Long-Term Lipid Lowering With Evolocumab in Older Individuals

BACKGROUND 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. OBJECTIVES This study aims to assess the long-term benefit of evolocumab among patients aged >= 75 years. METHODS 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. RESULTS 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 1/4 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. CONCLUSIONS 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. (JACC. 2025;85:504-512) (c) 2025 by the American College of Cardiology Foundation.