Cardiovascular disease is by far the most common cause of death worldwide, and myocardial infarction is the most common acute event. For those who survive a myocardial infarction, the risk of a new heart attack is greatest in the first year after the initial event because the blood vessels are more sensitive, making it easier for blood clots to develop. Reducing the "bad" cholesterol in the blood stabilises changes in the vessels, decreasing the risk for new events. The current established routine treatment is to treat with high-potency statins, immediately after the infarction. However, the majority of patients do not reach their treatment goals using only this medication. They need an add-on treatment in order to get down to the recommended cholesterol levels.
"Today's guidelines recommend stepwise addition of lipid-lowering treatment. But it's often the case that this escalation takes too long, it's ineffective and patients are lost to follow-up," says Margrét Leósdóttir, Associate Professor at Lund University and senior cardiology consultant at Skåne University Hospital in Malmö, Sweden.
In the study in question, she examined the prognosis of patients if the add-on therapy ezetimibe is applied early – (within 12 weeks after myocardial infarction), late (between 13 weeks and 16 months) or not at all. Based on Swedish registry data from 36,000 patients who had a myocardial infarction between 2015 and 2022, Margrét Leósdóttir´s research group has used advanced statistical models to emulate a clinical trial. The results show that patients who received a combination treatment of statins and ezetimibe within 12 weeks after the infarction and were able to lower cholesterol to the target level early, had a better prognosis and less risk of new cardiovascular events and death than those who received the add-on treatment late or never. Based on the results, many new heart attacks, strokes and deaths could be prevented every year if the treatment strategy would be changed.
"Combination therapy is not applied up-front for two main reasons. General recommendations are not included in today's guidelines and a precautionary principle is applied to avoid side effects and overmedication. However, there are positive effects from applying both medicines as soon after the infarction as possible. Not doing this entails an increased risk. In addition, the drug we have examined in the study causes few side effects and is readily available and inexpensive in many countries."
Margrét Leósdóttir hopes that the research results will in time provide support for changes in the recommendations. A treatment algorithm has already been introduced at her hospital in Sweden to help doctors to prescribe appropriate lipid-lowering treatment for patients who have had a myocardial infarction. It has been noted that patients achieve their treatment goals earlier and two months after the infarction twice as many patients have reduced their bad cholesterol to the target level, compared with previously.
"Several other hospitals in Sweden have also adopted the algorithm and there are similar examples from other countries that have produced as good results. My hope is that even more will review their procedures, so that more patients will get the right treatment in time, and we can thereby prevent unnecessary suffering and save lives."
