Disappointment in Timing of PCSK9 Inhibitor Treatment during Acute Heart Attack

Control de Colesterol en Pacientes con Infarto Agudo

Patients experiencing a heart attack saw quicker control of LDL cholesterol when they began PCSK9 inhibitor therapy immediately in the catheterization lab, as demonstrated by the AMUNDSEN trial. However, the expected clinical benefits were not established.

High-risk individuals who suffered an acute myocardial infarction (MI) and received their first dose of evolocumab (Repatha) just prior to percutaneous coronary intervention (PCI) were significantly more likely to meet cholesterol targets after one year. This finding was reported by Dr. Gilles Montalescot from Pitié-Salpêtrière Hospital in Paris.

Among those receiving upfront evolocumab, 82% achieved LDL cholesterol levels below 55 mg/dL and at least a 50% reduction from baseline at 12 months, compared to only 40% of those who received standard care (adjusted OR 5.54, 95% CI 4.50-6.82).

However, the rates of all-cause mortality or unplanned cardiovascular hospitalization at 12 months were similar in both the evolocumab and control groups, at 14.6% and 15.4% respectively (adjusted OR 0.94, 95% CI 0.73-1.19) in this study encompassing over 2,100 participants.

The AMUNDSEN trialists posited that this suggests PCSK9 inhibitors do not provide any clinically significant acute effects beyond those mediated by LDL cholesterol in conjunction with standard care.

This study is significant as it is purportedly the first adequately powered randomized trial assessing systematic PCSK9 inhibition in patients with acute MI during mechanical reperfusion in the catheterization laboratory, supplemented by standard care including high-intensity lipid-lowering therapy.

Managing lipid levels is particularly crucial for heart attack patients, given that individuals with elevated LDL cholesterol are at increased risk for long-term recurrent cardiovascular problems.

Some have argued that PCSK9 inhibitors are appropriately positioned for a more significant role in acute MI treatment. Previous studies indicated that another PCSK9 inhibitor, alirocumab (Praluent), was effective in augmenting LDL cholesterol lowering when used as an early adjunct to high-intensity statins in acute MI settings.

Nonetheless, findings from AMUNDSEN have tempered enthusiasm regarding immediate lipid-lowering efforts in the catheterization lab.

Dr. Davide Capodanno emphasized that the study challenges the prevailing notion of

Fuente: https://www.medpagetoday.com/meetingcoverage/esc/122820