RU2837845C2 - Using pcsk9 inhibitor for reducing cardiovascular risk - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to methods of treating diseases and disorders associated with high levels of lipids and lipoproteins. Method provides reducing the risk of fatal outcome for any reason in a patient with hypercholesterolemia in need thereof, having a serum LDL-C level greater than or equal to 100 mg/dl, while receiving therapy with maximum tolerable dose of statins and suffered acute coronary syndrome (ACS). A therapeutically effective amount of alirocumab is administered to the patient for at least 3 years.

EFFECT: invention provides a significant reduction in the risk of death in patients with high levels of atherogenic lipoproteins in intensive treatment with statins and suffered ACS.

11 cl, 35 dwg, 47 tbl, 12 ex

Description

RELATED APPLICATIONS

[1] This application claims priority to U.S. Provisional Patent Application Nos. 62/639,407, filed March 6, 2018; 62/640,361, filed March 8, 2018; 62/641,082, filed March 9, 2018; 62/641,918, filed March 12, 2018; 62/657,495, filed April 13, 2018; 62/683,695, filed June 12, 2018; 62/688,622, filed June 22, 2018; 62/717,530, filed August 10, 2018; 62/736,284, filed September 25, 2018; 62/744,008, filed October 10, 2018; 62/746,319, filed October 16, 2018; 62/770,530, filed November 21, 2018; 62/775,219, filed December 4, 2018; 62/797,680, filed January 28, 2019; 62/802,545, filed February 7, 2019; 62/806,313, filed February 15, 2019; and European Patent Application No. 19305247.9, filed March 4, 2019, the entire disclosures of which are incorporated herein by reference in their entirety.

FIELD OF TECHNOLOGY TO WHICH THE INVENTION RELATES

[2] The present invention relates to the field of methods for the therapeutic treatment of diseases and disorders that are associated with elevated levels of lipids and lipoproteins. More specifically, the present invention relates to the use of PCSK9 inhibitors for reducing cardiovascular risk, including mortality, and lowering levels of atherogenic lipoproteins in patients with high cardiovascular risk after acute coronary syndrome, despite therapy with the maximum tolerated dose of statins.

PREREQUISITES FOR THE CREATION OF THE INVENTION

[3] Despite modern therapy, including surgical coronary revascularization, dual antiplatelet therapy, and intensive statin therapy, cardiovascular events after acute coronary syndrome (ACS) occur with high frequency. Registry studies have reported cardiovascular mortality rates of up to 13% over 5 years, with the vast majority occurring after the first hospital discharge. Patients with recent ACS are at very high risk of experiencing recurrent coronary events in the near future. Approximately 10% of patients with ACS experience cardiovascular death, recurrent myocardial infarction, or stroke within 1 year. Based on the results of large clinical trials, early intensive statin therapy has become an established treatment recommendation for patients with ACS. Both epidemiologic and pharmacologic intervention studies have demonstrated a strong and linear association between low-density lipoprotein cholesterol (LDL-C) levels and cardiovascular (CV) events. However, many patients at high risk for CV events fail to achieve these levels with currently available lipid-lowering medications. Furthermore, a significant number of patients at high risk fail to achieve their recommended LDL-C targets, and most CV events are not effectively prevented, leaving patients with substantial “residual risk” of event occurrence. Thus, additional pharmacologic therapies are needed to treat patients at high CV risk, including to reduce the likelihood of death.

BRIEF DESCRIPTION OF THE INVENTION

[4] The present invention provides methods for reducing cardiovascular risk and lowering atherogenic lipoprotein levels using a PCSK9 inhibitor in patients at high cardiovascular risk. The methods of the present invention are particularly useful for reducing cardiovascular risk and/or events. Such methods are based in part on the results of clinical trials disclosed herein, which demonstrated for the first time that treatment with a PCSK9 inhibitor was associated with a reduced risk of death in patients at high cardiovascular risk receiving therapy with a maximally tolerated dose of a statin.

[5] Accordingly, in one aspect, the present invention provides a method for reducing the risk of death in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of death in the patient.

[6] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy. In certain embodiments, the patient's risk of death is reduced by about 15%. In other embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy. In other certain embodiments, the patient's risk of death is reduced by about 29%. In certain embodiments, the method results in an increase in patient survival. In certain embodiments, the death is a death due to cardiovascular disease ("CV death"). In other embodiments, the death is a death not due to cardiovascular disease ("non-CV death"). In certain embodiments, the non-CV death occurs as a result of a pulmonary infection, a lung malignancy, a gastrointestinal/liver and biliary tract/pancreas infection, a gastrointestinal/liver and biliary tract/pancreas malignancy, a hemorrhage, a neurological process that is not a stroke/hemorrhage, suicide, a non-cardiovascular procedure or surgery, an accident or injury, a kidney infection, a kidney malignancy, other non-cardiovascular infection, or other non-cardiovascular malignancy.

[7] In another aspect, the present invention provides a method for reducing the risk of death due to coronary artery disease (CHD), the risk of non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of CHD-related death, non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in the patient.

[8] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level of greater than or equal to 70 mg/dL despite treatment with maximally tolerated dose statin therapy. In certain embodiments, the patient's risk of CHD-related death, non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke is reduced by about 15%. In other embodiments, the patient has an LDL-C level of greater than or equal to 100 mg/dL despite treatment with maximally tolerated dose statin therapy. In other certain embodiments, the patient's risk of CHD-related death, non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke is reduced by about 24%. In certain embodiments, the method results in an increase in the time to death due to CHD, the first non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in a patient. In certain embodiments, a patient at high cardiovascular risk has an Lp(a) level greater than or equal to 20 mg/dL as measured by an automated nephelometric assay with latex addition despite treatment with maximum tolerated dose statin therapy. In some embodiments, the patient at high cardiovascular risk has peripheral arterial disease (PAD). In some embodiments, the patient at high cardiovascular risk has cerebrovascular disease (CeVD). In some embodiments, the patient has polyvascular disease. In some embodiments, the patient at high cardiovascular risk has previously undergone coronary artery bypass grafting (CABG).

[9] In certain embodiments, the patient with high cardiovascular risk has diabetes. In certain embodiments, the method results in a reduction in the patient with diabetes of the risk of death due to coronary heart disease (CHD), the risk of non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke by about 16%.

[10] In another aspect, the present invention provides a method for reducing the risk of a coronary heart disease (CHD) event in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of a CHD-related event in the patient.

[11] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, a CHD-related event includes death due to CHD, non-fatal myocardial infarction, unstable angina requiring hospitalization, or a coronary revascularization procedure due to ischemia. In certain embodiments, the patient has an LDL-C level of greater than or equal to 70 mg/dL despite treatment with maximum-tolerated dose statin therapy. In certain embodiments, the patient's risk of a CHD-related event is reduced by about 12%. In other embodiments, the patient has an LDL-C level of greater than or equal to 100 mg/dL despite treatment with maximum-tolerated dose statin therapy. In other certain embodiments, the patient's risk of a CHD-related event is reduced by about 22%. In certain embodiments, the method results in an increase in the time to the first occurrence of a CHD-related event in the patient.

[12] In another aspect, the present invention provides a method for reducing the risk of a major CHD-related event in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of a major CHD-related event in the patient.

[13] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In some embodiments, a significant CHD-related event includes death due to CHD or a non-fatal myocardial infarction. In certain embodiments, the patient has an LDL-C level of greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy. In certain embodiments, the patient's risk of a significant CHD-related event is reduced by about 12%. In other embodiments, the patient has an LDL-C level of greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy. In other certain embodiments, the patient's risk of a significant CHD-related event is reduced by about 23%. In certain embodiments, the method results in an increase in the time to the first occurrence of a significant CHD-related event in the patient.

[14] In another aspect, the present invention provides a method for reducing the risk of CHD-related death in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administering a PCSK9 inhibitor to the patient, thereby reducing the patient's risk of death due to CHD.

[15] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximally tolerated statin therapy. In certain embodiments, the patient's risk of CHD-related death is reduced by about 28%. In certain embodiments, the method results in an increase in the time to CHD-related death in the patient.

[16] In another aspect, the present invention provides a method for reducing the risk of a cardiovascular event in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of a cardiovascular event in the patient.

[17] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the cardiovascular event includes a non-fatal CHD-related event, a cardiovascular death, or a non-fatal ischemic stroke. In certain embodiments, the non-fatal CHD-related event includes a non-fatal myocardial infarction, unstable angina requiring hospitalization, or a need for a coronary revascularization procedure due to ischemia. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum-tolerated dose statin therapy. In certain embodiments, the patient's risk of a cardiovascular event is reduced by about 13%. In other embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum-tolerated dose statin therapy. In other specific embodiments, the risk of a cardiovascular event in a patient is reduced by about 22%. In specific embodiments, the method results in an increase in the time to the first occurrence of a cardiovascular event in a patient.

[18] In another aspect, the present invention provides a method for reducing the risk of cardiovascular death in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administering a PCSK9 inhibitor to the patient, thereby reducing the patient's risk of cardiovascular death.

[19] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximally tolerated statin therapy. In certain embodiments, the patient's risk of a cardiovascular event is reduced by about 31%. In certain embodiments, the method results in an increase in the time to cardiovascular death in the patient.

[20] In another aspect, the present invention provides a method for reducing the risk of a non-fatal cardiovascular event in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administering a PCSK9 inhibitor to the patient, thereby reducing the risk of a non-fatal cardiovascular event in the patient.

[21] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the non-fatal cardiovascular event includes myocardial infarction, stroke, unstable angina requiring hospitalization, heart failure requiring hospitalization, or the need for a coronary revascularization procedure due to ischemia. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximally tolerated statin therapy. In certain embodiments, the patient's risk of a non-fatal cardiovascular event is reduced by about 15%.

[22] In another aspect, the present invention provides a method for reducing the risk of a non-fatal cardiovascular (CV) event or death following an initial non-fatal CV event in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who is eligible and who has already suffered an initial non-fatal cardiovascular event; and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of a subsequent non-fatal CV event in the patient.

[23] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the non-fatal CV event includes a myocardial infarction, stroke, unstable angina requiring hospitalization, heart failure requiring hospitalization, or the need for a coronary revascularization procedure due to ischemia. In certain embodiments, the patient has already experienced one, two, three, four, or more than four non-fatal cardiovascular events. In one embodiment, the initial non-fatal CV event is a first non-fatal CV event and the subsequent non-fatal CV event is a second non-fatal CV event. In another embodiment, the initial non-fatal CV event is a second non-fatal CV event and the subsequent non-fatal CV event is a third non-fatal CV event. In another embodiment, the initial non-fatal CV event is a third non-fatal CV event, and the subsequent non-fatal CV event is a fourth non-fatal CV event. In another embodiment, the initial non-fatal CV event is a fourth non-fatal CV event, and the subsequent non-fatal CV event is a fifth non-fatal CV event. In certain embodiments, the patient has already experienced more than four non-fatal CV events.

[24] In another aspect, the present invention provides a method for reducing the overall occurrence of non-fatal cardiovascular (CV) events in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, which results in a reduction in the overall number of non-fatal CV events in the patient.

[25] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the non-fatal cardiovascular event comprises a non-fatal myocardial infarction, a non-fatal stroke, or a non-fatal unstable angina. In certain embodiments, the patient's risk of experiencing non-fatal cardiovascular events is reduced, thereby resulting in a reduction in the patient's risk of non-cardiovascular death. In certain embodiments, the patient's risk of non-cardiovascular death is reduced by about 19%.

[26] In another aspect, the present invention provides a method for reducing the risk of death, the risk of non-fatal myocardial infarction, or non-fatal ischemic stroke in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the patient's risk of death, non-fatal myocardial infarction, or non-fatal ischemic stroke.

[27] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level of greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy. In certain embodiments, the risk of death, the risk of non-fatal myocardial infarction, or non-fatal ischemic stroke in the patient is reduced by about 14%. In other embodiments, the patient has an LDL-C level of greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy. In other certain embodiments, the risk of death, the risk of non-fatal myocardial infarction, or non-fatal ischemic stroke in the patient is reduced by about 23%. In certain embodiments, the method results in an increase in the time to death, the first non-fatal myocardial infarction, or non-fatal ischemic stroke in the patient. In certain embodiments, the fatal outcome is a fatal outcome due to CV. In other embodiments, the fatal outcome is a fatal outcome not due to CV.

[28] In another aspect, the present invention provides a method for reducing the risk of ischemic stroke in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administering a PCSK9 inhibitor to the patient, thereby reducing the patient's risk of developing ischemic stroke.

[29] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum-tolerated-dose statin therapy. In certain embodiments, the patient's risk of experiencing ischemic stroke is reduced by about 27%. In other embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum-tolerated-dose statin therapy. In other certain embodiments, the patient's risk of experiencing ischemic stroke is reduced by about 40%. In certain embodiments, the method results in an increase in the time to the first occurrence of ischemic stroke in the patient.

[30] In another aspect, the present invention provides a method for reducing the risk of developing unstable angina requiring hospitalization in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration of a PCSK9 inhibitor to the patient, thereby reducing the patient's risk of developing unstable angina requiring hospitalization.

[31] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level of greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy. In certain embodiments, the patient's risk of developing unstable angina requiring hospitalization is reduced by about 39%. In other embodiments, the patient has an LDL-C level of greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy. In other certain embodiments, the patient's risk of developing unstable angina requiring hospitalization is reduced by about 52%. In certain embodiments, the method results in an increase in the time to the first event of unstable angina requiring hospitalization in the patient.

[32] In another aspect, the present invention provides a method for reducing the risk of non-fatal myocardial infarction in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the patient's risk of non-fatal myocardial infarction.

[33] In one embodiment, the PCSK9 inhibitor is a PCSK9 antibody or antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximally tolerated statin therapy. In certain embodiments, the patient's risk of non-fatal myocardial infarction is reduced by about 14%.

In one embodiment, the myocardial infarction is a type 1 myocardial infarction. In certain embodiments, the patient's risk of having a type 1 myocardial infarction is reduced by about 13%. In another embodiment, the myocardial infarction is a type 2 myocardial infarction. In certain embodiments, the patient's risk of having a type 2 myocardial infarction is reduced by about 23%. In certain embodiments, the method results in an increase in the time to the first non-fatal myocardial infarction in the patient.

[34] In another aspect, the present invention provides a method for reducing the risk of needing a coronary revascularization procedure due to ischemia in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administration of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor to the patient, thereby reducing the risk of the need for a coronary revascularization procedure due to ischemia in the patient.

[35] In one embodiment, the PCSK9 inhibitor is an antibody to PCSK9 or an antigen-binding fragment thereof. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximally tolerated dose statin therapy. In certain embodiments, the risk of the patient needing a coronary revascularization procedure due to ischemia is reduced by about 12%. In certain embodiments, the method results in an increase in the incidence of the need for a coronary revascularization procedure due to ischemia in a patient at high cardiovascular risk. In certain embodiments, the method results in an increase in the time to the first occurrence of the need for a coronary revascularization procedure due to ischemia in the patient.

[36] In another aspect, the present invention provides a method for reducing the risk of death due to coronary artery disease (CHD), the risk of non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in a patient at very high risk of future events related to atherosclerotic cardiovascular disease (ASCVD), the method comprising:

(a) selection of eligible patients at very high risk of future ASCVD-related events, and

(b) administration to the patient of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of CHD-related death, non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in the patient.

[37] In one embodiment, the PCSK9 inhibitor is a PCSK9 antibody or antigen-binding fragment thereof. In certain embodiments, a very high-risk patient is selected for having a history of either multiple significant ASCVD-related events or one significant ASCVD-related event and multiple high-risk conditions. In certain embodiments, high-risk conditions include heterozygous familial hypercholesterolemia, a history of coronary artery bypass grafting or percutaneous coronary intervention, diabetes mellitus, hypertension, CKD (eGFR 15-59 mL/min/1.73 ^m2 ), a history of smoking, persistently elevated LDL-C (LDL-C ≥100 mg/dL [≥2.6 mmol/L]) despite therapy with a maximally tolerated dose of a statin and ezetimibe, or a history of congestive heart failure.

[38] In another aspect, the present invention provides a method for reducing cardiovascular risk in a patient at high cardiovascular risk, the method comprising:

(a) selection of a patient with high cardiovascular risk who requires it and

(b) administering to the patient a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, whereby the patient's Lp(a) level is reduced, thereby reducing the patient's cardiovascular risk.

[39] In one embodiment, the PCSK9 inhibitor is a PCSK9 antibody or antigen-binding fragment thereof. In certain embodiments, the Lp(a) level is measured using an automated nephelometric assay with the addition of latex.

[40] In certain embodiments of any of the above aspects, the patient already has an established cardiovascular disease. In certain embodiments, the patient has clinically evident atherosclerotic cardiovascular disease (ASCVD). In certain embodiments, the patient has already experienced an acute coronary syndrome (ACS) event. In certain embodiments, the patient has already experienced an ACS event within the last 12 months. In certain embodiments, the ACS event is characterized by the following: (1) unstable myocardial ischemic symptoms occurring at rest or with minimal exertion within 72 hours of an unplanned hospitalization for suspected or proven obstructive coronary artery disease; and (2) at least one of the following: (i) elevated levels of cardiac biomarkers suggestive of acute myocardial infarction and (ii) resting ECG changes suggestive of ischemia or infarction along with additional evidence of obstructive coronary artery disease as a result of regional perfusion imaging abnormalities or wall motion abnormalities, epicardial coronary stenosis ≥70% confirmed by angiography, or the need for event-related coronary revascularization.

[41] In certain embodiments of any of the above aspects, the patient is administered a PCSK9 inhibitor for at least one year. In other embodiments, the patient is administered a PCSK9 inhibitor for at least three years.

[42] In certain embodiments, a PCSK9 inhibitor is administered to the patient in combination with maximum-tolerated-dose statin therapy. In certain embodiments, maximum-tolerated-dose statin therapy comprises atorvastatin at a daily dose of about 40 mg to about 80 mg. In certain embodiments, maximum-tolerated-dose statin therapy comprises rosuvastatin at a daily dose of about 20 mg to about 40 mg. In certain embodiments, maximum-tolerated-dose statin therapy comprises a low or moderate dose of atorvastatin or rosuvastatin. In certain embodiments, maximum-tolerated-dose statin therapy comprises a statin other than atorvastatin or rosuvastatin. In certain embodiments, the patient has already been treated with maximum-tolerated-dose statin therapy for at least two weeks.

[43] In certain embodiments, a PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds PCSK9. In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy chain variable region (HCVR) and light chain variable region (LCVR) complementarity determining regions (CDRs) comprising the amino acid sequences set forth in SEQ ID NOs: 1 and 6, respectively. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDR amino acid sequences of SEQ ID NOs: 2, 3, 4, 7, 8, and 10. In certain embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR with the amino acid sequence of SEQ ID NO: 1 and an LCVR with the amino acid sequence of SEQ ID NO: 6. In certain embodiments, the antibody or antigen-binding fragment thereof binds to the same epitope on PCSK9 as an antibody comprising the heavy and light chain CDR amino acid sequences of SEQ ID NOS: 2, 3, 4, 7, 8, and 10. In certain embodiments, the antibody or antigen-binding fragment thereof competes for binding to PCSK9 with an antibody comprising the heavy and light chain CDR amino acid sequences of SEQ ID NOS: 2, 3, 4, 7, 8, and 10. In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy chain variable region (HCVR) and light chain variable region (LCVR) complementarity determining regions (CDRs) comprising the amino acid sequences set forth in SEQ ID NOS: 85 and 89, respectively. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDR amino acid sequences of SEQ ID NOs: 86, 87, 88, 90, 91, and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR with an amino acid sequence that is at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO: 85, and an LCVR with an amino acid sequence that is at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO: 89.

[44] In certain embodiments of the methods disclosed herein, the step of administering an anti-PCSK9 antibody or antigen-binding fragment thereof (step (b)) comprises:

(i) administering to the patient one or more initial doses of 75 mg of the antibody or antigen-binding fragment thereof approximately every two weeks and

(ii) administering to the patient one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof approximately every two weeks if the patient's LDL-C level after step (i) is below the threshold level, or administering to the patient one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof approximately every two weeks if the patient's LDL-C level after step (i) is greater than or equal to the threshold level.

[45] In some embodiments, the threshold level is 50 mg/dL. In certain embodiments, step (b) of the above methods comprises administering to the patient one or more 150 mg doses of the antibody or antigen-binding fragment thereof about every two weeks. In other embodiments, step (b) of the above methods comprises administering to the patient one or more 300 mg doses of the antibody or antigen-binding fragment thereof about every two weeks or about every four weeks.

[46] In certain embodiments, the antibody or antigen-binding fragment thereof is administered to the patient about every two weeks for at least one year or more than one year.

[47] In another aspect, the present invention provides a method for reducing the risk of death due to coronary artery disease (CHD), the risk of non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke, the method comprising:

(a) selection of a patient with high cardiovascular risk who is eligible and who is not currently receiving statin therapy; and

(b) administration to a patient in need thereof of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, thereby reducing the risk of CHD-related death, non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in the patient.

[48] In certain embodiments, the patient has an intolerance to statins or a history of adverse reactions to statin therapy. In certain embodiments, the patient's risk of death due to coronary artery disease (CHD), the risk of non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke is reduced by approximately 35%.

[49] Other embodiments of the present invention will become apparent from consideration of the following detailed description.

BRIEF DESCRIPTION OF GRAPHIC MATERIALS

[50] Figures 1A through 1G provide graphical representations of marker levels in the on-treatment population. Figure 1A depicts a graph of LDL-C values for the on-treatment population at 48 months for patients receiving placebo or alirocumab. Figures 1B through 1G depict graphs showing levels of non-HDL cholesterol ( Figure 1B ), ApoB ( Figure 1C ), triglyceride ( Figure 1D ), HDL cholesterol ( Figure 1E ), lipoprotein(a) ( Figure 1F ), and total cholesterol ( Figure 1G ) in patients receiving placebo or alirocumab. Intention-to-treat (ITT) rates, shown as dashed lines, include all values, including those measured after a discontinuation, a concealed alirocumab dose change, or a concealed alirocumab-to-placebo switch. On-treatment rates, shown as solid lines, exclude values measured after a discontinuation or concealed alirocumab-to-placebo switch (but include values measured after a concealed alirocumab dose reduction).

[51] Figure 2 shows a graph of the primary efficacy endpoint, MACE, in patients treated with alirocumab or placebo. Alirocumab reduced the risk of MACE by 15% (HR=0.85, 0.78–0.93, p<0.001). The insets show the same data on an enlarged y-axis. P-values were calculated using log-rank tests stratified by geographic region.

[52] Figure 3 shows a graph of the odds ratio for all-cause death in patients treated with alirocumab versus placebo. The insets show the same data on an enlarged y-axis. P-values were calculated using log-rank tests stratified by geographic region.

[53] Figure 4 shows the results, including hazard ratios, for the various prespecified subgroup analyses, including P-values for the results of tests examining the association between the different subgroups. Cox proportional hazards regression analyses were performed in the patient subgroups for the primary outcomes (coronary heart disease-related death, first nonfatal myocardial infarction, ischemic stroke, or hospitalization for unstable angina). Apo, apolipoprotein; CI, confidence interval; HR, hazard ratio; hs-CRP, high-sensitivity C-reactive protein; NSTEMI, non-ST-segment elevation myocardial infarction; LDL-C, low-density lipoprotein cholesterol; STEMI, ST-segment elevation myocardial infarction.

[54] Figures 5A–5C show a set of plots showing the hazard ratios of MACE in three different subgroups of patients treated with alirocumab and placebo, stratified by baseline LDL-C levels (<80 mg/dL ( Figure 5A ), 80–100 mg/dL ( Figure 5B ), and ≥100 mg/dL ( Figure 5C )).

[55] Figures 6A–6B show a set of plots showing the hazard ratios of MACE in two different subgroups of patients treated with alirocumab and placebo, stratified by baseline LDL-C levels (<100 mg/dL ( Figure 6A ) and ≥100 mg/dL ( Figure 6B )).

[56] Figures 7A–7C show LDL-C levels examined in subgroups based on baseline LDL-cholesterol levels of <80 mg per deciliter ( Figure 7A ), 80–<100 mg per deciliter ( Figure 7B ), or ≥100 mg per deciliter ( Figure 7C ).

[57] Figures 8A–8C show a set of plots of the hazard ratios for all-cause death in three different subgroups of patients treated with alirocumab and placebo, stratified by baseline LDL-C levels (<80 mg/dL ( Figure 8A ), 80–100 mg/dL ( Figure 8B ), and ≥100 mg/dL ( Figure 8C )). Relative risk reduction relationship (RRR) p=0.12; absolute risk reduction relationship (ARR) p=0.005.

[58] Figure 9 shows a histogram showing the distribution of baseline Lp(a) levels. An approximate conversion from mg/dL to nmol/L can be calculated using the following formula: Lp(a) mg/dL* 0.357.

[59] Figure 10 shows a graph showing the incidence of MACE, non-fatal MI, ischemic stroke, CHD-related death, CV-related death, and all-cause death, shown by quartiles of baseline Lp(a) for the placebo group.

[60] Figure 11 is a graph showing a degree 3 spline function (fragmentary cubic curve) with a natural cubic base and 3 knots occupying the entire 25th percentile (6.7 mg/dL), the median (21.2 mg/dL), and the 75th percentile (59.6 mg/dL). P-value for the spline effect based on the Lagrange multiplier test. The odds ratio is set to 1.00 at the overall baseline median (21.2 mg/dL). P<0.0001 for the spline effect.

