Evolocumab Reduces First Cardiovascular Events in High-Risk Diabetes

Patients with diabetes mellitus face a disproportionately high risk of atherosclerotic cardiovascular disease, driven largely by the causal relationship between cumulative exposure to low-density lipoprotein cholesterol and vascular injury [1, 2]. While statins remain the first-line therapy for risk reduction, many patients continue to experience major adverse cardiovascular events (a composite of myocardial infarction, stroke, and cardiovascular death) despite reaching traditional lipid targets [3, 4]. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as evolocumab and alirocumab, reduce the risk of these major events by approximately 18% in patients with diabetes (odds ratio 0.82; 95% confidence interval, 0.74 to 0.90) [1, 5]. However, clinical guidelines have historically reserved these potent agents for secondary prevention in patients with established, symptomatic atherosclerosis [6, 7, 8]. A recent study, the VESALIUS-CV trial, investigates whether initiating evolocumab earlier in the disease continuum can prevent the first occurrence of major cardiovascular complications in high-risk patients with diabetes who have no prior history of myocardial infarction or stroke, potentially shifting how clinicians approach primary prevention in this vulnerable population [9].