The lower the better: high cholesterol is a silent killer that claims victims on a par with major cardiovascular diseases and diabetes and is a major contributor to strokes and heart attacks.
In the central-southern regions, only 20 percent of the population affected by this metabolic disorder reaches the target values indicated by the guidelines and scientific societies for prevention. Poor adherence to the doctor's instructions, the tendency to abandon treatments, the difficulties in accessing new therapies and drugs, inadequate communication to patients about the risks they run by letting cholesterol continue to silently damage the arteries are the main issues to be resolved in order to prevent the unfortunate outcomes of this metabolic condition and to strengthen and improve the diagnosis, prevention and treatment pathways.
A path that, in the central and southern regions, leads to unresolved needs, innovations that are not always accessible and new organizational needs of the connection networks between family medicine, specialist clinics, districts and hospitals.
This is what emerged during the event “PNRR, HYPERCHOLESTEROLEMIA, CARDIOVASCULAR RISK, BETWEEN UNRESOLVED NEEDS, INNOVATION AND NEW ORGANIZATIONAL NEEDS - LAZIO/CAMPANIA/SARDINIA” in two round tables of scientific study on the health and welfare reality of the central-southern regions promoted in Naples by Motore Sanità (with the unconditional contribution of Daiichi-Sankyo) in which Valeria Ciarambino, vice-president of the Regional Council of Campania, and Carla Cuccu, regional councilor of the Health Commission of Sardinia, participated for the institutional part.
Today we have pharmacological aids capable of reaching the recommended levels of cholesterolemia, however less than half of high-risk subjects are at target. The increase in LDL cholesterol, based on physiopathological and clinical evidence, is no longer considered only an important cardiovascular risk factor, but a causal agent of atherosclerosis and its progression. The recent guidelines on the treatment of dyslipidemia and cardiovascular prevention therefore propose to reach very low levels of LDL cholesterol around 50 mg/dl in high-risk subjects (those who have already had an acute cardiovascular event).
At the speakers' table Pasquale Perrone Filardi, Regional President of SIC and Professor of Cardiology at Federico II, Naples, Paolo Calabrò, Professor of Cardiovascular Diseases at Vanvitelli in Naples, Adriano Cristinziano, Director of the Pharmacy at Monaldi in Naples, Giovanni Esposito, National President of GISE, Mariano Fusco, Director of the Pharmaceutical Department of ASL Napoli 2 Nord, Paolo Golino, Director of Cardiology at Vanvitelli at Monaldi, Sergio Lai Member of the Italian Heart Foundation.
And also Marta Marziali, Cardiologist at the ASL Roma 2, Daniele Pastori, Medical Director at the Policlinico Umberto I in Rome, Damiano Parretti, Head of the Cardiovascular Chronicity Area at SIMG, Eliana Pisani, Outpatient Cardiology Specialist at the ASL Roma 2, Daniela Ricciardulli, Head of Pharmacy at the ASL Roma 1, Adriano Vercellone, Director of the ASL Napoli 3 Sud Department and Regional Councillor at SIFO and Francesco Saverio Mennini, Professor of Health Economics at Tor Vergata.
THE TREATMENTS
"In recent years, there has been a constant increase in the consumption of lipid-lowering drugs (+38% compared to 2014), in line with the increase in the prevalence and incidence of dyslipidemia (Osmed 2021 report) – Daniela Ricciardulli underlined – However, approximately 50% of subjects with dyslipidemia are not treated pharmacologically or are treated inadequately, without reaching the expected LDL cholesterol targets, and adherence to lipid-lowering therapies is limited with important repercussions in terms of public health and healthcare costs”.
Statins, often prescribed by family doctors, often fail to adequately reduce cholesterol levels, resulting in dropouts, poor adherence and even side effects such as muscle pain. Patients who have already used high-dose statins and ezetimibe but are intolerant to statins and have not yet reached the desired cholesterol levels can also benefit from bempedoic acid, which, according to the latest studies, reduces LDL levels by about 20% in 12 weeks without causing lesions and muscle pain like statins. A low-cost drug that can also be managed by primary care, although today it has only a specialist target and is still little used in clinical practice. The last option is the use of PCSK9, a very effective but high-cost monoclonal antibody and reserved as a third option for very high-risk patients (note 13).
