A new study reveals that heart attack survivors could greatly reduce their risk of a second event by starting combination cholesterol-lowering therapy sooner rather than later.
By adding ezetimibe to statins within 12 weeks, patients lowered their bad cholesterol faster and significantly improved their odds of avoiding future heart attacks, strokes, or death. Despite this, current treatment guidelines are slow to adapt, often delaying potentially life-saving interventions.
The Risk After a Heart Attack
Cardiovascular disease remains the leading cause of death worldwide, with heart attacks, also known as myocardial infarctions, being the most common acute event. For people who survive a heart attack, the risk of having another is highest within the first year. During this period, blood vessels are more vulnerable, making it easier for blood clots to form.
Lowering levels of LDL cholesterol, the so-called “bad” cholesterol, helps stabilize the blood vessels and reduces the risk of another event. The standard treatment after a heart attack is to immediately prescribe high-potency statins. However, many patients don’t reach recommended cholesterol targets with statins alone. To achieve these goals, most need an additional cholesterol-lowering medication.
Why Statins Alone Aren’t Enough
“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.
Early Add-On Therapy Shows Clear Benefits
In a recent study, Leósdóttir and her team explored whether adding the drug ezetimibe earlier after a heart attack could improve outcomes. They analyzed data from 36,000 Swedish patients who had heart attacks between 2015 and 2022, using advanced statistical models to simulate a clinical trial. Patients were grouped based on whether ezetimibe was added early (within 12 weeks), late (13 weeks to 16 months), or not at all.
The results were clear: patients who received early combination therapy with statins and ezetimibe, and were able to reach cholesterol targets quickly, had significantly better outcomes. They were less likely to suffer another heart attack, stroke, or die from cardiovascular causes, compared to those who received ezetimibe later or not at all. According to the researchers, updating treatment strategies could prevent thousands of serious cardiovascular events and deaths each year.
Guidelines Lag Behind the Evidence
“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.”
A New Algorithm Brings Hope
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.”
Explore Further: A Fast-Acting Drug Combo That Could Stop Your Next Heart Attack
Reference: “Early Ezetimibe Initiation After Myocardial Infarction Protects Against Later Cardiovascular Outcomes in the SWEDEHEART Registry” by Margret Leosdottir, Jessica Schubert, Julia Brandts, Stefan Gustafsson, Thomas Cars, Johan Sundström, Tomas Jernberg, Kausik K. Ray and Emil Hagström, 14 April 2025, Journal of the American College of Cardiology.
DOI: 10.1016/j.jacc.2025.02.007
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