Treating high cholesterol quickly and aggressively after a heart attack may help prevent thousands of new heart attacks and deaths worldwide. Scientists are now urging doctors to rethink the common step-by-step approach to cholesterol treatment and instead start a combination of two medications as early as possible.
The Problem With Waiting Too Long
When someone has a heart attack, doctors usually start treatment with high-intensity statins right away. These drugs lower “bad” LDL cholesterol, which can stabilize blood vessels and help prevent another heart attack. Clinical trials have shown that using high-intensity statins early after a heart attack leads to fewer cardiovascular problems over time.
Current guidelines recommend starting with statins and adding other drugs only if cholesterol levels stay too high. However, this slow, step-by-step strategy often delays getting cholesterol under control. Studies show fewer than 20% of heart attack patients reach their LDL cholesterol goals with statins alone.
A major problem is that two-thirds of heart attack patients are “statin-naive,” meaning they were not on statins when the heart attack happened. For many people, the first time they get any cholesterol-lowering treatment is after their heart event.
Even though high-intensity statins help, the majority still do not reach the recommended target of less than 1.8 mmol/L (70 mg/dL). This leaves patients vulnerable, especially in the first year after a heart attack when the risk of another event is highest.
New Evidence Supports Early Combination Therapy
New research led by Margrét Leósdóttir from Lund University and Kausik Ray from Imperial College London provides strong evidence that an early combination of statins and ezetimibe can change outcomes for the better. Their study used data from 36,000 Swedish heart attack patients collected between 2015 and 2022 through the SWEDEHEART registry.
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Rather than relying on a traditional randomized trial, which would be ethically challenging in this case, the researchers used advanced statistical modeling called a “trial emulation clone-censor-weight framework.” This method allowed them to closely mimic a real-world clinical trial without putting patients at risk.
The team compared three groups: patients who received ezetimibe within 12 weeks of their heart attack, those who received it later (between 13 weeks and 16 months), and those who never received it.
The results were clear: early combination therapy significantly reduced the risk of new cardiovascular events and death compared to waiting or not adding ezetimibe at all.
If 100% of heart attack patients received early ezetimibe alongside statins, researchers estimate 133 heart attacks could be prevented in a group of 10,000 people over three years. In the UK alone, with around 100,000 heart attacks each year, this could mean preventing 5,000 heart attacks over a decade.
Why Earlier Treatment Matters
When LDL cholesterol levels stay high after a heart attack, blood vessels remain sensitive and prone to clotting. Lowering cholesterol quickly stabilizes these vessels, cutting the chances of dangerous blockages. Yet many patients never get beyond statin therapy because of delays in follow-up or treatment escalation.
“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,” said Margrét Leósdóttir, senior cardiology consultant at Skåne University Hospital.
Ezetimibe, the add-on drug examined in this study, is low-cost, widely available, and causes very few side effects. This makes it an ideal candidate for immediate use after a heart attack. Despite its proven benefits, it is still not routinely given right away in most hospitals.
Professor Kausik Ray emphasized the larger impact: “This study shows that we could save lives and reduce further heart attacks by giving patients a combination of two low-cost drugs. But at the moment patients across the world aren’t receiving these drugs together. That’s causing unnecessary and avoidable heart attacks and deaths—and also places unnecessary costs on healthcare systems.”
