Intensive Statin Therapy Versus Upfront Combination Therapy of Statin and Ezetimibe in Patients with Acute Coronary Syndrome: A Propensity Score Matching Analysis Based on the PL-ACS Data
Background and Purpose:
- Acute coronary syndromes (ACS) are the leading cause of cardiovascular death and current strategies for lipid-lowering therapies (LLTs) have been insufficient for achieving target low-density lipoprotein cholesterol (LDL-C) goals.
- The authors aimed to assess the effectiveness of statin monotherapy versus upfront combination LLT of statin and ezetimibe at reducing all‐cause mortality in patients with ACS.
Methods:
- Patient Population – consecutive patients included in PL-ACS (Polish Registry of Acute Coronary Syndromes)
- Primary Endpoint – all-cause mortality, assessed at 1, 2, and 3 years
- Statistical Analysis
- Study patients were matched to achieve similar age, sex, LDL-C levels, ACS diagnosis, and medical history.
- 38,023 ACS patients who were discharged alive were included in the initial statistical analysis
- Data were matched using the Mahalanobis distance then multivariable stepwise logistic regression analysis was used in propensity score matching analysis.
- 2 groups were analyzed after propensity score matching
- Statin monotherapy (atorvastatin or rosuvastatin) – 768 patients
- Upfront combination therapy of statin and ezetimibe – 768 patients
Results:
- Upfront combination therapy was associated with a significant reduction of all-cause mortality in comparison with statin monotherapy, with an absolute risk reduction of 4.7% after 3 years
- Year 1 mortality: 5.9% (monotherapy) versus 3.5% (combination)
- Year 2 mortality: 7.8% (monotherapy) versus 4.3% (combination)
- Year 3 mortality: 10.2% (monotherapy) versus 5.5% (combination)
- Rosuvastatin significantly improved prognosis compared with atorvastatin in monotherapy.
Conclusions:
- The upfront combination therapy is superior to the statin monotherapy for reducing all-cause mortality in ACS patients, which suggests that upfront combination therapy, rather than a stepwise therapy approach, should be recommended in high-risk patients.
- The authors further state:
- Our study has important strengths, which include the following: (1) The population in our study was a real-world cohort treated because of ACS in multiple centers in Poland with a relatively high number of included patients, as well as a relatively long-time follow-up. (2) To the best of our knowledge, it is the first such analysis that presented results based on real-world data.
- Despite this, further prospective studies would be beneficial to confirm the positive role of immediate combined therapy with a maximally tolerated dose of statin with ezetimibe initiated in the acute phase of myocardial infarction.
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