WASHINGTON, April 18, 2025 (APMnews) – Delayed initiation of lipid-lowering therapy in addition to statins after myocardial infarction is associated with an increased risk of major cardiovascular events compared to early initiation, according to data from the SWEDEHEART registry published in the Journal of the American College of Cardiology (JACC).
Current guidelines recommend early use of high-intensity statins following myocardial infarction, along with treatment escalation to achieve LDL cholesterol targets below 1.4 mmol/L (0.55 g/L), recall Margret Leosdottir from the Department of Cardiology at Skåne University Hospital in Malmö, Sweden, and her colleagues.
However, “data from the SWEDEHEART registry show that approximately 75 to 80% of patients who experienced a myocardial infarction did not reach LDL-C targets with statin monotherapy,” they noted. “If the currently recommended LDL-C goals are to be rigorously implemented, the use of combination therapy is unavoidable.”
For ethical reasons, the authors did not conduct a randomized trial but instead used the SWEDEHEART registry data to emulate a clinical trial, applying an approach that accounts for confounding bias to assess the impact of delayed treatment escalation.
A total of 35,826 lipid-lowering treatment–naive patients who were hospitalizsed for myocardial infarction between 2015 and 2022 and discharged on statin therapy were included, with over 98% prescribed high-intensity statins.
Among them, 16.9% received ezetimibe within 12 weeks of hospital discharge, 18.1% received it after 12 weeks, and 65% remained on statin monotherapy during the 16 months following discharge.
Over a median follow-up of four years, 2,570 patients experienced a major adverse cardiovascular event (MACE), including deaths (440 of cardiovascular origin), myocardial infarctions, and strokes.
At one year, 38.4% of patients who received early ezetimibe achieved the LDL-C target of <1.4 mmol/L, compared to 28.8% of those who received it later and 25.3% of those treated with statins alone.
The incidence rate of MACE at one year was 1.8 per 100 person-years in the early combination therapy group, 2.6 per 100 person-years in the delayed ezetimibe group, and 4 per 100 person-years in the statin monotherapy group.
In the studied cohort, 477 major cardiovascular events could have been avoided
Compared to early combination therapy, the adjusted relative risk of MACE at three years was 14% higher with delayed combination therapy and 29% higher with statin monotherapy.
Cardiovascular mortality was also increased, with three-year risk increases of 64% and 83%, respectively.
Among the nearly 36,000 patients included in the cohort, “if all patients had received early combination therapy, this approach could have prevented an additional 477 events,” the authors emphasized.
“The need for combination therapy is inevitable for most patients after myocardial infarction,” the authors concluded, further stating that a delayed approach to intensifying lipid-lowering treatment “is associated with avoidable harm.”
“Care pathways can be streamlined with tangible health benefits if the standard of care for lipid-lowering therapy after myocardial infarction consists of early combination therapy with high-intensity statins and ezetimibe.”
(JACC)
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