Is Upfront Combination Therapy of Statin and Ezetimibe Superior to Intensive Statin Therapy in Patients With Acute Coronary Syndrome?
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.
- Lewek et. al (Journal Am Heart Association 2023) 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.
