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Role of dual lipid-lowering therapy in coronary atherosclerosis regression: Evidence from recent studies

  • Felice Gragnano
    Affiliations
    Division of Clinical Cardiology, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy

    Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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  • Paolo Calabrò
    Correspondence
    Corresponding author.
    Affiliations
    Division of Clinical Cardiology, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy

    Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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      Highlights

      • Plasma LDL-C is a central determinant of the progression of the atherosclerotic disease and its complications.
      • Lowering LDL-C by statins in individuals with CAD produces the stabilization and regression of coronary atherosclerosis.
      • Dual lipid-lowering therapy is superior in inducing plaque regression compared with statin monotherapy.
      • Controversies regarding the effect of non-statin agents on plaque composition have to be fully elucidated.
      • The selection process for patients that may benefit from dual lipid-lowering therapy has to be further implemented.

      Abstract

      Despite recent therapeutic advances, there is an unmet need in cardiovascular disease prevention. Clinical trials and meta-analyses have established that LDL-C lowering, particularly by statin therapy, reduces the progression of coronary atherosclerosis and the risk of coronary events. Insufficient LDL-C reduction and high residual risk in a significant proportion of statin-treated patients signify that additional therapies are required to deliver more effective coronary care. Pharmacological inhibition of cholesterol absorption (with ezetimibe) and PCSK9 activity (with evolocumab or alirocumab) provides potentially useful approaches for the therapeutic modulation of LDL-C metabolism in statin-treated patients. In recent trials, combination strategies involving a statin and non-statin agent (ezetimibe or evolocumab) have been shown to promote coronary atherosclerosis regression and improve cardiovascular outcomes in patients with moderate-to-high cardiovascular risk. This review summarizes recent evidence on the effects of dual lipid-lowering therapy on coronary atherosclerosis.

      Keywords

      Abbreviations:

      ACS (acute coronary syndrome), ASCVD (atherosclerotic cardiovascular disease), CuVIC (Effect of Cholesterol Absorption Inhibitor Usage on Target Vessel Dysfunction After Coronary Stenting), DAPT (dual antiplatelet therapy), DEBATE (Drugs and Evidence-Based Medicine in the Elderly), DULT (dual lipid-lowering therapy), GLAGOV (Global Assessment of Plaque Regression with a PCSK9 Antibody as Measured by Intravascular Ultrasound), IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial), IVUS (intravascular ultrasound), OCT (optical coherence tomography), PAV (percent atheroma volume), PCI (percutaneous coronary intervention), PRECISE-IVUS (Plaque Regression with Cholesterol Absorption Inhibitor or Synthesis Inhibitor Evaluated by Intravascular Ultrasound), REVEAL (Randomized EValuation of the Effects of Anacetrapib Through Lipid-modification), SAP (stable angina pectoris), TAV (total atheroma volume)
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