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Invited Commentary
July 17, 2019

Intensive Lipid Lowering in Elderly Patients

Author Affiliations
  • 1Weill Cornell Medicine, New York, New York
JAMA Cardiol. 2019;4(9):855-856. doi:10.1001/jamacardio.2019.2333

In this issue of JAMA Cardiology, a prespecified post hoc analysis of the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) examines the effect of age on higher-intensity lipid lowering in patients after an acute coronary syndrome.1 The IMPROVE-IT study was a large, randomized, double-blind clinical trial of individuals with recent acute coronary syndrome.2 Investigators reported that the combination of ezetimibe (10 mg/d) and simvastatin (40 mg/d) had greater efficacy in lowering low-density lipoprotein cholesterol (LDL-C) levels and in reducing cardiovascular events compared with simvastatin alone, and there were no safety issues. A 15-mg/dL to 17-mg/dL (to convert to millimoles per liter, multiply by 0.0259) greater reduction in LDL-C levels was associated with a significantly lower risk of cardiovascular death, major coronary events, and nonfatal stroke (hazard ratio, 0.94; 95% CI, 0.89-0.99). IMPROVE-IT provided additional confirmation of the LDL hypothesis and showed that lower is better in terms of LDL-C level reduction.3 The mean LDL-C level in the placebo group was approximately 69 mg/dL after 1 year, while the treatment arm reached a mean level of 53 mg/dL. Importantly, IMPROVE-IT showed that lowering LDL-C levels that were already below threshold values could produce further reductions in cardiovascular events.4