Abstract TP390: Tetrad Therapy With Antiplatelets, Antihypertensives, High Intensity Statins and a PCSK9 Inhibitor Reduces Vascular Events in Patients With a History of Stroke

Abstract

Background: The mainstay of medical secondary prevention of recurrent vascular events in patients with an index stroke of atherosclerotic origin has been the triad of 1) antiplatelet (AP), 2) antihypertensive (aHTN), and 3) high intensity statin agents. The PCSK9 inhibitors (-i) are a new class of cholesterol reducers. Recently, the FOURIER trial demonstrated that Evolocumab, a PCSK9-i, confers additional benefit in reducing recurrent vascular events. Indices of the degree of this additional benefit would be helpful to patients, physicians, and payers. Methods: Vascular event rates were extracted for patients with a history of stroke from the FOURIER database. We compared event rates versus those of established medical therapies. Results: Vascular events over 3 years in patients with an index stroke were reduced with a PCSK9-i (7.26%) versus control (8.87%) (RR 0.83,95% CI 0.69-1.0), resulting in a NNT of 62. Risk ratios were comparable to the established triad of medical therapies: antiplatelets (RR 0.83,CI 0.79-0.88), antihypertensives (RR 0.91,CI 0.87-0.96) and high intensity statins (RR 0.81,CI 0.71-0.92). Vascular event rates were lower with each sequential addition of medical intervention (AP 22.1%, AP+aHTN 17.1%, AP+aHTN+Statin 9.01%), down to 7.26% with tetrad therapy (triad therapy plus a PCSK9-i). Standard triad therapy results in a 66% reduction in vascular events while tetrad therapy results in a 73% reduction. Conclusions: In patients with an index stroke of atherosclerotic origin, tetrad therapy results in a 73% reduction of vascular events to a 3 year event rate of 7.26%. The magnitude of additional benefit with a PCSK9-i is comparable to established medical therapies and may be considered as part the medical armamentarium for the prevention of recurrent cardiovascular events in this high risk population.