Implications for Ezetimibe Therapy Use Based on IMPROVE-IT Criteria.

Virani SS, Akeroyd JM, Nambi V, Maddox TM, Gillette MA, Michael Ho P, Rumsfeld J, Petersen LA, Ballantyne CM. Implications for Ezetimibe Therapy Use Based on IMPROVE-IT Criteria. The American journal of medicine. 2015 Nov 1; 128(11):1253-6.

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• CDA 08-021 – Cardiac Risk Factor Management Among CAD Patients After Cardiac Catheterization
• CDA 09-028 – Attaining Optimal Non-HDL Cholesterol Levels to Improve Cardiac Outcomes

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Abstract:

PURPOSE: In the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), simvastatin/ezetimibe combination was associated with a 6% relative risk reduction in the combined cardiovascular outcome compared with simvastatin alone in patients with acute coronary syndrome. Given strict inclusion criteria (low-density lipoprotein cholesterol 50-125 mg/dL and no use of statins more potent than simvastatin 40 mg), the implications of this important trial in routine acute coronary syndrome care are unknown. METHODS: We identified patients with acute coronary syndrome from the Veterans Affairs health care system over a 5-year period and determined what proportion would be candidates for ezetimibe on the basis of IMPROVE-IT criteria. We then evaluated what proportion could potentially see an increase in ezetimibe use if IMPROVE-IT criteria are not strictly followed. RESULTS: Of 219,625 patients with acute coronary syndrome, 69,508 (31.6%) would qualify for ezetimibe on the basis of strict criteria. Among those who did not meet IMPROVE-IT criteria (n = 150,117), ezetimibe could potentially be prescribed by clinicians in a further 28% of patients (n = 61,635) using statins more potent than simvastatin 40 mg, 7.1% of patients (15,527) with a documented statin intolerance, and 10.4% of patients (22,758) with low-density lipoprotein cholesterol > 125 mg/dL. CONCLUSIONS: Our results provide a first look at the implications of this trial in a large health care system. Although 31.6% of patients would qualify for ezetimibe, there is a large potential for an increase in ezetimibe use in acute coronary syndrome outside of the strict trial inclusions. These findings call for a discussion on ezetimibe''s role in patients with acute coronary syndrome already taking high-intensity statins or those with statin intolerance.