A new paradigm for lipid-lowering therapy involves early initiation of upfront statin and ezetimibe combination therapy for patients at high or very high risk of cardiovascular disease. Because there is now substantial evidence for this strategy, it has been included in recent guidelines for lipid-lowering.
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- Removal of the PBS restrictions on ezetimibe in 2024 has enabled its coprescription with statins without the need for patients to have a prior eight-week period on statin monotherapy.
- Initiating lipid-lowering therapy with combination statin–ezetimibe (the ‘upfront’ approach) is now recommended by international guidelines rather than the traditional ‘stepwise’ approach.
- The upfront approach is particularly important in patients at high and very high risk of cardiovascular disease, especially those with acute coronary syndromes because it rapidly lowers LDL-cholesterol levels, stabilises atherosclerotic plaques and acutely reduces recurrent ischaemic events.
- Upfront ezetimibe–statin cotherapy may also be appropriate for initiating lipid-lowering therapy in patients at lower cardiovascular disease risk, as it allows lower doses of statins to be used with fewer side effects, improved compliance, fewer blood tests and clinic visits, and LDL-cholesterol lowering equivalent to that of maximum statin doses.
It’s time to say ‘Goodnight, sweetheart’ to statin monotherapy for our patients at high risk of cardiovascular disease (CVD).
The recently published SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) study illustrated the benefits of using early, aggressive lipid-lowering therapy (LLT) in patients with acute coronary syndrome (ACS).1,2 Those receiving early (within 12 weeks) upfront statin and ezetimibe combination therapy had improved outcomes for up to 12 years of follow up compared with patients receiving LLT within 12 to 16 months.1,2 Further details of SWEDEHEART are discussed below.