Lipoprotein(a) and the Effect of Alirocumab on Revascularization After Acute Coronary Syndrome

Many patients require revascularization after index acute coronary syndrome (ACS). Lipoprotein(a) is thought to play a pathogenic role in atherothrombosis. In ODYSSEY OUTCOMES, alirocumab reduced major adverse cardiovascular events after ACS, with greater reduction among those with higher lipoprotein(a) levels. We explored whether risk of revascularization after ACS was modified by the level of lipoprotein(a) and treatment with alirocumab or placebo. In ODYSSEY OUTCOMES alirocumab was compared with placebo in 18,924 patients with ACS and elevated atherogenic lipoprotein levels despite optimized statin treatment. In this post hoc analysis, treatment effects are summarized using competing risks proportional hazard models. A total of 1559 (8.2%) patients had coronary, 204 (1.1%) had limb, and 40 (0.2%) had carotid revascularization. Alirocumab reduced coronary revascularization (2.8 vs 3.2 events per 100 patient-years; hazard ratio [HR], 0.88 [95% confidence interval (CI), 0.80-0.97]; P = 0.01) and any revascularization (3.2 vs 3.7 events per 100 patient-years; HR, 0.85 [95% CI, 0.78-0.94]; P = 0.001). Baseline lipoprotein(a) quartile was directly associated with risk of coronary or any revascularization in the placebo arm and inversely related to treatment HRs (all P for trend < 0.01). Alirocumab produced the greatest reduction of coronary revascularization in patients with baseline lipoprotein(a) in the top quartile (≥ 59.6 mg/dL; HR, 0.69 [95% CI, 0.57-0.84]), but no apparent reduction in the bottom quartile (HR, 1.00 [95% CI, 0.82-1.22]). Findings were similar for the effect of alirocumab on any revascularization. Alirocumab reduced revascularization rates after ACS. The risk of revascularization and reduction in that risk with alirocumab were greatest in patients with elevated lipoprotein(a) at baseline. De nombreux patients ont besoin d’une revascularisation après un premier syndrome coronarien aigu (SCA), et la lipoprotéine A jouerait un rôle dans la pathogenèse de l’athérothrombose. Dans l’étude ODYSSEY OUTCOMES, l’alirocumab a permis de réduire la survenue d’événements cardiovasculaires indésirables majeurs après un SCA, et cette réduction a été plus importante chez les personnes dont le taux de lipoprotéine A était plus élevé. Nous avons cherché à savoir si le risque de revascularisation après un SCA variait en fonction du taux de lipoprotéine A et de l’administration d’alirocumab ou d’un placebo. Dans l’étude ODYSSEY OUTCOMES, l’alirocumab a été co