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Bempedoic acid vs ezetimibe added to statin therapy: Cardiovascular outcomes in the real-world-The BEYOND-REAL Study

Raechel T White1, Benedicta O Ansong2, Kevin Cowart3

  • 1Taneja College of Pharmacy, Department of Pharmacotherapeutics & Clinical Research, University of South Florida Tampa, FL, USA (White, Ansong, and Cowart); Morsani College of Medicine, Department of Family Medicine, University of South Florida Tampa, FL, USA (White and Cowart).

Journal of Clinical Lipidology
|March 12, 2026
PubMed

Insights

Bempedoic acid significantly lowered cardiovascular events compared to ezetimibe in patients on moderate-intensity statins. This suggests bempedoic acid may offer greater atherosclerotic cardiovascular disease risk reduction than previously thought.

Area of Science:

  • Cardiology
  • Pharmacology
  • Public Health

Background:

  • Residual atherosclerotic cardiovascular disease (ASCVD) risk persists despite moderate-intensity statin therapy, necessitating additional non-statin treatments.
  • Ezetimibe is a common first-line oral non-statin, while bempedoic acid is an alternative, especially for statin-intolerant patients.
  • Real-world cardiovascular outcomes data for bempedoic acid combined with moderate-intensity statins are limited.

Purpose of the Study:

  • To compare real-world cardiovascular outcomes between bempedoic acid and ezetimibe when used as add-on therapy to moderate-intensity statins.
  • To evaluate the effectiveness of these non-statin therapies in reducing major adverse cardiovascular events.

Main Methods:

  • A retrospective cohort study utilizing the TriNetX global federated health research network.
  • Inclusion criteria: adults (≥18 years) on moderate-intensity statin therapy with add-on bempedoic acid or ezetimibe.
  • Primary outcome: composite of stroke, myocardial infarction, ischemic heart disease, new-onset heart failure, or peripheral artery disease. Risk ratios (RRs) were calculated.

Main Results:

  • The study included 6706 matched patients (3353 per group).
  • Bempedoic acid was associated with a significantly lower risk of the composite outcome versus ezetimibe (16.7% vs 22.8%; RR: 0.73).
  • Individual cardiovascular endpoints favored bempedoic acid, although ezetimibe achieved greater low-density lipoprotein cholesterol (LDL-C) reduction.

Conclusions:

  • Bempedoic acid demonstrated significantly lower cardiovascular event rates compared to ezetimibe in adults on moderate-intensity statins.
  • Despite lower LDL-C reduction, bempedoic acid showed a greater potential for ASCVD risk reduction.
  • Findings support considering bempedoic acid for enhanced ASCVD risk management beyond current clinical guideline recommendations.
Abstract

Keywords:
Bempedoic acidCardiovascular riskEzetimibeLipid loweringPrimary preventionReal-world evidenceStatin

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