Physicians' Academy for Cardiovascular Education

Score identifies high-risk patients that benefit from ezetimibe at the long-term

Atherothrombotic Risk Stratification and Ezetimibe for Secondary Prevention

Literature - Bohula EA, Morrow DA, Giugliano RP, et al. - J Am Coll Cardiol 2017;69:911–21

Main results

Conclusion

The TIMI Risk Score for Secondary Prevention (TRS 2°P) identifies high-risk patients who derive the greatest benefit from the addition of ezetimibe to statin therapy for the long-term secondary prevention after ACS. These results contribute to the selection of stabilised post-ACS patients, who may need ezetimibe as an add-on therapy.

Editorial comment

In his editorial article [6], Schwartz notes that the original IMPROVE-IT findings showed a modest clinical benefit with ezetimibe, corresponding to 350 patient-years of treatment to prevent 1 primary endpoint event, without reducing mortality rates. The analysis of Bohula et al, better identifies those patients who may benefit from the add-on ezetimibe therapy, showing with the use of TRS 2°P that high-risk patients in the IMPROVE-IT study had a higher benefit, corresponding to 111 patient-years of treatment with ezetimibe to avoid 1 CV death, MI or ischemic stroke. However, he also notes that the background statin therapy with 40 mg of simvastatin daily, is not the optimal post-ACS treatment. He concludes: ‘Therefore, irrespective of the current findings from the IMPROVE-IT trial, it remains an open question whether ezetimibe, or any other lipid-modifying therapy, improves outcomes after ACS if added to a background of high-intensity statin treatment. In the near future, this question may be answered with more certainty. Large outcome trials will report whether treatment with monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 (PCSK9), expected to lower LDL-C to a much greater degree than ezetimibe, reduces cardiovascular events. One of these trials is studying this approach in patients with recent ACS who are receiving optimal, high-intensity statin treatment. Risk scores such as that presented by Bohula et al. may prove useful to determine which patients derive the greatest benefit from new lipid-modifying therapies.’

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