Cited by 142Lipoproteins and Cardiovascular HealthAcute Ischemic Stroke ManagementAcute Myocardial Infarction Research

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Prevention of Stroke with the Addition of Ezetimibe to Statin Therapy in Patients With Acute Coronary Syndrome in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial)

Bohula, Erin A., Wiviott, Stephen D., Giugliano, Robert P., Blazing, Michael A., Park, Jeong-Gun, Murphy, Sabina A., White, Jennifer A., Mach, Francois, Van de Werf, Frans, Dalby, Anthony J., White, Harvey D., Tershakovec, Andrew M., Cannon, Christopher P., Braunwald, Eugene·2017·Circulation

DOI 10.1161/circulationaha.117.029095

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Abstract

Background: Patients who experience an acute coronary syndrome are at heightened risk of recurrent ischemic events, including stroke. Ezetimibe improved cardiovascular outcomes when added to statin therapy in patients stabilized after acute coronary syndrome. We investigated the efficacy of the addition of ezetimibe to simvastatin for the prevention of stroke and other adverse cardiovascular events in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), with a focus on patients with a stroke before randomization. Methods: Patients who experienced acute coronary syndrome were randomized to a placebo/simvastatin or ezetimibe/simvastatin regimen and followed for a median of 6 years. Treatment efficacy was assessed for the entire population and by subgroups for the first and total (first and subsequent) events for the end points of stroke of any etiology, stroke subtypes, and the primary trial end point at 7 years. Results: Of 18 144 patients, 641 (3.5%) experienced at least 1 stroke; most were ischemic (527, 82%). Independent predictors of stroke included prior stroke, older age, atrial fibrillation, congestive heart failure, diabetes mellitus, myocardial infarction, and renal dysfunction. There was a nonsignificant reduction in the first event of stroke of any etiology (4.2% versus 4.8%; hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.73–1.00; P =0.052) with ezetimibe/simvastatin versus placebo/simvastatin, driven by a significant 21% reduction in ischemic stroke (3.4% versus 4.1%; HR, 0.79; 95% CI, 0.67–0.94; P =0.008) and a nonsignificant increase in hemorrhagic stroke (0.8% versus 0.6%; HR, 1.38; 95% CI, 0.93–2.04; P =0.11). Evaluating total events, including the first and all recurrent strokes, ezetimibe/simvastatin reduced stroke of any etiology (HR, 0.83; 95% CI, 0.70–0.98; P =0.029) and ischemic stroke (HR, 0.76; 95% CI, 0.63–0.91; P =0.003). Patients who had experienced a stroke prior to randomization were at a higher risk of recurrence and demonstrated an absolute risk reduction of 8.6% for stroke of any etiology (10.2% versus 18.8%; number needed to treat=12; HR, 0.60; 95% CI, 0.38–0.95; P =0.030) and 7.6% for ischemic stroke (8.7% versus 16.3%; number needed to treat=13; HR, 0.52; 95% CI, 0.31–0.86; P =0.011) with ezetimibe added to simvastatin therapy. Conclusions: The addition of ezetimibe to simvastatin in patients stabilized after acute coronary syndrome reduces the frequency of ischemic stroke, with a particularly large effect seen in patients with a prior stroke. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00202878.

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Authors: Bohula, E. A., Wiviott, S. D., Giugliano, R. P., Blazing, M. A., Park, J.-G., Murphy, S. A., White, J. A., Mach, F., Van de Werf, F., Dalby, A. J., White, H. D., Tershakovec, A. M., Cannon, C. P., & Braunwald, E.
Affiliations: Brigham and Women's Hospital (US)
Duke Clinical Research Institute (US)
Cardiology Dvision, Geneva University Hospital, Switzerland (F.M.)
Departments of Cardiovascular Medicine and Cardiovascular Sciences, University of Leuven, Belgium (F.V.d.F.)
Milpark Hospital (ZA)
Auckland City Hospital (NZ)
Merck & Co., Inc., Rahway, NJ, USA (United States) (US)
TIMI Study Group, Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (E.A.B., S.D.W., R.P.G., J.-G.P., S.A.M., C.P.C., E.B.)
ORCID: Bohula, Erin A.
Wiviott, Stephen D.
Giugliano, Robert P.
Park, Jeong-Gun
Murphy, Sabina A.
White, Jennifer A.
White, Harvey D.
Cannon, Christopher P.
Venue: Circulation
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2017-12-19
Volume: 136
Issue: 25
Pages: 2440-2450
ISSN: 0009-7322 (ISSN-L)
1524-4539
DOI: 10.1161/circulationaha.117.029095
OpenAlex: W2757304856
Cited by: 142
References: 24
Citations by year: 2026: 12 · 2025: 11 · 2024: 12 · 2023: 19 · 2022: 18 · 2021: 20 · 2020: 21 · 2019: 17 · 2018: 11 · 2017: 1
FWCI: 14.00
Type: journal article
Language: en
Open access: closed
Locations: Circulation (publishedVersion)
PubMed (publishedVersion)
Funders: Amgen
Bristol-Myers Squibb
Eli Lilly and Company
Pfizer
GlaxoSmithKline
Sanofi
Alnylam Pharmaceuticals
Regeneron Pharmaceuticals
Medicines Company
Kowa Company
Daiichi-Sankyo
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
Keywords: ezetimibe, simvastatin, acute coronary syndrome, stroke prevention, ischemic stroke, hemorrhagic stroke, IMPROVE-IT trial, LDL cholesterol lowering, cardiovascular risk factors, stroke recurrence, secondary prevention, statin therapy, lipid-lowering therapy, atrial fibrillation, diabetes mellitus, renal dysfunction, congestive heart failure, myocardial infarction
MeSH terms: Ezetimibe, Aged, Anticholesteremic Agents, Atrial Fibrillation, Double-Blind Method, Female, Humans, Cholesterol, LDL, Male, Middle Aged, Myocardial Infarction, Recurrence, Risk Factors, Placebo Effect, Proportional Hazards Models, Treatment Outcome, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Simvastatin, Stroke, Acute Coronary Syndrome

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Prevention of Stroke with the Addition of Ezetimibe to Statin Therapy in Patients With Acute Coronary Syndrome in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial)

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