Statin Intolerance, Evolocumab for Hyperlipidemia, and Arrhythmia: Lessons Learnt From a Challenging Clinical Scenario

PCSK9 inhibitors, such as evolocumab, provide a safe and effective therapeutic option for patients intolerant to statins. This is a report of a 78-year-old woman with extensive cardiovascular diseases including coronary artery disease, prior coronary artery bypass grafting, aortic and mitral valve replacements, stroke, hypertension, hypothyroidism, statin-induced myositis, and medication non-compliance, who required non-statin lipid therapy. After multiple statin failures due to side effects like myositis and discontinuation of ezetimibe for claimed gastrointestinal intolerance, she was prescribed a PCSK9 inhibitor. Four weeks later, she presented with elevated blood pressure and back pain. An electrocardiogram revealed atrial fibrillation (AF) with rapid ventricular response, which was a new development as the patient had no history of AF. Laboratory tests and chest imaging were unremarkable. She received intravenous diltiazem and was started on oral metoprolol and apixaban. Rate control proved challenging due to bradycardia, warranting the placement of a dual-chamber pacemaker. Evolocumab was resumed after discharge, and the patient remained clinically stable. This case examines the occurrence of an arrhythmia, or AF, in a patient receiving evolocumab. It discusses contributing risk factors, underlying comorbidities, and clinical considerations, underscoring the value of reporting such events to expand understanding of potential, though uncommon, cardiac effects during PCSK9 inhibitor therapy. While no definitive association between evolocumab and AF was established, this case highlights the importance of monitoring for rare cardiac events in complex patients on PCSK9 inhibitors.