[61] Figure 12 is a forest plot showing the relative and absolute risk reduction with alirocumab compared with placebo. The incidence of MACE is shown for the alirocumab and placebo groups stratified by baseline Lp(a) quartile and for the overall population.

[62] Figure 13 shows a graph showing the absolute risk reduction of MACE incident stratified by baseline Lp(a) and baseline LDL-C. Baseline LDL-C not adjusted for Lp(a).

[63] Figure 14 shows the distributions of Lp(a) levels (median and interquartile range) in the alirocumab and placebo groups at baseline, month 4, and month 12, stratified by quartile of baseline Lp(a) level.

[64] Figures 15A–15B show the median and interquartile range of absolute change from baseline to month 4 in LDL-cholesterol, adjusted LDL-cholesterol, and Lp(a), stratified by Lp(a) quartile, in the alirocumab treatment group ( Figure 15A ) and the placebo group ( Figure 15B ).

[65] Figures 16A through 16B depict a plot of the correlation between baseline Lp(a) and absolute change in Lp(a) ( Figure 16A ) and baseline Lp(a) and absolute change in _adjusted LDL-C ( Figure 16B ). The Pearson correlation values between baseline Lp(a) and absolute change in Lp(a) and _adjusted LDL-C are -0.56 (P<0.0001) and 0.05 (P<0.0001), respectively.

[66] OnFig. 17A - Fig. 17Bdepicted association between absolute change in Lp(a) level at month 4 and risk of MACE for the distribution of baseline Lp(a) level from 2 to 150 mg/dL.Fig. 17AResults obtained by adjusting the model-derived results for baseline and change from baseline to month 4 for LDL-C are shown_adjusted(model 3A). OnFig. 17BResults obtained by adjusting the model-derived results for baseline and change from baseline to month 4 of non-HDL-C are shown_adjusted(model 3B).

[67] Figure 18A is a graph showing the first quartile ("1Q"), median, and third quartile ("3Q") of Lp(a) levels in patients receiving placebo or alirocumab over the course of the study. Figure 18B is a graph showing the first quartile ("1Q"), median, and third quartile ("3Q") of absolute changes in Lp(a) levels in patients receiving placebo or alirocumab over the course of the study.

[68] Figures 19A through 19C show the results of spline analyses of all-cause mortality with continuous initiation of treatment LDL-C levels at month 4 for the following groups: all patients ( Figure 19A; * HR is relative to the median month 4 LDL-C level (1.68 mmol/L [65 mg/dL]), stratified by region. Grade=3, 3 nodes located in month 4 LDL-C quartiles (0.80, 1.68, and 2.38 mmol/L [31, 65, and 92 mg/dL]), model p-value=0.0070); placebo-treated patients ( Fig. 19B; HRs are presented relative to the median month 4 LDL-C level (2.25 mmol/L [87 mg/dL]), stratified by region. Grade=3, 3 nodes located in month 4 LDL-C quartiles (1.86, 2.25, and 2.64 mmol/L [72, 87, and 102 mg/dL]), model p-value=0.0007); and alirocumab-treated patients ( Fig. 19C; HRs are relative to the median month 4 LDL-C level (0.80 mmol/L [31 mg/dL]), stratified by region. Grade=3, 3 nodes located in month 4 LDL-C quartiles (0.52, 0.80, and 1.27 mmol/L [20, 31, and 49 mg/dL]), model p-value=0.0083. LDL-C=low-density lipoprotein cholesterol; HR=hazard ratio).

[69] Figures 20A – 20D show a set of graphs showing the hazard ratios for MACE ( Figure 20A and Figure 20B ) and all-cause death ( Figure 20C and Figure 20D ) in the overall population ( Figure 20A and Figure 20C ) and among eligible patients over > three years of follow-up ( Figure 20B and Figure 20D ).

[70] Figures 21A through 21B provide graphical depictions of the death data. Figure 21A provides a graph showing all-cause death, cardiovascular (CV) death, and non-cardiovascular (non-CV) death in the overall population of patients treated with alirocumab or placebo. Figure 21B shows the reduction in deaths among eligible patients over ≥3 years of follow-up.

[71] Figure 22 shows the mean cumulative distribution curves and Kaplan-Meier curves for non-fatal cardiovascular (CV) events. The mean cumulative distribution curves depict the expected total number of non-fatal CV events for a given patient in the placebo and alirocumab groups at a given time point after randomization.

[72] Figures 23A through 23B depict the mean cumulative distribution curves and Kaplan-Meier curves for non-fatal CV events in different patient groups. Figure 23A illustrates non-fatal CV events among patients with baseline LDL-C ≥100 mg/dL (n=5629). Figure 23B illustrates non-fatal CV events among patients with baseline LDL-C <100 mg/dL (n=13295).

[73] Figure 24 shows the first, subsequent, and total number of CV events and deaths per treatment group.

[74] Figure 25 shows the joint model accounting for individual vulnerability according to baseline LDL-C subgroups.

[75] Figure 26 shows a graph showing lipid levels 16 weeks after randomization (intention-to-treat analysis) in normoglycemic, prediabetic, and diabetic patients. The median percent change from baseline is presented below each column.

[76] Figure 27 shows a graph showing the incidence of cardiovascular events in patients with normoglycemia, prediabetes, and diabetes during a median (Q1, Q3) follow-up period of 2.8 (2.3, 3.4) years. *P<0.0001 for comparison of risk in people with diabetes and in people with normoglycemia or prediabetes.

[77] Figure 28 shows a series of graphs showing post-randomization A1c, fasting glucose, and incident diabetes as a function of baseline glucometabolic status using a repeated measures mixed-effects model for A1c and fasting glucose. Only post-randomization values before initiation of diabetes medication were included in the analysis. *No diabetes=prediabetes or normoglycemia.

[78] Figure 29A and Figure 29B show the Kaplan-Meier curves for the primary endpoint of MACE ( Figure 29A ) and all-cause death ( Figure 29B ) in patients with arterial disease in 1 (coronary artery disease and no PAD or CeVD), 2 (coronary artery disease and PAD or CeVD), or 3 (coronary artery disease and both PAD and CeVD) vascular beds after treatment with alirocumab (ALI; bold line) or placebo (PBO). ARR indicates absolute risk reduction.

[79] Figure 30 shows the hazard ratios for MACE and all-cause death and the corresponding absolute risk reduction (ARR) in patients with univascular disease (coronary artery disease without known PAD or CeVD), two-vessel bed polyvascular disease (coronary artery disease and either PAD or CeVD), and three-vessel bed polyvascular disease (coronary artery disease with both PAD and CeVD).

[80] Figure 31 shows the Kaplan-Meier curves of MACE occurrence according to prior coronary artery bypass grafting (CABG) status. The curves represent the following patients: (1) without prior CABG (“no”); (2) with CABG after established ACS but before randomization (“established”); and (3) with CABG before established ACS (“before”).

[81] Figure 32 shows the hazard ratios for MACE (primary endpoint) and all-cause death and the corresponding absolute risk reduction (ARR) in patients according to prior coronary artery bypass graft (CABG) status.

[82] Figure 33 shows the Kaplan-Meier curves for the occurrence of type 1 or type 2 myocardial infarctions (MI) and the effects of alirocumab over time compared with placebo.

[83] OnFig. 34Forest plot of type 1 or type 2 myocardial infarction (MI) during follow-up as prognostic factors for all-cause mortality is shown. Prognostic factors included in the models were age group (<65, 65 to <75, or ≥75 years), geographic region, history of diabetes, history of COPD, history of pre-event MI, history of PAD, history of hypertension, GFR group (<60 versus ≥60 mL/min per 1.73 m²), LDL-C group (<100 versus ≥100 mg/dL).

[84] Figure 35 shows the hazard ratios of treatment effects on the odds of all-cause and cause-specific death before and after type 1 or type 2 myocardial infarction (MI).

DETAILED DESCRIPTION

[85] Before describing the methods of the present invention, it should be understood that the present invention is not limited to the particular methods and experimental conditions described, as such methods and conditions may vary. It should also be understood that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting, as the scope of the methods presented will be limited only by the appended claims. All publications mentioned in this document are hereby incorporated by reference in their entirety.

Definitions

[86] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. As used herein, the term "about", when used in reference to a specific numerical value being described, means that the value may differ from the value being described by no more than 1%. For example, as used herein, the expression "about 100" includes 99 and 101 and all values in between (e.g., 99.1, 99.2, 99.3, 99.4, etc.).

[87] As used herein, the term "patient at high cardiovascular risk" refers to a patient with hypercholesterolemia and/or elevated levels of at least one atherogenic lipoprotein. In certain embodiments, the patient at high cardiovascular risk has hypercholesterolemia and/or elevated levels of at least one atherogenic lipoprotein that are not adequately controlled by lipid modulating therapy (LMT), including, for example, maximum tolerated dose statin therapy. In certain embodiments, the patient at high cardiovascular risk is a patient with clinically evident atherosclerotic cardiovascular disease (ASCVD). Patients with clinically evident ASCVD include patients with ACS, patients with a history of myocardial infarction, stable or unstable angina, or coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral arterial disease including aortic aneurysm, all of atherosclerotic origin.

[88] As used in this document, the term "acute coronary syndrome event" or "ACS event" refers to unstable myocardial ischemic symptoms occurring at rest or minimal exertion within 72 hours of an unplanned hospitalization for suspected or proven obstructive coronary artery disease. In certain embodiments, an established event constituting an ACS is required to meet at least one of the following criteria: elevated levels of cardiac biomarkers indicative of acute myocardial infarction and resting ECG changes indicative of ischemia or infarction along with additional evidence of obstructive coronary artery disease as a result of regional perfusion imaging abnormalities or wall motion abnormalities, epicardial coronary stenosis ≥70% confirmed by angiography, or the need for event-related coronary revascularization.

[89] As used in this document, the term "major adverse cardiovascular events" or "MACE" refers to one or more of the following: fatal coronary heart disease (CHD fatality), non-fatal myocardial infarction, unstable angina requiring hospitalization, and fatal or non-fatal ischemic stroke.

[90] As used in this document, the terms "fatal outcome", "fatal outcome from any cause" and "fatal outcome from any cause" are used interchangeably to refer to a fatal outcome caused by any cause.

[91] As used herein, the term "coronary heart disease event" or "CHD event" refers to a fatal outcome due to coronary heart disease, a non-fatal myocardial infarction, unstable angina requiring hospitalization, or the need for a coronary revascularization procedure due to ischemia. The term "major coronary heart disease event" refers to a fatal outcome due to coronary heart disease or a non-fatal myocardial infarction.

[92] The term "coronary revascularization due to ischemia" refers to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). For the clinical trials disclosed herein, coronary revascularization procedures performed solely for restenosis at the site of prior PCI were excluded from this definition. In certain embodiments, coronary revascularization due to ischemia must be prompted by one of the following: a) acute ischemia, b) new or worsening symptoms (angina or equivalent), or 3) new or worsening abnormalities in functional testing (e.g., stress testing or imaging).

[93] As used in this document, the terms "coronary heart disease death," "CHD death," and "coronary heart disease death" are used interchangeably to refer to a subset of cardiovascular deaths for which a relationship to underlying coronary heart disease has been established, including death due to acute myocardial infarction (MI), sudden death, heart failure, complication of a coronary revascularization procedure performed for symptoms, progression of coronary artery disease, or new myocardial ischemia with a cause clearly related to the procedure, uncertain or unexpected death, and other death that cannot be clearly attributed to a nonvascular death.

[94] As used herein, the terms "cardiovascular event" or "CV event" refer to any non-fatal event related to coronary artery disease, any death due to a cardiovascular event, and any non-fatal ischemic stroke. Illustrative CV events include, but are not limited to, myocardial infarction, stroke, unstable angina requiring hospitalization, heart failure requiring hospitalization, and the need for a coronary revascularization procedure due to ischemia.

[95] As used herein, the terms "cardiovascular death," "CV death," and "cardiovascular death" are used interchangeably to refer to death due to acute myocardial infarction, sudden cardiac death, heart failure death, stroke death, and other cardiovascular deaths. In certain embodiments, the CV death is CHD death. In other embodiments, the CV death is selected from the group consisting of heart failure or cardiogenic shock, stroke, ischemic cardiovascular causes, or a cardiovascular cause other than ischemia.

[96] As used herein, the term "non-fatal cardiovascular event" refers to any CV event that does not result in death. In certain embodiments, non-fatal CV events may occur sequentially in time, with an initial (e.g., first) CV event followed by a subsequent (e.g., second, third, or fourth) event.

[97] As used in this document, the terms "non-CV death" and "non-CV death" are used interchangeably to refer to any fatal outcome that is considered to be a CV death. Examples of non-cardiovascular deaths include, but are not limited to, pulmonary infection, lung malignancy, gastrointestinal/liver and biliary tract/pancreas infection, gastrointestinal/liver and biliary tract/pancreas malignancy, hemorrhage, a neurological process that is not a stroke/hemorrhage, suicide, a non-cardiovascular procedure or surgery, accident or injury, kidney infection, renal malignancy, other non-cardiovascular infection, or other non-cardiovascular malignancy.

[98] As used in this document, the term "non-fatal myocardial infarction" is defined and subclassified according to the ACC/AHA/ESC Universal Definition of Myocardial Infarction (see Thygesen et al., 2012. Third universal definition of myocardial infarction. Journal of the American College of Cardiology. 60(16): 1581–98, which is incorporated herein by reference in its entirety). For the clinical trials described herein, non-fatal myocardial infarction was not considered part of the primary endpoint.

[99] As used herein, the term "type 1 myocardial infarction" refers to spontaneous myocardial infarction associated with an event involving atherosclerotic plaque rupture, ulceration, fissure, erosion, or dissection resulting in intraluminal thrombus in one or more coronary arteries, resulting in decreased myocardial blood flow or formation of a peripheral platelet embolus with subsequent myocyte necrosis (see Thygesen et al., 2012. JACC 60(16): 1581-98). In some embodiments, type 1 myocardial infarction is defined as the detection of a rise and/or fall in cardiac troponin (cTn) with at least one value greater than the 99th percentile upper reference limit (URL) and at least one of the following: symptoms of acute myocardial ischemia, new ischemic changes on an ECG, development of pathological Q waves, imaging evidence of new loss of viable myocardium or new regional wall motion abnormalities of a type consistent with an ischemic etiology, or identification of a coronary thrombus by angiography, including intracoronary imaging, or autopsy.

[100] As used herein, the term "type 2 myocardial infarction" refers to cases of myocardial injury with necrosis in which a pathological condition other than coronary artery disease contributes to an imbalance between myocardial oxygen supply and/or myocardial oxygen demand (see Thygesen et al., 2012. JACC 60(16): 1581-98). In some embodiments, type 2 myocardial infarction is defined as detection of a rise and/or fall in cTn with at least one value greater than the 99th percentile URL and evidence of an imbalance between myocardial oxygen supply and myocardial oxygen demand not related to coronary thrombosis, requiring at least one of the following: symptoms of acute myocardial ischemia, new ischemic changes on the ECG, development of pathological Q waves, or imaging evidence of new loss of viable myocardium, or new regional wall motion abnormalities of a pattern consistent with an ischemic etiology.

[101] The term "type 3 myocardial infarction" as used herein refers to patients with cardiac death with symptoms suggestive of myocardial ischemia, accompanied by presumed new ischemic electrocardiogram (ECG) changes or new left bundle branch block, but without available biomarker values (see Thygesen et al., 2012. JACC 60(16): 1581-98).

[102] As used herein, the term "type 4a myocardial infarction" refers to myocardial infarction associated with percutaneous coronary intervention. As used herein, the term "type 4b myocardial infarction" refers to myocardial infarction associated with stent thrombosis (see Thygesen et al., 2012. JACC 60(16): 1581-98).

[103] As used herein, the term "type 5 myocardial infarction" refers to myocardial infarction associated with coronary artery bypass grafting (CABG) (see Thygesen et al., 2012. JACC 60(16): 1581-98).

[104] As used herein, the term "coronary artery bypass grafting (CABG)" refers to a procedure in which autologous arteries or veins are used as grafts to create bypass coronary arteries that are partially or completely blocked by atherosclerotic plaque (see Alexander & Smith, 2016, Coronary-Artery Bypass Grafting. NEJM 374:1954-64, which is incorporated herein by reference in its entirety).

[105] As used in this document, the terms "unstable angina requiring hospitalization" and "hospitalization due to unstable angina" are used interchangeably to refer to: admission to the inpatient or intensive care unit with symptoms of myocardial ischemia of accelerating rate within the previous 48 hours and/or chest discomfort at rest lasting ≥20 min, plus both of the following: a) new or suspected new ischemic changes on the ECG defined by ST depression >0.5 mm in 2 contiguous leads; T-wave inversion >1 mm in 2 contiguous leads with a major R wave or R/S>1; ST elevation in >2 contiguous leads of >0.2 mV in V2 or V3 in men, >0.15 mV in V2 or V3 in women, or >0.1 mV in other leads or LBBB; and b) clear current evidence of coronary obstruction requiring a coronary revascularization procedure or at least one epicardial stenosis ≥70%. For the clinical trials disclosed herein, coronary revascularization procedures or stenoses performed solely for restenosis at the site of prior PCI were excluded.

[106] As used herein, the term "ischemic stroke" refers to the following: 1) an acute episode of focal cerebral, spinal, or retinal dysfunction caused by an infarction defined by at least one of the following: a) pathologic, imaging, or other objective evidence of acute focal cerebral, spinal, or retinal ischemic injury in a defined vascular territory, or b) symptoms of acute cerebral, spinal, or retinal ischemic injury lasting ≥24 hours or until death, excluding other causes of disease; 2) hemorrhagic infarction other than stroke caused by intracerebral or subarachnoid hemorrhage; or 3) types of stroke not otherwise subclassified.

[107] As used herein, the terms "diabetes" and "diabetic" refer to a group of metabolic diseases in which an individual has high blood sugar levels either because the body does not produce enough insulin or because the cells do not respond to the insulin that is produced. The most common types of diabetes are (1) type 1 diabetes, in which the body is unable to produce insulin; (2) type 2 diabetes, in which the body is unable to use insulin properly with increasing insulin deficiency over time; and (3) gestational diabetes, in which a woman develops diabetes as a result of pregnancy. In certain embodiments, diabetes is defined as a history of type 1 or type 2 diabetes, a hemoglobin A1c level ≥6.5%, two fasting serum or plasma glucose (FPG) values ≥126 mg/dL, or the use of a medication to treat diabetes. In certain embodiments, diabetes is diagnosed according to standards recommended by the American Diabetes Association. (See Standards of Medical Care in Diabetes - 2012. Diabetes Care. Jan 2012; 35 Suppl 1:S11-63, which is incorporated herein by reference in its entirety.) In a specific embodiment, diabetes is diagnosed as having an FPG level greater than or equal to 126 mg/dL; a two-hour 75-gram oral glucose tolerance test (OGTT) value greater than or equal to 200 mg/dL; a hemoglobin A1c level greater than or equal to 6.5%; or a random plasma glucose level greater than or equal to 200 mg/dL in a patient with classic symptoms of hyperglycemia or a hyperglycemic crisis. As used herein, the term "prediabetes" refers to an A1c ≥5.7% and <6.5% at baseline, or two FPG measurements >100 mg/dL but not more than one ≥126 mg/dL. As used herein, the term "normoglycemia" refers to the absence of all of the listed parameters of diabetes or prediabetes. As used herein, the term "new-onset diabetes" refers to any of the following: at least two A1c measurements ≥6.5%, at least two FPG measurements ≥126 mg/dL, an investigator-reported diabetes-related adverse event, or initiation of a medication for the treatment of diabetes.

[108] As used herein, the term "peripheral arterial disease" or "PAD" encompasses vascular diseases primarily caused by atherosclerotic and thromboembolic pathophysiological processes that alter the normal structure and function of the aorta, its splanchnic arterial branches, and the arteries of the lower extremities. PAD refers to stenotic, occlusive, and aneurysmal diseases of the aorta and its branch arteries, excluding the coronary arteries (see Hirsch et al , 2006, ACC/AHA 2005 practice guidelines for the management of patients with peripheral artery disease, Circulation. 113: 1475–1547, which is incorporated herein by reference in its entirety).

[109] As used herein, the term "cerebrovascular disease" or "CeVD" refers to a collection of all disorders in which an area of the brain is temporarily or permanently damaged by ischemia or hemorrhage and one or more cerebral blood vessels are involved in the pathological process. CeVD includes, but is not limited to, stroke, carotid artery stenosis, vertebral and intracranial stenosis, aneurysms, and vascular malformations (see Advisory Council for the National Institute of Neurological and Communicative Disorders and Stroke, 1975, A Classification and Outline of Cerebrovascular Diseases II, Stroke. 6: 564-616, which is incorporated herein by reference in its entirety).

[110] As used herein, the term "polyvascular disease,""PoVD," or "PVD" refers to pre-existing disease in multiple arterial beds or two or more vascular beds with atherosclerotic lesions (Bhatt et al ., 2009. Eur. Heart J. 30: 1195-1202, which is incorporated herein by reference in its entirety). In certain embodiments, patients with polyvascular disease have coronary artery disease with concurrent peripheral arterial disease (PAD), cerebrovascular disease (CeVD), or both.

[111] As used in this document, the terms "high-intensity statin therapy" and "high-dose atorvastatin/rosuvastatin" are used interchangeably to refer to the administration of 40-80 mg atorvastatin daily or 20-40 mg rosuvastatin daily.

[112] As used herein, the term "maximum-tolerated-dose statin therapy" or "maximum-tolerated-dose statin therapy" is used interchangeably to refer to a treatment regimen that includes a daily dose of a statin that is the highest dose of the statin that can be administered to a particular patient without causing adverse side effects to the patient. Maximum-tolerated-dose statin therapy includes, but is not limited to, high-intensity statin therapy.

[113] For the purposes of this document, a patient is considered "statin intolerant" or "statin intolerant" if the patient has a history of one or more adverse reactions that began or worsened during a daily statin regimen and resolved upon discontinuation of statin therapy. In certain embodiments, the adverse reactions are musculoskeletal in nature, such as musculoskeletal pain, aches, weakness, or cramping of skeletal muscles (e.g., myalgia, myopathy, rhabdomyolysis, etc.). Such adverse reactions are often worsened by exercise or physical exertion. Statin-associated adverse reactions also include hepatic, gastrointestinal, and psychiatric symptoms that correlate with statin administration. According to certain embodiments, a patient is considered "statin intolerant" or "statin intolerant" if, for example, any of the following apply to the patient: (1) the patient has a history of musculoskeletal symptoms associated with at least two different and separate daily statin treatment regimens; (2) the patient experiences one or more statin-related adverse reactions to the lowest approved daily dose of one or more statins; (3) the patient is unable to tolerate a cumulative weekly dose of a statin consisting of seven tablets of the lowest approved tablet size; (4) the patient is able to tolerate low-dose statin therapy but develops symptoms when the dose is increased (e.g., to achieve a target LDL-C level); or (5) the patient is contraindicated for statins.

[114] As used in this document, the term "inadequately controlled" in relation to hypercholesterolemia means that the patient's serum low-density lipoprotein cholesterol (LDL-C), total cholesterol, and/or triglyceride concentrations are not reduced to a recognized, medically acceptable level (taking into account the patient's relative risk of developing coronary heart disease) after at least 4 weeks of treatment with a stable daily dose of a statin. For example, a patient with hypercholesterolemia that is inadequately controlled with a statin includes a patient or patients with a serum LDL-C concentration greater than or equal to approximately 70 mg/dL, 80 mg/dL, 90 mg/dL, 100 mg/dL, 110 mg/dL, 120 mg/dL, 130 mg/dL, 140 mg/dL or more (depending on the patient's baseline risk of developing heart disease), after the patient has been on a regimen with constant daily doses of a statin for at least 4 weeks.

[115] As used herein, the term "inadequately controlled" with respect to atherogenic lipoprotein levels means that the patient's serum low-density lipoprotein cholesterol (LDL-C), non-HDL-cholesterol, and/or apolipoprotein B levels are not reduced to a recognized, medically acceptable level (taking into account the patient's relative risk of developing coronary heart disease) after at least 4 weeks of treatment with a stable daily dose of a statin. For example, a patient with elevated levels of atherogenic lipoproteins that are inadequately controlled with a statin includes a patient or patients with a serum LDL-C concentration greater than or equal to approximately 70 mg/dL, 80 mg/dL, 90 mg/dL, 100 mg/dL, 110 mg/dL, 120 mg/dL, 130 mg/dL, 140 mg/dL or more (depending on the patient's baseline risk of developing heart disease); a non-HDL cholesterol concentration greater than or equal to approximately 100 mg/dL; or an apolipoprotein B concentration greater than or equal to approximately 80 mg/dL, after the patient has been on a regimen with constant daily doses of a statin for at least 4 weeks.

Hypercholesterolemia and other atherogenic lipoprotein levels that are not adequately controlled with maximally tolerated statin therapy

[116] The present invention generally relates to methods and compositions for treating patients at high cardiovascular risk who have hypercholesterolemia that is inadequately controlled with statins, i.e., hypercholesterolemia that is inadequately controlled with a treatment regimen that includes a daily maximum tolerated dose of a statin.

