arabia.     

CAD Severity on Cardiac CTA Identifies Patients With Most Benefit of Treating LDL-Cholesterol to ACC/AHA and ESC/EAS Targets

ObjectivesThis study aimed to assess if information on CAD severity from coronary computed tomography angiography (CTA) can identify patients that benefit most from treating low-density lipoprotein-cholesterol (LDL-C) to American Heart Association/American College of Cardiology (ACC/AHA) and European Society of Cardiology (ESC) guidelines targets.BackgroundCurrent treatment guidelines for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) disregard severity of coronary artery disease (CAD) for treatment choices. It is unclear whether severity of CAD should be considered in treatment recommendations.MethodsAmong 20,241 symptomatic patients undergoing diagnostic CTA from the Western Denmark Heart Registry, we assessed the number needed to treat (NNT) in 6 years to prevent 1 ASCVD event as well as the proportion of all events that could be prevented by treating LDL-C to targets. We assumed a 22% relative reduction of ASCVD events per 1 mmol/l reduction in LDL-C.ResultsIn multivariable analysis with no CAD as the reference, the subdistribution hazard ratio for ASCVD events was 4.0 (95% confidence interval [CI]: 3.3 to 4.9) for 1-vessel disease, 4.6 (3.5 to 6.0) for 2-vessel disease, and 5.6 (4.0 to 8.0) for 3-vessel disease. Consequently, the NNT to prevent 1 ASCVD event in 6 years by treating LDL-C to targets varied greatly from 233 (ESC) and 110 (ACC/AHA) for patients with no CAD to 8-9 for patients with 3-vessel disease (both ACC/AHA and ESC). The estimated percentage of ASCVD events that could be prevented by achieving guideline targets was 30% to 36% for patients with obstructive disease. However, <20% of patients achieved targets.ConclusionsAn individualized approach based on CAD severity can identify symptomatic patients that are likely to derive most and least benefit from treating LDL-C to ACC/AHA and ESC treatment targets.     

A Clinical Guide to Combination Lipid-Lowering Therapy

Purpose of Review

We provide an overview of our current understanding of combination lipid-lowering therapies intended for dyslipidemia treatment and cardiovascular disease prevention. First, we analyze recent statin and non-statin combination therapy guidelines and clinical studies since the publication of 2013 American College of Cardiology Cholesterol Guidelines. Second, we examine the clinical utility of non-statin agents alone and in combination in terms of LDL-C lowering and ASCVD risk reduction.

Recent Findings

Medical societies, including the American College of Cardiology (ACC), National Lipid Association (NLA), and American Association of Clinical Endocrinologists (AACE), have released guidelines to address the appropriate use of non-statin therapies. The guidelines incorporated new evidence, including the IMPROVE-IT and FOURIER clinical trials, which demonstrate that the combination of statin therapy with other non-statin agents such as ezetimibe and PCSK9 inhibitors has a significant clinical benefit. Increasing evidence that aggressive low-density lipoprotein cholesterol (LDL-C) lowering leads to lower cardiovascular disease risk supports the need for continued exploration of the role of combination lipid-lowering therapies.

Summary

A review of guidelines and clinical trials evaluating non-statin agents illuminates the growing base of evidence and expert opinion supporting the use of combination lipid-lowering therapies. While the majority of clinical trial data utilizes dyslipidemia monotherapy, especially statins, combination therapies represent an opportunity for individualized, patient-centered approach to LDL-C lowering and atherosclerotic cardiovascular disease (ASCVD) risk reduction. The overview provides a perspective on lipid management intended for clinicians who seek additional information and guidance on the use of combination therapies.

