@DrScottMurray
Pinned post
🚨 Ezetimibe has been called a "numbers drug" that lowers LDL but does not save lives.
IMPROVE-IT proved that wrong in over 18,000 patients.
Heart attacks dropped 13%. Strokes dropped 21%. And no, it is not just moving a number on your lab report.
"But the data says otherwise."
I am a cardiologist. I have hundreds of patients on ezetimibe right now, most of them paired with rosuvastatin from day one.
🔬 Here is the mechanism. Statins block cholesterol production in your liver. Ezetimibe blocks cholesterol absorption in your gut through NPC1L1. Two different doors, same wall. The effects stack.
🩺 This is why I do not just double the statin dose when a patient needs more LDL lowering.
✅ Doubling a statin dose: about 10% additional LDL reduction
✅ Adding ezetimibe instead: about 26% additional LDL reduction
That comes from a pooled analysis of 17 trials and gets confirmed again in the ACTE trial. Ezetimibe wins by a wide margin.
💓 IMPROVE-IT is the trial that changed everything. 18,144 patients already had a heart attack or unstable angina. All were on simvastatin. Adding ezetimibe dropped LDL to 53.7 mg/dL compared to 69.5 mg/dL.
✅ Heart attacks cut 13%
✅ Ischemic strokes cut 21%
✅ First major cardiovascular event fell from 34.7% to 32.7% at 7 years
No difference in death from any cause. I am not going to pretend otherwise. The benefit is real but it is specific: fewer nonfatal heart attacks and strokes, not longer life.
🫀 The benefit was not spread evenly. It concentrated hard in high-risk patients.
Diabetics: 5.5 fewer events per 100 people, compared to only 0.7 in nondiabetics.
Age 75 and older: 8.7 fewer events per 100 people. The largest benefit of any subgroup in the entire trial.
Three or more risk factors: 6.3 fewer events per 100 people, with only 16 people needing treatment for 7 years to prevent one event.
That matters because the question is no longer does ezetimibe work. The question is who benefits the most. And the answer is your sickest, oldest, highest-risk patients.
🩺 RACING backs this up from a different angle. A moderate dose of rosuvastatin plus ezetimibe matched high-dose rosuvastatin alone for events, 9.1% versus 9.9%. More patients hit goal LDL under 70, 72% versus 58%. And fewer people quit from side effects, 4.8% versus 8.2%.
❌ ENHANCE in 2008 is where the "ezetimibe doesn't work" myth came from. That trial measured carotid artery wall thickness in familial hypercholesterolemia patients. It never measured a single heart attack or stroke. IMPROVE-IT measured real outcomes in a population 25 times larger. You cannot compare an imaging study to an outcomes trial and call it settled.
⚠️ One more correction I make constantly. CLEAR Outcomes tested bempedoic acid, not ezetimibe. Different drug. They do get combined in Nexlizet, which lowered LDL about 38% more than placebo. But do not let anyone tell you CLEAR Outcomes is ezetimibe data. It is not.
🔸 SHARP, EWTOPIA 75, and a Cochrane review of 26 trials covering 23,499 people all point the same direction. Fewer major cardiovascular events. No clear mortality benefit. Consistent pattern across different populations.
❤️ Bottom line:
Ezetimibe is not a numbers drug. It is not fake cardiology.
It has been tested in tens of thousands of patients across multiple major trials.
It lowers LDL more than doubling your statin.
It prevents nonfatal heart attacks and strokes, especially if you are diabetic, over 75, or carry multiple risk factors.
Side effect rates match placebo across the data.
I start most of my patients on rosuvastatin and ezetimibe together. I do not wait to max out the statin first.
The question is not whether ezetimibe works. The question is why more doctors are not using it this way.
#Cardiology #HeartDisease #HeartHealth #CView quoted post on X
Imagine following nearly 13 million real people for more than 10 years just to see what cholesterol level helps them live the longest. That is exactly what Korean scientists did in a giant 2019 study. They tracked 12.8 million adults who had check-ups between 2001 and 2004, and they kept watching until 2013. More than 694,000 people died during that long stretch.
The results were clear and surprising. Cholesterol and death formed a U-shape. Very low cholesterol was linked to higher death rates. So was very high cholesterol. The sweet spot for the longest life was 210 to 249 mg/dL for most adults. That is higher than many doctors call “ideal.” Younger people had a slightly lower best range, but still not the super-low numbers often pushed today.
Because the study lasted so many years, reverse causality is less likely to explain the low-cholesterol danger. Reverse causality means a hidden illness might lower your cholesterol right before it kills you. With more than a decade of follow-up, early sickness cannot easily account for the extra deaths seen in people who started with low cholesterol. The pattern held across ages and for both men and women.
The huge number of people—almost the entire adult population of a country—makes the findings hard to ignore. Smaller studies can be wrong by chance. This one is massive. It shows that moderately higher total cholesterol, not the lowest possible number, went with the best chance of living longer in this large group.
In short, the biggest study of its kind found that cholesterol levels in the low-to-mid 200s were tied to the longest lives, and the long tracking time makes it tougher to blame the higher death rates at low levels on reverse causality alone.View quoted post on X
More on Billy our 157th case of drug free T2Diabetes remission Giving up his TEN breakfast Weetabix helped him achieve remission in only EIGHT weeks !! T2D? Maybe avoid foods that put your blood sugar up 👍 @AmDiabetesAssn @IntDiabetesFed @DiabetesUKView quoted post on X
