Clinical Effect of Evolocumab treatment in coronary artery bypass surgery

Aims – Evolocumab, a PCSK9 inhibitor, has been shown to significantly reduce cholesterol levels when added to statin + ezetimibe therapy after coronary artery bypass grafting (CABG), though short-term follow-up did not reveal reductions in major clinical events. Beyond lipid-lowering, PCSK9 inhibitors may offer anti-inflammatory and plaque-stabilizing effects, especially relevant in the perioperative phase of CABG. Evolocumab enhances LDL clearance by upregulating LDL receptor recycling and may also reduce lipoprotein(a) and inflammatory markers. Importantly, residual inflammatory risk remains a contributor to post-CABG events, even in patients with well-controlled lipid levels. Due to its unique pharmacologic profile, Evolocumab warrants dedicated evaluation in surgical populations. Methods and Results – This retrospective study included 254 dyslipidemic patients undergoing CABG. Of these, 111 received statin + ezetimibe plus Evolocumab, while 143 received only statin + ezetimibe. Over 18 months of follow-up, the two groups were compared for lipid levels and cardiovascular outcomes. Cox regression analysis identified significant predictors of events, including treatment group, hypertension, EUROSCORE_II, and prior stroke. Evolocumab treatment showed a protective effect on major cardiovascular events—such as recurrent angina, myocardial infarction, cerebrovascular events, revascularization procedures, and cardiac death—with a hazard ratio (HR) of 0.38 (95% CI 0.15–0.99, p = 0.047).Cholesterol levels decreased more rapidly in the Evolocumab group, with a mean total cholesterol reduction of 27 mg/dL (p < 0.01), LDL by 30 mg/dL (p < 0.001), triglycerides by 18.77 mg/dL (p < 0.001), and an HDL increase of 2.7 mg/dL (p < 0.001), compared to the control group. Conclusion – In patients undergoing CABG, the addition of Evolocumab to standard lipid-lowering therapy significantly reduced cholesterol levels and, importantly, lowered the incidence of major cardiac events at 18-month follow-up. These findings, the first of their kind in the surgical setting, support the use of Evolocumab perioperatively, particularly in patients resistant to statin therapy.