South Asians with ASCVD are often eligible for icosapent ethyl
Generalizability of the REDUCE-IT trial to South Asians with cardiovascular diseaseLiterature - Krishnaraj A, Bakbak E, Teoh H, et al. - Med. 2023 Feb 10;4(2):130-138. doi: 10.1016/j.medj.2022.12.008.
Introduction and methods
Individuals with South Asian (SA) ancestry are at disproportionally high risk for CV deaths compared to other races . However, this patient population is often underrepresented in contemporary clinical trials. The REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention) trial previously demonstrated in a predominantly white patient population (90% white) that icosapent ethyl (IPE) reduces the risk of MACE in people with hypertriglyceridemia who are at high CV risk and on statins. It remains unknown whether the results of the REDUCE-IT trial can be generalized to people of non-white ethnicity.
Aim of the study
This study investigated the proportion of SA patients with atherosclerotic CV disease (ASCVD) that would be eligible for IPE treatment.
In this Canadian cross-sectional observational study, 200 statin-treated SAs (≥ 45 years old; mean age 67 years, 82% male) with ASCVD (presence of coronary, carotid, or peripheral atherosclerosis within the last 10 years) were included. SA ethnicity was self-identified, and included Anglo-Indian, Bangladeshi, Bengali, Bhutanese, Goan, Gujarati, Indian, Jatt, Kashmiri, Maharashtrian, Malayali, Nepali, Pakistani, Punjabi, Sindhi, Sinhalese, Sri Lankan, Tamil, Telugu, or other SA descent. Exclusion criteria where participants with HF, liver disease, or any known un-cured malignancy. Patients on omega-3 fatty acid supplements, fish oil, or IPE were ineligible.
The main outcome was the proportion of SA patients that were eligible for IPE.
- In this cohort, the predominant ASCVD phenotype was coronary artery disease (94%). 56.5% of patients had a history of diabetes, mostly T2DM, and 94% had a history of hypertension. Blood pressure, LDL-c, and triglycerides were relatively well controlled.
- According to the Health Canada guidelines, statin-treated patients with elevated triglyceride (unspecified threshold), who are at high CV risk due to either established CV disease, or diabetes, and ≥ 1 other CV risk factor are eligible for IPE treatment. According to these guidelines, using a ≥ 1.52 mmol/L threshold for hypertriglyceridemia, 33% of participants would be eligible for IPE treatment.
- The Canadian Cardiovascular Society (CCS) guidelines and Health Canada guidelines for IPE differ slightly, and the CCS guidelines specify that IPE can be considered when triglyceride levels fall between 1.5 mmol/L and 5.6 mmol/L. The proportion of patients eligible for IPE treatment was similar according to the CCS guidelines and Health Canada guidelines (both 33%).
- The FDA indicates that IPE can be considered to reduce CV risk in statin-treated people with triglycerides ≥ 1.69 mmol/L. According to these guidelines, 24.5% of the participants would be eligible for IPE treatment.
A large proportion of statin-treated SAs with ASCVD were eligible for IPE (one in three according to Canadian indications, and one in four according to American guidelines). The authors of this study stated “Given the high-risk nature of SA patients with ASCVD, IPE should be strongly considered in this population”.