[117] According to certain embodiments, a patient at high cardiovascular risk that is treatable by the methods of the present invention has hypercholesterolemia (e.g., a serum LDL-C concentration greater than or equal to 70 mg/dL) despite receiving a stable daily dose of a statin (with or without other lipid-modifying therapy) for at least 4 weeks, 5 weeks, 6 weeks, or more. In certain embodiments, the patient at high cardiovascular risk has hypercholesterolemia that is inadequately controlled with maximum-tolerated-dose statin therapy.

[118] The present invention also generally relates to methods and compositions for treating patients at high cardiovascular risk who have elevated levels of atherogenic lipoproteins that are not adequately controlled by statins, i.e., elevated levels of atherogenic lipoproteins that are not adequately controlled by a treatment regimen that includes a daily maximum tolerated dose of a statin.

[119] According to certain embodiments, a patient at high cardiovascular risk that is treatable by the methods of the present invention has elevated levels of atherogenic lipoproteins (e.g., a serum LDL-C concentration greater than or equal to 70 mg/dL) despite receiving a stable daily dose of a statin (with or without other lipid-modifying therapy) for at least 4 weeks, 5 weeks, 6 weeks, or more. In certain embodiments, the patient at high cardiovascular risk has elevated levels of atherogenic lipoproteins that are not adequately controlled with the maximum tolerated dose of statin therapy.

[120] The present invention also provides methods for treating patients at high cardiovascular risk with hypercholesterolemia and elevated levels of atherogenic lipoproteins that are inadequately controlled by the maximum tolerated dose of statin therapy. The maximum tolerated dose of statin therapy involves daily administration of statins such as cerivastatin, pitavastatin, fluvastatin, lovastatin, and pravastatin.

Patient selection

[121] The present invention provides methods and compositions useful for treating patients at high cardiovascular risk who have hypercholesterolemia and elevated atherogenic lipoprotein levels that are not adequately controlled by daily maximally tolerated dose statin therapy.

[122] In certain embodiments of the present invention, the antibody or antigen-binding fragment thereof is administered as a dietary supplement.

[123] In some embodiments, the antibody or antigen-binding fragment thereof is administered to reduce the number of cardiovascular events in patients with a recent acute coronary syndrome (ACS) (e.g., an ACS event within the last 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18 months relative to the ACS event). In some embodiments, the antibody or antigen-binding fragment thereof is administered to reduce cardiovascular risk in patients with a recent ACS. In certain embodiments, the ACS event is myocardial infarction. In certain embodiments, the ACS event is unstable angina.

[124] In some embodiments, the antibody or antigen-binding fragment thereof is used either in combination with a statin or as monotherapy, including in patients who are intolerant to statins.

[125] Patients at high cardiovascular risk who are amenable to treatment with the methods of the present invention include patients hospitalized for ACS.

[126] In certain embodiments, a patient at high cardiovascular risk may be selected based on observed inadequate control of atherogenic lipoproteins despite steady-state (at least 2 weeks) treatment with 40-80 mg atorvastatin daily, 20-40 mg rosuvastatin daily, or the maximum tolerated dose of one of these agents. In some embodiments, the patient has an LDL-C level greater than or equal to 70, 80, 90, 100, 110, 120, 130, or 140 mg/dL despite treatment with high-intensity or maximum tolerated dose statin therapy. In some embodiments, the patient has a non-HDL-C level greater than or equal to 100 mg/dL despite treatment with high-intensity or maximum tolerated dose statin therapy. In some embodiments, the patient has an apolipoprotein B level greater than or equal to 80 mg/dL despite treatment with high-intensity or maximum tolerated dose statin therapy. In some embodiments, the patient has an Lp(a) level greater than or equal to 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 30, 35, 40, 45, 50, 55, or 60 mg/dL as measured by an automated latex-spiked nephelometric assay despite treatment with high-intensity or maximum tolerated dose statin therapy. In one embodiment, the patient has an Lp(a) level greater than or equal to 21.2 mg/dL as measured by an automated latex-spiked nephelometric assay despite treatment with high-intensity or maximum tolerated dose statin therapy.

[127] According to certain embodiments, a patient at high cardiovascular risk may be selected based on the presence of one or more additional risk factors selected from the group consisting of age (e.g., over 40, 45, 50, 55, 60, 65, 70, 75, or 80 years of age), race, national origin, gender (male or female), exercise patterns (e.g., regularly exercises, does not exercise), other pre-existing medical conditions (e.g., diabetes, high blood pressure, etc.), and current medication status (e.g., current use of beta blockers, niacin, ezetimibe, fibrates, omega-3 fatty acids, bile acid sequestrants, etc.). In certain embodiments, a patient at high cardiovascular risk is selected based on pre-existing diabetes (e.g., type I diabetes or type II diabetes), either alone or in combination with the above selection criteria based on recent ACS and/or inadequate control of atherogenic lipoproteins.

[128] In certain embodiments, a patient at high cardiovascular risk has clinically evident atherosclerotic cardiovascular disease (ASCVD). Clinically evident ASCVD includes ACS, patients with a history of MI, stable or unstable angina, or coronary or other vascular revascularization, stroke, TIA, or PAD, including aortic aneurysm, all of atherosclerotic origin.

[129] According to the present invention, patients with high cardiovascular risk can be selected based on a combination of one or more of the above-mentioned selection criteria or therapeutic characteristics. A patient with high cardiovascular risk or very high cardiovascular risk can also be selected based on clinical guidelines, including, for example, the clinical practice guidelines of the American Heart Association (AHA) and the American College of Cardiology (ACC). See, for example, Stone et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation (2014) 129:S1–45. Grundy SM, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol, Journal of the American College of Cardiology (2018) (in press – accessed online November 10, 2018), each of which is incorporated herein by reference in its entirety.

Introduction of PCSK9 inhibitor as add-on therapy to maximally tolerated statin therapy

[130] Methods of treatment are provided, including methods of treating a patient at high cardiovascular risk with a PCSK9 inhibitor, such as an antibody or antigen-binding fragment thereof that specifically binds PCKS9, wherein the patient has hypercholesterolemia and/or elevated levels of other atherogenic lipoproteins that are not adequately controlled with a maximum tolerated dose or highly effective dose of statin therapy in the absence of a PCSK9 inhibitor. In some embodiments, the PCSK9 inhibitor can be administered as an adjunct to the patient's existing lipid modification therapy (LMT) (if applicable), such as as an adjunct to the patient's existing daily statin regimen.

[131] For example, methods include additional treatment regimens in which the PCSK9 inhibitor is administered as an add-on therapy to the same stable daily statin regimen (i.e., the same dosage amount of the statin) that the patient was receiving prior to receiving the PCSK9 inhibitor. In other embodiments, the PCSK9 inhibitor is administered as an add-on therapy to a statin regimen that includes a statin in an amount that is greater or less than the statin dose the patient was receiving prior to receiving the PCSK9 inhibitor. For example, after initiating a regimen that includes a PCSK9 inhibitor administered at a particular dosing frequency and in a particular amount, the daily dose of the statin administered or prescribed to the patient may (a) remain the same, (b) increase, or (c) decrease (e.g., the dose is increased or the dose is decreased) compared to the daily dose of the statin the patient was receiving prior to initiating the PCSK9 inhibitor regimen, depending on the therapeutic needs of the patient.

Therapeutic efficacy

[132] The methods of the present invention result in a decrease in serum levels of one or more lipid components selected from the group consisting of LDL-C, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, Lp(a), and remnant cholesterol. For example, according to certain embodiments of the present invention, administration of a pharmaceutical composition comprising a PCSK9 inhibitor to a patient at high cardiovascular risk with hypercholesterolemia or elevated levels of other atherogenic lipoproteins that are not adequately controlled by stable daily maximum tolerated dose statin therapy (e.g., administration of a PCSK9 inhibitor along with the maximum tolerated dose of statin therapy to a patient at high cardiovascular risk) will result in an average percentage decrease from baseline in serum low-density lipoprotein cholesterol (LDL-C) of at least about 25%, about 30%, about 40%, about 50%, about 60%, or more; an average percentage decrease from baseline in ApoB100 of at least about 25%, about 30%, about 40%, about 50%, about 60%, or more; a mean percentage decrease from baseline in non-HDL-C level of at least about 25%, about 30%, about 40%, about 50%, about 60%, or more; a mean percentage decrease from baseline in total cholesterol level of at least about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, or more; a mean percentage decrease from baseline in VLDL-C level of at least about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, or more; a mean percentage decrease from baseline in triglyceride levels of at least about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35% or more and/or a mean percentage decrease from baseline in Lp(a) levels of at least about 5%, about 10%, about 15%, about 20%, about 25% or more (e.g., as measured by an automated nephelometric assay with the addition of latex).

[133] In certain embodiments, the methods of the present invention also reduce cardiovascular risk. In certain embodiments, the methods of the present invention are used to reduce cardiovascular risk. Exemplary types of cardiovascular risk include, but are not limited to, the risk or incidence of death due to coronary artery disease (CHD), non-fatal myocardial infarction, ischemic stroke (fatal or non-fatal), or unstable angina requiring hospitalization; the risk of any CHD-related event; the risk of a major CHD-related event; the risk of any cardiovascular event; the risk of death (i.e., death from any cause), non-fatal myocardial infarction, or non-fatal ischemic stroke; the risk of death due to CHD; the risk of death due to a cardiovascular disorder; risk of death (i.e., death from any cause); risk of non-fatal myocardial infarction; risk of fatal or non-fatal ischemic stroke; risk of unstable angina requiring hospitalization; risk of needing a coronary revascularization procedure due to ischemia; risk of congestive heart failure requiring hospitalization; risk of a non-fatal cardiovascular event; and risk of non-fatal myocardial infarction, stroke, or unstable angina.

[134] In one aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of death in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of death for the patient. In certain embodiments, the patient's risk of death is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the patient's risk of death is reduced by about 15%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 29%. In certain embodiments, the survival time of the patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[135] In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk who has additional diseases according to the method disclosed herein reduces the risk of death in the patient. In some embodiments, the patient has peripheral arterial disease (PAD), and the risk of death in the patient is reduced by about 29% in patients with PAD. In certain embodiments, the absolute risk of death is reduced by about 2.8% in patients with PAD. In other embodiments, the patient at high cardiovascular risk has cerebrovascular disease (CeVD). In certain embodiments, the risk of death is reduced by about 42% in patients with CeVD. In certain embodiments, the absolute risk of death is reduced by about 4.9% in patients with CeVD. In certain embodiments, the risk of death is reduced by about 80% in patients with both PAD and CeVD who are administered a disclosed PCSK9 inhibitor. In certain embodiments, the absolute risk is reduced by about 16.2% in patients with both PAD and CeVD. In certain embodiments, the patient has previously undergone coronary artery bypass grafting (CABG). In certain embodiments, the patient with high cardiovascular risk has previously had an initial acute coronary syndrome (ACS) event prior to CABG. In certain embodiments, the risk of death is reduced by about 15% in patients with an initial ACS event prior to CABG. In certain embodiments, the absolute risk of death is reduced by about 0.5% in patients with an initial ACS event prior to CABG. In certain embodiments, the patient with high cardiovascular risk has previously had an ACS event after CABG. In certain embodiments, the risk of death is reduced by about 33% in patients with an ACS event after CABG. In certain embodiments, the absolute risk of death is reduced by approximately 3.6% in patients with an ACS event following CABG.

[136] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of major adverse cardiovascular events (MACE) in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of MACE in the patient. In certain embodiments, ischemic stroke includes fatal ischemic stroke and non-fatal ischemic stroke. In certain embodiments, the risk of developing MACE is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk of MACE is reduced by about 15%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk of MACE is reduced by about 24%. In another embodiment, the patient is not currently receiving statin therapy, and the risk of MACE is reduced by about 35%. In another embodiment, the patient has diabetes and the risk of MACE is reduced by about 16% and/or the absolute risk is reduced by about 2.3%. In one embodiment, the patient has an Lp(a) level greater than or equal to 21.2 mg/dL as measured by an automated nephelometric assay with latex addition despite treatment with high-intensity and maximum tolerated dose statin therapy. In certain embodiments, the time to death due to CHD, first non-fatal myocardial infarction, unstable angina requiring hospitalization, or ischemic stroke in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, approximately 41%, approximately 42%, approximately 43%, approximately 44%, approximately 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[137] In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk who has additional diseases according to the method disclosed herein reduces the risk of MACE in the patient. In some embodiments, the patient has peripheral arterial disease (PAD), and the risk of MACE is reduced by about 17% in patients with PAD. In certain embodiments, the absolute risk of MACE is reduced by about 3.4% in patients with PAD. In some embodiments, the patient has cerebrovascular disease (CeVD), and the risk of MACE is reduced by about 19% in patients with CeVD. In certain embodiments, the absolute risk of MACE is reduced by about 4.5% in patients with CeVD. In certain embodiments, the risk of MACE is reduced by about 46% in patients with both PAD and CeVD. In certain embodiments, the absolute risk of MACE is reduced by about 13% in patients with both PAD and CeVD. In some embodiments, the patient has previously undergone coronary artery bypass grafting (CABG). In certain embodiments, the patient at high cardiovascular risk has previously had an initial acute coronary syndrome (ACS) event prior to the CABG. In certain embodiments, the risk of MACE is reduced by about 15% in patients with an initial ACS event prior to the CABG. In certain embodiments, the absolute risk of MACE is reduced by about 0.9% in patients with an initial ACS event prior to the CABG. In certain embodiments, the patient at high cardiovascular risk has previously had an ACS event after the CABG. In certain embodiments, the risk of MACE is reduced by about 23% in patients with an ACS event after the CABG. In certain embodiments, the absolute risk of MACE is reduced by about 6.4% in patients with an ACS event after the CABG.

[138] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of ischemic stroke (fatal or non-fatal) in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of ischemic stroke (fatal or non-fatal) in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk is reduced by about 27%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk is reduced by about 40%. In certain embodiments, the time to the first ischemic stroke event in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In certain embodiments, the ischemic stroke is fatal. In certain embodiments, the ischemic stroke is non-fatal.

[139] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of developing unstable angina requiring hospitalization in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of developing unstable angina requiring hospitalization in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk is reduced by about 39%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk is reduced by about 52%. In certain embodiments, the time to the first event of unstable angina requiring hospitalization in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[140] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of death due to CHD in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of death due to CHD in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with the maximum tolerated dose of statin therapy, and the risk is reduced by about 28%. In certain embodiments, the time to death due to CHD in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[141] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of cardiovascular death in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of cardiovascular death in the patient. As used herein, the term "cardiovascular death," "CV death," and "cardiovascular death" are used interchangeably. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 31%. In certain embodiments, the time to cardiovascular death in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[142] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of a CHD-related event in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of a CHD-related event in the patient. In certain embodiments, a CHD-related event is defined as a CHD-related death, a non-fatal myocardial infarction, unstable angina requiring hospitalization, or a need for a coronary revascularization procedure due to ischemia. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 12%. In certain embodiments, the time to first occurrence of a CHD-related event in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[143] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of a significant CHD-related event in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of a significant CHD-related event in the patient. In certain embodiments, a significant CHD-related event is defined as a CHD-related death and a non-fatal myocardial infarction. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 12%. In certain embodiments, the time to first occurrence of a significant CHD-related event in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[144] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of a cardiovascular event in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on a need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk in accordance with the method disclosed herein reduces the risk of a cardiovascular event in the patient. In certain embodiments, a cardiovascular event is defined as a non-fatal CHD event, a cardiovascular death, and a non-fatal ischemic stroke. In certain embodiments, a cardiovascular event is defined as a non-fatal myocardial infarction, unstable angina requiring hospitalization, a need for a coronary revascularization procedure due to ischemia, a cardiovascular death, and a non-fatal ischemic stroke. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 13%. In certain embodiments, the time to first occurrence of a cardiovascular event in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[145] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of death, the risk of non-fatal myocardial infarction, or non-fatal ischemic stroke in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of death, the risk of non-fatal myocardial infarction, or non-fatal ischemic stroke in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 14%. In certain embodiments, the time to death from any cause, to the first occurrence of a non-fatal myocardial infarction or non-fatal ischemic stroke in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, approximately 43%, approximately 44%, approximately 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[146] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of non-fatal myocardial infarction in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of non-fatal myocardial infarction in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 14%. In another embodiment, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 21%. In certain embodiments, the patient has an Lp(a) level greater than or equal to 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 30, 35, 40, 45, 50, 55, or 60 mg/dL as measured by an automated latex-added nephelometric assay despite treatment with high-intensity or maximum tolerated dose statin therapy. In one embodiment, the patient has an Lp(a) level greater than or equal to 21.2 mg/dL as measured by an automated latex-added nephelometric assay despite treatment with high-intensity or maximum tolerated dose statin therapy. In certain embodiments, the time to the first non-fatal myocardial infarction in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[147] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the incidence of the need for a coronary revascularization procedure due to ischemia in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the incidence of the need for a coronary revascularization procedure due to ischemia in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In one embodiment, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy, and the risk is reduced by about 12%. In certain embodiments, the time to the first need for a coronary revascularization procedure due to ischemia in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, approximately 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[148] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of developing congestive heart failure requiring hospitalization in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of developing congestive heart failure requiring hospitalization in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%. In certain embodiments, the time to the first event of congestive heart failure requiring hospitalization in a patient is increased by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[149] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of a non-fatal cardiovascular event in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of a non-fatal cardiovascular event in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%. In certain embodiments, the overall incidence of non-fatal cardiovascular events in a patient is reduced by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[150] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of non-fatal myocardial infarction, stroke, or unstable angina in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of non-fatal myocardial infarction, stroke, or unstable angina in the patient. In certain embodiments, the risk is reduced by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%. In certain embodiments, the overall incidence of non-fatal myocardial infarction, stroke, or unstable angina in a patient is reduced, such as by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, approximately 44%, approximately 45%, approximately 46%, approximately 47%, approximately 48%, approximately 49%, approximately 50%, approximately 51%, approximately 52%, approximately 53%, approximately 54%, approximately 55%, approximately 56%, approximately 57%, approximately 58%, approximately 59%, approximately 60%, approximately 65%, approximately 70%, approximately 75%, or approximately 80%.

[151] In another aspect, the present invention provides a PCSK9 inhibitor for use in reducing the risk of type 1 or type 2 myocardial infarction in a patient at high cardiovascular risk. In certain embodiments, the patient is selected based on the need for such therapy. In certain embodiments, administering a PCSK9 inhibitor to a patient at high cardiovascular risk according to the method disclosed herein reduces the risk of type 1 or type 2 myocardial infarction in the patient. In certain embodiments, the risk of having a type 1 myocardial infarction is reduced by, e.g., about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In certain embodiments, the risk of type 1 myocardial infarction is reduced by about 13%. In certain embodiments, the risk of having a type 2 myocardial infarction is reduced, such as by about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 65%, about 70%, about 75%, or about 80%. In certain embodiments, the risk of type 2 myocardial infarction is reduced by about 23%. In certain embodiments, the patient has an LDL-C level greater than or equal to 70 mg/dL despite treatment with maximum tolerated dose statin therapy. In certain embodiments, the patient has an LDL-C level greater than or equal to 100 mg/dL despite treatment with maximum tolerated dose statin therapy.

PCSK9 inhibitors

[152] The methods include administering to a patient a therapeutic composition comprising a PCSK9 inhibitor. As used herein, "PCSK9 inhibitor" means any agent that binds or interacts with human PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo . Non-limiting examples of categories of PCSK9 inhibitors include small molecule PCSK9 antagonists, nucleic acid-based inhibitors of PCSK9 expression or activity (e.g., siRNA or antisense), peptide-based molecules that specifically interact with PCSK9 (e.g., peptide antibodies), receptor molecules that specifically interact with PCSK9, proteins comprising the ligand-binding portion of the LDL receptor, PCSK9-binding scaffold molecules (e.g., ankyrin repeat engineered proteins, HEAT repeat proteins, ARM repeat proteins, tetratricopeptide repeat proteins, fibronectin-based scaffolds, and other scaffolds based on naturally occurring repeat proteins, etc. [see, e.g., Boersma and Pluckthun, 2011, Curr. Opin. Biotechnol. 22 :849-857, and references cited therein, each of which is incorporated herein by reference in its entirety]), and PCSK9 aptamers or portions thereof. According to some embodiments, PCSK9 inhibitors that may be used in the context of the methods of the present invention are PCSK9 antibodies or antigen-binding antibody fragments that specifically bind human PCSK9.

[153] The term "human proprotein convertase subtilisin/kexin type 9" or "human PCSK9" or "hPCSK9" as used herein refers to PCSK9 having the nucleic acid sequence set forth in SEQ ID NO:197 and the amino acid sequence set forth in SEQ ID NO:198, or a biologically active fragment thereof.

[154] The term "antibody" as used herein is intended to refer to immunoglobulin molecules comprising four polypeptide chains, two heavy (H) chains and two light (L) chains, linked together by disulfide bonds, as well as multimers thereof (e.g., IgM). Each heavy chain contains a heavy chain variable region (abbreviated herein as HCVR or V_H) and the constant region of the heavy chain. The constant region of the heavy chain contains three domains: C_H1, C_H2 and C_H3. Each light chain contains a light chain variable region (abbreviated herein as LCVR or V_L) and the light chain constant region. The light chain constant region contains one domain (C_L1). Regions V_Hand V_Lcan be further subdivided into regions of hypervariability, called complementarity determining regions (CDRs), interspersed with regions that are more conserved, called framework regions (FRs). Each V_Hand V_Lconsists of three CDRs and four FRs arranged from amino-terminus to carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In various embodiments, the FRs of the PCSK9 antibody (or antigen-binding portion thereof) may be identical to human germline immunoglobulin sequences or may be naturally or artificially altered. The amino acid consensus sequence may be determined based on a side-by-side analysis of two or more CDRs.

[155] The term "antibody" as used herein also includes antigen-binding fragments of entire antibody molecules. The terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, etc., as used herein include any naturally occurring, enzymatically produced, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds an antigen to form a complex. Antigen-binding fragments of an antibody can be prepared, for example, from whole antibody molecules by any suitable standard techniques such as proteolytic cleavage or recombinant genetic engineering techniques involving manipulation and expression of DNA encoding the variable and optionally constant domains of antibodies. Such DNA is known and/or readily available, for example, from commercial sources, DNA libraries (including, for example, phage-antibody libraries), or it can be synthesized. The DNA can be sequenced and manipulated chemically or using molecular biology techniques, for example, to arrange one or more variable and/or constant domains in a suitable configuration or to introduce codons, create cysteine residues, modify, add or delete amino acids, etc.

[156] Non-limiting examples of antigen-binding fragments include (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single-chain Fv molecules (scFv); (vi) dAb fragments, and (vii) minimal recognition units consisting of amino acid residues that mimic the hypervariable region of an antibody (e.g., isolated complementarity determining region (CDR) such as peptide CDR3) or peptide with limited conformational freedom FR3-CDR3-FR4. Other engineered molecules such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, triabodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.), small molecule modular protein (SMIP)-based immunopreparations and shark IgNAR variable domains are also included in the expression "antigen-binding moiety" used in this document.

[157] An antigen-binding fragment of an antibody will typically comprise at least one variable domain. The variable domain may be of any size or amino acid composition, and will typically comprise at least one CDR that is adjacent to or in frame with one or more framework sequences. In antigen-binding fragments having a V _H domain linked to a V _L domain, the V _H and V _L domains may be positioned relative to one another in any suitable arrangement. For example, the variable region may be dimeric and comprise V _H -V _H , V _H -V _L , or V _L -V _L dimers. Alternatively, the antigen-binding fragment of an antibody may comprise a monomeric V _H or V _L domain.

[158] In certain embodiments, an antigen-binding fragment of an antibody may comprise at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary configurations of variable and constant domains that may be found in an antigen-binding fragment of an antibody include (i) V _H -C _H 1; (ii) V _H -C _H 2; (iii) V _H -C _H 3; (iv) V _H -C _H 1-C _H 2; (v) V _H -C _H 1-C _H 2-C _H 3; (vi) V _H -C _H 2-C _H 3; (vii) V _H -C _L ; (viii) V _L -C _H 1; (ix) V _L -C _H 2; (x) V _L -C _H 3; (xi) V _L -C _H 1-C _H 2; (xii) V _{L -CH1} - _CH2 - _CH3 ; (xiii) V _{L -CH2} - _CH3 ; and (xiv) V _{L -CH} . In any configuration of the variable and constant domains, including any of the exemplary configurations listed above, the variable and constant domains may either be directly linked to each other or may be linked by a complete or partial hinge or linker region. The hinge region may be comprised of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, resulting in the formation of a flexible or semi-flexible linkage between adjacent variable and/or constant domains in a single polypeptide molecule. In addition, the antigen-binding fragment of an antibody may comprise a homodimer or heterodimer (or other multimer) of any of the variable and constant domain configurations set forth above in non-covalent association with each other and/or with one or more monomeric V _H or r V _L domains (e.g., via disulfide bond(s)).

[159] As with whole antibody molecules, antigen-binding fragments may be monospecific or multispecific (e.g., bispecific). A multispecific antigen-binding fragment of an antibody will typically comprise at least two different variable domains, where each variable domain is capable of specifically binding to a different antigen or to a different epitope of the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be adapted for use in the context of an antigen-binding fragment of an antibody according to the methods of the present invention using standard techniques available in the art.