“For over 10 years, SISA (Italian Society for the Study of Atherosclerosis) – added Daniele Pastori – through his Foundation he has created a network of centers specialized in the clinical and molecular diagnosis of genetic dyslipidemias”. Spotlight on the Lipigen project (Lipid TransPort Disorders Italian Genetic Network): 49 active centers distributed throughout Italy.
Local doctors must be aware of the activities of the centers and have the possibility of sending patients with suspected genetic dyslipidemia to the reference center in their region. Given the very high cardiovascular risk of these patients, early recognition of genetic dyslipidemia is essential for reducing cardiovascular complications”.
Despite this scenario, out of over 1 million patients in Italy at higher risk, of which 100 thousand in Campania alone, 80% do not reach the target indicated by the most recent international guidelines. A health problem that has drastically worsened during the recent pandemic due to fewer checks, missed diagnoses and the loss of therapeutic adherence.
THE MINDS
“High cholesterol is a health threat, a silent killer that after a few years, if nothing is done to control it and lower its levels, attacks the heart and arteries just like high blood pressure and diabetes. – Perrone Filardi underlined – causing strokes and heart attacks over time that can arise even at a young age if there is homozygous familial hypercholesterolemia, that is, inherited from both the father and the mother”.
“In Italy, every year, more than 224 thousand people die from cardiovascular diseases (23 thousand in Campania, a little more in Lazio and a little less in other southern regions such as Sicily, Puglia and Sardinia) – added Marcello Pani, National Secretary of SIFO, Director of Pharmacy at the A. Gemelli University Hospital IRCCS Rome – but not everyone is aware of the role that high cholesterol plays in these avoidable deaths, which is the main cause of about 47.000 deaths (about 5 in Campania). Hospitalizations are thus the final and inappropriate outcome of a pathological process that takes years before translating into irreparable damage to the arteries of the heart and brain”.
The knot to untie is therefore to allow quick and appropriate access to treatment pathways.
“The lack of communication and poorly informed patients on the consequences of not reaching the target cholesterol values – Paolo Severino then underlined – indicate the problems to overcome for those who move and operate on these pathologies. The numbers of avoidable mortality and morbidity due to uncontrolled cholesterol are important, cerebral and coronary ischemia are only the final landing point of a problem not addressed for 10, 15 years that also affects the levels of hospitalization”.
Primary and secondary prevention and risk mitigation in chronic patients, also through correct indication of the values to be achieved according to the patient's clinical status and risk factors, are the elements to be taken into account during cholesterol-lowering therapy.
“Even analysis laboratories, when indicating the range of normal values, often do not take into account the various possible risk configurations and the indications of scientific societies. A heart attack victim or a diabetic, for example – continues Pani – will have to achieve different values compared to an overweight but young patient with no family history, so even an atherosclerotic patient over 55 who has a plaque recognizable with a simple Doppler of the supra-aortic trunks will have to have an LDL cholesterol value below the level of 75”.
CARE NETWORKS
The goal to be achieved is therefore to network internists, general practitioners and specialists from various disciplines to make the information widespread and shared to decide to take a certain innovative drug considering that today the reference indications are common throughout Europe. "Today - concludes the specialist - the only way in which hospital and territory communicate is represented by the letter of discharge from the hospital".
THE FAMILIARITY
In most cases, the predisposition to hypercholesterolemia is more nuanced and elusive, influenced more by diet, lifestyle, sedentary lifestyle and lack of physical activity. “Once certain levels of LDL cholesterol are exceeded (on average above 100) – added Calabrò – treatment and the intake of specific drugs become indispensable to avoid finding yourself at 50 or 60 with the classic carotid plaques and worrying levels of risk of acute cardiovascular events with patients who then end up in hospital UTIC and stroke units”.
THE ADHESION
Poor adherence to therapy has multiple causes: poor perception of the disease, fear of adverse events (damage to the muscles from statins), polytherapy, co-payment costs. Information and empowerment, also with respect to correct lifestyles, and use of more effective and innovative treatments are the objectives to be pursued in the perspective of proactive healthcare and personalized care.
"General medicine has a fundamental role in the periodic review of adherence. Through drug-utilization analyses it is possible to provide prescribers with operational tools useful for identifying patients who are not adherent to therapies (statin therapeutic coverage less than 80%) on whom to proactively intervene in collaboration with the reference specialist".
Choose the social channel you want to subscribe to