Bempedoic acid and PCSK9 inhibitor eligibility in a contemporary population with atherosclerotic cardiovascular disease

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose The reduction of low-density lipoprotein cholesterol (LDL-C) in patients with established coronary heart disease (CHD) reduces the risk of atherosclerotic cardiovascular disease (ASCVD) events.(1) Many CHD patients fail to achieve guideline-recommended LDL-C targets without prohibitively expensive proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9 inhibitors).(2, 3, 4) This study aims to assess the impact that bempedoic acid may have on PCSK9 inhibitor eligibility in a population with CHD and ascertain whether its universal adoption would lead to overall cost-savings and a cost-effective reduction in ASCVD events. Methods and Results This retrospective analysis included 635 participants from the iASPIRE study, which recently assessed secondary prevention in an Irish cohort of CHD patients. We applied the 2019 ESC/EAS dyslipidaemia guideline LDL-C target of <1.4mmol/L and simulated the average treatment effect of improved lipid-lowering therapy with statins, ezetimibe and bempedoic acid. 86.3% of iASPIRE participants did not have LDL-C control and qualified for treatment intensification. Optimisation of statin therapy would allow 24.4% of patients to achieve their LDL-C goal, while the addition of ezetimibe would improve this to 55.7% leaving 44.3% eligible for a PCSK9 inhibitor. Utilising bempedoic acid would further reduce the proportion eligible to 18.7%. Based on current market prices and the universal application of ESC/EAS recommendations,(1, 5) the adoption of bempedoic acid would reduce the annual treatment costs associated with PCSK9 inhibitor use by almost 50% and result in cost savings per prevented CVD event. Conclusions The vast majority of CHD patients currently fail to achieve the recommended LDL-C target in everyday clinical practice. Ezetimibe and optimised statin therapy would enable most patients to meet their LDL-C goal. Employing bempedoic acid in patients with poor LDL-C control would significantly reduce the requirement for PCSK9 inhibitors and lead to cost savings per prevented CVD event.