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Potential use of PCSK9 inhibitors as a secondary preventative measure for cardiovascular disease following acute coronary syndrome: a UK real-world study
  1. Ahmed Farouk Mohamed Elamin1,2,
  2. Ciaran Grafton-Clarke3,
  3. Kai Wen Chen3,
  4. Toba Obafemi1,
  5. Ahai Luvai4,
  6. Ravish Katira2,
  7. Gershan Davis, Professor of Cardiovascular Medicine5,6
  1. 1 Aintree Cardiac Centre, University Hospital Aintree, Liverpool, UK
  2. 2 Whiston Hospital, Prescot, UK
  3. 3 School of Medicine, University of Liverpool, Liverpool, UK
  4. 4 Clinical Biochemistry and Metabolic Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
  5. 5 Academic Cardiovascular Group, School of Medicine, University of Central Lancashire, Preston, UK
  6. 6 Department of Cardiology, North Cumbria University Hospitals NHS Trust, Cumbria, UK
  1. Correspondence to Professor Gershan Davis, School of Medicine, University of Central Lancashire, Preston PR1 2HE, UK; GDavis1{at}


Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a major development in the prevention of cardiovascular disease (CVD) and is one of the most significant discoveries since the development of statin therapy. Administration of two human monoclonal antibodies to PCSK9 (alirocumab and evolocumab) can significantly reduce low-density lipoprotein cholesterol (LDL-c) concentrations, thus improving lipid management. Accordingly, guidelines on the specific indications for alirocumab and evolocumab usage have been released. This multicentre study aimed to estimate the proportion of patients treated for an acute myocardial infarction (MI) who could be considered for PCSK9 inhibitors under the current National Institute for Health and Care Excellence (NICE) lipid targets criteria.

Methods The records of 596 patients in two large hospitals in Liverpool, UK were analysed. Information was collected on lipid profiles during and after admission, lipid-lowering therapy and previous CVD.

Results At least 2.2% of patients were eligible for PCSK9 inhibitors post-MI under the current NICE guidance. Additionally, 29% of patients failed to achieve LDL-c concentrations <2.0 mmol/L despite maximum statin therapy and failed to meet eligibility for PCSK9 inhibitors as per the NICE criteria. This cohort represents a group of patients ‘in limbo’, in which statin therapy alone is not sufficient to reduce LDL-c.

Conclusions PCSK9 inhibitors are expensive and so their use must be highly selective. At present, in a real-world setting with ezetimibe underprescribing, ~2% of patients are eligible and a further 30% are deprived of benefit and improved outcomes by lack of optimisation and/or potential use of PCSK9 inhibitors.

  • PCSK9 inhibitors
  • cardiovascular disease
  • secondary prevention
  • acute coronary syndrome
  • lipids

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  • Contributors All persons who meet the authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication before its appearance in the Postgraduate Medical Journal. AFME: study design, data collection, statistical analysis, manuscript writing. CG-C: data collection, statistical analysis, contribution to manuscript. KWC, TO: data collection. AL: proof-reading. RK, GD: study design, proof-reading.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.