Evolocumab vs ezetimibe: 20% fewer heart attacks in a cohort study of patients on statins

A study published on 5 November 2026 in the American Journal of Preventive Medicine compared evolocumab with ezetimibe in patients with atherosclerotic cardiovascular disease (ASCVD) whose LDL cholesterol stayed elevated despite statin therapy, according to ad-hoc-news.de ad-hoc-news.dead-hoc-news.dead-hoc-news.deOpen source ↗. The authors report a lower heart attack risk with evolocumab. This is an emulated cohort study based on real-world care data, not a randomized trial. Nihar Desai of Yale University took part in the work.

Study design and patient groups

The analysis uses care data from the US database Komodo Health Healthcare Map. It compares clinical courses in patients with a baseline LDL-C above 0.7 g/l. The study population consists of 64,421 patients treated with evolocumab, known under the brand name Repatha, and 479,682 patients treated with ezetimibe.

Heart attack risk and LDL-C reduction

Over four years, patients on evolocumab had a 20 percent lower risk of fatal and non-fatal heart attacks than those on ezetimibe. In a detailed analysis of cases with a known baseline LDL-C, the four-year risk of a fatal or non-fatal heart attack was 5.88 percent with evolocumab versus 7.76 percent with ezetimibe.

The difference corresponds to the size of the cholesterol reduction. Evolocumab lowered LDL-C by 53 to 65 percent, while the reduction under ezetimibe was 17 to 24 percent ad-hoc-news.dead-hoc-news.dead-hoc-news.deOpen source ↗.

The authors link the results to earlier randomized trials. In FOURIER, evolocumab was associated with a 27 percent reduction in heart attack risk, and VESALIUS-CV reported a 36 percent reduction for the same drug. IMPROVE-IT found a 13 percent risk reduction for ezetimibe.

The publication adds real-world data on secondary prevention in high-risk patients who do not respond sufficiently to statin monotherapy. As an observational comparison, it does not replace randomized trials, and the figures describe groups of patients rather than individual treatment decisions.