Background: Hypercholesterinaemia is a well-known risk factor in cardiovascular disease and guidelines recommend to lower LDL cholesterol levels (LCL-C) in manifest coronary heart disease. Patient education leads to better drug compliance; however, until now most prevention programs did not show significant effects on lipid levels, especially LDL-C. The IMPROVE-IT-trial proved significant effects in lowering LDL-C by adding ezetimibe to standard therapy, but its effect in prevention programs is not researched yet.

Purpose: Aim of the study was to prove the effects of a modern intensive prevention program (IPP) for 12 months after acute myocardial infarction on lipid levels in a longtime view with focus on the effect of ezetimibe.

Methods: This analysis is a substudy of the randomized multicenter IPP (Intensive Prevention Program) trial, which showed effectiveness of a 12-months program of intensive prevention (IPP) vs. usual care (UC). IPP was coordinated by prevention assistants and included educational sessions (≥1/month), telemetric risk factor control, telephone visits and clinical visits to control and intervene if risk factors did not reach the guideline-recommended targets. LDL-C-modifying medication was escalated if the (former) guideline recommended goal of < 70 mg/dl wasn’t reached. The present sub-study analyzes interventions on lipid profile with focus on ezetimibe and its effects after 6, 12 and 24 months.

Results: 237 probands completed 12 months follow-up (IPP: n = 117, UC: n = 120). There was no difference in the baseline-characteristics between both groups. At discharge from hospital 99% (IPP) and 100% (UC) were treated with LDL-C-lowering drugs, mostly statins. Changes in drug-therapy took place in 52% of the IPP-probands and in 35% in UC (p 0,06). Due to the prevention program 61% reached the LDL-C-goal (mean LDL-C 66 ± 20 mg/dl), while only 45% in UC achieved an LDL-C < 70 mg/dl after 12 months (p < 0,01; mean LDL-C 76 ± 29 mg/dl, p < 0,01; see Figure). Ezetimibe was prescribed in 21% of the interventions in the IPP-group (11% in UC, p < 0,01). Ezetimibe was highly effective (mean LDL-C in the IPP-subgroup [n = 18] at randomization 99 ± 18 mg/dl, 12-months 65 ± 12 mg/dl, p 0,03). Stopping the prevention program led to increasing LDL-C-levels one year later.

Conclusion: An intensive prevention program after myocardial infarction leads to significantly lower LDL-C levels, especially by adding ezetimibe to standard therapy with statins. After termination of the intervention program LDL-C levels increased again, indicating that even a 12 months prevention program is not long enough to achieve sustainable low LDL-C levels and longer lasting prevention is needed. Ezetimibe in addition to statin-therapy has a high potential for reaching LDL-C-goals, but further studies are needed to research the effect of ezetimibe in reaching the new LDL-C-goal of < 55 mg/dl. 
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