July 30, 2024BMC Cardiovascular Disorders17 citationsOpen Access
Early administration of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in patients with acute coronary syndrome: a systematic review and meta-analysis
Key Result
Early administration of PCSK9 inhibitors within 48 hours of hospitalization for acute coronary syndrome significantly reduced the incidence of myocardial infarction (RR 0.59) and ACS hospitalization (RR 0.53) at 6 to 18 months compared to usual care.
Study Design
Type
Meta-Analysis (n=3,250)
Structured PICO
Does early administration of PCSK9 inhibitors within 48 hours of hospitalization reduce cardiovascular events in patients with acute coronary syndrome?
P
Population
Patients with acute coronary syndrome (pooled from 9 RCTs and 3 cohort studies)
I
Intervention
PCSK9 inhibitors administered within 48 hours of hospitalization
O
Outcome
Incidence of MI, ACS hospitalization, and revascularization at 6-18 months post-ACShard clinical
Early initiation of PCSK9 inhibitors within 48 hours of hospitalization for ACS reduces major adverse cardiovascular events and improves lipid control.
Main Result
Effect estimate: RR 0.59 (95% CI 0.38-0.92)
Limitations
- Only one RCT and three cohorts were available for MACE assessment, contributing to heterogeneity
- Lack of long-term assessment of early injection of evolocumab and alirocumab in ACS patients
- Absence of data on composite MACE incidence in the included studies due to the possibility of overlapping components
- Small sample sizes of included studies, especially relevant to MACE which have a low incidence
- Different time frames for follow-up and evaluation of outcomes across included studies
Abstract
BACKGROUND: High-intensity statin therapy is currently recommended initial guideline therapy in ACS treatment. However, only a minority of patients are achieving LDL-C attainment goal at 6 months. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are on recommended guideline therapy post-ACS if LDL-C goal attainment is not achieved after high-intensity statin (4-6 weeks) and after the addition of ezetimibe if guideline goal attainment is not achieved after an additional 4-6 weeks. Thus, it has been recommended that PCSK9 inhibitors be considered earlier post-ACS. However, the efficacy of early PCSK9 inhibitors initiation in ACS patients remains uncertain. METHODS: This systematic review and meta-analysis was conducted following PRISMA guidelines. Randomized controlled trials (RCTs) and observational studies involving ACS patients who received PCSK9 inhibitors within 48 h of hospitalization were included. Common and random effects models were used to evaluate the pooled effect of early PCSK9 inhibitor administration. Nine RCTs and three cohort studies were included. RESULTS: Early PCSK9 inhibitor administration reduced the incidence of MI, ACS hospitalization, and revascularization at 6-18 months post-ACS. Although there was a drift towards reduced stroke, all-cause mortality, and cardiovascular death, no statistically significant reduction was observed. Additionally, PCSK9 inhibitors significantly enhanced lipid control at 4-12 weeks after index hospitalization. CONCLUSION: Early PCSK9 inhibitors initiation in ACS patients reduces MACE and improves lipid profiles. While the results propose promising benefits in terms of stroke and mortality, further research with longer follow-up is required for more decisive evidence.