Effect of Evolocumab on Complex Coronary Disease Requiring Revascularization Evaluated

December 1, 2020—Kazuma Oyama, PhD, et al published findings of a study on the effect of evolocumab on complex coronary disease requiring revascularization. The study, which is available online in Journal of the American College of Cardiology (JACC), concluded that adding evolocumab to statin therapy did significantly reduce the risk of developing complex coronary disease that would need revascularization, including complex percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) individually.

The investigators sought to evaluate the ability of PCSK9 inhibitors to reduce the risk of complex coronary atherosclerosis that requires revascularization. They noted that PCSK9 inhibitors induce plaque regression and reduce the risk of coronary revascularization overall.

In JACC, investigators reported that the study was a randomized trial of evolocumab (a PCSK9 inhibitor) versus placebo in 27,564 patients with stable atherosclerosis on statin therapy followed for a median of 2.2 years. Clinical documentation of revascularization events was blindly reviewed to assess coronary anatomy and procedural characteristics.

Complex revascularization was the composite of complex PCI (as per previous analyses, more than one of the following: multivessel PCI, ≥ 3 stents, ≥ 3 lesions treated, bifurcation PCI, or total stent length > 60 mm) or CABG.

As summarized in JACC, the study was composed of 1,724 patients who underwent coronary revascularization, including 1,482 who underwent PCI, 296 who underwent CABG, and 54 who underwent both. Complex revascularization was performed in 632 (37%) patients.

Evolocumab reduced the risk as follows:

• In coronary revascularization by 22% (hazard ratio [HR], 0.78 [0.71-0.86]; P < .001)
• In simple PCI by 22% (HR, 0.78, [0.7-0.88]; P < .001)
• In complex PCI by 33% (HR, 0.67 [0.54-0.84]; P < .001)
• In CABG by 24% (HR 0.76 [0.6-0.96]; P = .019)
• In complex revascularization by 29% (HR, 0.71 [0.61-0.84]; P < .001).

Lastly, the magnitude of the risk reduction with evolocumab in complex revascularization tended to increase over time: 20%, 36%, and 41% risk reductions in year 1, year 2, and beyond year 2, respectively.