PCSK9 Inhibitors Conquer Primary Prevention: The VESALIUS-CV Study

Abstract Elevated low-density lipoprotein cholesterol (LDL-C) represents a key causal factor in atherosclerotic cardiovascular disease (ASCVD). Robust evidence demonstrates that early, marked, and sustained reduction of LDL-C is associated with a significant decrease in the risk of major adverse cardiovascular events (MACE). However, a substantial proportion of high-risk patients fail to achieve guideline-recommended LDL-C targets with statin therapy alone, thus requiring additional lipid-lowering treatments. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, particularly the monoclonal antibodies evolocumab and alirocumab, have been shown to reduce LDL-C levels by approximately 60% and to provide clear cardiovascular outcome benefits in secondary prevention. More recently, the VESALIUS-CV trial extended these findings to the setting of primary prevention in high cardiovascular risk patients without prior major cardiovascular events. In this trial, evolocumab achieved a significant and sustained reduction in LDL-C levels and significantly reduced the risk of a first cardiovascular event, including myocardial infarction and ischemia-driven revascularization, while maintaining a safety profile comparable to placebo. Overall, the available evidence supports the role of evolocumab as an effective and safe strategy for cardiovascular risk reduction across the entire risk continuum, from secondary to primary prevention, underscoring the importance of a personalized therapeutic approach based on the patient’s global cardiovascular risk profile.