     

Rheumatoid Arthritis,Statin Indication and Lipid Goals: Analysis According to Different Recommendations

BackgroundDifferent strategies have been proposed for the cardiovascular risk management of patients with rheumatoid arthritis (RA).Objectives(1) To estimate the cardiovascular risk by different strategies in RA patients, analyzing which proportion of patients would be candidates to receive statin therapy; (2) to identify how many patients meet the recommended lipid goals.MethodsA cross-sectional study was performed from a secondary database. The QRISK-3 score, the Framingham score (adjusted for a multiplying factor × 1.5), the ASCVD calculator and the SCORE calculator were estimated. The indications for statin therapy according to NICE, Argentine Consensus, ACC/AHA, and new European guidelines were analyzed. The recommended LDL-C goals were analyzed.ResultsA total of 420 patients were included. In total, 24.7% and 48.7% of patients in primary and secondary prevention were receiving statins, respectively. Only 19.4% of patients with cardiovascular history received high intensity statins. Applying the ACC/AHA guidelines (based on ASCVD score), the Argentine Consensuses (based on adjusted Framingham score), the NICE guidelines (based on QRISK-3) and European recommendations (based on SCORE), 26.9%, 26.5%, 41.1% and 18.2% of the population were eligible for statin therapy, respectively. Following the new European recommendations, 50.0%, 46.2% and 15.9% of the patients with low-moderate, high or very high risk achieved the suggested lipid goals.ConclusionApplying four strategies for lipid management in our population, the cardiovascular risk stratification and the indication for statins were different. A significant gap was observed when comparing the expected and observed statin indication, with few patients achieving the LDL-C goals.     

Icosapent ethyl for dyslipidaemia in patients with diabetes and coronary artery disease: Act now to reduce it

The risk of atherosclerotic cardiovascular disease (ASCVD) can be significantly reduced in patients with diabetes who are undergoing low-density lipoprotein cholesterol-reducing therapies. However, the elevated triglyceride levels seen in diabetic dyslipidaemia can contribute to residual ASCVD risk. Icosapent ethyl (IPE) has recently been shown to substantially reduce major cardiovascular events in high-risk patients with hypertriglyceridaemia who are undergoing statin therapy. In a real-world study of patients with diabetes and acute coronary syndrome (ACS), 17.1% were found to be eligible for treatment with IPE based on Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) criteria. A significant proportion of patients with diabetes and ACS merit receiving IPE therapy, with important implications for evolving clinical practice guidelines and best standard of care.     

The 2018 AHA/ACC/Multi-Society Cholesterol guidelines: Looking at past,present and future

The authors review more than three decades of progress in providing clinicians and patients with guidance on risk assessment, patient evaluation and cholesterol management. Beginning with the National Cholesterol Education Program's Initial Adult Treatment Panel report, the cholesterol guidelines increasingly reflect the progress made in understanding the benefits of improved lifestyle and nutrition to improve lipid profiles, major risk factors and reduce ASCVD risk. Moreover, they now provide qualitative and quantitative assessment tools to guide appropriate risk reduction LDL-C lowering therapy. Use of the Pooled Cohort Equations to determine Low, Borderline, Intermediate and High 10-year ASCVD risk is now joined by recognition of conditions and biomarkers that enhance ASCVD risk. This personalizes the risk discussion for the patient. An important addition is the selective use of coronary artery calcium (CAC) scoring to reclassify risk in patients at borderline or intermediate risk, but for whom a risk decision regarding statin therapy is uncertain.In secondary prevention, current guidelines provide criteria for determining a “very high” risk group in whom risk is especially high and in whom aggressive LDL-C lowering can be shown to provide increased absolute benefit. Current guidelines provide a comprehensive look at children and adolescents, young adults, elderly, women and issues specific to women through the life course. They provide guidance for those adults at risk due to severe hypercholesterolemia, persistent hypertriglyceridemia after secondary causes have been addressed, those with inflammatory disorders and HIV, those adults with chronic kidney disease, and those affected by issues of race/ethnicity. They conclude with a brief summary of recommendations emphasizing important concepts for providing safety with LDL-C lowering therapy. This combination of best external evidence and clinical expertise from the expert panel should provide a solid foundation for lipid management of patients at risk for or with clinical ASCVD.     