[160] The constant region of an antibody is important in terms of the ability of the antibody to bind complement and mediate cell-dependent cytotoxicity. Thus, the antibody isotype can be selected based on whether the antibody is required to mediate cytotoxicity.

[161] The term "human antibody" as used herein is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies may include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesisin vitroor somatic mutation in vivo), such as in the CDRs, and in particular CDR3. However, the term "human antibody" as used herein is not intended to include antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, are grafted onto human framework sequences.

[162] The term "recombinant human antibody" as used herein is intended to include all human antibodies that are produced, expressed, created, or isolated by recombinant means, such as antibodies expressed by a recombinant expression vector transfected into a host cell (described in further detail below), antibodies isolated from a combinatorial library of recombinant human antibodies (described in further detail below), antibodies isolated from an animal (e.g., a mouse) that is transgenic for human immunoglobulin genes (see, e.g., Taylor et al. (1992) Nucl. Acids Res. 20:6287-6295), or antibodies produced, expressed, created, or isolated by any other means that involves linking human immunoglobulin gene sequences to other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies are subjected to in vitro mutagenesis (or in the case of an animal transgenic for human Ig sequences, in vivo somatic mutagenesis), and thus the amino acid sequences of the V _H and V _L regions of the recombinant antibodies are sequences that, although derived from and related to human germline V _H and V _L sequences, may not naturally occur in the human germline antibody repertoire in vivo .

[163] Human antibodies can occur in two forms, due to the heterogeneity of the hinge regions. In one form, the immunoglobulin molecule contains a stable four-chain structure of approximately 150-160 kDa, in which the dimers are held together by a disulfide bond that links the heavy chains. In the second form, the dimers are not linked by disulfide bonds that link the chains, and a molecule of approximately 75-80 kDa is formed, consisting of covalently linked light and heavy chains (a half-antibody). These forms are extremely difficult to separate, even after affinity purification.

[164] The frequency of occurrence of the second form in different intact IgG isotypes is due, without limitation, to structural differences associated with the isotype of the antibody hinge region. A single amino acid substitution in the hinge region of human IgG4 can significantly reduce the occurrence of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels typically observed with the human IgG1 hinge. The methods of the present invention encompass antibodies with one or more mutations in the hinge, C _H 2, or C _H 3 region, which may be advantageous, for example, in production, to increase the yield of the preferred form of the antibody.

[165] The term "isolated antibody" as used herein means an antibody that has been identified and separated and/or recovered from at least one component of its natural environment. For example, an antibody that has been separated or recovered from at least one component of the organism or tissue or cell in which the antibody is originally present or naturally produced is an "isolated antibody" for purposes of the methods of the present invention. An isolated antibody also includes an antibody in situ in a recombinant cell. Isolated antibodies are antibodies that have undergone at least one purification or isolation step. In certain embodiments, an isolated antibody may be substantially free of other cellular material and/or other chemical compounds.

[166] The term "specifically binds," etc., means that the antibody or its antigen-binding fragment forms a complex with the antigen that is relatively stable under physiological conditions. Methods for determining the presence of specific binding of an antibody to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that "specifically binds" PCSK9, as used in the context of the methods of the present invention, includes antibodies that bind PCSK9 or a portion thereof with a K _D of less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM, less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM, less than about 40 nM, less than about 30 nM, less than about 20 nM, less than about 10 nM, less than about 5 nM, less than about 4 nM, less than about 3 nM, less than about 2 nM, less than about 1 nM, or less than about 0.5 nM, as measured in a surface plasmon resonance assay. However, an isolated antibody that specifically binds to human PCSK9 is cross-reactive with other antigens, such as PCSK9 molecules from other (non-human) species.

[167] Anti-PCSK9 antibodies useful in the methods of the present invention may comprise one or more amino acid substitutions, insertions, and/or deletions in the framework regions and/or CDR regions of the variable domains of the heavy and light chains, compared to the corresponding germline sequences from which the antibodies were derived. Such mutations can be readily identified by comparing the amino acid sequences disclosed herein with germline sequences available, for example, from public antibody sequence databases. The methods include using antibodies and antigen-binding fragments thereof that are derived from any of the amino acid sequences disclosed herein, wherein one or more amino acids in one or more framework and/or CDR regions are mutated to the corresponding residue(s) of the germline sequence from which the antibody was derived, or to the corresponding residue(s) of another human germline sequence, or to a conservative amino acid substitution of the corresponding germline residue(s) (such sequence changes are referred to herein collectively as "germline mutations"). One of skill in the art, given the heavy and light chain variable region sequences disclosed herein, can readily generate a variety of antibodies and antigen-binding fragments that contain one or more individual germline mutations, or combinations thereof. In certain embodiments, all of the framework and/or CDR residues in the V domains _H and/or V _L backmutated to residues occurring in the original germline sequence from which the antibody is derived. In other embodiments, only certain residues are backmutated to residues of the original germline sequence, such as only residues located in the first 8 amino acids of FR1 or the last 8 amino acids of FR4 are mutated, or only residues located in CDR1, CDR2, or CDR3 are mutated. In other embodiments, one or more framework and/or CDR residues are mutated to the corresponding residue(s) of a different germline sequence (i.e., germline sequence that is different from the germline sequence from which the antibody was originally derived). Additionally, the antibodies may comprise any combination of two or more germline mutations in the framework and/or CDR regions, such as where certain individual residues are mutated to the corresponding residue of a particular germline sequence, while certain other residues that are different from the original germline sequence are retained or are mutated to the corresponding residue of a different germline sequence. Once produced, antibodies and antigen-binding fragments that contain one or more germline mutations can be readily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced biological antagonist or agonist properties (if desired), reduced immunogenicity, etc. The use of antibodies and antigen-binding fragments produced by this general method is encompassed by the methods of the present invention.

[168] The methods include using anti-PCSK9 antibodies comprising variants of any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein with one or more conservative substitutions. For example, the methods of the present invention include using anti-PCSK9 antibodies with HCVR, LCVR, and/or CDR amino acid sequences with, e.g., 10 or less, 8 or less, 6 or less, 4 or less, etc., conservative amino acid substitutions relative to any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein.

[169] The term "surface plasmon resonance" as used herein refers to an optical phenomenon that enables real-time analysis of interactions by detecting changes in protein concentrations in a biosensor matrix, such as with the BIAcore ^™ system (Biacore Life Sciences Division of GE Healthcare, Piscataway, NJ, USA).

[170] The term "K _D " as used herein refers to the equilibrium dissociation constant of a particular antibody-antigen interaction.

[171] The term "epitope" refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable region of an antibody molecule, known as a paratope. A single antigen may have more than one epitope. Thus, different antibodies may bind to different sites on the antigen and may exert different biological effects. Epitopes may be conformational or linear. A conformational epitope is formed by spatially juxtaposed amino acids from different segments of a linear polypeptide chain. A linear epitope is formed by contiguous amino acid residues in a polypeptide chain. Under certain conditions, an epitope may include fragments of saccharides, phosphoryl groups, or sulfonyl groups of the antigen.

[172] In certain embodiments, the anti-PCSK9 antibody used in the methods is an antibody with pH-dependent binding characteristics. As used herein, the phrase "pH-dependent binding" means that the antibody or antigen-binding fragment thereof exhibits "reduced binding to PCSK9 at acidic pH compared to neutral pH" (both phrases may be used interchangeably in the context of the present invention). For example, antibodies "with pH-dependent binding characteristics" include antibodies and antigen-binding fragments thereof that bind PCSK9 with higher affinity at neutral pH than at acidic pH. In certain embodiments, antibodies and antigen-binding fragments bind PCSK9 at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 times or more with higher affinity at neutral pH than at acidic pH.

[173] According to this aspect, the anti-PCSK9 antibodies with pH-dependent binding characteristics may be characterized by one or more amino acid variations relative to the parent anti-PCSK9 antibody. For example, the anti-PCSK9 antibody with pH-dependent binding characteristics may comprise one or more histidine substitutions or histidine insertions, for example, in one or more CDRs of a parent PCSK9 antibody. Thus, certain embodiments provide methods comprising administering an anti-PCSK9 antibody that comprises CDR amino acid sequences (e.g., heavy and light chain CDRs) that are identical to the amino acid sequences of the CDRs of the parent anti-PCSK9 antibody, except for the substitution of one or more amino acids in one or more CDRs of the parent antibody with a histidine residue. Anti-PCSK9 antibodies with pH-dependent binding can be characterized by, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions, either within a single CDR of the parent antibody or distributed over multiple (e.g., 2, 3, 4, 5 or 6) CDRs of the parent anti-PCSK9 antibody. For example, the methods of the present invention include using pH-dependent binding PCSK9 antibodies comprising one or more histidine substitutions in HCDR1, one or more histidine substitutions in HCDR2, one or more histidine substitutions in HCDR3, one or more histidine substitutions in LCDR1, one or more histidine substitutions in LCDR2, and/or one or more histidine substitutions in LCDR3 of a parent PCSK9 antibody.

[174] As used herein, the term "acidic pH" means a pH of 6.0 or less (e.g., less than about 6.0, less than about 5.5, less than about 5.0, etc.). The term "acidic pH" includes pH values of about 6.0, 5.95, 5.90, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0, or less. As used herein, the term "neutral pH" means a pH of from about 7.0 to about 7.4. The term "neutral pH" includes pH values of approximately 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35, and 7.4.

[175] Non-limiting examples of PCSK9 antibodies that can be used in the context of the methods of the present invention include, for example, alirocumab, evolocumab (having the following amino acid sequence characteristics: a heavy chain complementarity determining region 1 (HCDR1) comprising SEQ ID NO: 86; HCDR2 comprising SEQ ID NO: 87; HCDR3 comprising SEQ ID NO: 88; a light chain complementarity determining region 1 (LCDR1) comprising SEQ ID NO: 90; LCDR2 comprising SEQ ID NO: 91; and LCDR3 comprising SEQ ID NO: 92), bococizumab, lodelcizumab, ralpancizumab, LY3015014, or antigen-binding portions of any of the foregoing.

Obtaining human antibodies

[176] Methods for producing human antibodies in transgenic mice are known in the art. Any such known methods can be used in the context of the methods of the present invention to generate human antibodies that specifically bind to human PCSK9.

[177] Using VELOCIMMUNE ^™ technology (see, for example, US 6,596,541, Regeneron Pharmaceuticals) or any other known method for producing monoclonal antibodies, high-affinity chimeric antibodies to PCSK9 with a human variable region and a murine constant region are initially isolated. VELOCIMMUNE® technology involves generating a transgenic mouse with a genome comprising human heavy and light chain variable regions operably linked to endogenous murine constant region loci such that the mouse produces an antibody comprising a human variable region and a murine constant region in response to antigen stimulation. DNA encoding the heavy and light chain variable regions of the antibody is isolated and operably linked to DNA encoding the human heavy and light chain constant regions. The DNA is then expressed in a cell capable of expressing a fully human antibody.

[178] Typically, a VELOCIMMUNE® mouse is exposed to an antigen of interest and lymphatic cells (such as B cells) are recovered from mice that express the antibodies. The lymphatic cells can be fused with a myeloma cell line to produce immortalized hybridoma cell lines, and such hybridoma cell lines are screened and selected to identify hybridoma cell lines that produce antibodies specific for the antigen of interest. DNA encoding the variable regions of the heavy chain and light chain can be isolated and linked to the constant regions of the desired heavy chain and light chain isotypes. Such an antibody protein can be produced in a cell, such as a CHO cell. Alternatively, DNA encoding antigen-specific chimeric antibodies or the variable domains of the light and heavy chains can be isolated directly from antigen-specific lymphocytes.

[179] Initially, high-affinity chimeric antibodies with a human variable region and a murine constant region are isolated. The antibodies are characterized and selected for preferred characteristics, including affinity, selectivity, epitope, etc., using standard procedures known to those skilled in the art. The murine constant regions are replaced with the desired human constant region to produce a fully human antibody, such as a wild-type IgG1 or IgG4 or a modified IgG1 or IgG4. While the constant region selected may vary depending on the specific application, the variable region retains the characteristics of high affinity antigen binding and target specificity. In general, antibodies that can be used have high affinity values, as described above, when measuring binding to the antigen during both solid-phase and liquid-phase immobilization.

[180] Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind PCSK9 that can be used in the context of the methods of the present invention include any antibody or antigen-binding fragment that comprises three heavy chain CDRs (HCDR1, HCDR2, and HCDR3) contained within a heavy chain variable region (HCVR) with an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 and 11 or a substantially similar sequence thereto that has at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind PCSK9 that may be used in the context of the methods of the present invention include any antibody or antigen-binding fragment that comprises three heavy chain CDRs (HCDR1, HCDR2, and HCDR3) contained within a heavy chain variable region (HCVR) with an amino acid sequence selected from the group consisting of SEQ ID NOs 37, 45, 53, 61, 69, 77, 85, 93, 101, 109, 117, 125, 133, 141, 149, 157, 165, 173, 181, and 189, or a substantially similar sequence thereto that exhibits at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. The antibody or antigen-binding fragment may comprise three light chain CDRs (LCVR1, LCVR2 and LCVR3) contained within a light chain variable region (LCVR) with an amino acid sequence selected from the group consisting of SEQ ID NO:6 and 15 or a substantially similar sequence that is characterized by at least 90%, at least 95%, at least 98% or at least 99% sequence identity. Alternatively, the antibody or antigen-binding fragment may comprise three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) with an amino acid sequence selected from the group consisting of SEQ ID NOs 41, 49, 57, 65, 73, 81, 89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185, and 193 or a substantially similar sequence that has at least 90%, at least 95%, at least 98%, or at least 99% sequence identity.

[181] The sequence identity between two amino acid sequences is determined over the entire length of a reference amino acid sequence, i.e., the amino acid sequence identified by SEQ ID NO, using the best sequence alignment and/or over the region of the best sequence alignment between the two amino acid sequences, where the best sequence alignment can be obtained by tools known in the art, such as Align using standard settings, preferably EMBOSS::needle, matrix: Blosum62, gap opening penalty 10.0, gap extension penalty 0.5.

[182] In certain embodiments, the antibody or antigen-binding protein comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of heavy and light chain variable region amino acid sequence pairs (HCVR/LCVR) selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. Alternatively, in certain embodiments, the antibody or antigen-binding protein comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of heavy and light chain variable region amino acid sequence pairs (HCVR/LCVR) selected from the group consisting of SEQ ID NOs: 37/41, 45/49, 53/57, 61/65, 69/73, 77/81, 85/89, 93/97, 101/105, 109/113, 117/121, 125/129, 133/137, 141/145, 149/153, 157/161, 165/169, 173/177, 181/185, and 189/193.

[183] In certain embodiments, an anti-PCSK9 antibody or antigen-binding protein that may be used in the methods of the present invention has HCDR1/HCDR2/HCDR3/LCDR1/LCDR2/LCDR3 amino acid sequences selected from SEQ ID NOs: 2/3/4/7/8/10 (mAb316P [also referred to as "REGN727" or "alirocumab"]), and 12/13/14/16/17/18 (mAb300N) (see U.S. Patent Application Publication No. 2010/0166768, which is incorporated herein by reference in its entirety), and 12/13/14/16/17/18, wherein SEQ ID NO:16 comprises a histidine for leucine substitution at amino acid residue 30 (L30H), and 86/87/88/90/91/92.

[184] In certain embodiments, the antibody or antigen-binding protein comprises HCVR/LCVR amino acid sequence pairs selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. In certain exemplary embodiments, the antibody or antigen-binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 1 and the LCVR amino acid sequence of SEQ ID NO: 6. In certain exemplary embodiments, the antibody or antigen-binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 11 and the LCVR amino acid sequence of SEQ ID NO: 15. In certain exemplary embodiments, the antibody or antigen-binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 11 and the LCVR amino acid sequence of SEQ ID NO: 15 comprising a histidine for leucine substitution at amino acid residue 30 (L30H).

Pharmaceutical compositions and routes of administration

[185] The methods of the present invention include administering to a patient a PCSK9 inhibitor, wherein the PCSK9 inhibitor is contained in a pharmaceutical composition. The pharmaceutical compositions are formulated with suitable carriers, excipients, and other agents that provide suitable transport, delivery, tolerability, etc. A variety of suitable formulations can be found in a reference book known to pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, lipid-containing vesicles (cationic or anionic) (such as LIPOFECTIN ^™ ), DNA conjugates, anhydrous absorption pastes, oil-in-water and water-in-oil emulsions, carbowax emulsions (polyethylene glycols of various molecular weights), semi-liquid gels, and semi-liquid mixtures containing carbowax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52:238-311, which is incorporated herein by reference in its entirety.

[186] Illustrative pharmaceutical formulations comprising antibodies to PCSK9 that may be used in the context of the methods of the present invention include any of the formulations set forth in U.S. Patent No. 8,795,669 (describing, among others, illustrative formulations comprising alirocumab), or in WO2013/166448, or in WO2012/168491, each of which is incorporated herein by reference in its entirety.

[187] Various delivery systems are known and can be used to administer the pharmaceutical composition, such as encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endocytosis (see, for example, Wu et al., 1987, J. Biol. Chem. 262:4429-4432). Routes of administration include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural and oral routes. The composition can be administered by any convenient route, such as by infusion or bolus injection, by absorption through epithelial or mucous membranes (e.g., oral mucosa, rectal and intestinal mucosa, etc.), and can be administered together with other biologically active agents.

[188] The pharmaceutical composition can be delivered subcutaneously or intravenously using a standard needle and syringe. In addition, with respect to subcutaneous delivery, a pen delivery device is widely used in delivering the pharmaceutical composition. Such a pen delivery device can be reusable or disposable. A reusable pen delivery device typically uses a replaceable cartridge that contains the pharmaceutical composition. After all of the pharmaceutical composition has been administered from the cartridge and after the cartridge has been emptied, the empty cartridge can be easily disposed of and replaced with a new cartridge that contains the pharmaceutical composition. The pen delivery device can then be reused. A disposable pen delivery device does not have a replaceable cartridge. Instead, the disposable pen delivery device is supplied pre-filled with the pharmaceutical composition contained in a reservoir of the device. After the reservoir has been emptied of the pharmaceutical composition, the device is completely disposed of.

[189] Numerous reusable pens and autoinjector delivery devices are used in the subcutaneous delivery of pharmaceutical compositions. Examples include, but are not limited to, AUTOPEN ^™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC ^™ pen (Disetronic Medical Systems, Burgdorf, Switzerland), HUMALOG MIX 75/25 ^™ pen, HUMALOG ^™ pen, HUMALIN 70/30 ^™ pen (Eli Lilly and Co., Indianapolis, IN, USA), NOVOPEN ^™ I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR ^™ (Novo Nordisk, Copenhagen, Denmark), BD ^™ pen (Becton Dickinson, Franklin Lakes, NJ, USA), OPTIPEN ^™ , OPTIPEN PRO ^™ , OPTIPEN STARLET ^™ and OPTICLIK ^™ (Sanofi-Aventis, Frankfurt, Germany) and the like. Examples of single-use pen delivery devices used in subcutaneous administration of a pharmaceutical composition according to the methods of the present invention include, but are not limited to, the SOLOSTAR ^™ pen (Sanofi-Aventis), FLEXPEN ^™ (Novo Nordisk) and KWIKPEN ^™ (Eli Lilly), the SURECLICK ^™ autoinjector (Amgen, Thousand Oaks, Calif., U.S.A.), PENLET ^™ (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP) and the HUMIRA ^™ pen (Abbott Labs, Abbott Park, Ill., U.S.A.) and the like.

[190] In certain situations, the pharmaceutical composition may be delivered in a controlled release system. In one embodiment, a pump may be used (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another embodiment, polymeric materials may be used; see Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, the controlled release system may be placed near the target of the composition, requiring only a fraction of the systemic dose (see, e.g., Goodson, 1984, in Medical Applications of Controlled Release, supra, vol. 2, pp. 115-138). Other controlled release systems are reviewed by Langer, 1990, Science 249:1527-1533.

[191] Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injections, drip infusions, etc. These injectable preparations can be produced by known methods. For example, the injectable preparations can be produced by, for example, dissolving, suspending or emulsifying the antibody or salt thereof described above in a sterile aqueous medium or oil medium commonly used for injection. The aqueous medium for injection is, for example, a physiological saline solution, an isotonic solution containing glucose and other auxiliary agents, etc., which can be used together with a suitable solubilizing agent such as an alcohol (e.g. ethanol), a polyhydric alcohol (e.g. propylene glycol, polyethylene glycol), a nonionic surfactant [e.g. polysorbate 80, HCO-50 (polyoxyethylene (50 mol) adduct of hydrogenated castor oil)], etc. The following are used as an oil medium, for example: sesame oil, soybean oil, etc., which can be used together with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injection composition thus obtained is preferably filled into a suitable ampoule.

[192] Advantageously, the pharmaceutical compositions for oral or parenteral use described above are prepared in unit dose dosage forms suitable for adjusting the dosage of the active ingredients. Such unit dose dosage forms include, for example, tablets, pills, capsules, injection forms (ampoules), suppositories, etc.

[193] In some embodiments, the antibody or antigen-binding fragment thereof is administered as a subcutaneous injection into the thigh, abdomen, or upper arm using a pre-filled disposable pen or a pre-filled disposable syringe. The injection site may be alternated with each injection. The antibody or antigen-binding fragment thereof should not be administered into areas of active skin disease or injury, such as sunburn, skin rash, inflammation, or skin infections.

Dose

[194] The amount of PCSK9 inhibitor (e.g., PCSK9 antibody) administered to a patient is typically a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount" means a dose of a PCSK9 inhibitor that results in a detectable reduction (e.g., at least about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75% or more from baseline) in one or more parameters selected from the group consisting of LDL-C, ApoB, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, ApoC3, TRL particles, Lp(a), and remnant cholesterol).

[195] In the case of an antibody to PCSK9, the therapeutically effective amount can be from about 0.05 mg to about 600 mg, such as about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 75 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, about 320 mg, about 330 mg, about 340 mg, about 350 mg, about 360 mg, about 370 mg, about 380 mg, about 390 mg, about 400 mg, about 410 mg, about 420 mg, about 430 mg, about 440 mg, about 450 mg, about 460 mg, about 470 mg, about 480 mg, about 490 mg, about 500 mg, about 510 mg, about 520 mg, about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570 mg, about 580 mg, about 590 mg, or about 600 mg of an antibody to PCSK9. According to certain exemplary embodiments, the therapeutically effective amount of the PCSK9 antibody is 30 mg, 40 mg, or 75 mg (e.g., for alirocumab for patients weighing less than 50 kg and/or aged 17 years or younger), 50 mg, 75 mg, or 150 mg (e.g., for alirocumab for patients weighing greater than or equal to 50 kg and/or aged 17 years or younger), or 140 mg or 420 mg (e.g., for evolocumab). Other dosage amounts of PCSK9 inhibitors will be apparent to those skilled in the art.

[196] The amount of PCSK9 antibody contained in individual doses can be expressed as milligrams of antibody per kilogram of patient body weight (i.e., mg/kg). For example, the PCSK9 antibody can be administered to a patient at a dose of from about 0.0001 to about 10 mg/kg of body weight.

Administration schemes

[197] In certain embodiments, multiple doses of a PCSK9 inhibitor (i.e., a pharmaceutical composition comprising a PCSK9 inhibitor) can be administered to the patient over a period of time (e.g., along with a treatment regimen of daily administration of a statin or other background LMT). The methods of this aspect involve sequentially administering multiple doses of a PCSK9 inhibitor to the patient. As used herein, the term "sequential administration" means that each dose of the PCSK9 inhibitor is administered to the patient at different time points, such as on different days separated by a predetermined interval (e.g., hours, days, weeks, or months). The methods of the present invention involve sequentially administering to the patient one initial dose of a PCSK9 inhibitor, then one or more secondary doses of a PCSK9 inhibitor, and then, optionally, one or more tertiary doses of a PCSK9 inhibitor.

[198] The terms "initial dose," "secondary doses," and "tertiary doses" refer to the temporal sequence of administration of individual doses of a pharmaceutical composition comprising a PCSK9 inhibitor. Thus, an "initial dose" is a dose that is administered at the beginning of a treatment regimen (also referred to as an "initial dose"); "secondary doses" are doses that are administered after the initial dose; and "tertiary doses" are doses that are administered after the secondary doses. The initial, secondary, and tertiary doses may all contain the same amount of PCSK9 inhibitor, but typically may differ from one another in the frequency of administration. However, in certain embodiments, the amounts of PCSK9 inhibitor contained in the initial, secondary, and/or tertiary doses differ from one another (e.g., adjusted upward or downward as needed) over the course of treatment. In certain embodiments, two or more (e.g., 2, 3, 4, or 5) doses are administered at the beginning of the treatment regimen as "loading doses," then subsequent doses are administered at less frequent intervals (e.g., "maintenance doses").

[199] According to exemplary embodiments, each secondary and/or tertiary dose is administered at 1-26 (e.g., 1, 1 , 2, 2 , 3, 3 , 4, 4 , 5, 5 , 6, 6 , 7, 7 , 8, 8 , 9, 9 , 10, 10 , 11, 11 , 12, 12 , 13, 13 , 14, 14 , 15, 15 , 16, 16 , 17, 17 , 18, 18 , 19, 19 , 20, 20 , 21, 21 , 22, 22 , 23, 23 , 24, 24 , 25, 25 , 26, 26 or more) weeks after the immediately preceding dose. The term "immediately preceding dose" as used herein means the dose of an antigen-binding molecule in a multi-dose sequence that is administered to a patient prior to the administration of the next subsequent dose in the sequence, with no intermediate doses.

