Comprehensive review of statin-intolerance and the practical application of Bempedoic Acid.

Statin-intolerance (SI) has prevalence between 8.0 % and 10 %, and muscular complaints are the most common reason for discontinuation. Bempedoic acid (BA), an ATP citrate lyase inhibitor, decreases hepatic generation of cholesterol, upregulates low-density lipoprotein (LDL) receptor expression in the liver, and eventually clears circulating LDL-cholesterol from the blood. Multiple randomized clinical trials studying BA demonstrate a reduction in LDL levels by 17-28 % in SI. The CLEAR OUTCOME trial established significant cardiovascular benefits with BA. A dose of 180 mg/day of BA showed promising results. BA alone or in combination with ezetimibe is US Food and Drug Administration-approved for use in adults with heterozygous familial hypercholesterolemia and/or established atherosclerotic cardiovascular disease. BA reduced HbA1c by 0.12 % (p < 0.0001) in patients with diabetes. Adverse events of BA include myalgia (4.7 %), anemia (3.4 %), and increased aminotransferases (0.3 %). BA can cause up to four times higher risk of gout in those with a previous gout diagnosis or high serum uric acid levels. Reports of increased blood urea nitrogen and serum creatinine were noted. Current evidence does not demonstrate a reduction in deaths from cardiovascular causes. More studies that include a diverse population and patients with both high and low LDL levels should be conducted. We recommend that providers consider BA as an adjunct to statin therapy in patients with a maximally tolerated dosage to specifically target LDL levels.

Trajectory of illness for patients with congestive heart failure.

BACKGROUND AND OBJECTIVE: This study describes progression to death for patients with congestive heart failure (CHF). METHODS: We used SAS procedure Proc Traj to fit a semiparametric model to longitudinal data on prognosis of patients with CHF in the 12 months prior to death. Data were collected on 744 patients with CHF in 2010 at Bay Pines VA Healthcare System; 386 subjects had sufficient data points (minimum of five encounters) to trace their risk in 12 months prior to death. The prognosis of the patient was calculated using the comorbidities of the patient. RESULTS: Unexpected death occurred in 20.5% of patients; all remaining patients had a gradual progression toward death. For 13.3% of patients, progression toward death started 12 months prior to death. For 29.9% of patients, increased risk started at 6 months prior to death. For 36.3% of patients, it started 3 months prior to death. One month prior to death, 79.5% of the patients had a more than 97% chance of mortality. It may be possible to use progression toward death over 3 consecutive months as a predictor of need for hospice consultation. CONCLUSIONS: Five typical illness trajectories have been described for patients with progressive heart failure. The needs of patients and their caregivers are likely to vary according to the trajectory patients are following. Contrary to reports in the literature about unexpected death in patients with CHF, the majority of decedents in our study had a predictable and gradual progression toward death. Recognizing these trajectories may help clinicians implement an appropriate plan to meet the needs of patients and their caregivers.

Validity of Amino Terminal pro-Brain Natiuretic Peptide in a Medically Complex Elderly Population.

BACKGROUND: The routine use of natiuretic peptides in severely dyspneic patients has recently been called into question. We hypothesized that the diagnostic utility of Amino Terminal pro Brain Natiuretic Peptide (NT-proBNP) is diminished in a complex elderly population. METHODS: We studied 502 consecutive patients in whom NT-proBNP values were obtained to evaluate severe dyspnea in the emergency department. The diagnostic utility of NT-proBNP for the diagnosis of congestive heart failure (CHF) was assessed utilizing several published guidelines, as well as the manufacturers suggested age dependent cut-off points. RESULTS: The area under the receiver operator curve (AUC) for NT-proBNP was 0.70. Using age-related cut points, the diagnostic accuracy of NT-proBNP for the diagnosis of CHF was below prior reports (70% vs. 83%). Age and estimated creatinine clearance correlated directly with NT-proBNP levels, while hematocrit correlated inversely. Both age > 50 years and to a lesser extent hematocrit < 30% affected the diagnostic accuracy of NT-proBNP, while renal function had no effect. In multivariate analysis, a prior history of CHF was the best predictor of current CHF, odds ratio (OR) = 45; CI: 23-88. CONCLUSIONS: The diagnostic accuracy of NT-proBNP for the evaluation of CHF appears less robust in an elderly population with a high prevalence of prior CHF. Age and hematocrit levels, may adversely affect the diagnostic accuracy off NT-proBNP. KEYWORDS: Congestive Heart Failure; Natriuretic peptides; Diagnosis; Elderly Patients.