Lipid lowering in PAD patients

Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease: Insights From the FOURIER Trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk); Bonaca MP et al

Patients with peripheral artery disease (PAD) are at very high risk for cardiovascular events, therefore lipid lowering has a high level of recommendation in the current ESC guidelines “Peripheral artery diseases” [1]. In particular, statins are recommended to improve cardiovascular prognosis and clinical symptoms of intermittent claudication (IA recommendation). 

In the Fourier (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) study evolocumab reduced low-density lipoprotein cholesterol and cardiovascular events in patients with atherosclerotic disease [2, 3]. In the subgroup of patients with PAD of lower extremities MALE (major adverse limb events) have also been reduced in the treatment arm [3]. Recently the results from the ODYSSEY outcomes study have been published [4]. Patients were randomized to alirocumab or placebo after an acute coronary syndrome. Alirocumab significantly reduced a composite endpoint of cardiovascular death, myocardial infarction, stroke, or unstable angina requiring hospitalization. In the current subgroup analysis prognosis was improved especially in patients with additional atherosclerosis in the carotid or peripheral arteries [5].

In contrast to guideline recommendations and current publications, PAD patients are still undertreated concerning lipid lowering therapy. Two major studies show that compared to patients with coronary artery disease only a minority of PAD patients are treated with high intense statins such as atorvastatin or rosuvastatin [6, 7]. In fact, treatment with high intensive statins reduced mortality and amputation rate in PAD patients compared with patients treated with simvastatin [7].

In conclusion, patients with PAD have a large improvement from intensive lipid lovering therapy using stains and PCSK9 inhibitors. In clinical practice there is an urgent need for more consequent treatment of these high risk patients.