[200] The methods of this aspect may include administering to the patient any number of secondary and/or tertiary doses of the PCSK9 inhibitor. For example, in certain embodiments, the patient is administered only one secondary dose. In other embodiments, the patient is administered two or more (e.g., 2, 3, 4, 5, 6, 7, 8 or more) secondary doses. Similarly, in certain embodiments, only one tertiary dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses.

[201] In embodiments comprising multiple secondary doses, each secondary dose may be administered at the same frequency as the other secondary doses. For example, each secondary dose may be administered to the patient 1-2, 4, 6, 8, or more weeks after the immediately preceding dose. Similarly, in embodiments comprising multiple tertiary doses, each tertiary dose may be administered at the same frequency as the other tertiary doses. For example, each tertiary dose may be administered to the patient 1-2, 4, 6, 8, or more weeks after the immediately preceding dose. Alternatively, the frequency with which secondary and/or tertiary doses are administered to the patient may vary over the course of the treatment regimen. The frequency of administration may be adjusted by the physician over the course of the treatment course based on the needs of the individual patient after clinical evaluation.

[202] The methods of the present invention include administration regimens that include an escalation option (also referred to herein as "dose escalation"). As used herein, the term "dose escalation option" means that after receiving a certain number of doses of the PCSK9 inhibitor, if the patient has not achieved a certain reduction in one or more certain therapeutic parameters, the dose of the PCSK9 inhibitor is subsequently increased. For example, if a regimen is used that involves administering 75 mg of PCSK9 antibody to a patient every two weeks, if the patient has not achieved a serum LDL-C concentration of less than 50 mg/dL after 4 weeks (i.e., 2 doses) or 8 weeks (i.e., after 5 doses administered at week 0, week 2, week 4, week 6, and week 8), the dose of PCSK9 antibody is increased to, for example, 150 mg, which is administered every two weeks thereafter (e.g., starting at week 10 or week 12 or later).

[203] In certain embodiments, an antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a dose of about 75 mg at a frequency of once every two weeks. In certain embodiments, the dose of about 75 mg is continued if the patient's LDL-C level, measured after one or more, two or more, three or more, four or more, or five or more doses, is <70 mg/dL. In certain embodiments, administration of the dose of about 75 mg is discontinued if the patient's LDL-C level, measured after one or more, two or more, three or more, four or more, or five or more doses, remains ≥70 mg/dL, and wherein the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is subsequently administered to the patient at a dose of about 150 mg at a frequency of once every two weeks.

[204] In certain embodiments, an antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to a patient at a dose of about 150 mg at a frequency of once every two weeks. In certain embodiments, if an antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to a patient at a dose of about 150 mg at a frequency of once every two weeks, then administration of the about 150 mg dose is discontinued if the patient's LDL-C level, measured after at least one dose or at least two, three, four, or five consecutive doses, is <10, 15, 20, or 25 mg/dL, and wherein the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is sequentially administered to the patient at a dose of about 75 mg at a frequency of once every two weeks. In certain embodiments, a dose of about 150 mg is administered to the patient as a constant dose. In certain embodiments, a dose of about 150 mg is administered to the patient after dose adjustments as described herein (e.g., from about 75 mg every two weeks or from about 300 mg every four weeks).

[205] In certain embodiments, an antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a dose of about 300 mg at a frequency of once every four weeks. In certain embodiments, the dose of about 300 mg is continued if the patient's LDL-C level, measured after one or more, two or more, three or more, four or more, or five or more doses, is <70 mg/dL. In certain embodiments, administration of the dose of about 300 mg is discontinued if the patient's LDL-C level, measured after one or more, two or more, three or more, four or more, or five or more doses, remains ≥70 mg/dL, and wherein the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is subsequently administered to the patient at a dose of about 150 mg at a frequency of once every two weeks.

[206] In certain embodiments, the PCSK9 antibody is administered to the patient at a dose of about 75 mg every two weeks, such as in at least two doses.

[207] In certain embodiments, the PCSK9 antibody is administered to the patient at a dose of about 150 mg every two weeks, such as in at least two doses.

[208] In some embodiments, the antibody is administered to the patient at a dose of about 300 mg every two weeks or every 4 weeks.

[209] In additional embodiments, if the patient's LDL-C level is <25 mg/dL on any of 2 consecutive measurements at a dose of 150 mg, then the dose is subsequently reduced to 75 mg.

Combination therapy agents

[210] As described elsewhere herein, the methods may comprise administering to the patient a PCSK9 inhibitor in combination with ("along with") a previously prescribed lipid-modifying therapy (LMT) to the patient. LMTs include, but are not limited to, statins, fibrates, niacin (e.g., nicotinic acid and its derivatives), bile acid sequestrants, ezetimibe, lomitapide, phytosterols, orlistat, etc. For example, a PCSK9 inhibitor may be administered to the patient in combination with a chronic daily statin regimen. Exemplary daily statin therapeutic regimens with which a PCSK9 inhibitor can be administered in combination in the context of the methods of the present invention include, for example, atorvastatin (10, 20, 40, or 80 mg per day), (atorvastatin/ezetimibe 10/10 or 40/10 mg per day), rosuvastatin (5, 10, or 20 mg per day), cerivastatin (0.4 or 0.8 mg per day), pitavastatin (1, 2, or 4 mg per day), fluvastatin (20, 40, or 80 mg per day), simvastatin (5, 10, 20, 40, or 80 mg per day), simvastatin/ezetimibe (10/10, 20/10, 40/10, or 80/10 mg per day), lovastatin (10, 20, 40, or 80 mg per day), pravastatin (10, 20, 40, or 80 mg per day), and combinations thereof. In certain embodiments, the statin-based therapy is a statin-based therapy at the maximum tolerated dose for the patient. Other LMT agents that can be administered in combination with a PCSK9 inhibitor in accordance with the context of the methods of the present invention include, for example, (1) an agent that inhibits cholesterol absorption and/or bile acid reabsorption (e.g., ezetimibe); (2) an agent that increases lipoprotein catabolism (such as niacin); and/or (3) activators of the LXR transcription factor, which plays a role in the elimination of cholesterol, such as 22-hydroxycholesterol.

[211] In the context of such methods, the additional therapeutically active component(s), such as any of the above agents or derivatives thereof, may be administered immediately prior to, simultaneously with, or immediately following administration of the PCSK9 inhibitor; (for purposes of the present invention, such administration regimens are considered to be administering the PCSK9 inhibitor "in combination with" the additional therapeutically active component). The methods of the present invention include pharmaceutical compositions and methods of use thereof in which the PCSK9 inhibitor is formulated together with one or more additional therapeutically active components as described elsewhere herein.

EXAMPLES

[212] The following examples are set forth to provide those of ordinary skill in the art with a complete disclosure and description of how to make and use the methods and prepare and use the compositions of the present invention, and are not intended to limit the scope of what the present inventors consider to be their invention. Efforts have been made to ensure accuracy with respect to the numbers (e.g., amounts, temperatures, etc.) used, however, some experimental errors and variations must be taken into account. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is atmospheric or near atmospheric.

Example 1. Obtaining human antibodies to human PCSK9

[213] Human anti-PCSK9 antibodies were prepared as described in U.S. Patent No. 8,062,640, which is incorporated herein by reference in its entirety. An exemplary PCSK9 inhibitor used in the following examples is a human anti-PCSK9 antibody designated "mAb316P," also known as "REGN727" or "alirocumab." mAb316P has the following amino acid sequence characteristics: a heavy chain comprising SEQ ID NO:5 and a light chain comprising SEQ ID NO:9; a heavy chain variable region (HCVR) comprising SEQ ID NO:1 and a light chain variable domain (LCVR) comprising SEQ ID NO:6; heavy chain complementarity determining region 1 (HCDR1) comprising SEQ ID NO:2, HCDR2 comprising SEQ ID NO:3, HCDR3 comprising SEQ ID NO:4, light chain complementarity determining region 1 (LCDR1) comprising SEQ ID NO:7, LCDR2 comprising SEQ ID NO:8, and LCDR3 comprising SEQ ID NO:10.

Example 2. Effect of alirocumab, a monoclonal antibody to PCSK9, on long-term cardiovascular outcomes after acute coronary syndrome. Protocol

INTRODUCTION

[214] Statins were approved for clinical use in 1987. However, since then, no non-statin lipid-modifying therapy has been associated with a reduction in all-cause mortality. PCSK9 inhibition provides an opportunity to determine whether significant additional reductions in LDL-C and other atherogenic lipoproteins can provide additional improvements in cardiovascular outcomes beyond those provided by statins, including a reduction in mortality.

[215] This study asked whether alirocumab, a fully human monoclonal antibody to PCSK9, could reduce cardiovascular risk, including death, when added to optimal statin therapy. Patients with recent acute coronary syndrome were selected as the study population because they face a higher risk of recurrent events than patients with stable cardiovascular disease and therefore may derive greater absolute benefit from an effective new treatment. The study population was further defined by minimum atherogenic lipoprotein cutoff levels to identify those whose residual cardiovascular risk was likely to be altered by subsequent reduction in these lipoprotein levels. This study also provided important information regarding the safety of PCSK9 inhibition.

PURPOSE OF THE STUDY

[216] The current study is an investigator-initiated, international, multicenter, randomized, double-blind, placebo-controlled trial of approximately 18,000 patients with a recent acute coronary syndrome (ACS). The primary objective was to evaluate whether alirocumab (75-150 mg subcutaneously every 2 weeks), initiated 1-12 months after an ACS event, reduces the incidence of a composite outcome of coronary artery disease-related death, major nonfatal coronary events (acute myocardial infarction or hospitalization for unstable angina), or ischemic stroke.

STUDY POPULATION

[217] The primary inclusion criteria were: 1) hospitalization for ACS characterized by symptoms of unstable myocardial ischemia occurring at rest or minimal exertion within 72 hours of unplanned inpatient treatment for suspected or proven obstructive coronary artery disease, and at least one of the following: a) elevated cardiac biomarkers or b) resting ECG changes consistent with ischemia or infarction along with additional evidence of obstructive coronary artery disease due to regional wall motion or perfusion abnormalities, ≥70% epicardial coronary stenosis confirmed by angiography, or the need for a coronary revascularization procedure; and 2) lipid levels inadequately controlled with 40-80 mg atorvastatin or 20-40 mg rosuvastatin daily or the maximum tolerated dose of one of these agents, characterized by at least one of the following: a) LDL-C ≥70 mg/dL, b) non-HDL-C ≥100 mg/dL, or c) apolipoprotein B ≥80 mg/dL.

[218] The main exclusion criteria were: 1) age <40 years; 2) a qualifying defined event of ACS in the period <4 or >52 weeks before randomization; 3) lack of continuous lipid-correcting therapy for at least 2 weeks before randomization; 4) uncontrolled hypertension (>180 mmHg systolic and/or >110 mmHg diastolic at the randomization visit); 5) persistent New York Heart Association class III or IV congestive heart failure despite treatment or LVEF <25% when measured; 6) history of hemorrhagic stroke; 7) fasting triglyceride level >400 mg/dL (4.52 mmol/L) at the qualifying laboratory visit; 8) recurrent events representing ACS within 2 weeks before the randomization visit; 9) coronary revascularization procedure performed within 2 weeks before the randomization visit or planned after randomization; 10) liver transaminase level >3 times the limit of normal; laboratory evidence of current hepatitis B or C virus infection; creatine kinase level >3 times the limit of normal; estimated glomerular filtration rate <30 mL/min/1.73 ^m2 ; positive urine or serum pregnancy test; 11) recent diagnosis of hypothyroidism with treatment started within 1 month of the screening laboratory visit; 12) cancer within the previous 5 years, except for as-cured as possible basal cell or squamous cell skin cancer or cervical carcinoma in situ; 13) previous treatment with any PCSK9 antibody; 14) use of fibrates other than fenofibrate or fenofibric acid during the run-in period; and 15) failure to provide informed consent or comply with study requirements; pregnancy, lactation, or potential for childbearing without the use of effective contraception.

[219] The trial included male and female patients at least 40 years of age who were hospitalized for ACS, characterized by unstable myocardial ischemia symptoms occurring at rest or minimal exertion, within 72 hours of an unplanned inpatient stay for suspected or proven obstructive coronary artery disease. In addition, a qualifying event representing an ACS is required to meet at least one of the following criteria: elevated cardiac biomarkers consistent with acute myocardial infarction or resting ECG changes consistent with ischemia or infarction along with additional evidence of obstructive coronary artery disease as a result of regional perfusion imaging abnormalities or wall motion abnormalities, ≥70% epicardial coronary stenosis confirmed by angiography, or the need for event-related coronary revascularization.

[220] At inclusion, patients were required to demonstrate inadequate control of atherogenic lipoprotein levels despite in-patient (at least 2 weeks) treatment with 40–80 mg atorvastatin daily, 20–40 mg rosuvastatin daily, or the maximal tolerated dose of one of these agents. Thus, background statin treatment in this trial was consistent with the American Heart Association/American Heart Society secondary prevention guidelines for lowering cholesterol levels (see Stone et al., Circulation (2014) 129:S1–45.). Inadequate control of atherogenic lipoprotein levels was defined by at least one of the following: LDL-C ≥70 mg/dL (1.81 mmol/L), non-high-density lipoprotein cholesterol (non-HDL-C) ≥100 mg/dL (2.59 mmol/L), or apolipoprotein B ≥80 mg/dL (0.8 mmol/L).

RESEARCH PROCEDURES

[221] Patients entered a 2-16 week run-in period. During this period, patients were instructed in self-administration technique using the study autoinjector device. Atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) was started and/or adjusted as needed to determine the maximum tolerated dose. Other non-excluded lipid-modifying therapies could also be started during the run-in period at the discretion of the investigator. After at least two weeks of inpatient lipid-modifying therapy, a fasting blood sample was collected to determine whether at least one of the lipoprotein eligibility criteria was met.

[222] Patients who met all inclusion criteria and none of the exclusion criteria at the end of the run-in period were randomly assigned to initial treatment with 75 mg alirocumab (1 mL injection volume) subcutaneously every 2 weeks or matching placebo. Follow-up visits occurred at 1, 2, 4, 8, 12, 16, 20, and 24 months after randomization, then at 6-month intervals until the end date of the entire study. At randomization and at multiple time points after randomization, patients were assessed for study endpoints and adverse events and had blood and urine samples collected for measurements including lipoprotein and apolipoprotein levels; complete blood count and biochemistry tests including liver, muscle, and renal function tests; and hemoglobin A1c; hsCRP, alirocumab antibody levels, and pregnancy diagnosis were performed in women of childbearing potential. LDL-C was calculated using the Friedewald formula unless values <15 mg/dL were confirmed by direct measurement (and TG values were >400 mg/dL (4.52 mmol/L)). Samples were also collected for measurement of PCSK9, lipoprotein subfractions, and other mediators of inflammation and cardiovascular risk. Electrocardiograms were recorded at randomization and study completion. During the randomized treatment period, lipoprotein levels were blinded to patients and investigators and treating physicians were instructed to refrain from routine clinical lipoprotein testing.

[223] This study sought to determine whether achieving LDL-C levels in the lower physiologic range improves clinical outcomes; the trial was not designed to examine the safety of sustained subphysiologic LDL-C levels. Accordingly, the protocol included procedures for masked dose adjustment and tracking as follows. Among patients assigned to receive alirocumab, if LDL-C measured 1 month after randomization (ie, after 2 doses of alirocumab 75 mg every 2 weeks) remained ≥50 mg/dL, the alirocumab dose was maskedly increased to 150 mg every 2 weeks. If LDL-C measured 1 month after randomization was <50 mg/dL, the alirocumab dose was continued at 75 mg. If LDL-C was <25 mg/dL on either of 2 consecutive measurements with the 150 mg dose of alirocumab, the dose was reduced to 75 mg. If LDL-C was <25 mg/dL but ≥15 mg/dL on 2 consecutive measurements with the 75 mg dose of alirocumab, the 75 mg dose was continued but the patient was monitored for potential related adverse events by an independent safety physician who reported individual and overall findings to the independent trial Data and Safety Monitoring Board (DSMB) and recommended concealed discontinuation of treatment if data indicated that the adverse event was causally related to treatment. If LDL-C was <15 mg/dL at 2 consecutive measurements during treatment with 75 mg alirocumab, active treatment was discontinued at the next study visit and masked to placebo injections for the remainder of the study. Overall, these masked dose adjustments were intended to maximize the number of patients in the alirocumab group with LDL-C levels <50 mg/dL while minimizing the number of patients with persistent LDL-C levels <15 mg/dL.

RESEARCH RESULTS

[224] The primary efficacy outcome was time to death due to coronary artery disease, the first major non-fatal coronary event (myocardial infarction or hospitalization for unstable angina) or ischemic stroke.

[225] Secondary endpoints included the need for coronary revascularization procedures due to ischemia, hospitalization for congestive heart failure, and all-cause death.

[226] The primary efficacy outcomes were time to death due to coronary artery disease, non-fatal acute myocardial infarction, fatal or non-fatal ischemic stroke, or unstable angina requiring hospitalization.

[227] The main secondary efficacy outcomes were (in hierarchical order): 1) time from randomization to the first major coronary heart disease event (coronary heart disease death or nonfatal myocardial infarction), unstable angina requiring hospitalization, or need for ischemic coronary revascularization; 2) time from randomization to the first major coronary heart disease event; 3) time from randomization to the first any cardiovascular event (any cardiovascular death, any nonfatal coronary heart disease event, or nonfatal ischemic stroke); 4) the time from randomization to the occurrence of death from any cause, first non-fatal myocardial infarction, or first non-fatal ischemic stroke; and 5) the time from randomization to death (death from any cause).

[228] Other secondary efficacy measures were: 1) time from randomization to death due to coronary artery disease; 2) time from randomization to the first nonfatal myocardial infarction; 3) time from randomization to the first ischemic stroke; 4) time from randomization to the first unstable angina requiring hospitalization; 5) time from randomization to the first need for coronary revascularization due to ischemia; and 6) time from randomization to the first congestive heart failure requiring hospitalization.

[229] Safety outcomes included all adverse events, heart rate and blood pressure, complete blood count and biochemistry tests.

[230] Other outcome measures included 1) the level of antibodies to alirocumab, which was assessed throughout the study, and 2) the percentage change in LDL cholesterol, apolipoprotein B, non-HDL cholesterol, and high-sensitivity C-reactive protein levels.

[231] Laboratory efficacy endpoints included change from baseline in calculated LDL-C, apolipoprotein B, non-HDL-C, and hsCRP levels. The safety of alirocumab treatment was assessed by adverse event reports and laboratory test results. Adverse events of particular interest in this trial included allergic events, local injection site reactions, liver enzyme elevations, and hemolytic anemia.

STATISTICAL FEATURES

[232] The Kaplan-Meier predicted incidence of the primary endpoint in the placebo group was 3.8% at 12 months, 6.4% at 24 months, 9.0% at 36 months, and 11.4% at 48 months. Other assumptions included a 1% loss to 24-month follow-up, a median baseline LDL-C of 90 mg/dL, and a 50% reduction in LDL-C from baseline with alirocumab treatment, resulting in a 15% risk reduction. Based on these assumptions and specifying a log-rank test with a 1-sided significance level of 2.49% to account for two interim analyses, the trial had 90% power with 1613 primary endpoint events, corresponding to a sample size of 18,000 patients randomized for 40 months. To ensure sufficient duration of alirocumab exposure for rigorous assessments of safety and efficacy, the trial was continued until 1613 primary endpoint events had occurred and all evaluable surviving patients had completed at least 2 years of follow-up. For the primary outcome, treatment effects were examined among subgroups classified by sex, age, race, geographic region, and time from ACS event to randomization. Secondary time-to-event outcomes were analyzed using the same methodology as for the primary endpoint. For the main secondary outcomes, overall type 1 error was controlled using a sequential inferential approach. Proportional hazards regression models were constructed to include changes or absolute values of LDL-C and other lipid parameters. Subpopulations defined by categorical and continuous variables were analyzed according to a prespecified statistical analysis plan. Safety outcomes were reported by treatment group without formal inferential testing.

[233] An independent DSMB consisting of 3 cardiologists, 1 lipidologist, and 1 statistician reviewed interim data at regular intervals to assess safety and efficacy. When approximately 50% of events occurred, the DSMB conducted an interim analysis of futility (optional cutoff corresponding to a hazard ratio >1.008). When approximately 75% of events occurred, the DSMB conducted a second interim analysis of futility (optional cutoff corresponding to a hazard ratio >0.951) and superior efficacy (hazard ratio <0.802 corresponding to p<0.0001 for the primary endpoint with consistency across subgroups and regions, positive trends for secondary endpoints including all-cause death and absence of excess non-CV deaths).

Example 3. Effect of alirocumab, a monoclonal antibody to PCSK9, on long-term cardiovascular outcomes after acute coronary syndrome. Results

[234] This study is the first and only to demonstrate that non-statin lipid-modifying therapy was associated with a reduced odds of death from any cause.

STUDY PATIENTS

[235] A total of 18,924 patients were included in this study at 1,315 centers in 57 countries. Acute coronary syndrome (ACS) status was defined as myocardial infarction in 83.2% of patients and unstable angina in 16.8% of patients. Most patients (92.1%) were selected with LDL cholesterol levels of 70 mg per deciliter or greater. An additional 4.2% met the non-HDL cholesterol level criterion only and 0.3% met the apolipoprotein B level criterion only. The median time from acute coronary syndrome qualifying status to randomization was 2.6 months (interquartile range, 1.7 to 4.3) for the overall population, 2.6 months (interquartile range, 1.7 to 4.4) for the alirocumab treatment group, and 2.6 months (interquartile range, 1.7 to 4.3) for the placebo treatment group.

[236] Of these patients, 9462 were in the alirocumab treatment group and 9462 were in the placebo treatment group. At randomization, the baseline characteristics of the two treatment groups were well balanced ( Table 1 ). Most patients were receiving guideline-recommended secondary prevention medications and had undergone coronary revascularization for a defined event. At randomization, 88.8% of patients were receiving atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily. At 1 and 3 years of follow-up, the corresponding percentages were 84.7% and 82.8% in the alirocumab group and 86.2% and 86.6% in the placebo group. There were no nominally significant differences in baseline characteristics between the two groups.

Table 1. Baseline characteristics of patients*

Characteristic Alirocumab
(N=9462) Placebo
(N=9462) Age - years 58.5 ± 9.3 58.6 ± 9.4 Female gender - number (%) 2390 (25.3) 2372 (25.1) Race - quantity (%) Caucasoids 7500 (79.3) 7524 (79.5) Mongoloids 1251 (13.2) 1247 (13.2) Negroid race or African Americans 235 (2.5) 238 (2.5) Other 475 (5.0) 451 (4.8) Region of enrollment in the study - number (%) Central and Eastern Europe 2719 (28.7) 2718 (28.7) Western Europe 2084 (22.0) 2091 (22.1) Canada/USA 1435 (15.2) 1436 (15.2) Latin America 1293 (13.7) 1295 (13.7) Asia 1150 (12.2) 1143 (12.1) The rest of the world 781 (8.3) 779 (8.2) Medical history prior to diagnosis of acute coronary syndrome - number (%) Hypertension 6205 (65.6) 6044 (63.9) Diabetes mellitus 2693 (28.5) 2751 (29.1) Current status of tobacco smoker 2282 (24.1) 2278 (24.1) Family history of early coronary heart disease 3408 (36.0) 3365 (35.6) Myocardial infarction 1790 (18.9) 1843 (19.5) Percutaneous coronary intervention 1626 (17.2) 1615 (17.1) Coronary artery bypass grafting 521 (5.5) 526 (5.6) Stroke 306 (3.2) 305 (3.2) Peripheral arterial disease 373 (3.9) 386 (4.1) Congestive heart failure 1365 (14.4) 1449 (15.3) Acute coronary syndrome event identified - number (%) ST-segment elevation myocardial infarction 3301 (35.0) 3235 (34.2) Non-ST-segment elevation myocardial infarction 4574 (48.4) 4601 (48.7) Unstable angina 1568 (16.6) 1614 (17.1) Percutaneous coronary intervention or coronary artery bypass grafting due to established acute coronary syndrome - number (%) 6798 (71.8) 6878 (72.7) Time from established acute coronary syndrome to randomization - weeks 11.3 (7.6-19.0) 11.4 (7.6-18.7) Body mass index 28.5 ± 4.9 28.5 ± 4.8 Medicinal products at randomization - quantity (%) Lipid-correcting agents Atorvastatin/rosuvastatin in high doses 8380 (88.6) 8431 (89.1) 80 mg atorvastatin or 40 mg rosuvastatin 2607 (27.6) 2572 (27.2) 40 mg atorvastatin or 20 mg rosuvastatin 5773 (61.0) 5859 (61.9) Atorvastatin/rosuvastatin low/medium doses 830 (8.8) 777 (8.2) Another statin 19 (0.2) 27 (0.3) No statins 227 (2.4) 233 (2.5) Ezetimibe 269 (2.8) 285 (3.0) Other Antiplatelet agents 9350 (98.8) 9354 (98.9) Aspirin 9050 (95.6) 9036 (95.5) Adenosine diphosphate receptor antagonist 8296 (87.7) 8245 (87.1) Vitamin K antagonist or other oral anticoagulant 378 (4.1) 403 (4.3) Beta blocker 7998 (84.5) 7992 (84.5) Angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker 7356 (77.7) 7360 (77.8) Statin use within 3 months immediately before established acute coronary syndrome - number (%) 3090 (32.7) 3074 (32.5) Lipid levels at randomization* LDL cholesterol level§ Average value 92 ± 31 92 ± 31 Median value 87 (73-104) 87 (73-104) Non-HDL cholesterol level Average value 122 ± 35 123 ± 36 Median value 115 (99-136) 115 (99-137) Apolipoprotein B level Average value 83 ± 21 83 ± 22 Median value 79 (69-93) 80 (69-93) HDL cholesterol level 43 (37-50) 42 (36-50) Apolipoprotein A1 level 131 (118-148) 132 (117-147) Triglyceride levels 129 (94-181) 129 (95-183) Lipoprotein(a) level 21 (7-59) 22 (7-60) Hemoglobin A _1c level - % 6.21 ± 1.23 6.21 ± 1.23 Creatinine clearance - ml/min per 1.73 ^m2 79.5±19.4 79.8±19.2 High-sensitivity C-reactive protein level - mg/L 1.61 (0.78-3.79) 1.67 (0.79-3.94)

* Lipid levels are reported in units of mg per deciliter. To convert cholesterol values to millimoles per liter, multiply by 0.02586. To convert triglyceride values to millimoles per liter, multiply by 0.01129. HDL stands for high-density lipoprotein and LDL for low-density lipoprotein. Data are presented as median (interquartile range) except where presented as mean (standard deviation) and are indicated.

