Very Low LDL-C Improves Risk of MACE in Patients With ASCVD, With Michelle O’Donoghue, MD

Lower achieved LDL-C has shown a monotonic relationship with lower incidence of future major adverse cardiovascular events, including recurrent stroke, in patients with atherosclerotic cardiovascular disease (ASCVD) and prior ischemic stroke, according to an analysis of the FOURIER trial. These data also support that an LDL-C of <40 mg/dL may be a reasonable target for cardiovascular outcome improvement.1

ASCVD is a well-known contributor to the pathogenesis of first and recurrent ischemic stroke. Although existing guidelines have long endorsed lowering LDL-C for the prevention of major adverse cardiovascular events in patients with ASCVD, limited data exist regarding patients who have already experienced an ischemic stroke. To that end, O’Donoghue and colleagues conducted this analysis.1

The editorial team at HCPLive spoke with Michelle O’Donoghue, MD, the McGillycuddy-Logue Endowed Chair in Cardiology at Brigham and Women’s Hospital and associate professor at Harvard Medical School, to discuss the impacts these data may have on LDL-C-lowering therapies going forward.

“There really didn’t seem to be a floor or a basement in terms of lowering LDL further translating into even lower risk,” O’Donoghue told HCPLive. “Perhaps even more importantly, there did not appear to be any safety signals – for patients who achieved very, very low LDL cholesterol concentrations, we did not see an increased risk of hemorrhagic stroke or any other adverse events of concern. I think that provides important reassurances that pushing LDL cholesterol even further down is safe.”

FOURIER was a double-blind, randomized, placebo-controlled, multicenter study investigating the impacts of evolocumab combined with statin therapy in patients with cardiovascular disease. Patients aged ≥40 to ≤85 years with a history of clinically evident cardiovascular disease at high risk for a recurrent event, as well as fasting LDL-C ≥70 mg/dL or non-HDL-C ≥100 mg/dL and fasting triglycerides ≤400 mg/dL were eligible for inclusion. Investigators excluded patients with NYHA class III or IV heart failure, uncontrolled hypertension, uncontrolled or recurrent ventricular tachycardia, untreated hyper- or hypothyroidism, homozygous familial hypercholesterolemia, or LDL or plasma apheresis.2

A total of 27,564 patients were enrolled in FOURIER and were randomly assigned to either evolocumab 140 mg every 2 weeks or 420 mg once a month, or matching placebo, both of which were administered subcutaneously with a prefilled 1.0 mL pen. The primary endpoint was a composite of time to cardiovascular death, myocardial infarction (MI), hospitalization for unstable angina, stroke, or coronary revascularization.2

Ultimately, investigators observed a significant reduction in the primary endpoint with evolocumab compared with placebo (1344 patients [9.8%] vs 1563 patients [11.3%]; HR, 0.85; 95% CI, 0.79-0.92; P <.001), with a consistent effectacross all subgroups. Additionally, the least-squares mean percentage reduction in LDL cholesterol levels was 59% with evolocumab, from a median baseline of 92 mg/dL to 30 mg/dL.3

Based on these data, O’Donoghue and colleagues selected 5291 patients from the FOURIER study group. The team used modified Poisson regression models to examine the relationship between achieved LDL-C and the incidence of the composite primary endpoint in the original trial.1

O’Donoghue and colleagues followed patients for a total of 14,418 patient years, with a maximum follow-up of 8.6 years. Median achieved LDL-C with evolocumab was 31.5 mg/dL (IQR 21.5-47 mg/dL). Additionally, investigators found that patients with lower achieved LDL-C exhibited substantially lower annualized incidence rates of the primary composite endpoint. When modeled categorically, the lowest incidence rates of the primary endpoint were observed in patients with achieved LDL-C <40 mg/dL.1

O’Donoghue and colleagues highlighted these results as endorsing the longstanding suggestion to lower LDL-C targets in patients with prior ischemic stroke. Additionally, they suggest that these data indicate the safety of even lower LDL-C goals than are present in current guidelines.1

“I think providing further supporting evidence that we should be even more aggressive than we are right now for lowering LDL-C will translate into greater benefits for patients,” O’Donoghue said. “Mainly, I think it would just further increase the absolute benefit, because people are at higher risk when they’re close to the time of their event. And so, we expect that the number needed to treat would probably be even smaller for that very high-risk group.”

Editor's Note: O'Donoghue reports disclosures with Amgen, Novartis, AstraZeneca, Janssen, Novo Nordisk, Verve, and others.

References

1. Monguillon V, Kelly P, O’Donoghue ML, et al. Efficacy and safety of very low achieved LDL-cholesterol in patients with prior ischemic stroke. Circulation. Published online November 3, 2025. doi:10.1161/circulationaha.125.077549

2. Amgen Pharmaceuticals. Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER). ClinicalTrials.gov Identifier: NCT01764633. Updated May 28, 2024. Accessed November 26, 2025. https://clinicaltrials.gov/study/NCT01764633

3. Sabatine MS, Giugliano RP, Keech AC, et al. EVOLOCUMAB and clinical outcomes in patients with cardiovascular disease. New England Journal of Medicine. 2017;376(18):1713-1722. doi:10.1056/nejmoa1615664