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Comparative Efficacy of LDL-C-Lowering Therapies in First-time versus Recurrent Myocardial Infarction Prevention: A
Bao-Qiang Guo1, Hong-Bin Li1, Bing Zhao2
1School of Public Health, Xinxiang Medical University, Xinxiang, Henan 453003, China.
Insights
Low-density lipoprotein cholesterol (LDL-C) lowering therapies significantly reduce myocardial infarction (MI) risk. These therapies show greater benefit in preventing first-time MI compared to recurrent MI.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Trials
Background:
- Elevated low-density lipoprotein cholesterol (LDL-C) is a primary target for preventing myocardial infarction (MI).
- While LDL-C-lowering therapies are widely used, direct comparisons of their efficacy in first-time versus recurrent MI prevention are limited.
Purpose of the Study:
- To systematically review and meta-analyze randomized controlled trials (RCTs).
- To compare the efficacy of LDL-C-lowering therapies in preventing first-time MI versus recurrent MI.
Main Methods:
- Searched three databases for RCTs with ≥1,000 patient-years of follow-up.
- Quantified efficacy using relative risk (RR) and 95% confidence intervals (CIs).
- Assessed differences in benefit magnitude using Cochran's Q test and employed random-effects models for data pooling.
Main Results:
- Included 22 RCTs with 180,304 participants.
- LDL-C-lowering therapies reduced first-time MI risk by 38% (RR, 0.62; P <0.001).
- These therapies reduced recurrent MI risk by 16% (RR, 0.84; P <0.001), with a significantly greater benefit in first-time MI prevention (Q=22.63; P <0.001).
Conclusions:
- LDL-C-lowering therapies demonstrate a greater relative benefit in preventing first-time myocardial infarction.
- Findings are supported by high-quality evidence and robust analyses, including GRADE assessment.
Aims:
Reducing elevated low-density lipoprotein cholesterol (LDL-C) is central to global efforts to prevent myocardial infarction (MI). While many studies have evaluated LDL-C-lowering therapies in first-time and recurrent MI prevention, direct comparisons of their relative efficacy are lacking. Therefore, we conducted a systematic review and meta-analysis to compare the efficacy of LDL-C-lowering therapies in first-time versus recurrent MI prevention.
Methods:
We searched three databases until November 30, 2024, for randomized controlled trials (RCTs) with at least 1,000 patient-years of follow-up. Efficacy was quantified as relative risk (RR) with 95% confidence intervals (CIs). Differences in benefit magnitude were assessed using Cochran's Q test. Data were pooled with a random-effects model, and heterogeneity was measured using the I2 statistic. Additionally, we applied the Cochrane Risk of Bias Tool to evaluate study quality and utilized the GRADE method to assess the certainty of the evidence.
Results:
This study included 22 large-scale RCTs involving 180,304 participants. In first-time MI prevention, LDL-C-lowering therapies achieved a remarkable 38% reduction in MI risk (12 RCTs; 79,604 participants; RR, 0.62 [95% CI, 0.55-0.69]; P <0.001). In recurrent MI prevention, these therapies were associated with a more modest but significant 16% risk reduction (11 RCTs; 100,700 participants; RR, 0.84 [95% CI, 0.80-0.88]; P <0.001). Importantly, the benefit magnitude between the two groups was significantly different (Q=22.63; P <0.001), highlighting the greater relative benefit in first-time MI prevention. Furthermore, the robustness of our findings was consistently supported by leave-one-out analyses, the absence of publication bias, high-quality GRADE evidence, and subgroup and sensitivity analyses.
Conclusion:
Our findings suggest that LDL-C-lowering therapies may offer a greater benefit in preventing first-time MI compared to recurrent MI.
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