Evolocumab in patients with multivessel coronary disease after acute myocardial infarction: A target trial emulation.

BACKGROUND AND AIMS: The proprotein convertase subtilisin/kexin type 9 inhibitors, i.e. evolocumab, promote coronary plaque regression in patients with acute myocardial infarction (AMI). However, its clinical benefit for non-culprit intermediate lesions deferred for revascularization remains uncertain. This study evaluated whether early evolocumab initiation improves outcomes in this specific population.

METHODS

Using target trial emulation to a multicenter registry of AMI patients in Shanghai (2021-2022), this study enrolled patients with successful culprit-vessel revascularization but ≥1 deferred non-culprit intermediate lesion. The intervention was evolocumab initiation during index hospitalization versus standard care alone. The primary outcome was a major adverse cardiac event (MACE) at 2 years. Treatment effects were estimated using the multivariable-adjusted Cox regression model, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) to adjust for confounding.

RESULTS

Among 1862 eligible patients (4034 lesions), 174 received evolocumab and 1688 did not. The evolocumab group exhibited a higher baseline cardiovascular risk profile, including elevated LDL-C (126.8 vs. 87.8 mg/dL; p < 0.001). Over 2 years, MACE occurred in 5.9% of evolocumab-treated lesions compared with 11.9% in controls. While the hazard ratio (HR) for the full 2-year period was 0.72 (95% CI 0.48-1.09), a landmark analysis at 30 days demonstrated a significant reduction in MACE risk (HR 0.35; 95% CI 0.16-0.74). Results were consistent across PSM and IPTW adjustments.

CONCLUSIONS

In AMI patients with deferred non-culprit lesions, early initiation of evolocumab was associated with a significant reduction in early MACE, driven by benefits within 30 days post-discharge.