A new study out of Sweden has found that initiating combination cholesterol-lowering therapy early after a heart attack can significantly reduce the risk of subsequent cardiovascular events and death. The findings, published by researchers at Lund University and based on data from over 36,000 patients, challenge existing global treatment guidelines and could prompt a shift in how post-heart attack care is delivered.
Heart Attacks Remain a Leading Global Killer
Cardiovascular disease is the number one cause of death globally, and myocardial infarction—more commonly known as a heart attack—is the most prevalent acute cardiovascular event. For those who survive the initial episode, the first year afterward is the most dangerous, as their blood vessels remain highly vulnerable to further blockages and clots.
Lowering LDL-C (commonly referred to as “bad” cholesterol) has long been known to reduce these risks by stabilising vascular plaques and preventing future cardiac events. Current standard care recommends high-potency statins immediately after a heart attack. However, research shows that most patients do not reach their target cholesterol levels with statins alone.
Current Treatment Guidelines: Too Little, Too Late?
Current international guidelines advocate for a stepwise approach to cholesterol-lowering therapy. If a patient does not reach cholesterol targets with statins alone, an additional drug—usually ezetimibe—is introduced later in the treatment plan. However, this gradual escalation often delays effective treatment.
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“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 Associate Professor Margrét Leósdóttir, senior cardiology consultant at Skåne University Hospital and lead author of the new study.
Leósdóttir and her team wanted to know what would happen if combination therapy using both statins and ezetimibe was initiated early—within 12 weeks of a heart attack—rather than much later or not at all.
A Data-Driven Emulation of a Clinical Trial
To answer this question, researchers turned to Sweden’s robust national registry system, examining data from 36,000 patients who experienced a myocardial infarction between 2015 and 2022. Using advanced statistical models to emulate the effects of a clinical trial, the team compared three groups of patients:
- Those who received combination therapy early (within 12 weeks)
- Those who received it later (between 13 weeks and 16 months)
- Those who never received combination therapy
The results were striking. Patients who received early combination therapy were significantly more likely to reach cholesterol targets and had fewer new heart attacks, strokes, and cardiovascular-related deaths compared to those who received therapy later—or not at all.
An Underutilised, Safe, and Affordable Solution
Ezetimibe, the drug used in the study alongside statins, is both widely available and affordable in most countries. It also has a favourable safety profile, making it an ideal candidate for broader and earlier use.
“Combination therapy is not applied up-front for two main reasons,” Leósdóttir explained. “General recommendations are not included in today’s guidelines, and a precautionary principle is applied to avoid side effects and overmedication. However, there are positive effects from applying both medicines as soon after the infarction as possible. Not doing this entails an increased risk.”
Early Implementation Yields Encouraging Results
In response to the study’s findings, Skåne University Hospital has already adopted a new treatment algorithm to ensure that patients receive the appropriate lipid-lowering therapy shortly after their heart attack. Results have been promising.
Two months post-infarction, twice as many patients are reaching their LDL-C targets compared to before the algorithm was introduced. Several other hospitals in Sweden have followed suit, and similar success has been observed in other countries that have adopted the early treatment strategy.
Leósdóttir hopes the evidence will be strong enough to support changes in global treatment recommendations.
A Call for Global Review of Cardiac Care Protocols
Given the potential for preventing thousands of heart attacks, strokes, and deaths each year, the implications of this research are enormous. Yet, updating clinical guidelines on a global scale requires compelling and consistent evidence, something this study now contributes.
“This work shows that we can prevent unnecessary suffering and save lives by simply adjusting the timing of a treatment we already use,” said Leósdóttir. “My hope is that more hospitals and health systems around the world will review their current procedures to ensure patients are receiving optimal care as soon as possible.”
Understanding the Mechanism: Why Timing Matters
The biological explanation behind these findings lies in the nature of blood vessels following a heart attack. The vascular system becomes more inflamed and sensitive during the first few months after a myocardial infarction. This makes patients particularly susceptible to new clots forming—an issue that is compounded if cholesterol levels remain high.
By aggressively lowering LDL-C levels early on, the combined use of statins and ezetimibe helps to stabilise vascular inflammation and prevent the progression of arterial plaques. The study supports the notion that it is not only the medication itself that matters, but also when it is given.
Balancing Risks and Benefits
Although the addition of a second drug might raise concerns about overmedication, experts argue that in this case, the benefits far outweigh the risks. Ezetimibe has a low incidence of side effects, is inexpensive, and is already approved in many countries for use in conjunction with statins.
“Too often, we hold off on adding treatments out of fear of side effects,” said Leósdóttir. “But when we’re dealing with a high-risk period like the first year after a heart attack, inaction is also a risk—and one that’s not always recognised.”
A New Era in Post-Infarction Therapy?
This study adds weight to a growing body of evidence suggesting that the medical community must rethink the one-size-fits-all approach to post-infarction therapy. Rather than waiting for patients to fail statins alone, doctors may now be encouraged to consider upfront dual therapy, especially for those at high risk of recurrence.
Ultimately, this research sends a clear message: time is of the essence. Treating high cholesterol aggressively—and early—after a heart attack could be a game-changer for thousands of patients around the world.
As guidelines come under review and hospitals experiment with new protocols, the hope is that fewer lives will be lost to repeat cardiac events, and that patients will live longer, healthier lives after surviving a heart attack.