Race was self-reported by the participant.

Body mass index is weight in kilograms divided by the square of height in meters.

§ LDL cholesterol was calculated using the Friedewald formula; calculated values <15 mg per deciliter were confirmed by ultracentrifugation/quantitation of beta-cholesterol.

TREATMENT METHOD UNDER INVESTIGATION

[237] At the first postrandomization assessment, 2615 (27.6%) alirocumab-treated patients had LDL-cholesterol levels of 50 mg per deciliter or greater and subsequently had their alirocumab dose secretly increased from 75 mg to 150 mg. Of these 2615 patients, 805 subsequently had their dose secretly decreased to 75 mg after two consecutive LDL-cholesterol levels below 25 mg per deciliter. Of all alirocumab-treated patients, 730 (7.7%) had two consecutive LDL-cholesterol levels below 15 mg per deciliter at the 75 mg dose, resulting in a secret crossover to placebo injections at a median of 8.3 months after randomization. In patients who were masked to placebo, the median baseline LDL cholesterol was 71 (interquartile range, 58 to 83) mg per deciliter. Of the total alirocumab treatment period, 78% and 22% received the 75 mg and 150 mg doses, respectively.

[238] Patients were followed for a median of 2.8 (interquartile range 2.3 to 3.4) years. Treatment discontinuations other than death occurred in 1343 (14.2%) patients in the alirocumab group and 1496 (15.8%) patients in the placebo group. In addition, 14 and 9 patients in the alirocumab and placebo groups, respectively, were lost to follow-up. Due to two consecutive LDL values below 15 mg/dL, 730 (7.7%) patients in the alirocumab group were masked to the placebo group. The intended treatment exposure (including concealed crossover from alirocumab to placebo) as a percentage of total follow-up time was 86% and 91%, respectively, in the alirocumab and placebo groups. Accurate definition was complete for 99.1% and 99.8% of potential patient-years of follow-up for the primary endpoint and death, respectively.

[239] Patients were treated for a median of 33 months.

TREATMENT EFFECT ON LIPOPROTEIN LEVELS

[240] At baseline, LDL cholesterol was 92 ± 31 mg per deciliter (2.39 ± 0.80 mmol per liter) (mean ± standard deviation). Based on intent-to-treat, in the alirocumab group, mean LDL cholesterol reached a nadir of 40 mg per deciliter (1.03 mmol per liter) at 4 months, increasing to 48 mg per deciliter (1.24 mmol per liter) at 12 months and 66 mg per deciliter (1.72 mmol per liter) at 48 months ( Figure 1A ). Excluding values after stopping alirocumab, mean LDL-cholesterol levels at 4, 12, and 48 months were 38, 42, and 53 mg per deciliter (0.97, 1.09, and 1.38 mmol per liter), respectively, representing mean placebo-adjusted reductions of 62.7%, 61.0%, and 54.7%. The absolute reductions in mean LDL-cholesterol levels in the alirocumab group compared with placebo were 55.7 mg/dL, 54.1 mg/dL, and 48.1 mg/dL, respectively, at 4, 12, and 48 months. In the placebo group, mean LDL-cholesterol levels (at baseline) at 4, 12, and 48 months, respectively, were 93, 96, and 103 mg per deciliter (2.42, 2.50, and 2.67 mmol per liter). Results for other lipid measurements are shown in Figures 1B–1G .

EFFICACY ASSESSMENT ENDPOINTS

[241] The primary endpoint occurred in 903 (9.5%) patients in the alirocumab group and 1052 (11.1%) patients in the placebo group ( Table 2 ); the 4-year Kaplan-Meier incidence estimates were 12.5% and 14.5%, respectively, in the alirocumab and placebo groups (hazard ratio, 0.85; 95% confidence interval, 0.78 to 0.93; P < 0.001) ( Figure 2 ). Thus, for this endpoint, alirocumab reduced the risk of MACE by 15%. Forty-nine patients were required to be treated for 4 years to prevent one event of the primary endpoint. MACE was a composite endpoint that included patients with (1) death due to coronary artery disease (CHD), (2) nonfatal MI, (3) fatal or nonfatal ischemic stroke, or (4) unstable angina requiring hospitalization. As shown in Table 2 , each component of the MACE endpoint was lower in patients treated with alirocumab, as demonstrated by a statistically significant difference compared with placebo in nonfatal MI, fatal or nonfatal ischemic stroke, and unstable angina requiring hospitalization.

Table 2. Primary endpoint and secondary endpoints (intent-to-treat population)*

Conclusion Alirocumab
(N=9462) Placebo
(N=9462) Risk ratio
(95% confidence interval) P-value Number of patients (%) Primary endpoint: death due to coronary artery disease, non-fatal myocardial infarction, fatal or non-fatal ischemic stroke, or hospitalization for unstable angina 903 (9.5) 1052 (11.1) 0.85 (0.78, 0.93) <0.001 Secondary endpoints (in order of hierarchical testing) Any event associated with coronary heart disease* 1199 (12.7) 1349 (14.3) 0.88 (0.81, 0.95) 0,001 Major coronary heart disease event 793 (8.4) 899 (9.5) 0.88 (0.80, 0.96) 0.006 Any cardiovascular event 1301 (13.7) 1474 (15.6) 0.87 (0.81, 0.94) <0.001 Death from any cause, non-fatal myocardial infarction, non-fatal ischemic stroke 973 (10.3) 1126 (11.9) 0.86 (0.79, 0.93) <0.001 Fatal outcome due to coronary heart disease 205 (2.2) 222 (2.3) 0.92 (0.76, 1.11) 0.38 Fatal outcome due to cardiovascular disorder 240 (2.5) 271 (2.9) 0.88 (0.74, 1.05) 0.15 Fatal outcome from any cause 334 (3.5) 392 (4.1) 0.85 (0.73, 0.98) 0.026 Other endpoints Non-fatal myocardial infarction 626 (6.6) 722 (7.6) 0.86 (0.77, 0.96) 0.006 Fatal or non-fatal ischemic stroke 111 (1.2) 152 (1.6) 0.73 (0.57, 0.93) 0.01 Unstable angina requiring hospitalization 37 (0.4) 60 (0.6) 0.61 (0.41, 0.92) 0.02 The need for coronary revascularization procedure due to ischemia 731 (7.7) 828 (8.8) 0.88 (0.79, 0.97) 0,009 Congestive heart failure requiring hospitalization 176 (1.9) 179 (1.9) 0.98 (0.79, 1.20) 0.84

* Death due to coronary artery disease, nonfatal myocardial infarction, unstable angina requiring hospitalization, or coronary revascularization procedure due to ischemia.

Fatal outcome due to coronary heart disease or non-fatal myocardial infarction.

Any non-fatal coronary heart disease event, death due to any cardiovascular event, or non-fatal ischemic stroke.

[242] Alirocumab reduced the risk of any coronary heart disease event, major coronary heart disease event, any cardiovascular event, and the composite of death, non-fatal myocardial infarction, and non-fatal stroke ( Table 2 ). Although the reductions in coronary heart disease-specific death or cardiovascular death were not statistically significant, all-cause death occurred less frequently in patients in the alirocumab group (334 vs 392 patients; estimated 4-year event rates: 5.3% vs 6.4%; hazard ratio: 0.85; 95% confidence interval: 0.73-0.98; P=0.026; Figure 3 ). Because all-cause death was equal to death due to coronary heart disease and cardiovascular disease in the hierarchy of key secondary endpoints, the P-value for all-cause death was considered nominally significant. To prevent one death, 87 patients were required to be treated for 4 years. Alirocumab also reduced the risk of non-fatal myocardial infarction, non-fatal ischemic stroke, hospitalization for unstable angina, and coronary revascularization due to ischemia, but not hospitalization for congestive heart failure.

[243] The effect of alirocumab on the primary endpoint was consistent across pre-specified subgroups ( Figure 4 ), including three pre-specified baseline LDL-cholesterol subgroups (less than 80 mg per deciliter, 80 to 100 mg per deciliter, and 100 mg per deciliter or greater; P-value for interaction, 0.09) (see Figures 5A, 5B, and 5C ). However, the cumulative incidence of the primary endpoint among placebo-treated patients was 9.5%, 9.5%, and 14.9%, respectively, in the three subgroups. Accordingly, in the subgroup with the highest baseline LDL-cholesterol and highest absolute risk, alirocumab resulted in the largest absolute risk reduction compared with placebo ( Figure 5C ).

[244] Of particular interest, MACE was significantly reduced by 24% in those patients with baseline LDL-C greater than 100 mg/dL (HR=0.76 (95% CI 0.65-0.87)), which was significantly different (p=0.05) from those with baseline LDL-C less than 100 mg/dL ( Figure 6 ). To detect the primary endpoint in this subgroup, 16 patients were required to be treated for 4 years. The corresponding LDL-C levels for each of the three prespecified subgroups, based on intention-to-treat (ITT), are shown in Figures 7A, 7B, and 7C .

[245] In a post hoc analysis across three predefined subgroups of baseline LDL-C levels, there was no significant heterogeneity in the effect of alirocumab on death (ARR interaction P value of 0.12) ( see Figures 8A, 8B, and 8C ). Similar to the primary endpoint, the absolute risk of death in the placebo group and the absolute difference in death between the alirocumab and placebo groups were greatest in the subgroup with baseline LDL-C of at least 100 mg per deciliter. The risk of death was significantly reduced by 29% in patients with baseline LDL-C levels of 100 mg/dL or greater (HR=0.71 (95% CI 0.56-0.90)). ( Table 3A ).

[246] No significant difference in risk reduction was observed in patients analyzed by age (<65 versus > 65), gender (male versus female), region (Eastern Europe, Western Europe, North America, South America, Asia, and Rest of World), or time from randomization.

[247] Tables 3A and 3B focus on patients with baseline LDL-C levels > 100 mg/dL. Table 3A shows the results of additional analyses in the subpopulation of patients with baseline LDL-C levels of 100 mg/dL or greater. In the subgroup of patients, alirocumab significantly reduced the risk of major cardiovascular events by 24%, and additional post hoc analyses also found that alirocumab reduced coronary heart disease-related death (CHD) by 28% and all-cause death by 29%. The risk reduction was also significant for the secondary endpoint of CHD-related event, major CHD-related event, death, nonfatal myocardial infarction or nonfatal ischemic stroke, and cardiovascular death. Similar results were observed in prespecified subgroup analyses according to baseline LDL-C levels of <80 mg/dL, 80 to <100 mg/dL, or ≥100 mg/dL (median baseline LDL-C: 118 mg/dL) ( Table 3B ).

Table 3A. Efficacy: Subgroup with baseline LDL-C ≥ 100 mg/dL (median baseline LDL-C: 118 mg/dL)

End point, n (%) Alirocumab
(N=2814) Placebo
(N=2815) Absolute risk reduction (%) HR (95% CI) MACE 324 (11.5) 420 (14.9) 3.4 0.76 (0.65-0.87) Fatal outcome due to CHD 69 (2.5) 96 (3.4) 1.0 0.72 (0.53-0.98) Fatal outcome due to CV 81 (2.9) 117 (4.2) 1.3 0.69 (0.52-0.92) Fatal outcome from any cause 114 (4.1) 161 (5.7) 1.7 0.71 (0.56-0.90)

Table 3B. Efficacy: Subgroups according to baseline LDL-C levels of <80 mg/dL, 80 to <100 mg/dL, or ≥100 mg/dL (median baseline LDL-C: 118 mg/dL)

Summary by Baseline LDL Cholesterol Category Alirocumab Placebo Risk ratio
(95% CI) P-value of association for relative risk reduction Absolute risk reduction
% (95% CI) P-value of association for absolute risk reduction Number of patients (%) Primary endpoint 0.09 <0.001 <80 mg/dL 296 (8.3) 341 (9.5) 0.86 (from 0.74 to 1.01) 1.3 (from -0.1 to 2.6) 80 to <100 mg/dL 283 (9.2) 291 (9.5) 0.96 (from 0.82 to 1.14) 0.3 (from -1.2 to 1.8) ≥100 mg/dL 324 (11.5) 420 (14.9) 0.76 (from 0.65 to 0.87) 3.4 (from 1.6 to 5.2) Any coronary heart disease event 0.09 <0.001 <80 mg/dL 421 (11.8) 454 (12.7) 0.93 (from 0.81 to 1.06) 0.9 (from -0.6 to 2.4) 80 to <100 mg/dL 374 (12.2) 387 (12.6) 0.95 (from 0.83 to 1.10) 0.4 (from -1.2 to 2.1) ≥100 mg/dL 404 (14.4) 508 (18.0) 0.78 (from 0.69 to 0.89) 3.7 (from 1.8 to 5.6) Major coronary heart disease event 0.09 0.002 <80 mg/dL 257 (7.2) 286 (8.0) 0.90 (from 0.76 to 1.06) 0.8 (from -0.4 to 2.0) 80 to <100 mg/dL 251 (8.2) 249 (8.1) 1.00 (from 0.84 to 1.19) -0.1 (from -1.4 to 1.3) ≥100 mg/dL 285 (10.1) 364 (12.9) 0.77 (from 0.66 to 0.90) 2.8 (from 1.1 to 4.5) Any cardiovascular event 0.11 <0.001 <80 mg/dL 454 (12.7) 493 (13.8) 0.92 (from 0.81 to 1.04) 1.1 (from -0.5 to 2.7) 80 to <100 mg/dL 406 (13.2) 429 (14.0) 0.93 (from 0.82 to 1.07) 0.8 (from -1.0 to 2.5) ≥100 mg/dL 441 (15.7) 552 (19.6) 0.78 (from 0.69 to 0.89) 3.9 (from 2.0 to 5.9) Fatal outcome, non-fatal myocardial infarction, or non-fatal ischemic stroke 0.11 <0.001 <80 mg/dL 318 (8.9) 364 (10.2) 0.87 (from 0.75 to 1.01) 1.3 (from -0.1 to 2.6) 80 to <100 mg/dL 306 (10.0) 316 (10.3) 0.96 (from 0.82 to 1.12) 0.3 (from -1.2 to 1.9) ≥100 mg/dL 349 (12.4) 446 (15.8) 0.77 (from 0.67 to 0.88) 3.4 (from 1.6 to 5.3) Fatal outcome due to coronary heart disease <80 mg/dL 74 (2.1) 73 (2.0) 1.00 (from 0.73 to 1.39) 0 (from -0.7 to 0.6) 80 to <100 mg/dL 62 (2.0) 53 (1.7) 1.17 (from 0.81 to 1.68) -0.3 (from -1.0 to 0.4) ≥100 mg/dL 69 (2.5) 96 (3.4) 0.72 (from 0.53 to 0.98) 1.0 (from 0.1 to 1.8) Fatal outcome due to cardiovascular disorder <80 mg/dL 85 (2.4) 88 (2.5) 0.96 (from 0.71 to 1.29) 0.1 (from -0.6 to 0.8) 80 to <100 mg/dL 74 (2.4) 66 (2.2) 1.12 (from 0.80 to 1.56) -0.3 (from -1.0 to 0.5) ≥100 mg/dL 81 (2.9) 117 (4.2) 0.69 (from 0.52 to 0.92) 1.3 (from 0.3 to 2.2) Fatal outcome from any cause <80 mg/dL 118 (3.3) 132 (3.7) 0.89 (from 0.69 to 1.14) 0.4 (from -0.5 to 1.2) 80 to <100 mg/dL 102 (3.3) 99 (3.2) 1.03 (from 0.78 to 1.36) -0.1 (from -1.0 to 0.9) ≥100 mg/dL 114 (4.1) 161 (5.7) 0.71 (from 0.56 to 0.90) 1.7 (from 0.5 to 2.8)

SAFETY

a. Adverse events

[248] Among patients treated with alirocumab compared with placebo, there were no excess adverse events or laboratory abnormalities ( Table 4 ), except for injection site reactions (3.8% vs. 2.1%, respectively). Neurocognitive events occurred in 1.5% of patients receiving alirocumab and 1.8% of patients receiving placebo, new-onset diabetes in 9.6% vs. 10.1%, respectively, and hemorrhagic stroke (adjudicated) in <0.1% vs. 0.2%. Neutralizing drug antibodies were detected in 0.5% of patients receiving alirocumab and <0.1% of patients receiving placebo.

b. Very low LDL-C

[249] The safety and efficacy of alirocumab were analyzed in patients who achieved very low LDL-C levels compared with matched patients in the placebo group.

[250] Of 9462 patients randomized to alirocumab, 730 (7.7%) achieved very low LDL-C (<15 mg/dL or 0.39 mmol/L) on two consecutive measurements and were crossed over to placebo a median of 8.3 months after randomization. They were matched (3:1) with 2152 patients originally assigned to placebo using propensity score matching. Propensity score matching was also used to compare new-onset diabetes in 525 patients without diabetes at baseline who had two consecutive very low LDL-C levels and were crossed over to placebo with 1675 matched patients in the placebo group. Neurocognitive events and hemorrhagic stroke in association with very low LDL-C were also assessed.

[251] Characteristics associated with very low LDL-C used for propensity score matching included male sex, diabetes, lower baseline LDL-C and lipoprotein(a) levels, and enrollment in Asia. Despite crossing over to placebo, patients with very low LDL-C who received alirocumab had a lower incidence of MACE than those in the placebo group (6.4% vs 8.5%, HR 0.71, 95% CI 0.52–0.98, P=0.039). Very low LDL-C in alirocumab recipients was not associated with a higher risk of new-onset diabetes compared with those in the placebo group (15.1% vs 13.0%, HR 1.10, 95% CI 0.85–1.43, P=0.46). There was also no association between very low LDL-C levels and neurocognitive events or hemorrhagic stroke.

Table 4. Adverse events and laboratory test results

Conclusion Alirocumab
(N=9451) Placebo
(N=9443) Adverse events - number of patients (%) Any 7165 (75.8) 7282 (77.1) Serious 2202 (23.3) 2350 (24.9) Leading to death 181 (1.9) 222 (2.4) Leading to discontinuation of treatment 343 (3.6) 324 (3.4) Local reaction at the injection site 360 (3.8) 203 (2.1) General allergic reaction 748 (7.9) 736 (7.8) Exacerbation of diabetes or diabetic complication (in patients with diabetes at baseline) - number/total number of patients (%) 506/2688 (18.8) 583/2747 (21.2) New-onset diabetes* (in patients without diabetes at baseline) - number/total number of patients (%) 648/6763 (9.6) 676/6696 (10.1) Neurocognitive disorder 143 (1.5) 167 (1.8) Liver disorder 500 (5.3) 534 (5.7) Types of cataracts 120 (1.3) 134 (1.4) Hemorrhagic stroke (confirmed by examination) 9 (<0.1) 16 (0.2) Abnormal laboratory values at any given time - number/total number of patients (%) Alanine transaminase level >3 times the upper limit of normal range 212/9369 (2.3) 228/9341 (2.4) Aspartate aminotransferase level > 3 times the upper limit of normal 160/9367 (1.7) 166/9338 (1.8) Total bilirubin >2 times the upper limit of normal 61/9368 (0.7) 78/9341 (0.8) Creatine kinase level >10 times the upper limit of normal 46/9369 (0.5) 48/9338 (0.5) Antibodies to drugs 67/9091 (0.7) 32/9097 (0.4) Neutralizing antibodies to drugs 43/9091 (0.5) 6/9097 (<0.1)

*Defined by one or more of the following criteria with confirmation of diagnosis by blinded external review by experts in diabetes: adverse event reporting, new prescription for diabetes medication, hemoglobin A1c level of at least 6.5% on two occasions (and baseline <6.5%), fasting blood glucose level of at least 126 mg per deciliter on two occasions (and baseline <126 mg per deciliter).

CONCLUSIONS

[252] Overall, the ODYSSEY OUTCOMES trial met its primary endpoint as effective (15% relative risk reduction in major CV events/MACE). Consistent improvements were achieved in all individual endpoints (significant for MI, ischemic stroke, unstable angina requiring hospitalization, and ischemic coronary revascularization, and with a positive trend in CHD- and CV-specific death). This was the first non-statin trial to demonstrate a nominally significant improvement in all-cause death. In patients with LDL > 100 mg/dL, all MACE endpoints were significantly improved, including CHD-specific death, CV-specific death, and all-cause death. During up to 5 years of double-blind follow-up, no imbalance in overall safety or safety events of interest (including new-onset diabetes, cataract, neurocognitive events, and hemorrhagic stroke) was observed between the alirocumab and placebo groups.

[253] Compared with placebo in patients with prior ACS, alirocumab 75 or 150 mg Q2W, targeting LDL-C levels of 25–50 mg/dL and allowing for a lower limit of 15 mg/dL: (1) reduced the odds of MACE, MI, and ischemic stroke; (2) was associated with a lower rate of all-cause death; and (3) was safe and well tolerated throughout the trial. Notably, there were no safety events associated with alirocumab in this placebo-controlled trial of nearly 19,000 patients, including more than 6,000 patients treated for ≥3 years.

[254] In patients with ACS and baseline LDL-C ≥ 100 mg/dL, alirocumab reduced the odds of MACE by 24% (ARR: 3.4%) and the odds of all-cause death by 29% (ARR: 1.7%) compared with placebo. Without wishing to be bound by any particular scientific theory, these are the patients who may benefit most from treatment.

Example 4. Association of baseline Lp(a) levels with the risk of MACE and death

[255] Elevated lipoprotein(a) (Lp(a)) levels are an independent risk factor for cardiovascular disease. Lp(a) is a proatherosclerotic and prothrombotic/antifibrinolytic lipid and is not reduced by statins or ezetimibe. Attempts to demonstrate the potential benefit of lowering Lp(a) levels have been unsuccessful over the past 30 years. This example demonstrates a specific benefit of alirocumab in lowering Lp(a) levels in the ODYSSEY OUTCOMES clinical trial.

a. Methods

[256] Lp(a) was measured at baseline, 4 months after initial alirocumab or placebo administration, 12 months after initial alirocumab or placebo administration, and at study end using automated latex nephelometry (Siemens Healthcare Diagnostics, Deerfield, IL, USA). In this analysis, apolipoprotein(a) size heterogeneity had only a modest effect on Lp(a) recovery. The interassay coefficient of variation ranged from 3.1% to 4.8% depending on Lp(a) concentration. Lp(a) and LDL-C distributions were assessed for the overall population and separately in the alirocumab and placebo groups at baseline and at 4 and 12 months (±4 weeks) after randomization. If a patient had multiple values in each of these visit intervals, the last value in that interval was analyzed.

[257] Calculated or directly measured LDL-C levels included cholesterol contained in Lp(a), which represented approximately 30% of the mass of Lp(a). To account for this and provide an estimate of the cholesterol contained in LDL particles, _adjusted LDL-C was calculated using the following equation: LDL-C - 0.3×[Lp(a)]. Similarly, to provide an estimate of the cholesterol present in all apo-B-containing particles other than Lp(a) particles, adjusted non-HDL cholesterol was calculated using the following equation: _adjusted non-HDL C = (total cholesterol - HDL-C) - 0.3×[Lp(a)].

