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Purpose Clinical trials have demonstrated efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing risk of cardiovascular disease events, but effectiveness in routine clinical care has not been well‐studied. We used negative control outcomes to assess potential confounding in an observational study of PCSK9i versus ezetimibe or high‐intensity statin. Methods: Using commercial claims, we identified U.S. adults initiating PCSK9i, ezetimibe, or high‐intensity statin in 2015–2018, with other lipid‐lowering therapy (LLT) use in the year prior (LLT cohort) or atherosclerotic cardiovascular disease (ASCVD) in the past 90 days (ASCVD cohort). We compared initiators of PCSK9i to ezetimibe and high‐intensity statin by estimating one‐year risks of negative control outcomes influenced by frailty or health‐seeking behaviors. Inverse probability of treatment and censoring weighted estimators of risk differences (RDs) were used to evaluate residual confounding after controlling for covariates. Results: PCSK9i initiators had lower one‐year risks of negative control outcomes associated with frailty, such as decubitus ulcer in the ASCVD cohort (PCSK9i vs. high‐intensity statin RD = −3.5%, 95% confidence interval (CI): −4.6%, −2.5%; PCSK9i vs. ezetimibe RD = −1.3%, 95% CI: −2.1%, −0.6%), with similar but attenuated associations in the LLT cohort. Lower risks of accidents and fractures were also observed for PCSK9i, varying by cohort. Risks were similar for outcomes associated with health‐seeking behaviors, although trended higher for PCSK9i in the ASCVD cohort. Conclusions: Observed associations suggest lower frailty and potentially greater health‐seeking behaviors among PCSK9i initiators, particularly those with a recent ASCVD diagnosis, with the potential to bias real‐world analyses of treatment effectiveness. [ABSTRACT FROM AUTHOR]

Concerns about the efficacy and safety of intensive low-density lipoprotein cholesterol lowering in older patients have led to weaker recommendations in the U.S. guidelines for patients ≥75 years of age compared to younger patients. Data are sparse on long-term benefits of proprotein convertase subtilisin/kexin type 9 inhibition in older patients. This study aims to assess the long-term benefit of evolocumab among patients aged ≥75 years. The FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) trial randomized 27,564 patients who were 18 to 85 years of age with atherosclerotic cardiovascular disease to evolocumab vs placebo with 2.2 years of median follow-up. In the open-label extension (FOURIER-OLE), 6,635 participants were transitioned to open-label evolocumab for an additional 5-year median follow-up. The primary endpoint (cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization) was compared based on the original allocation to evolocumab vs placebo stratified by age (<75 vs ≥75 years). Analyses were underpowered for individual components of the composite endpoint. The annualized incidence rates for adverse events of interest were calculated for the OLE population across age groups during the parent FOURIER trial by randomized treatment arm and during the combined parent and FOURIER-OLE studies for patients originally allocated to evolocumab. Of 27,564 patients, 2,526 (9%) were ≥75 years of age at entry into FOURIER (median age: 77 years [Q1-Q3: 76-79 years]). The median follow-up in FOURIER and FOURIER-OLE was 7.1 years (Q1-Q3: 6.7-7.6 years), with a maximum of 8.7 years. Earlier initiation of evolocumab reduced the rate of the primary endpoint at least as well in older (HR: 0.79; 95% CI: 0.64-0.97) as in younger patients (HR: 0.86; 95% CI: 0.80-0.92; P interaction = 0.43). The absolute risk reductions were 5.4% (95% CI: –2.0% to 12.8%) in older and 2.3% (95% CI: 0.1%-4.5%) in younger patients, leading to numbers needed to treat of 19 and 44, respectively. The annualized incidence rates of safety events generally appeared similar across treatment arms in both age groups. Early initiation of long-term evolocumab provides older patients with atherosclerotic cardiovascular disease cardiovascular benefits at least as good as those observed in younger patients, with a more favorable number needed to treat in older patients for reducing a composite endpoint and no significant safety concerns. These findings may be helpful in guiding future recommendations. [Display omitted] [ABSTRACT FROM AUTHOR]