HOUSTON—Veterans who have experienced acute coronary syndrome within the past year face a substantial risk of a repeat event. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly reduce that risk, but determining who would benefit most and when they should be initiated has been challenging.
A team led by Salim S. Virani, MD, PhD, of the Michael DeBakey VAMC in Houston, tackled those questions and determined that PCSK9 inhibitors clearly have a role in reducing mortality in high-risk veterans with acute coronary syndrome. Their analysis also demonstrated that a rigorous stepped approach to low-density lipoprotein cholesterol reduction can contribute to both improved outcomes and reduced costs for the VA.1
Two large studies have shown a 15% reduction in relative risk of major cardiovascular events with the addition of a U.S. Food and Drug Administration-approved PCSK9 inhibitor to statin therapy. The ODYSSEY Outcomes trial evaluated alirocumab; the FOURIER study assessed evolocumab.2,3
To determine the proportion of patients in the VA Health Care System might benefit from PCSK9 inhibitor therapy, the Houston team searched a national cohort and found that 164,446 veterans with a history of ACS in the system between Oct. 1, 2014 and Sept. 30, 2015. Applying the ODYSSEY Outcomes criteria brought the number eligible down to 10,342, with most of the exclusions occurring because of the diagnosis of ACS was less than four weeks before or more than 52 weeks before the index primary care visit.
This treatment window “is typical for studies including those who’ve had ACS,” Virani told U.S. Medicine. “The first month has a higher chance of complication. After one year, the risk reduces. This typically is a good timeframe or range to include ACS patients.”
While 89% of participants in the ODYSSEY Outcomes trial were taking high-intensity statins at baseline, among veterans, the rates was a little more than half that. About 50% of veterans were on high-intensity statins, 28.5% were on moderate-intensity statins, 5.3% were on low-intensity statins and 15.3% were not on any statin.
The rate of statin use within the VA roughly reflects that seen in the general population.
“ODYSSEY was a randomized controlled trial,” said study co-author Vijay Nambi, MD, PhD. “To be in the study, patients had to be on statins at a maximum tolerated dose. What we were trying to do was to evaluate how many individuals in the VA would meet ODYSSEY criteria based on cholesterol levels. The low use of high-intensity statin therapy in patients with atherosclerotic cardiovascular disease is also seen in other large healthcare systems.”
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