Show 1353: Cutting Edge Cardiology from a Top Heart Doctor

When you think of preventing heart disease, what comes to mind? We hope you envision regular exercise and a healthful diet (whatever that means to you). Perhaps you also plan for regular checkups and know what your cholesterol levels are. If they have been high, you may be taking a statin cholesterol-lowering drug to get them down. What else does cutting edge cardiology have to offer?

Cutting Edge Cardiology Goes Beyond Statins:

Statins such as atorvastatin (Lipitor), rosuvastatin (Crestor) or simvastatin (Zocor) are quite effective at lowering cholesterol. However, not everyone is able to benefit from a statin. Some people find that they cause side effects that may be intolerable. Others need more cholesterol-lowering power than a statin can provide. Our guest today, Dr. Steve Nissen, describes the advantages of a relatively new drug called bempedoic acid (Nexletol).

Is Nexletol the Next Thing for Lowering Cholesterol?

The FDA approved Nexletol in 2020, and doctors have been wondering how best to use it. Initially, they were encouraged to add a prescription for Nexletol if a patient did not get enough response from a statin alone.

Dr. Nissen and his colleagues conducted a world-wide study of nearly 14,000 people at high risk for cardiovascular events like heart attacks (JAMA, July 11, 2023). These were people who found statins challenging, so Nexletol was the only cholesterol-lowering therapy they used during 40 months of the trial.

More than 4,000 volunteers didn’t have heart disease at the start of the study. For them, Nexletol significantly reduced the chance of cardiovascular complications compared to placebo. According to the researchers, 43 people would need to take Nexletol for that time so that one person could avoid a serious outcome. This is what we call the “Number Needed to Treat,” or NNT.

Other Drugs Used in Cutting Edge Cardiology:

Dr. Nissen’s big study demonstrates that bempedoic acid has important health consequences as well as lowering cholesterol. We also asked him about other lipid-lowering medications known as PCSK-9 inhibitors. He reviewed the benefits and risks of alirocumab (Praluent), evolocumab (Repatha) and inclisiran (Leqvio). These long-acting injectable medications work differently from both statins and bempedoic acid to lower cholesterol, especially LDL cholesterol. They are especially helpful for people with familial hyperlipidemia, a genetic condition in which cholesterol soars. As it does, it raises the risk of heart disease. For such people, cardiologists try to get LDL down to 55 mg/dL or so.

Have You Had Your Lp(a) Tested?

Another genetic factor making its way into cutting edge cardiology is lipoprotein a, also called Lp(a) [ell-pee-little a]. Although doctors have known about this blood particle for decades, they have not given it much attention. Diets that are usually recommended for heart health don’t seem to change Lp(a) levels much, and neither does exercise. Cardiologists have not had any prescription medicines to offer, either. They do work hard to help these people lower all their other cardiac risk factors and minimize their chances of a heart attack otherwise.

Now that is about to change. Dr. Nissen has been overseeing a clinical trial of a drug, pelacarsen, that may be able to reduce the levels of this sticky substance that can clog arteries and cause blood clots. If the medication makes a real difference, the FDA could well approve it and cardiologists will begin to use it. Patients who could benefit most are those with a strong family history of early heart attacks as well as elevated levels of Lp(a). We will be interested to learn how much the medication is able to reduce rates of heart attack and death compared to placebo.

One other topic in our discussion of cutting edge cardiology involves a drug that is more than a hundred years old! Cardiologists do not recommend aspirin for people who have never had a heart attack. But it can be quite helpful for those who do have heart disease. Moreover, aspirin can significantly reduce the risk of cardiovascular problems among people with elevated Lp(a) (Journal of the American College of Cardiology, Oct. 2022).

This Week's Guest:

Steven Nissen, MD, MACC, is Chief Academic Officer of the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at the Cleveland Clinic. Dr. Nissen holds the Lewis and Patricia Dickey Chair in Cardiovascular Medicine at the Lerner School of Medicine. He is the co-author, with Mark Gillinov, MD, of Heart 411: The only guide to heart health you'll ever need.
His website is https://my.clevelandclinic.org/staff/1185-steven-nissen

[caption id="attachment_127352" align="alignnone" width="293"] Steven E. Nissen, MD, MACC, of the Cleveland Clinic[/caption]