[258] We assessed whether there was heterogeneity in the relative and absolute effects of alirocumab treatment on MACE according to baseline Lp(a) quartile. To assess the former, we constructed a Cox proportional hazards model stratified by geographic region, with terms for baseline Lp(a) quartile, treatment modality, and interaction. To assess the latter, the absolute risk reduction with alirocumab, quantified as the difference in observed incidence rates between the two treatment groups, was compared across baseline Lp(a) quartiles using the Gale-Simon test. The effect of treatment on absolute reduction in MACE risk was also assessed by categories of Lp(a) level (< median, ≥ median) and baseline LDL-C level (<100 mg/dL, ≥100 mg/dL [<2.59 mmol/L, ≥2.59 mmol/L]).

b. Initial characteristics

[259] For 18,924 patients, the mean (SD) baseline Lp(a) level was 39.0 (43.2) mg/dL. The distribution of baseline Lp(a) levels was highly variable, with a median of 21.2 mg/dL (interquartile range, 6.7 to 59.6 mg/dL) ( Figure 9 ). The trough level was 1 mg/dL, the 90th percentile level was 101 mg/dL, and the maximum level was 361 mg/dL. Baseline characteristics were compared according to Lp(a) quartile using chi-square tests (categorical measures) or rank tests (continuous measures). Demographic and clinical characteristics by baseline Lp(a) level are shown in Tables 5 and 6 , respectively. Participants in the highest quartiles of Lp(a) levels were more likely to be women, black, and from North America, but less likely to smoke or have diabetes. LDL-C concentrations and the percentage of patients treated with high-intensity statins were highest in the highest quartile of Lp(a) levels. Conversely, _adjusted LDL-C and non- _adjusted HDL-C levels decreased with increasing quartiles of Lp(a) levels. Participants with higher quartiles of Lp(a) levels were more likely to have a hidden dose increase of alirocumab and less likely to have a hidden switch from alirocumab to placebo.

Table 5. Demographic data by baseline Lp(a) quartile

Measured quantity Q1: <6.7 mg/dL
(n=4730) Q2: 6.7 to <21.2 mg/dL
(n=4731) Q3: 21.2 to <59.6 mg/dL
(n=4729) Q4: ≥59.6 mg/dL
(n=4734) P-value* Age, years 58 (52-65) 58 (52-65) 58 (52-65) 58 (52-65) 0.14 Female 20.2% 24.2% 24.5% 31.8% <0.0001 Race <0.0001 Caucasoids 84.3% 79.8% 75.3% 78.2% Negroid race or African Americans 0.6% 1.0% 3.1% 5.2% Mongoloids 10.3% 14.3% 16.7% 11.5% Other 4.9% 4.8% 4.9% 5.1% Region <0.0001 East Europe 35.9% 30.7% 25.3% 23.0% Western Europe 21.2% 20.9% 22.9% 23.3% North America 12.5% 13.1% 14.5% 20.6% South America 14.3% 13.5% 12.4% 14.5% Asia 9.7% 13.3% 15.3% 10.3% The rest of the world 6.6% 8.5% 9.6% 8.3% * P-value indicates whether there is a significant difference in the values of the 4 quartiles.

Table 6. Clinical characteristics by quartile of baseline Lp(a) level

Measured quantity Q1: <6.7 mg/dL (n=4730) Q2: 6.7 to <21.2 mg/dL (n=4731) Q3: 21.2 to <59.6 mg/dL (n=4729) Q4: ≥59.6 mg/dL (n=4734) P-value* Time from ACS to randomization, months 2.6 (1.7-4.2) 2.6 (1.7-4.4) 2.6 (1.7-4.3) 2.6 (1.7-4.4) 0.41 ACS type 0,0079 NSTEMI 47.8% 47.4% 48.4% 50.8% STEMI 35.2% 36.2% 34.3% 32.7% Unstable angina 17.1% 16.4% 17.4% 16.5% Revascularization due to established event 70.7% 72.4% 72.6% 73.4% 0.02 Medicines High intensity statin 88.3% 87.4% 88.7% 91.0% <0.0001 Aspirin 95.3% 95.5% 95.7% 95.8% 0.56 P2Y12 antagonist 86.3% 87.6% 87.6% 88.2% 0.04 ACE/ARB inhibitor 79.0% 78.2% 77.0% 76.9% 0.04 Beta blocker 85.2% 84.6% 83.6% 84.6% 0.18 Lp(a) level, mg/dl 2.0 (2.0-4.8) 12.2 (9.3-15.9) 37.6 (28.3-47.7) 92.2 (73.2-119.0) Total cholesterol, mg/dL 159 (141-183) 158 (141-180) 158 (140-181) 164 (146-186) <0.001 HDL-C level, mg/dL 42 (36-50) 42 (36-50) 42 (36-50) 43 (37-51) <0.001 LDL-C level, mg/dL 83 (69-101) 85 (72-102) 86 (73-104) 92 (78-109) <0.001 _Corrected LDL-C level, mg/dL 82 (69-100) 81 (68-98) 75 (61-92) 62 (48-79) <0.001 Non-HDL-C level, mg/dL 115 (99-138) 113 (98-135) 113 (98-135) 119 (103-139) <0.001 Triglyceride level, mg/dL 144 (103-205) 129 (95-183) 123 (90-171) 123 (91-169) <0.001 ApoB level, mg/dL 79 (68-93) 78 (68-92) 78 (68-92) 82 (71-95) <0.001 BMI (kg/ ^m2 ) 28.5 (25.7-31.6) 27.9 (25.2-30.9) 27.7 (24.9-30.8) 27.7 (25.0-31.0) <0.001 Diabetes 30.7% 29.0% 29.0% 26.5% 0,001 Having a smoking habit 26.0% 25.2% 23.7% 21.5% <0.001 Hypertension 66.2% 64.2% 63.2% 65.2% 0,0184 History of MI 18.7% 17.8% 18.8% 21.5% <0.0001 History of stroke 3.2% 3.1% 3.4% 3.3% 0.92 Family history of premature CHD 34.9% 34.0% 34.7% 39.6% <0.0001 Treatment outcome measures among patients treated with alirocumab (n=2327) (n=2438) (n=2356) (n=2341) % of treatment time with each dose <0.001 75 mg 81.4% 82.3% 79.3% 68.6% 150 mg 18.6% 17.7% 20.7% 31.4% % transition to placebo 12.2% 9.7% 7.0% 1.9% <0.001 * P-value indicates whether there is a significant difference in the values of the 4 quartiles.

c. Baseline Lp(a), cardiovascular events and death in the placebo group

[260] The incidence of MACE, fatal CHD, and nonfatal myocardial infarction (MI) was compared across four baseline Lp(a) categories stratified into quartiles using a Cox regression model on baseline Lp(a) levels. Adjustment was made for age, sex, race, geographic region, time since event, BMI, history of smoking, diabetes status, baseline LDL-C, and/or treatment assignment. The association between baseline Lp(a) quartile and event rates in the placebo group is shown in Figure 10 ; modeling results for this association are shown below in Table 7 .

Table 7. Quartile of baseline Lp(a) level and cardiovascular events and death in the placebo group

Unadjusted model Adjusted model End point Q2 vs Q1
HR (95% CI) Q3 vs Q1
HR (95% CI) Q4 vs Q1
HR (95% CI) Linear trend
p-value Q2 vs Q1
HR (95% CI) Q3 vs Q1
HR (95% CI) Q4 vs Q1
HR (95% CI) Linear trend
p-value MACE 1,12
(0.93, 1.34) 1.22
(1.03, 1.46) 1.46
(1.23, 1.73) <0.0001 1.13
(0.94, 1.36) 1.29
(1.08, 1.54) 1.68
(1.41, 2.00) <0.0001 Non-lethal MI 1.11
(0.89, 1.38) 1.25
(1.01, 1.55) 1.58
(1.29, 1.94) <0.0001 1,12
(0.90, 1.40) 1.31
(1.05, 1.62) 1.80
(1.46, 2.22) <0.0001 Ischemic stroke 0.93
(0.58, 1.47) 1.06
(0.68, 1.64) 1.03
(0.66, 1.61) 0.7506 0.94
(0,60,1,50) 1.14
(0.73, 1.77) 1.26
(0.80, 1.99) 0.2333 Fatal outcome due to CHD 1.13
0.77, 1.65) 1.04
(0.71, 1.52) 1.27
(0.88, 1.83) 0.2917 1.15
(0.79, 1.68) 1.10
(0.75, 1.62) 1.50
(1.03, 2.18) 0.0571 Fatal outcome due to CV 1.04
(0.73, 1.47) 1.20
(0.86, 1.68) 1.17
(0.83, 1.64) 0.2659 1.06
(0.74, 1.50) 1.27
(0.91, 1.78) 1.37
(0.97, 1.94) 0.0418 Fatal outcome from any cause 0.88
(0.67, 1.17) 1.02
(0.78, 1.33) 0.90
(0.68, 1.20) 0.7261 0.89
(0.67, 1.18) 1.06
(0.81, 1.39) 1.02
(0.77, 1.36) 0.6079

The quartile of baseline Lp(a) is the reference quartile. The adjusted model is adjusted for adjusted baseline LDL-cholesterol.

[261] As shown in Table 8 , significantly higher rates of MACE, fatal CHD, and nonfatal MI were observed with increasing baseline Lp(a) levels. In unadjusted Cox models, individuals with the highest, compared with the lowest, quartile of baseline Lp(a) levels had 46% to 58% greater odds of experiencing MACE or nonfatal MI. The association between baseline Lp(a) quartile and MACE, nonfatal MI, and cardiovascular death was strengthened after adjustment for baseline LDL-C _adjusted . Spline analysis of progressive baseline Lp(a) and hazard ratios for MACE ( Figure 11 ) showed a relatively linear association between baseline Lp(a) levels and MACE. The P values for the associations for MACE, non-fatal MI, and CHD-specific death with alirocumab treatment in the adjusted model were 0.44, 0.19, and 0.52, respectively. The P values for the associations for MACE, non-fatal MI, and CHD-specific death with baseline LDL-C in the adjusted model were 0.67, 0.25, and 0.92, respectively. No association was observed between quartile of baseline Lp(a) and ischemic stroke, CHD-specific death, or all-cause death.

Table 8. Cardiovascular events by quartile of baseline Lp(a) level

Cardiovascular event Q1: <6.7 mg/dL (n=4730) Q2: 6.7 to <21.2 mg/dL (n=4731) Q3: 21.2 to <59.6 mg/dL (n=4729) Q4: ≥59.6 mg/dL (n=4734) MACE Events, number/total number (%) 439/4730 (9.3) 458/4731 (9.7) 481/4729 (10.2) 577/4734 (12.2) HR (95% CI), adjusted Reference 1.06 (0.93-1.21) 1.12 (0.99-1.28) 1.37 (1.21-1.55) p-value for trend across quartiles, unadjusted p<0.0001 HR (95% CI), adjusted* 1.05 (0.92-1.20) 1.08 (0.95-1.23) 1.28 (1.13-1.46) p-value for trend across quartiles, adjusted p=0.0005 Non-lethal MI Events, number/total number (%) 305/4730 (6.5) 306/4731 (6.5) 326/4729 (6.9) 411/4734 (8.7) HR (95% CI), adjusted Reference 1.02 (0.87-1.19) 1.09 (0.94-1.28) 1.39 (1.20-1.62) p-value for trend across quartiles, unadjusted p<0.0001 HR (95% CI), adjusted* 1.00(0.85-1.17) 1.04 (0.89-1.22) 1.26 (1.08-1.46) p-value for trend across quartiles, adjusted p=0.0052 Fatal outcome due to CHD Events, number/total number (%) 90/4730 (1.9) 104/4731 (2.2) 109/4729 (2.3) 124/4734 (2.6) HR (95% CI), adjusted Reference 1.18 (0.89-1.56) 1.24 (0.94-1.65) 1.43 (1.09-1.88) p-value for trend across quartiles, unadjusted p=0.07 HR (95% CI), adjusted* 1.18 (0.89-1.57) 1.23 (0.93-1.64) 1.46 (1.10-1.93) p-value for trend across quartiles, adjusted p=0.07 Adjusted for age, sex, race, geographic region, time since event, BMI, history of smoking, diabetes status, baseline LDL-C, and/or treatment assignment.

d. Effects of alirocumab on MACE stratified by quartile of baseline Lp(a)

[262] The relative rates of MACE, non-fatal MI, CHD-related death, and all-cause death in the alirocumab group versus placebo were compared across four quartiles of baseline Lp(a) levels. Adjustments were made for age, sex, race, geographic region, time since event, BMI, history of smoking, diabetes status, and baseline LDL-C. The relative and absolute treatment effects on MACE, stratified by quartile of baseline Lp(a), are shown in Figure 12 . As shown in Table 9 , larger reductions in MACE and non-fatal MI were observed with alirocumab as baseline Lp(a) levels increased. No association was observed between baseline Lp(a) quartile and the effect of alirocumab on reducing the incidence of CHD-related death or all-cause death.

[263] Overall, the hazard ratio for MACE (alirocumab/placebo) was 0.85 (95% confidence interval [CI] 0.78–0.93, P<0.001), with an absolute risk reduction of 1.6%. There was no statistically significant interaction between treatment and baseline Lp(a) quartile on the relative risk of MACE. In contrast, the absolute risk reduction with alirocumab was several-fold greater in the upper quartiles (2.3% and 2.1%) than in the lower quartiles of baseline Lp(a) levels (0.4% and 1.4%, P-value for interaction 0.0011). The numbers of patients needed to be treated with alirocumab for a median period of 2.8 years to prevent one MACE were 250, 71, 43, and 47, respectively, in quartiles 1, 2, 3, and 4 of baseline Lp(a) levels.

[264] Patients who benefited from alirocumab treatment were found to have a baseline LDL-C level >100 mg/dL (>2.59 mmol/L), a baseline Lp(a) level >median (21.2 mg/dL), or both ( Figure 13 ).

Table 9. Cardiovascular events by quartile of baseline Lp(a) level

Cardiovascular event Q1: <6.7 mg/dL (n=4730) Q2: 6.7 to <21.2 mg/dL (n=4731) Q3: 21.2 to <59.6 mg/dL (n=4729) Q4: ≥59.6 mg/dL (n=4734) MACE Treatment HR (95% CI), unadjusted 0.95 (0.79-1.14) 0.85 (0.71-1.03) 0.79 (0.66-0.95) 0.83 (0.70-0.98) Treatment HR (95% CI), adjusted* 0.97 (0.80-1.17) 0.87 (0.72-1.04) 0.79 (0.66-0.96) 0.82 (0.70-0.97) Non-lethal MI Treatment HR (95% CI), unadjusted 1.04 (0.83-1.30) 0.88 (0.70-1.10) 0.79 (0.63-0.98) 0.80 (0.66-0.97) Treatment HR (95% CI), adjusted* 1.07 (0.85-1.34) 0.89 (0.71-1.01) 0.80 (0.64-0.99) 0.78 (0.64-0.95) Fatal outcome due to CHD Treatment HR (95% CI), unadjusted 0.75 (0.50-1.14) 0.83 (0.57-1.23) 1.11 (0.76-1.61) 0.99 (0.69-1.40) Treatment HR (95% CI), adjusted* 0.76 (0.50-1.16) 0.85 (0.58-1.26) 1.13 (0.77-1.65) 1.05 (0.77-1.50) Fatal outcome from any cause Treatment HR (95% CI), unadjusted 0.70 (0.52-0.94) 0.94 (0.70-1.27) 0.85 (0.64-1.13) 0.93 (0.69-1.25) Treatment HR (95% CI), adjusted* 0.73 (0.54-0.98) 0.97 (0.73-1.31) 0.87 (0.65-1.15) 0.95 (0.70-1.28) Adjusted for age, sex, race, geographic region, time since event, BMI, history of smoking, diabetes status, and baseline LDL-C.

e. Effect of alirocumab on Lp(a) levels

[265] Lp(a) levels were also analyzed in patients during the study. Figure 14 shows the median Lp(a) concentration by baseline Lp(a) quartile and treatment group. The distributions of baseline Lp(a) levels were similar in both treatment groups. As shown in Figures 18A and 18B , alirocumab significantly reduced Lp(a) levels in patients at 4 months after treatment initiation, and these reductions were maintained through the end of the study. Additionally, absolute changes from baseline in LDL-C and Lp(a) at month 4 were comparable in the alirocumab group across the four quartiles of baseline Lp(a) levels. Figure 15 shows the absolute change from baseline to month 4 in Lp(a), LDL-C, and _adjusted LDL-C levels in the alirocumab group ( Figure 15A ) and the placebo group ( Figure 15B ). The absolute change in Lp(a) levels increased across Lp(a) quartiles, whereas the absolute change in LDL-C levels remained unchanged across Lp(a) quartiles ( Table 10 ). Therefore, no correlation was observed between LDL-C reduction and Lp(a) reduction in these patients.

[266] Overall, the median relative and absolute changes from baseline to month 4 in the alirocumab group were -23% (IQR -47%, 0%) and -5.0 mg/dL (IQR -13.5, 0), respectively. Although the relative change in Lp(a) with alirocumab treatment was similar across quartiles of baseline Lp(a) levels, there was a large gradient in median absolute change, ranging from 0 mg/dL in quartile 1 to -20.2 mg/dL in quartile 4. The change in LDL-C was similar across quartiles of Lp(a) levels; In contrast, changes in _adjusted LDL-C levels were smaller in the upper quartiles of Lp(a) levels, with an overall median change of -51.1 mg/dL (IQR -67.2, -33.7) ( Figure 15A ). Baseline Lp(a) levels were strongly correlated with the change from baseline to month 4 in Lp(a) levels and weakly correlated with the change in adjusted LDL-C and adjusted non-HDL-C levels ( Figures 16A, 16B , and 16C ). There were no systemic changes in Lp(a) levels over time in the placebo group ( Figure 15B ).

Table 10. Changes in LDL-C and Lp(a) levels by quartiles of Lp(a) levels

Alirocumab group Q1: <6.7 mg/dL (n=4730) Q2: 6.7 to <21.2 mg/dL (n=4731) Q3: 21.2 to <59.6 mg/dL (n=4729) Q4: ≥59.6 mg/dL (n=4734) Absolute change* LDL-C level (mg/dL) -53.7 (-35.5, -69.0) -54.1 (-37.1, -71.0) -53.3 (-36.3, -70.3) -54.1 (-36.7, -71.0) Lp(a) level (mg/dl) 0 (0, -1.42) -5.12 (-2.25, -7.86) -9.8 (-3.18, -16.2) -20.2 (-8.0, -34.3) *Values in the table are median (interquartile range); change between baseline and month 4.

f. The effect of changing the level of Lp(a) on the results

[267] To determine the association between the modification of Lp(a) levels with alirocumab treatment and endpoint events, Cox proportional hazards regression models were used for patients in the alirocumab group to describe the associations between the change in Lp(a) levels from baseline to month 4 and the risk of incident MACE and secondary endpoints after month 4. Four models were constructed for each outcome of interest: a model with no covariates (unadjusted model; Model 1); a model adjusted for baseline Lp(a) level (Model 2); a model additionally adjusted for either baseline _adjusted LDL C level and the change from baseline to month 4 in _adjusted LDL C level (Model 3A) or baseline _adjusted non-HDL C level and the change from baseline to month 4 _{in adjusted} non-HDL C level (Model 3B); and a model adjusted for all measures in Model 3, as well as the demographic and clinical measures listed above, with either _adjusted LDL C (Model 4A) or _adjusted non-HDL C (Model 4B). Thus, this fourth model demonstrated the effect of change in Lp(a) on the outcome of interest with alirocumab treatment that was independent of the effect of alirocumab on change in _adjusted LDL-C and _adjusted non-HDL C .

[268] Comparison of Models 2 and 3A tested whether the association between change in Lp(a) and MACE was modified by adjustment for concomitant change in _adjusted LDL C. Similarly, comparison of Models 2 and 3B tested whether the association between change in Lp(a) and MACE was modified by adjustment for concomitant change in all other apoB-containing lipoprotein levels. Effects were summarized using hazard ratios for a 1 mg/dL decrease in Lp(a) (all models) _{and adjusted} or non-HDL C (Models 3A, 3B, 4A, and 4B) at month 4. The estimated risk reduction in MACE with alirocumab, associated with Lp(a) reduction and concomitant reduction in _adjusted LDL C (Model 3A) or _adjusted non-HDL C (Model 3B), was calculated for the entire distribution of baseline Lp(a) levels. Table 11 shows the results of sequential Cox proportional hazards models relating the change in Lp(a) with alirocumab treatment to the risk of MACE, simultaneously adjusting for adjusted LDL-C or adjusted non-HDL-C.

Table 11. Association of Lp(a) levels with the risk of MACE during alirocumab treatment

Model Model adjustments Changeable parameter HR (95% CI) for a reduction of 1 mg/dL p-value 1 Absent Lp(a) level 0.998 (0.993, 1.002) 0.2730 2 Initial level of Lp(a) Lp(a) level 0.993 (0.989, 0.998) 0.0027 3A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4 Lp(a) level
_Corrected LDL-C level 0.994 (0.990, 0.999)
0.996 (0.994, 0.998) 0,0081
0.0002 3B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4 Lp(a) level
Non-HDL-C level _corrected 0.994 (0.990, 0.998)
0.997 (0.995, 0.998) 0.0078
0,0004 4A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
_Corrected LDL-C level 0.994 (0.990, 0.998)
0.995 (0.993, 0.997) 0.0071
<0.0001 4B Baseline Lp(a), baseline _adjusted non-HDL-C, change in _adjusted non-HDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
Non-HDL-C level _corrected 0.994 (0.990, 0.998)
0.996 (0.994, 0.998) 0.0064
0,0001

[269] Table 12 shows the modelling results for CHD-related death or non-fatal MI, CV-related death, and all-cause death. In the unadjusted models, no significant association was found between change in Lp(a) and the risk of MACE (Model 1). After adjusting for baseline Lp(a), change in Lp(a) was significantly associated with MACE (Model 2). This is because higher baseline Lp(a) is associated with greater CV risk and greater reduction in Lp(a) with alirocumab treatment, and therefore taking the former into account allows the latter to be associated with MACE risk. Importantly, additional adjustment for baseline and change from baseline to month 4 in _adjusted LDL-C or baseline and change from baseline to month 4 _{in adjusted} non-HDL-C did not attenuate the association (comparison of Models 2 and 3A and 3B, respectively). In models adjusted for _adjusted LDL-C or _adjusted non-HDL-C (Models 3A and 3B), a 1 mg/dL decrease in Lp(a) was associated with hazard ratios for MACE of 0.994 (95% CI 0.990-0.998) and 0.994 (95% CI 0.990-0.998), respectively. This indicated that a reduction in Lp(a) with alirocumab treatment was associated with a reduced risk of MACE, independent of a concurrent reduction in _adjusted or non- _adjusted LDL-C levels. Additional adjustment for demographic and clinical measures had minimal effects on the associations (Models 4A and 4B).

Table 12. Association of changes in Lp(a) and LDL-C levels from baseline to month 4 with outcomes after month 4 in the alirocumab group

End point Model Model adjustments Changeable parameter HR (95% CI) for a reduction of 1 mg/dL p-value Fatal CHD + nonfatal MI 1 Absent Lp(a) level 0.998 (0.993, 1.002) 0.3517 2 Initial level of Lp(a) Lp(a) level 0.993 (0.989, 0.998) 0.0029 3A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4 Lp(a) level
_Corrected LDL-C level 0.994 (0.990, 0.998)
0.996 (0.993, 0.998) 0,0086
0,0004 3B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4 Lp(a) level
Non-HDL-C level _corrected 0.994 (0.990, 0.999)
0.996 (0.994, 0.998) 0,0087
0,0004 4A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
_Corrected LDL-C level 0.994 (0.990, 0.999)
0.995 (0.993, 0.997) 0,0090
<0.0001 4B Baseline Lp(a), baseline _adjusted non-HDL-C, change in _adjusted non-HDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
Non-HDL-C level _corrected 0.994 (0.990, 0.999)
0.996 (0.994, 0.998) 0,0084
0,0001 Ischemic stroke 1 Absent Lp(a) level 0.990 (0.979, 1.002) 0,0905 2 Initial level of Lp(a) Lp(a) level 0.993 (0.979, 1.006) 0.2833 3A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4 Lp(a) level
_Corrected LDL-C level 0.993 (0.980, 1.007)
0.996 (0.990, 1.003) 0.3455
0.2536 3B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4 Lp(a) level
Non-HDL-C level _corrected 0.994 (0.980, 1.007)
0.996 (0.991, 1.002) 0.3556
0.1638 4A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
_Corrected LDL-C level 0.993 (0.980, 1.005)
0.996 (0.990, 1.002) 0.2530
0.2282 4B Baseline Lp(a), baseline _adjusted non-HDL-C, change in _adjusted non-HDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
Non-HDL-C level _corrected 0.993 (0.981, 1.005)
0.996 (0.991, 1.001) 0.2637
0.1463 Fatal outcome due to CV 1 Absent Lp(a) level 1,000 (0,992, 1,008) 0.9649 2 Initial level of Lp(a) Lp(a) level 0.997 (0.989, 1.005) 0.4667 3A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4 Lp(a) level
_Corrected LDL-C level 0.998 (0.989, 1.006)
0.995 (0.991, 0.999) 0.5953
0,0155 3B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4 Lp(a) level
Non-HDL-C level _corrected 0.998 (0.990, 1.006)
0.995 (0.992, 0.999) 0.6055
0.0062 4A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
_Corrected LDL-C level 0.996 (0.988, 1.004)
0.994 (0.990, 0.998) 0.3316
0.0038 4B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4, demographic and clinical characteristics Lp(a) level
Non-HDL-C level _corrected 0.996 (0.989, 1.004)
0.994 (0.991, 0.998) 0.3508
0.0014 Fatal outcome from any cause 1 Absent Lp(a) level 0.998 (0.992, 1.005) 0.6046 2 Initial level of Lp(a) Lp(a) level 0.997 (0.990, 1.005) 0.4986 3A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4 Lp(a) level
_Corrected LDL-C level 0.998 (0.991, 1.006)
0.995 (0.991, 0.998) 0.6671
0.0019 3B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4 Lp(a) level
Non-HDL-C level _corrected 0.998 (0.991, 1.006)
0.996 (0.993, 0.999) 0.6375
0.0056 4A Baseline Lp(a), baseline _adjusted LDL-C, change in _adjusted LDL-C from baseline to month 4, demographic and clinical characteristics Lp(a) level
_Corrected LDL-C level 0.998 (0.991, 1.004)
0.994 (0.990, 0.997) 0.4959
0.0002 4B Baseline Lp(a), baseline non-HDL-C _adjusted , change in non-HDL-C _adjusted from baseline to month 4, demographic and clinical characteristics Lp(a) level
Non-HDL-C level _corrected 0.998 (0.991, 1.004)
0.995 (0.992, 0.998) 0.4771
0,0007

[270] The magnitude of the change in Lp(a) with alirocumab treatment increased with increasing baseline Lp(a) concentration. For example, patients with baseline Lp(a) distributions at the ^25th , ^50th , and ^75th percentiles had expected changes in Lp(a) with alirocumab treatment of -1.6, -4.8, and -13.4 mg/dL. Figure 17A and B show the relationship between absolute change in Lp(a) at month 4 adjusted for baseline Lp(a) and baseline and absolute change in _adjusted LDL-C ( Figure 17A ) or baseline and absolute change in _adjusted non-HDL-C ( Figure 17B ). In these models, the proportions of the pooled relative risk reductions per change in _adjusted Lp(a) and LDL-C that could be attributed to Lp(a) based on the log hazard ratios were 4%, 11%, and 27% at the 25th, 50th, and 75th percentiles of baseline Lp(a), respectively. The corresponding proportions of the pooled relative risk reductions per change in Lp(a) in the non-HDL-C _-adjusted model were 4%, 12%, and 29% at the 25th, 50th, and 75th percentiles of baseline Lp(a), respectively. Thus, among patients with low baseline Lp(a), lowering Lp(a) with alirocumab made a minimal contribution to reducing MACE. In contrast, among patients with high baseline Lp(a), Lp(a) reduction with alirocumab contributed significantly to the reduction in MACE, although the main effect remained the reduction in corrected LDL (or non-HDL)-C.

