Dual Lipid-Lowering Strategy and Coronary Plaque Regression

Study Questions:

What are the effects of ezetimibe plus atorvastatin versus atorvastatin monotherapy on the lipid profile and coronary atherosclerosis in Japanese patients undergoing percutaneous coronary intervention (PCI)?


PRECISE-IVUS (Plaque Regression With Cholesterol Absorption Inhibitor or Synthesis Inhibitor Evaluated by Intravascular Ultrasound) was a prospective, randomized, controlled, multicenter trial. Eligible patients undergoing PCI were randomly assigned to atorvastatin alone or atorvastatin plus ezetimibe (10 mg) daily. Atorvastatin was uptitrated with a treatment goal of low-density lipoprotein cholesterol (LDL-C) <70 mg/dl. Serial volumetric intravascular ultrasound was performed at baseline and again at 9-12 months to quantify the coronary plaque response in 202 patients.


The combination of atorvastatin/ezetimibe resulted in lower levels of LDL-C than atorvastatin monotherapy (63.2 ± 16.3 mg/dl vs. 73.3 ± 20.3 mg/dl; p < 0.001). For the absolute change in percent atheroma volume (PAV), the mean difference between the two groups (-1.538%; 95% confidence interval, -3.079% to 0.003%) did not exceed the predefined noninferiority margin of 3%, but the absolute change in PAV did show superiority for the dual lipid-lowering strategy (-1.4% [-3.4% to -0.1%] vs. -0.3% [-1.9% to 0.9%] with atorvastatin alone; p = 0.001). For PAV, a significantly greater percentage of patients receiving atorvastatin/ezetimibe showed coronary plaque regression (78% vs. 58%; p = 0.004). Both strategies had acceptable side-effect profiles, with a low incidence of laboratory abnormalities and cardiovascular events.


The authors concluded that compared with standard statin monotherapy, the combination of statin plus ezetimibe showed greater coronary plaque regression.


This study reports that a dual lipid-lowering strategy combining atorvastatin and ezetimibe resulted in more remarkable reduction of LDL-C than atorvastatin monotherapy, and volumetric IVUS analysis demonstrated superiority regarding coronary plaque regression with negative vascular remodeling in the analyzed target segment. Furthermore, significant favorable effect of the dual lipid-lowering strategy on the coronary atherosclerotic development was noted, especially in the acute coronary syndrome cohort, along with a reduction of cholesterol absorption markers and lower LDL-C levels. Combination therapy with statin plus ezetimibe appears to be a promising lipid-lowering option, particularly for high-risk patients.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Acute Coronary Syndrome, Anticholesteremic Agents, Atherosclerosis, Cholesterol, Cholesterol, LDL, Coronary Artery Disease, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipoproteins, LDL, Percutaneous Coronary Intervention, Plaque, Atherosclerotic, Primary Prevention, Ultrasonography, Interventional

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