Values & turf
A values / turf tradeoff — more data alone will not resolve it.
Resolves via: Shared decision-making + role clarity
If this expands, millions of statin-treated patients with diabetes or plaque but no prior heart attack become candidates for an expensive lifelong injectable.
Active since Oct 2025
The debate
9 clinicians quoted on the record
A large trial now shows evolocumab cuts first heart attacks and strokes in these patients, so waiting for an event before lowering LDL hard means letting preventable damage happen.
“The results from the VESALIUS-CV trial represent the first demonstration of improved cardiovascular outcomes with a PCSK9 inhibitor, or any nonstatin for that matter, in patients without a previous heart attack or stroke who are already being treated with a high-intensity lipid-l”
“VESALIUS-CV is an important and practice-changing trial. It demonstrates that more intensive lipid lowering therapy earlier in the atherosclerotic disease process is better to reduce major cardiovascular events.”
+ 3 more on this side
The absolute benefit in patients who've never had an event is smaller than in secondary prevention, and treating this huge group with a costly drug for years may not be worth it without cost-effectiveness and long-term data.
“As much as we do like [PCSK9 inhibitors] and use them, we have to always think about cost”
“show the benefit of evolocumab in a high-risk primary prevention patient population... but raise additional questions about long-term results, cost-effectiveness and age of treatment in younger, lower risk patients”
+ 1 more on this side
Where the experts land
5–3 on record · 1 unplaced
Expand to high-risk primary prevention · 5
On the record, unplaced · 1
Don't broaden yet · 3
“The results from the VESALIUS-CV trial represent the first demonstration of improved cardiovascular outcomes with a PCSK9 inhibitor, or any nonstatin for that matter, in patients without a previous heart attack or stroke who are already being treated with a high-intensity lipid-l”
Where the field stands
Common ground
Evolocumab lowers first cardiovascular events in high-risk patients who have not yet had a heart attack or stroke.
The crux
The open question is whether that modest absolute benefit justifies routine, costly injectable therapy before a first event, or whether it should stay mainly after one.
Still unknown
Longer-term outcome data and solid cost-effectiveness analyses across risk and age groups would settle who should get it.
On the record
Their own words — position stated as published
similar effect to secondary prevention
“We are seeing a similar effect in this primary prevention cohort.”
Amit Khera · Preventive cardiologist · 2 statements · Medscape ↗
Where do you land?
No votes yet — the measured split appears at 10.
Where the evidence stands
VESALIUS-CV (n=12,257) cut 3-point MACE 25% (HR 0.75) over 4.6 years; FDA had already expanded evolocumab to high-risk primary prevention. Absolute risk reductions are modest (~1.8% over 5 years for 3-point MACE). Cost, injection burden, and how far down the risk ladder to go remain contested.
What's settled
3What's still open
4How this gets settled
Who could settle it
Know an expert who could settle this? Suggest one →
Who this affects
Who could fund or run it
Institutions that could fund, run, or adopt
Sources & verification
+ 38 more, each dated and verification-tagged
Who we found publicly on the record — a snapshot, not a poll of the field. Larger dots are deciders; dashed dots are scan-reported, not yet verified.