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Ezetimibe boosts statin effect in ACS patients with dyslipidaemia, low EPA/AA ratio

Tristan Manalac
11 Sep 2019

The addition of ezetimibe improves statin treatment in acute coronary syndrome (ACS) patients with dyslipidaemia and low eicosapentaenoic acid-to-arachidonic acid (EPA/AA) ratio, resulting in a lowered risk of cardiovascular events compared to monotherapy, according to a study presented at the recently concluded 2019 Congress of the European Society of Cardiology (ESC 2019) held in Paris, France.

Researchers performed a sub-analysis of the HIJ-PROPER* study, where 1,734 ACS patients with dyslipidaemia were assigned to receive pitavastatin either alone or with ezetimibe. In the present study, participants were grouped into high (n=603; mean age, 68.7±9.8 years) and low (n=584; mean age, 62.6±12.6 years) EPA/AA groups based on a cutoff value of 0.34 µg/mL.

In the low EPA/AA group, the primary endpointa composite of all-cause death, nonfatal stroke and myocardial infarction, ischaemia-driven revascularization, and unstable angina pectorisoccurred in 36.6 percent and 27.2 percent of patients who received pitavastatin alone or with ezetimibe, respectively. [ESC 2019, abstract P824]

The resulting reduction in risk was statistically significant (hazard ratio [HR], 0.69, 95 percent CI, 0.52–0.93; p=0.02). This was driven primarily by the effect of add-on ezetimibe on ischaemia-driven revascularization, which occurred significantly less frequently in those who received the combination intervention (20.3 percent vs 30.4 percent; HR, 0.63, 0.45–0.87; p<0.01).

The other components of the primary composite outcome did not differ between treatment groups: all-cause death (HR, 0.65, 0.32–1.30; p=0.22), nonfatal myocardial infarction (HR, 0.43, 0.06–2.24; p=0.32) and stroke (HR, 2.1, 0.58–9.6; p=0.27), and unstable angina pectoris (HR, 1.35, 0.61–3.11; p=0.45).

Similarly, ezetimibe did not seem to yield any additional benefit for participants with high baseline EPA/AA, such that the primary composite outcome occurred with similar frequency between treatment groups (36.6 percent vs 33.0 percent; HR, 0.92, 0.70–1.20; p=0.52).

Disaggregation into the individual components did not change the initial finding.

Researchers then performed multivariable analysis in the low-EPA/AA group to search for independent predictors of the primary outcome. The use of ezetimibe was identified as a significant protective factor (HR, 0.70, 0.52–0.94; p=0.02), as were high-density lipoprotein cholesterol (HR, 0.88, 0.78–1.01; p=0.05) and docosahexaenoic acid (HR, 0.95, 0.91–0.99; p=0.04).

Glomerular filtration rate (HR, 0.92, 0.85–1.01; p=0.09) and non-ST elevation myocardial infarction (HR, 0.59, 0.29–1.06; p=0.08) also emerged as putative protective factors, though only of borderline significance.

“Among ACS patients who had dyslipidaemia with baseline EPA/AA ratio <0.34, combination therapy with ezetimibe and statin decreased the risk of cardiovascular events compared with statin monotherapy,” researchers concluded.

*Heart Institute of Japan-Proper level of lipid lowering with Pitavastatin and Ezetimibe in acute coronary syndrome

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Most Read Articles
Elaine Soliven, 27 Nov 2019
High levels of trunk fat mass (FM) may be associated with an increased risk of cardiovascular disease (CVD)-related events such as coronary death, nonfatal myocardial infarction, or coronary heart disease in postmenopausal women with normal body mass index (BMI), according to a recent study presented at AHA 2019.
28 Nov 2019
Slideshow: Highlights from the American Heart Association (AHA) Scientific Sessions 2019
28 Oct 2019
The C-reactive protein (CRP)-to-albumin ratio (CAR) appears to be linked to the development of acute kidney injury in patients with ST elevation myocardial infarction (STEMI), a recent study has found.
28 Nov 2019
The addition of evolocumab to high-intensity statin therapy is both well tolerated and effective in significantly reducing low-density lipoprotein cholesterol (LDL-C) levels in patients hospitalized for acute coronary syndromes (ACS), allowing most of them to achieve current recommended target levels, a study has shown.