February 2025: A Blog About Blocked Arteries
Adding a PCSK9 Inhibitor or Ezetimibe to a Statin Lowers LDL and Cardiovascular Risk in High-Risk Individuals
Lowering LDL cholesterol is a cornerstone of cardiovascular disease (CVD) prevention, but for many high-risk patients, statins alone may not be enough. This study evaluates the effectiveness of adding either a PCSK9 inhibitor (PCSK9i) or ezetimibe to background statin therapy in individuals with high cardiovascular risk.
The meta-analysis reviewed multiple randomized controlled trials, comparing the outcomes of patients on statin monotherapy versus combination therapy with either PCSK9 inhibitors or ezetimibe.
Key Findings:
LDL Reduction:
PCSK9 inhibitors (such as evolocumab or alirocumab) lowered LDL-C by an additional 50–60% beyond statins.
Ezetimibe lowered LDL-C by approximately 20–25% beyond statins.
Cardiovascular Outcomes:
Both PCSK9 inhibitors and ezetimibe reduced major adverse cardiovascular events (MACE), including heart attacks and strokes.
The benefit was most pronounced in high-risk patients, including those with prior cardiovascular disease (CVD), diabetes, or genetic hypercholesterolemia.
Bempedoic Acid (for statin-intolerant patients):
This newer medication showed a 17–20% LDL reduction and a modest reduction in cardiovascular events, but less evidence exists compared to PCSK9i or ezetimibe.
It may be a reasonable alternative for patients who cannot tolerate statins due to muscle aches (myopathy) or other side effects.
Side Effects & Considerations:
PCSK9 inhibitors are injectable and expensive but well-tolerated with minimal side effects.
Ezetimibe is an affordable oral medication, but some patients experience mild gastrointestinal side effects.
Bempedoic acid does not cause muscle pain like statins but may increase uric acid levels, which is important in patients with a history of gout.
Takeaway:
For high-risk individuals, particularly those with a history of CVD, high LDL, or statin intolerance, adding a second-line agent further reduces cardiovascular risk. PCSK9 inhibitors are highly effective but expensive, while ezetimibe and bempedoic acid offer alternative oral options. Personalized treatment should be guided by LDL levels, risk factors, tolerance, and patient preference.
The Foundation of Heart Health: Nutrition First
Before considering medications, my framework for cardiovascular risk reduction always begins with diet. A whole-food, anti-inflammatory approach is key: eliminating trans fats, minimizing inflammatory saturated and monounsaturated fats, and optimizing omega-3 to omega-6 ratios through food and supplementation. The Mediterranean diet—rich in vegetables, lean proteins, and healthy fats—remains a gold standard for heart health.
This month, we’re featuring buckwheat crepes as our heart-healthy recipe. Buckwheat is an ancient grain high in fiber, antioxidants, and heart-protective compounds. These crepes, cooked in avocado oil, offer a nutrient-dense alternative to traditional refined grains and promote metabolic health.
Buckwheat Crepes Recipe
These gluten-free, nutty-flavored crepes are versatile and perfect for savory or sweet fillings. Makes about 8-10 crepes.
Ingredients:
1 cup (120g) buckwheat flour
2 large pasture raised eggs
1 ½ cups (375ml) milk (organic dairy or plant-based)
1 tablespoon (15ml) melted butter
Avocado Oil for cooking
Pinch of salt
Optional: 1 teaspoon monkfruit (for sweet crepes)
Instructions:
1. Prepare the Batter:
In a large mixing bowl, whisk together the buckwheat flour and salt (and sweetener if making sweet
crepes).
Make a well in the center of the flour mixture, crack in the eggs, and whisk until combined.
Gradually pour in the milk, whisking constantly, until the batter is smooth and free of lumps.
Stir in the melted butter or oil. The batter should have a thin, pourable consistency similar to heavy cream. If it’s too thick, add a little more milk.
2. Rest the Batter:
Cover the batter and let it rest at room temperature for at least 30 minutes (or refrigerate for up to 12 hours). This helps the flour fully hydrate and improves texture.
3. Cook the Crepes:
Heat a nonstick skillet or crepe pan over medium heat. Lightly grease with oil.
Pour about ¼ cup of batter into the pan, swirling it to coat the bottom in a thin, even layer.
Cook for 1-2 minutes until the edges lift and the bottom is golden brown. Flip the crepe with a
spatula and cook for another 30 seconds to 1 minute.
Transfer to a plate and repeat with the remaining batter, greasing the pan as needed.
4. Serve:
For savory crepes, fill with ingredients like ham, cheese, eggs, spinach, or smoked salmon.
For sweet crepes, try fillings like Nutella, fresh fruit, whipped cream, or jam.
Tips:
Use a well-seasoned cast iron on high heat or non toxic nonstick pan to prevent adherence.
If the batter thickens while resting, thin it with a little water or milk.
Keep cooked crepes warm in a low oven (200°F/90°C) or covered with foil until ready to serve.
Enjoy your delicious buckwheat crepes!
Mindfulness & Cardiometabolic Training: Slowing Down to Go Further
Mindfulness isn’t just about meditation—it’s also about how we move. I used to hate running because I ran too hard. Over time, I’ve discovered the meditative effects of long-duration, low-intensity cardiovascular training. Running or rowing at slower paces allows for focus on breath and movement, unlocking mental clarity and enhancing endurance.
This type of training not only improves cardiovascular health but also reduces stress, sharpens cognitive function, and fosters longevity. If high-intensity exercise feels overwhelming, consider incorporating more zone 2 cardio (moderate effort, conversational pace) into your routine. Not only will it support heart health, but it may also change the way you think about movement.
For further reading, check out these studies on cardiovascular training and brain health:
Heart Month is a perfect time to refocus on prevention. Whether through diet, medication, or movement, small changes can make a lasting impact. Let’s make heart health a priority all year long!
