:
IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) was a randomized clini-
cal trial (18,144 patients) that evaluated the efficacy of the combination of ezetimibe with simvastatin vs simvastatin mono-
therapy in patients with acute coronary syndrome (ACS) and moderately increased low-density lipoprotein cholesterol
(LDL-C) levels (of up to 2.6-3.2 mmol/L; 100-120 mg/dL). After 7 years of follow-up, combination therapy resulted in an
additional LDL-C decrease [1.8 mmol/L, or 70 mg/dL, within the simvastatin (40 mg/day) monotherapy arm and 1.4
mmol/L, or 53 mg/dL for simvastatin (40 mg/day) + ezetimibe (10 mg/day)] and showed an incremental clinical benefit
(composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary re-
vascularization (≥30 days after randomization), or nonfatal stroke; hazard ratio (HR) of 0.936, and 95% CI 0.887-0.996,
p=0.016). Therefore, for very high cardiovascular risk patients “even lower is even better” regarding LDL-C, independently
of the LDL-C reducing strategy. These findings confirm ezetimibe as an option to treat very-high-risk patients who cannot
achieve LDL-C targets with statin monotherapy. Additional analyses of the IMPROVE-IT (both prespecified and post-hoc)
include specific very-high-risk subgroups of patients (those with previous acute events and/or coronary revascularization,
older than 75 years, as well as patients with diabetes mellitus, chronic kidney disease or non-alcoholic fatty liver disease).
The data from IMPROVE-IT also provide reassurance regarding longer-term safety and efficacy of the intensification of li-
pid-lowering therapy in very-high-risk patients resulting in very low LDL-C levels. We comment on the results of several
(sub) analyses of IMPROVE-IT.
Diabetes mellitus increases the risk of significant hepatic fibrosis in patients with non-alcoholic fatty liver disease
