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UK study supports use of high-potency statin after heart attack

Heart attack patients who are subsequently prescribed a high-potency statin have a better chance of long-term survival than patients given simvastatin, but a survival benefit is not observed with statin/ezetimibe combinations, according to the results of a retrospective observational study (Heart, online 19 February 2014).

The authors of the study used the UK General Practice Research Database (see Panel) to analyse outcomes for patients admitted to hospital with a heart attack for the first time. The findings show a mortality benefit associated with a switch to a high-potency statin and are in accordance with results from previous randomised trials comparing high-dose statins with low to moderate doses for patients with acute coronary syndrome and coronary artery disease.

Sotiris Antoniou, consultant pharmacist in cardiovascular medicine at Barts Health NHS Trust, described the study as “interesting” and said it was representative of real-life practice. He added that the findings clearly support guidance from the National Institute for Health and Care Excellence: “Anyone admitted with acute coronary syndrome should be considered for high intensity statin therapy and, with atorvastatin now generic, there really should not be any practice that does not recommend atorvastatin 80mg as first-line management,” he said.

Lead author Chim Lang, consultant cardiologist and clinical pharmacologist at the University of Dundee Medical School, pointed out that there is a lot of interest in ezetimibe for heart patients. He added that there is evidence that the drug is effective at lowering cholesterol, but its effect on survival is unknown. Ezetimibe’s effect on cardiovascular events in combination with simvastatin is currently being tested in the IMPROVE-IT trial, the study authors highlight.

Speaking about the results of the current study, Dr Lang said: “Those who had ezetimibe added [to their statin treatment] did not appear to have a better outcome. So for the moment, the data support the use of high-potency statins.”

However, the researchers add that the results should be interpreted with caution because the number of patients receiving ezetimibe was smaller than the other two groups and the confidence intervals were large (see Panel).

Another recent study, a meta-analysis from the US, suggested that ezetimibe combined with a low to medium dose of statin could be an alternative treatment for patients who could not tolerate the side effects of, or who did not respond to, high-intensity statins. However, the authors warned that there were no long-term outcome data to support this.

Study design and results

Researchers used the UK General Practice Research Database to collect all records of patients who had suffered a heart attack and survived the following 30-day period. Patients were included in the study if they had been started on a statin therapy for the first time in those 30 days. They were then divided into three groups: those who received simvastatin (n=6,990), those who began with simvastatin and were switched to a high-potency statin (n=1,883) and those who received a statin plus ezetimibe (n=724). Patients were followed up for an average of 3.2 years.

High-potency statins, either rosuvastatin or atorvastatin, were associated with a reduced risk of death compared with simvastatin monotherapy (hazard ratio 0.72, 95 per cent confidence interval 0.59–0.88; P<0.001). But the statin/ezetimibe combination was not associated with a reduced risk of death compared with simvastatin monotherapy (HR 0.96, 95 per cent CI 0.64–1.43).  

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11134984

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