IMPORTANCECoronary plaques that are prone to rupture and cause adverse cardiac events are characterized by large plaque burden, large lipid content, and thin fibrous caps. Statins can halt the progression of coronary atherosclerosis; however, the effect of the proprotein convertase subtilisin kexin type 9 inhibitor alirocumab added to statin therapy on plaque burden and composition remains largely unknown.OBJECTIVE To determine the effects of alirocumab on coronary atherosclerosis using serial multimodality intracoronary imaging in patients with acute myocardial infarction. DESIGN, SETTING, AND PARTICIPANTSThe PACMAN-AMI double-blind, placebo-controlled, randomized clinical trial (enrollment: May 9, 2017, through October 7, 2020; final follow-up: October 13, 2021) enrolled 300 patients undergoing percutaneous coronary intervention for acute myocardial infarction at 9 academic European hospitals.INTERVENTIONS Patients were randomized to receive biweekly subcutaneous alirocumab (150 mg; n = 148) or placebo (n = 152), initiated less than 24 hours after urgent percutaneous coronary intervention of the culprit lesion, for 52 weeks in addition to high-intensity statin therapy (rosuvastatin, 20 mg).MAIN OUTCOMES AND MEASURES Intravascular ultrasonography (IVUS), near-infrared spectroscopy, and optical coherence tomography were serially performed in the 2 non-infarct-related coronary arteries at baseline and after 52 weeks. The primary efficacy end point was the change in IVUS-derived percent atheroma volume from baseline to week 52. Two powered secondary end points were changes in near-infrared spectroscopy-derived maximum lipid core burden index within 4 mm (higher values indicating greater lipid content) and optical coherence tomography-derived minimal fibrous cap thickness (smaller values indicating thin-capped, vulnerable plaques) from baseline to week 52. RESULTS Among 300 randomized patients (mean [SD] age, 58.5 [9.7] years; 56 [18.7%] women; mean [SD] low-density lipoprotein cholesterol level, 152.4 [33.8] mg/dL), 265 (88.3%) underwent serial IVUS imaging in 537 arteries. At 52 weeks, mean change in percent atheroma volume was −2.13% with alirocumab vs −0.92% with placebo (difference, −1.21% [95% CI, −1.78% to −0.65%], P < .001). Mean change in maximum lipid core burden index within 4 mm was −79.42 with alirocumab vs −37.60 with placebo (difference, −41.24 [95% CI, −70.71 to −11.77]; P = .006). Mean change in minimal fibrous cap thickness was 62.67 μm with alirocumab vs 33.19 μm with placebo (difference, 29.65 μm [95% CI,]; P = .001). Adverse events occurred in 70.7% of patients treated with alirocumab vs 72.8% of patients receiving placebo.CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction, the addition of subcutaneous biweekly alirocumab, compared with placebo, to high-intensity statin therapy resulted in significantly greater coronary plaque regression in non-infarct-related arteries after 52 weeks. Further research is needed to understand whether alirocumab improves clinical outcomes ...

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Background Muscle wasting is an important predictor of long‐term outcome in patients with cardiovascular disease, but the prognostic value of muscle wasting in patients with non‒ST‐segment‒elevation myocardial infarction is not established. The aim of this study is to investigate the prognostic value of muscle wasting, defined by psoas muscle mass index (PMI), in patients with non‒ST‐segment‒elevation myocardial infarction. Methods and Results A total of 132 consecutive patients with non‒ST‐segment‒elevation myocardial infarction were prospectively enrolled between 2015 and 2018. Primary end point was incidence of cardiovascular events including cardiovascular deaths, non‐fatal myocardial infarction, or non‐fatal stroke. Cross‐sectional area of the psoas muscle at the L3 vertebral level was obtained by computed tomography and PMI was calculated. The median follow‐up period was 2.4 years (interquartile range, 1.1–4.0 years). There were 45 cardiovascular events (34%) during the study periods. The optimal cutoff value of PMI to predict cardiovascular events was 772 mm 2 /m 2 , as assessed by receiver operating curve analysis. Patients with reduced PMI (PMI<772 mm 2 /m 2 ) had significantly higher cardiovascular events than those with preserved PMI (PMI≥772 mm 2 /m 2 ) (48% versus 21%; log‐rank test P <0.001). Multivariate Cox proportional hazards model revealed that reduced PMI was a statistically significant predictor of cardiovascular events (hazard ratio, 3.30; 95% CI, 1.70–6.40; P <0.001). Conclusions Muscle wasting defined as PMI is a simple and useful objective marker to predict future cardiovascular outcome in patients with non‒ST‐segment‒elevation myocardial infarction. Registration Information URL: https://www.umin.ac.jp/ctr/ ; Unique identifier: UMIN000013445.

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