ESC Congress 2026: Evolocumab after MI doubles LDL goal attainment

Clinical takeaway: Consider initiating evolocumab during hospitalization in high-risk patients with acute MI undergoing PCI when rapid, intensive LDL-C lowering is a priority, but do not expect the strategy to reduce death or cardiovascular hospitalization within the first year.

Patients remain at particularly high risk for recurrent cardiovascular events during the year after an MI, yet real-world LDL-C goal attainment remains poor. The AMUNDSEN trial, presented at ESC Congress 2026 in Munich and published simultaneously in JAMA, tested whether starting a PCSK9 inhibitor before PCI could accelerate lipid control and potentially improve short-term outcomes.

Among 2,161 high-risk patients with ST-elevation or non-ST-elevation MI undergoing PCI, immediate evolocumab plus standard care dramatically improved LDL-C goal attainment compared with standard care alone. At 12 months, 82% of patients receiving evolocumab achieved both a ≥50% LDL-C reduction and an LDL-C level <55 mg/dL, versus 40% of those receiving standard care.

Patients treated with evolocumab also reached LDL-C goals much faster, achieving targets in a median of 9 weeks compared with 19 weeks in the standard-care group. Despite frequent follow-up visits and guideline-directed treatment intensification, LDL-C control remained "low and slow" in the standard-care arm.

However, better lipid control did not translate into an early clinical benefit. The composite outcome of all-cause death or unplanned cardiovascular hospitalization occurred in 14.6% of patients receiving evolocumab and 15.4% of those receiving standard care at 1 year. A prespecified per-protocol analysis suggested a possible reduction in events (10.2% vs 14.3%), but investigators emphasized that this finding was hypothesis-generating.

“Immediate in-hospital initiation of evolocumab substantially improved LDL-C goal attainment but even then, 1 in 5 patients failed to reach their target a year later,” said lead investigator Gilles Montalescot, MD. “Developing additional preventive strategies and delivering them early remains an imperative for high-risk patients.”

Source: Montalescot G, et al. (2026 Aug 29) JAMA. LDL Cholesterol Lowering With Evolocumab Before Percutaneous Coronary Intervention for Acute Myocardial Infarction: The AMUNDSEN Randomized Clinical Trial