The largest analysis to examine the best way to lower levels of ‘bad’ cholesterol in patients with blocked arteries shows that they should immediately be given a combination of a statin and another drug called ezetimibe, rather than statins alone.
This could prevent thousands of deaths a year from heart attacks, strokes and other cardiovascular diseases.
The meta-analysis of 108,353 patients in 14 studies who were at very high risk of suffering heart attack or stroke, or who had already suffered one of these cardiovascular events was published last week.
It shows that when ezetimibe was combined with a high dose statin to reduce levels of low density lipoprotein cholesterol (LDL-C), there was a significant 19 per cent reduction in the risk of death from any cause, a 16 per cent reduction in deaths from cardiovascular causes.
There was also a significant reduction in the incidence of major adverse cardiovascular events or stroke by 18 per cent and 17 per cent respectively, compared to high doses of statins alone.
The combination therapy also significantly reduced LDL-C levels by an extra 13mg per decilitre (dL) of blood compared to statins alone, measured from the baseline – the time at which the patient first started the treatment.
This increased the chances of reaching the ideal goal of less than 70mg/dL of LDL-C by 85 per cent.
Maciej Banach is Professor of Cardiology at the John Paul II Catholic University of Lublin, Poland, and Adjunct Professor at the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine.
Banach said: “These results were even more pronounced in the network meta-analysis, which enables a direct comparison of different therapy regimens used in the study.
“This showed a 49 per cent reduction in all-cause mortality and a 39 per cent reduction in major adverse cardiovascular events, when compared to high dose statin therapy alone.
“The combination therapy is safe and efficacious; the risk of adverse events and the therapy discontinuation rate was comparable between groups.
“In the network meta-analysis, we showed a significant 44 per cent reduction in the risk of discontinuation in those treated with moderately high dose statin therapy plus ezetimibe versus a high dose statin alone.”
Until now, there have been inconsistent findings about whether or not combined cholesterol lowering therapy should be given to high risk patients immediately, even before they suffer a heart attack or stroke, or whether doctors should start these patients on a high dose statin first and monitor the effects on cholesterol levels after at least two months before deciding if the patients need ezetimibe as well.
Peter Toth, Professor of Clinical Family and Community Medicine, University of Illinois, and Adjunct Associate Professor of Medicine at Johns Hopkins University, USA, is co-author of the study.
Toth said: “This study confirms that combined cholesterol lowering therapy should be considered immediately and should be the gold standard for treatment of very high-risk patients after an acute cardiovascular event.
“Simply adding ezetimibe to statin therapy, without waiting for at least two months to see the effects of statin monotherapy, which is suboptimal in many patients, is associated with more effective LDL-C goal achievement and is responsible for significant incremental reductions in cardiovascular health problems and deaths.
“This approach does not require additional funding or reimbursement of new expensive drugs.
“In fact, it may translate into lower rates of first and subsequent heart attacks and stroke, and their complications like heart failure, which are extremely costly for all healthcare systems.”
