Patients who receive a combination of drugs shortly after a heart attack experience significantly better outcomes than those treated later
Cardiovascular disease is the most common cause of death worldwide, with heart attacks being the most common acute event. Those who survive a heart attack have an increased risk of a new attack in the first year after the initial event because blood vessels are more sensitive.
New findings from researchers at Lund University in Sweden and Imperial College London suggest that treating patients with statins and the cholesterol-lowering drug ezetimibe could prevent thousands of new heart attacks over a decade.
“Our findings suggest that a simple change in treatment guidelines could have a huge impact on patients and reduce the demand on the NHS,” commented Professor Kausik Ray of the School of Public Health.
Additional treatment can stabilise changes in blood vessels
The risk of additional heart attacks can be decreased by reducing “bad” cholesterol in the blood vessels. Currently, patients are treated with high-potency statins immediately after a heart attack to lower cholesterol levels. However, most patients do not reach recommended cholesterol levels using only statins. Therefore, an add-on treatment would be beneficial.
“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. “By giving patients a combination treatment earlier, we could help to prevent many more heart attacks.”
Co-investigator Professor Kausik Ray, from Imperial College London’s School of Public Health, said: “This study shows that we could save lives and reduce further heart attacks by giving patients a combination of two low-cost drugs.
“But at the moment, patients worldwide aren’t receiving these drugs together. That’s causing unnecessary and avoidable heart attacks and deaths – and also places unnecessary costs on healthcare systems.
“Our study shows the way forward; care pathways must now change for patients after this type of heart event.”
Ezetimibe proves effective in reducing new heart attacks
The international team examined outcomes for heart attack patients if they received a combination of statins with the add-on therapy ezetimibe (within 12 weeks after a heart attack), statins with ezetimibe added later (between 13 weeks and 16 months), or just statins with no ezetimibe at all.
The team used advanced statistical models to emulate a clinical trial using Swedish registry data from 36,000 heart attack patients between 2015 and 2022.
The results showed that patients who received a combination treatment of statins and ezetimibe within 12 weeks of a heart attack 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 later, or not at all.
Following this analysis, the researchers believe that many new heart attacks, strokes and deaths could be prevented every year if the new treatment combination was introduced. For example, the study found that if 100% of patients received ezetimibe early, an estimated 133 heart attacks could be prevented over three years in a population of 10,000.
Dr Leósdóttir said: “Combination therapy is not applied up-front for two main reasons. Today’s guidelines do not include general recommendations, but a precautionary principle is used 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.”
Professor Ray added: “Our findings suggest that a simple change in treatment guidelines could have a significant impact on patients and reduce the demand on the NHS. Ezetimibe is already widely available and prescribed for relatively low cost.
“This add on therapy could be rolled out for around £350 a year per patient, which is a huge cost saving compared to the lasting impacts of treating heart attacks and the impact they have on patients’ lives.”
