P6244Rapid carotid plaques reversal of PCSK9 inhibitors when added to statins and eicosapentaenoic acid in high risk cardiovascular patients

Abstract

Background: Statins are the most widely prescribed lipid‐lowering medications, have been shown to lower the relative risk for cardiovascular event (CVE) by 20‐50%. Substantial residual cardiovascular risk persists in some patients while on statins, in those patients with combined mixed dyslipidemia, i.e., high triglycerides (TG) and low HDL. Research data suggests that pure eicosapentaenoic acid (EPA) could reduce residual risk in statin‐treated population especially those with TG >150mg/dL. Purpose: We attempt to determine whether triple combination of statins, EPA, PCSK9 inhibitors (PCSK9i) evolocumab henceforth known as Trio Combo could promote faster and larger carotid plaque regression. Method: 57 patients with high risk cardio‐cerebrovascular diseases were entered into the study. Age between 55 to 88 years old, average age 72 years, male/female ratio 30/27. 57/57 (100%) have treated obstructive sleep apnea, 55/57 (96%) have diabetes mellitus, 12/57 (21%) had previous myocardial infarction, 20/57 (35%) had percutaneous coronary stenting, 12/57 (21%) had transient ischemic attacks, 22/57 (39%) have congestive heart failure. All were treated atorvastatin 40 mg and EPA 4 grams daily for more than one year that served as Control. CIMT measurements using high‐resolution 2‐D ultrasound systems with a 5‐ to 13‐MHz linear array transducer were done on Control subjects; and repeat CIMT measurements at 3 to 6 months after initiation of Trio Combo. CIMT was measured as the distance between the leading edge of the lumen intima boundary and the leading edge of the media‐adventitia of the carotid artery with the patient in the supine position. Results: Average LDL‐C was 75, TG 102 in the Control group, and LDL‐C 22, TG 92 in the Trio Combo group 3 months after therapy. 20%% to 65% plaque reversal occurred after 6 months of Trio Combo therapy in 37 patients (65%), ‐ 28% (progression) to 0% reversals in 10 patients who took evolocumab for only 3 months. ‐ 6% (progression) to 10% reversal in 3 patients elected to receive evolocumab once a month instead of once every 2 weeks. 1 patient had 50% left common carotid stenosis that was reversed down to 2.5 mm CIMT plaques after only 3 months of evolocumab. 2 patients with active chronic periodontitis (P) have 0% to 10% CIMT plaque reversals. 4 patients took EPA 2 grams a day instead of the usual 4 grams a day resulted in CIMT plaque reversals of ‐3% to 12%. Conclusion: Trio Combo therapy of atorvastatin, EPA, evolocumab resulted in rapid and significant CIMT plaque reversal within 6 months compared to the Control group of EPA, atorvastatin in high risk elderly CV patients. The added cost of evolocumab as part of Trio Combo therapy in high risk patients could more than offset the lesser occurrence of CVE and its associated economic cost to healthcare.