Ezetimibe use and mortality after myocardial infarction: a nationwide cohort study

Abstract Background Inhibition of intestinal cholesterol absorption by ezetimibe improves outcomes after myocardial infarction (MI), yet real-world data on ezetimibe is lacking. Purpose To study usage and outcome impact of ezetimibe after MI. Methods Consecutive MI patients in Finland (2010-2018) were retrospectively studied (N=57,505; 65% men; mean age 69 years). Study data were combined from national registries. The median follow-up was 4.5 (IQR 2.8-7.1) years. Differences between groups were adjusted with multivariable regression. Ezetimibe use was studied with competing risk analyses. Median follow-up was 4.5 (IQR 2.8-7.1) years. Results The cumulative incidence of ezetimibe use was 3.7% at 90-days, 13.4% at 5-years and 19.8% at 10-years. Younger age was the strongest predictor for ezetimibe use (adj. sHR 6.67; CI 5.88-7.69 for patients aged <60 vs. ≥80 years). Women were more likely to use ezetimibe during follow-up than men. The average proportion of patients using ezetimibe during follow-up was 6.8%. (11.7% at 10-years). Ezetimibe was discontinued by 43.6% of patients during the follow-up. Patients with early ezetimibe after MI had lower all-cause mortality during follow-up (33.6% vs. 45.1%; adj. HR 0.77; CI 0.69-0.86; p<0.0001). Early ezetimibe use was associated with lower mortality irrespective of sex, age, atrial fibrillation, diabetes, heart failure, malignancy, revascularization, or statin use. Ongoing ezetimibe therapy during follow-up was associated with lower mortality in time-dependent analysis (adj. HR 0.53; CI 0.48-0.59; p<0.0001). Conclusion Ezetimibe is associated with lower risk of death after MI, but therapy use is limited and discontinuity is frequent.