PCSK9 inhibitor therapy and 1-year risk of incident heart failure among adults with dyslipidaemia and coronary artery disease: a propensity-matched cohort study

Background/Introduction Whether proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) lower the risk of incident heart failure (HF) beyond statins in patients with dyslipidaemia and coronary artery disease (CAD) is unclear. Purpose To compare 1-year risk of new-onset HF between PCSK9i and statin therapy among adults with dyslipidaemia and CAD. Methods We performed a retrospective cohort study on a large federated electronic health record network. Adults (≥18 years) with dyslipidaemia and CAD who newly initiated a PCSK9i (alirocumab, evolocumab or inclisiran) or a statin (ATC C10AA) between 2015–2025 were eligible. One-to-one propensity score matching (caliper 0.1 SD) balanced demographics, comorbidities, laboratory values and concomitant medications. Follow-up began the day after index prescription and continued to 365 days. Primary outcome: new-onset HF. Secondary outcomes: three-point major adverse cardiovascular events (MACE; myocardial infarction, stroke, cardiovascular death) and all-cause mortality. Cox models estimated hazard ratios (HRs) with 95% CIs. Results After matching, 20,698 patients remained in each group. Over 1 year, PCSK9i users had fewer primary events than statin users (466 vs 844), yielding HR 0.566 (95% CI 0.506–0.634; p<0.0001). Three-point MACE was also lower (483 vs 840; HR 0.594, 95% CI 0.532–0.665; p<0.0001). All-cause mortality was markedly reduced (166 vs 532; HR 0.325, 95% CI 0.273–0.387; p<0.0001). Results were robust in sensitivity analyses; a negative control outcome showed no association. Conclusions In adults with dyslipidaemia and CAD, initiation of a PCSK9i was associated with a significantly lower 1-year risk of new-onset HF, alongside reductions in three-point MACE and all-cause mortality versus statins. These real-world findings support a potential secondary-prevention role of PCSK9i for HF risk reduction and warrant prospective confirmation.For image description, please refer to the figure legend and surrounding text.