Ezetimibe plus a Statin after Acute Coronary Syndromes

To the Editor: With regard to the article by Cannon et al. (June 18 issue),1 human serum cholesterol derives from two sources: it is either synthesized endogenously or absorbed in the intestine. Statins inhibit endogenous cholesterol synthesis, whereas ezetimibe inhibits intestinal cholesterol absorption.2 According to findings from the Scandinavian Simvastatin Survival Study3 and the German Diabetes and Dialysis Study,4 patients with a high level of cholesterol absorption may receive less benefit from statin therapy than those with a low level of cholesterol absorption. However, patients with elevated absorption may particularly benefit from the addition of ezetimibe to a statin regimen.2 Patients with elevated intestinal cholesterol absorption can be identified with genetic testing for risk alleles in the ATP-binding cassette transporters G5 and G8 (ABCG5/8), Niemann–Pick C1– like 1 (NPC1L1), and ABO genes.5,6 It remains to be investigated whether these alleles will predict whether statins will be less effective in reducing cardiovascular risk in patients harboring them than in those not harboring them. If so, testing for these alleles in addition to measuring lowdensity lipoprotein (LDL) cholesterol levels may be helpful in deciding when to add ezetimibe treatment to ongoing statin therapy. This would be an approach toward personalized prevention of cardiovascular disease.