Blood pressure goals: A moving target

Clinical guidelines on hypertension have evolved over the past several decades. Each recommends varying blood pressure (BP) cut-offs which define hypertension, determine the thresholds to initiate pharmacotherapy, and guide treatment targets. In addition, different techniques of measuring BP in clinical trials may further contribute to the discrepancies in the achieved BP targets. Physicians find it difficult to navigate through different recommendations for hypertension management based on studies among different age groups and patients with a variety of co-morbidities and target organ involvement. In 2003, JNC 7 recommended a BP goal of < 140/90 mmHg in the general population and < 130/80 mmHg in those with diabetes mellitus or renal disease. JNC 8 re-set the BP target at < 140/90 mmHg for all adults under the age of 60 regardless of co-morbidities, and an even higher target of < 150/90 mmHg for those 60 years or older without diabetes or chronic kidney disease. The more recent results of the Systolic BP Intervention Trial (SPRINT) have a significant influence on the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) guideline which redefines hypertension as BP ≥ 130/80 mmHg. It emphasizes individualized cardiovascular risk assessment and recommends a more aggressive BP target of < 130/80 mmHg and a treatment threshold based on the age, co-morbidities, and cardiovascular risk. The 2017 ACC/AHA guideline also advocates proper BP measurement and provides the estimates of corresponding BP values for clinic, home, and ambulatory BP monitoring measurements. A higher prevalence of hypertension is expected based on the ACC/AHA 2017 guideline. Its implementation may potentially lead to better BP control through enhanced awareness, improved adherence, and more timely initiation and intensification of pharmacologic therapy. Although there is no one-size-fits-all BP target, the ACC/AHA 2017 guideline is simple, inclusive and practical. Nonetheless, more studies are warranted to help further individualize BP goals for elderly patients and those with certain co-morbidities or multiple cardiovascular risk factors.     

Therapeutic approaches to dyslipidemia in diabetes mellitus and metabolic syndrome

Type 2 diabetes mellitus and the closely related metabolic syndrome are associated with significant risk for cardiovascular disease. Recent evidence suggests that both conditions are increasing in epidemic proportions. Dyslipidemia is characterized by increased triglyceride-rich lipoproteins; low high-density lipoprotein cholesterol; small, dense low-density lipoprotein particles; increased postprandial lipemia; and abnormal apolipoprotein A1 and B metabolism. All these lipoprotein disturbances accelerate atherosclerosis in these patients. It is likely that many patients will need combinations of lipid-modifying therapy to achieve American Diabetes Association (ADA), Adult Treatment Panel III, and American Heart Association (AHA)/American College of Cardiology (ACC) guidelines to help prevent cardiovascular disease and death.     

Regional evidence and international recommendations to guide lipid management in Asian patients with type 2 diabetes with special reference to renal dysfunction

The anticipated increase in the prevalence and incidence of type 2 diabetes in Asia, and its associated cardiovascular–renal complications, will place a significant burden on patients, caregivers, and society. Despite the proven effectiveness of lipid management in reducing these complications, there are major treatment gaps, especially in Asian patients with young‐onset diabetes and chronic kidney disease (CKD). Recent international guidelines recommended the adoption of absolute risk estimation of atherosclerosis and cardiovascular disease to guide treatment intensity. These recommendations replaced the previous strategy of using low‐density lipoprotein cholesterol targets to guide initiation and intensification of lipid lowering, albeit still widely practiced in Asia. The latest guidelines also highlight the high risk of atherosclerosis and cardiovascular disease (ASCVD) for people with diabetes, who should be protected with statins, except for young patients without other risk factors, who will need yearly monitoring of blood lipid levels. Given the propensity of Asian patients with diabetes to develop CKD and the amplifying effect of CKD on ASCVD, the use of statins in Asian patients is particularly important. Due to interethnic differences in drug metabolism, rosuvastatin, which is largely cleared by the kidney, should be prescribed in low dosages (5–10 mg daily) in Asian populations. Conversely, epidemiological and experimental data confirm pleotropic and organ‐protective effects of atorvastatin, with proven safety in Asian populations within a daily dose range of 10–40 mg. Thus, there is a need for Asian countries to review and align their lipid‐lowering treatment guidelines to reduce the substantial burden of diabetes in the Asian region.