[271] Accordingly, the magnitude of the change in Lp(a) with alirocumab treatment and its contribution to cardiovascular risk reduction increased with increasing baseline Lp(a) concentrations. For example, at the 25th, 50th, and 75th percentiles of baseline Lp(a) concentrations, the hazard ratios for MACE associated with changes in Lp(a) concentrations of -1.6, -4.8, and -13.4 mg/dL were 0.991, 0.973, and 0.928, respectively, and the proportion of MACE risk reduction attributable to the change in Lp(a) concentrations was 4%, 10%, and 26%. Thus, among patients with higher baseline Lp(a) concentrations, Lp(a) reduction with alirocumab became an important contributor to MACE reduction. These results indicated that the association between Lp(a) reduction and MACE or nonfatal MI was independent of LDL-C levels. There was no association between the time-weighted moving average of absolute change in Lp(a) and ischemic stroke, CHD-related death, CV-related death, or all-cause death.

g. Effect of changing the level of Lp(a) on the total number of events

[272] To examine the contribution of Lp(a) reduction to the reduction in overall events (non-fatal CV events and death) observed with alirocumab treatment, patients with ACS and LDL-C ≥70 mg/dL, non-HDL-C ≥100 mg/dL, or apoB ≥80 mg/dL who were receiving intensive statin therapy or maximum-tolerated statin therapy were randomized 1:1 to alirocumab or placebo. The association between change in Lp(a) from baseline to month 4 and subsequent events was described in the alirocumab group using individual vulnerability models adjusted for demographic and clinical measures, baseline Lp(a) and LDL-C levels, and change in LDL-C from baseline to month 4. Effects were summarized by hazard ratios at different percentiles of baseline Lp(a) levels (see Table 13 ).

[273] There were 1636 nonfatal events and 299 deaths in the alirocumab group. Among the pooled effects of Lp(a) and LDL-C reductions, the proportions of risk reductions attributable to change in Lp(a) were 5%, 13%, and 30% at the 25th, 50th, and 75th percentiles of baseline Lp(a) levels, respectively. Thus, Lp(a) reduction with alirocumab contributed to a reduction in overall events, particularly among patients with higher baseline Lp(a) levels. Even after adjustment for change in LDL-C, alirocumab-induced Lp(a) reduction was associated with a lower overall risk of events.

Table 13. Relationship between absolute change in Lp(a) level at month 4 and overall risk of events

Model adjustments Parameter Baseline Lp(a) ² percentile Change parameter ³ HR (95% CI) p-value Initial level of Lp(a) Lp(a) level ^{25th
50th
75th} a decrease of 1.6 mg/dL
a decrease of 4.8 mg/dL
a decrease of 13.4 mg/dL 0.991 (0.984, 0.998)
0.973 (0.952, 0.994)
0.926 (0.872, 0.982) 0,0109 Baseline Lp(a), demographic and clinical characteristics, ¹ baseline LDL-C Lp(a) level ^{25th
50th
75th} a decrease of 1.6 mg/dL
a decrease of 4.8 mg/dL
a decrease of 13.4 mg/dL 0.988 (0.981, 0.995)
0.966 (0.946, 0.986)
0.907 (0.855, 0.963) 0,0013 Baseline Lp(a), demographic and clinical characteristics, ¹ baseline LDL-C, change in LDL-C Lp(a) level
LDL-C level ^{25th
50th
75th
25th
50th
75th} a decrease of 1.6 mg/dL
a decrease of 4.8 mg/dL
a decrease of 13.4 mg/dL
a decrease of 51.1 mg/dL
decrease of 50.5 mg/dL
a decrease of 48.9 mg/dL 0.990 (0.983, 0.997)
0.970 (0.950, 0.991)
0.920 (0.867, 0.976)
0.816 (0.728, 0.915)
0.818 (0.731, 0.916)
0.824 (0.738, 0.919) 0.0056
0,0005

¹ Age, sex, race, geographic region, body mass index, history of smoking habits, diabetes status, time from ACS assessment to randomization

^{2 25th} percentile = 6.7 mg/dL; ^50th percentile = 21.2 mg/dL; ^75th percentile = 59.6 mg/dL

³ Expected change in the specified parameter for the patient at the specified quartile of the baseline Lp(a) level

CONCLUSION

[274] Baseline Lp(a) predicted MACE, fatal CHD, and nonfatal MI in both the alirocumab and placebo groups, independent of baseline LDL-C and demographic and clinical measures. Baseline Lp(a) did not predict death or ischemic stroke. Baseline Lp(a) was also associated with beneficial effects of alirocumab treatment on MACE and nonfatal MI. Therefore, baseline Lp(a) was an independent predictor of MACE and nonfatal MI in patients with recent ACS, independent of alirocumab treatment and baseline LDL-C.

[275] Furthermore, the median change from baseline in Lp(a) was approximately -5 mg/dL with alirocumab and 0 mg/dL with placebo. In the alirocumab group, Lp(a) reduction predicted a reduction in the risk of MACE and nonfatal MI in models adjusting for demographic and clinical measures, baseline LDL-C, and change from baseline in LDL-C. No association was observed between Lp(a) reduction and stroke or death. In the placebo group, where there were no systemic changes from baseline, change in Lp(a) did not predict any outcome event. In this study, patients with Lp(a) levels equal to or greater than the cohort median (21 mg/dL) or LDL-C levels equal to or greater than 100 mg/dL benefited from alirocumab treatment. Thus, Lp(a) reduction with alirocumab was associated with a reduced risk of MACE, nonfatal MI, and total events, independent of baseline LDL-C and concurrent LDL-C reduction.

Example 5. Secondary analysis: effect of alirocumab on death and MACE following acute coronary syndrome in patients treated for more than one year

[276] A special population of interest in a secondary (retrospective) analysis included patients who had already been treated for longer than 12 months. As shown in Table 14 , patients with baseline LDL-C levels equal to or greater than 100 mg/dL who were treated with alirocumab for less than twelve months demonstrated a reduction in MACE events (HR=0.81 (CI 0.66-1.01)). When the same population was treated with alirocumab for longer than twelve months, the reduction in MACE events was enhanced and significant (HR=0.71 (CI 0.58-0.87)). A similar trend was observed for all-cause death. Patients with baseline LDL-C greater than 100 mg/dL who were treated with alirocumab for less than twelve months had a reduced risk of all-cause death (HR=0.79 (CI 0.51-1.22)). When the same population was treated with alirocumab for more than twelve months, the odds of all-cause death were reduced and this change was significant (HR=0.67 (CI 0.50-0.89)). Results of an additional pre-specified analysis of MACE and all-cause death in 8,242 patients who met pre-specified criteria for at least three years of follow-up are shown in Figure 20 . More than 44% of the intent-to-treat (ITT) population received treatment for more than three years. As can be seen, lower rates of MACE events ( Figure 20B ; HR 0.83) and all-cause death ( Figure 20D ; HR 0.78) were observed in the population treated for at least three years compared with the rates of MACE events ( Figure 20A ; HR 0.85) and all-cause death ( Figure 20C ; HR 0.85) in the overall study population.

[277] These results indicated that the beneficial effects of alirocumab treatment continued to accumulate, with further risk reductions observed beyond the first year in the overall population and in patients with baseline LDL-C levels equal to or greater than 100 mg/dL.

Table 14. Retrospective analysis of treatment results depending on the severity of the therapeutic response at certain treatment times

All patients Patients with ≥100 mg/dL LDL-C at baseline General HR 0-12 months After 12 months General HR 0-12 months After 12 months Time until first MACE event 0.85
(0.78-0.93) 0.94
(0.83-1.08) 0.77
(0.69-0.87) 0.76
(0.65-0.87) 0.81
(0.66-1.01) 0.71
(0.58-0.87) Time to death from any cause 0.85
(0.73-0.98) 1.01
(0.77-1.32) 0.79
(0.66-0.94) 0.71
(0.56-0.90) 0.79
(0.51-1.22) 0.67
(0.50-0.89)

Example 6: Secondary Analysis - Effect of Alirocumab on All-Cause Death, Cardiovascular Death, and Non-CV Death in Patients Treated for More Than One Year

a. Effect on all-cause mortality

[278] A total of 726 patients (3.8%) died during the trial. Baseline characteristics of the entire cohort, survivors, and deceased patients are summarized in Table 16 . There were fewer deaths in the alirocumab group than in the placebo group (334 [3.5%] vs 392 [4.1%], respectively; HR 0.85, 95% CI 0.73–0.98; p=0.026; Table 15 ). Based on the 4-year Kaplan-Meier estimates of death at 4 years of 5.3% and 6.4% in the alirocumab group and placebo group, respectively, the absolute risk reduction was 1.1% and the number needed to be treated for 4 years to prevent 1 death was 87.

Table 15. Summary of all-cause, cardiovascular, and non-cardiovascular death endpoints

End point Alirocumab
(n=9462) Placebo
(n=9462) HR (95% CI)* Log rank
p-value* Fatal outcome from any cause 334 (3.5%) 392 (4.1%) 0.85 (0.73, 0.98) 0.03 Fatal outcome due to cardiovascular disorder 240 (2.5%) 271 (2.9%) 0.88 (0.74, 1.05) 0.15 Fatal outcome not due to cardiovascular disorder 94 (1.0%) 121 (1.3%) 0.77 (0.59, 1.01) 0.06 *Stratified by region.

[279] Similar to the primary endpoint, adjustment for the risk of treatment discontinuity for all-cause death allowed for a delay in the effect of alirocumab treatment; a treatment benefit was not evident during the first year (HR 1.01, 95% CI 0.77-1.32; p=0.95) but was evident after the first year (HR 0.79, 95% CI 0.66-0.94; p=0.0073; p=0.13 for improved model fit relative to the constant-hazards model [with HR 0.85]).

[280] Given prior evidence for delayed lipid-lowering benefits in many statin trials, a prespecified analysis examined whether the reduction in mortality with alirocumab was associated with potential treatment duration. Death was examined among 8242 patients (44% of the entire study cohort) who met prespecified criteria for ≥3 years of follow-up. Baseline characteristics for this subgroup and the remaining subgroup of patients who participated in the study for <3 years before the overall study end date are described in Table 17 . Among patients meeting the pre-treatment criteria with ≥3 years of follow-up, the benefit of alirocumab for all-cause death was greater than in the overall trial population, with alirocumab reducing the odds of death by 22% (HR 0.78, 95% CI 0.65-0.94; p=0.01; Figure 20D ). For patients meeting the pre-treatment criteria with <3 years of follow-up, the treatment hazard ratio for all-cause death was 0.96 (95% CI 0.76-1.21; p=0.71; interaction p=0.19).

Table 16. Initial characteristics

Characteristic All patients
(N=18924) Died during follow-up
(N=726) Survived until the end of follow-up
(N=18198) Age, years 59 (52, 65) 64 (57, 71) 58 (52, 65) Female gender 4762 (25.2%) 202 (27.8%) 4560 (25.1%) Race Caucasoids 15,024 (79.4%) 551 (75.9%) 14,443 (79.5%) Mongoloids 2498 (13.2%) 93 (12.8%) 2405 (13.2%) Negroid race or African Americans 473 (2.5%) 26 (3.6%) 447 (2.5%) Other 929 (4.9%) 56 (7.7%) 873 (4.8%) Region of enrollment in the study Central and Eastern Europe 5437 (28.7%) 234 (32.2%) 5203 (28.6%) Western Europe 4175 (22.1%) 84 (11.6%) 4091 (22.5%) Canada/USA 2871 (15.2%) 136 (18.7%) 2735 (15.0%) Latin America 2588 (13.7%) 133 (18.3%) 2455 (13.5%) Asia 2293 (12.1%) 75 (10.3%) 2218 (12.2%) The rest of the world 1560 (8.2%) 64 (8.8%) 1496 (8.2%) Medical history prior to ACS diagnosis Hypertension 12,249 (64.7%) 583 (80.3%) 11,666 (64.1%) Family history of premature CHD 6773 (35.8%) 272 (37.5%) 6501 (35.7%) Myocardial infarction 3639 (19.2%) 245 (33.7%) 3394 (18.7%) PCI 3241 (17.1%) 188 (25.9%) 3053 (16.8%) CABG 1047 (5.5%) 98 (13.5%) 949 (5.2%) Stroke 611 (3.2%) 68 (9.4%) 543 (3.0%) Peripheral arterial disease 759 (4.0%) 76 (10.5%) 683 (3.8%) Congestive heart failure 241 (8.6%) 2574 (14.1%) 2815 (14.9%) COPD 746 (3.9%) 102 (14.0%) 644 (3.5%) Malignant disease 532 (2.8%) 35 (4.8%) 497 (2.7%) Diabetic status Diabetes mellitus 5444 (28.8%) 346 (47.7%) 5098 (28.0%) Prediabetes 8246 (43.6%) 253 (34.8%) 7993 (43.9%) Norm 5234 (27.7%) 127 (17.5%) 5107 (28.1%) Status of a tobacco smoker Smokes 4560 (24.1%) 164 (22.6%) 4396 (24.2%) I smoked before 7811 (41.3%) 311 (42.8%) 7500 (41.2%) Never smoked 6552 (34.6%) 251 (34.6%) 6301 (34.6%) The event set represents ACS STEMI 6536 (34.6%) 181 (25.1%) 6355 (35.0%) Non-STEMI 9175 (48.6%) 407 (56.5%) 8768 (48.2%) Unstable angina 3182 (16.8%) 132 (18.3%) 3050 (16.8%) PCI or CABG if ACS is installed 13677 (72.3) 421 (58.0) 13256 (72.8) Time from established ACS to randomization, months 2.6 (1.7, 4.3) 2.5 (1.7, 3.7) 2.6 (1.7, 4.4) Body mass index 27.9 (25.2, 31.1) 27.7 (24.5, 31.5) 27.9 (25.2, 31.1) Medications at randomization Lipid-correcting agents High-intensity dose of atorvastatin/rosuvastatin 16,811 (88.8%) 639 (88.0%) 16 172 (88.9%) Low/moderate dose atorvastatin/rosuvastatin 1607 (8.5%) 61 (8.4%) 1546 (8.5%) Another statin 46 (0.2%) 1 (0.1%) 45 (0.2%) Ezetimibe 554 (2.9) 18 (2.5) 536 (2.9) Aspirin 18,086 (95.6%) 667 (91.9%) 17,419 (95.7%) P2Y antagonist ₁₂ 16,541 (87.4%) 597 (82.2%) 15,944 (87.6%) Beta blocker 15,990 (84.5%) 603 (83.1%) 15,387 (84.6%) ACE inhibitor or ARB 14,716 (77.8%) 589 (81.1%) 14 127 (77.6%) Statin use within 3 months immediately prior to ACS appointment 6164 (32.6%) 286 (39.6%) 5878 (32.3%) Lipid levels at randomization (mg/dL)* LDL-C level§ 86 (73, 104) 91 (74, 110) 86 (73, 104) Non-HDL-C level 115 (99, 137) 120 (100, 143) 115 (99, 136) Apolipoprotein B level 79 (69, 93) 82 (71, 98) 79 (69, 93) HDL cholesterol level 43 (36, 50) 42 (36, 51) 43 (36, 50) Triglyceride levels 129 (94, 182) 132 (92, 187) 129 (94, 182) Lipoprotein(a) level 21 (7, 60) 22 (7, 57) 21 (7, 60) Hemoglobin A _1c level, % 5.8 (5.5, 6.3) 6.1 (5.7, 7.3) 5.8 (5.5, 6.3) GFR, ml/min per 1.73 ^m2 78.2 (67.4, 90.1) 70.2 (54.9, 85.2) 78.5 (67.8, 90.4) High-sensitivity C-reactive protein level, mg/L 1.6 (0.8, 3.9) 2.8 (1.1, 6.6) 1.6 (0.8, 3.8)

ACE=angiotensin-converting enzyme; ACS=acute coronary syndrome; ARB=angiotensin II receptor blocker; CABG=coronary artery bypass grafting; CHD=coronary artery disease; GFR=glomerular filtration rate; HDL=high-density lipoprotein cholesterol; LDL-C=low-density lipoprotein cholesterol; PCI=percutaneous coronary intervention; STEMI=ST-segment elevation myocardial infarction.

*To convert cholesterol values to mmol/L, multiply by 0.02586. To convert triglyceride values to mmol/L, multiply by 0.01129. Data are presented as median values (interquartile range) except where presented as mean values (standard deviation) and where indicated.

Race was self-reported by the participant.

Body mass index is weight in kilograms divided by the square of height in meters.

§ LDL-C was calculated using the Friedewald formula; calculated values <15 mg/dL were confirmed by ultracentrifugation/quantitation of beta-cholesterol.

Table 17. Baseline characteristics according to duration of potential follow-up

Characteristic Satisfying specified criteria for ≥3 years of follow-up
(n=8242) Not meeting the specified criteria for ≥3 years of follow-up
(n=10682) Age, years 58 (52, 65) 58 (52, 65) Female gender 2069 (25.1%) 2693 (25.2%) Race Caucasoids 7055 (85.6%) 7969 (74.6%) Mongoloids 585 (7.1%) 1913 (17.9%) Negroid race or African Americans 205 (2.5%) 268 (2.5%) Other 397 (4.8%) 532 (5.0%) Region of enrollment in the study Central and Eastern Europe 2428 (29.5%) 3009 (28.2%) Western Europe 1957 (23.7%) 2218 (20.8%) Canada/USA 1474 (17.9%) 1397 (13.1%) Latin America 1041 (12.6%) 1547 (14.5%) Asia 459 (5.6%) 1834 (17.2%) The rest of the world 883 (10.7%) 677 (6.3%) Medical history prior to ACS diagnosis Hypertension 5373 (65.2%) 6876 (64.4%) Family history of premature CHD 3114 (37.8%) 3659 (34.3%) Myocardial infarction 1753 (21.3%) 1886 (17.7%) PCI 1567 (19.0%) 1674 (15.7%) CABG 515 (6.3%) 532 (5.0%) Stroke 269 (3.3%) 342 (3.2%) Peripheral arterial disease 380 (4.6%) 379 (3.6%) Congestive heart failure 1242 (15.1%) 1573 (14.7%) COPD 357 (4.3%) 389 (3.6%) Malignant disease 250 (3.0%) 282 (2.6%) Diabetic status Diabetes mellitus 2287 (27.7%) 3157 (29.6%) Prediabetes 3550 (41.1%) 4696 (44.0%) Norm 2405 (29.2%) 2829 (26.5%) Status of a tobacco smoker Smokes 2058 (25.0%) 2502 (23.4%) I smoked before 3318 (40.3%) 4493 (42.1%) Never smoked 2865 (34.8%) 3687 (34.5%) The event set represents ACS STEMI 2752 (33.5%) 3784 (35.5%) Non-STEMI 4286 (52.1%) 4889 (45.8%) Unstable angina 1183 (14.4%) 1999 (18.7%) PCI or CABG if ACS is installed 5815 (70.6) 7862 (73.6) Time from established ACS to randomization, months 2.3 (1.6, 3.3) 3.1 (1.9, 5.9) Body mass index 28.2 (25.5, 31.4) 27.7 (25.0, 30.9) Medications at randomization Lipid-correcting agents High-intensity dose of atorvastatin/rosuvastatin 7487 (90.8%) 9324 (87.3%) Low/moderate dose atorvastatin/rosuvastatin 535 (6.5%) 1072 (10.0%) Another statin 28 (0.3%) 18 (0.2%) Ezetimibe 233 (2.8) 321 (3.0) Aspirin 7866 (95.4%) 10220 (95.7%) P2Y antagonist ₁₂ 7194 (87.3%) 9347 (87.5%) Beta blocker 7019 (85.2%) 8971 (84.0%) ACE inhibitor or ARB 6458 (78.4%) 8258 (77.3%) Statin use within 3 months immediately prior to ACS appointment 2754 (33.4) 3410 (31.9) Lipid levels at randomization* LDL cholesterol level§ 87 (74, 104) 86 (73, 104) Non-HDL cholesterol level 115 (100, 137) 115 (99, 137) Apolipoprotein B level 80 (69, 93) 79 (69, 93) HDL cholesterol level 42 (37, 50) 42 (36, 50) Triglyceride levels 127 (92, 181) 131 (96, 182) Lipoprotein(a) level 19 (6, 56) 22 (7, 62) Hemoglobin A _1c level, % 5.8 (5.5, 6.3) 5.9 (5.6, 6.4) GFR, ml/min per 1.73 ^m2 High-sensitivity C-reactive protein level, mg/L 1.7 (0.8, 4.1) 1.6 (0.7, 3.7)

ACE=angiotensin-converting enzyme; ACS=acute coronary syndrome; ARB=angiotensin II receptor blocker; CABG=coronary artery bypass grafting; CHD=coronary artery disease; GFR=glomerular filtration rate; HDL=high-density lipoprotein; LDL=low-density lipoprotein; PCI=percutaneous coronary intervention; STEMI=ST-segment elevation myocardial infarction.

* Lipid levels are reported in units of mg/dL. To convert cholesterol values to mmol/L, multiply by 0.02586. To convert triglyceride values to mmol/L, multiply by 0.01129. Data are presented as median (interquartile range) except where presented as mean (standard deviation) and are indicated.

Race was self-reported by the participant.

Body mass index is weight in kilograms divided by the square of height in meters.

§ LDL cholesterol was calculated using the Friedewald formula; calculated values <15 mg/dL were confirmed by ultracentrifugation/quantitation of beta-cholesterol.

b. Effect on cardiovascular and non-cardiovascular mortality

[281] CHD-related deaths occurred in 205 (2.2%) patients in the alirocumab group and 222 (2.3%) patients in the placebo group (HR 0.92, 95% CI 0.76-1.11; p=0.38) and represented 427 (58.8%) of the 726 deaths. Cardiovascular deaths occurred in 240 (2.5%) patients in the alirocumab group and 271 (2.9%) patients in the placebo group (HR 0.88, 95% CI 0.74-1.05; p=0.15) and represented 511 (70.4%) of the all-cause deaths. Non-CV deaths were numerically but not significantly lower with alirocumab (94 [1.0%] vs 121 [1.3%]; HR 0.77, 95% CI 0.59–1.01; p=0.06) than with placebo ( Table 15 ). The peer-reviewed CV and non-CV causes of death are summarized in Tables 18 and 19 . There was a small proportion of undetermined causes of death. In addition to 31 fewer CV deaths in the alirocumab group than in the placebo group, the largest differences between groups were fatal myocardial infarction (n=10) and sudden cardiac death (n=8). In addition to 27 fewer non-CV deaths in the alirocumab group compared with the placebo group, the largest difference was in deaths from pulmonary causes (n=14).

Table 18. Causes of death due to cardiovascular disorder confirmed by examination

Cause of death, n Alirocumab (n=240) Placebo (n=271) Delta Acute myocardial infarction 41 51 -10 Cardiovascular bleeding 0 2 -2 Procedure on vessels and heart 5 4 +1 Heart failure or cardiogenic shock 29 33 -4 Other cardiovascular causes 16 14 +2 Stroke Hemorrhage 9 8 +1 Ischemic 10 14 -4 Uncertain 0 2 -2 Sudden cardiac death 109 117 -8 Uncertain 21 26 -5

Table 19. Causes of death not caused by cardiovascular disorder confirmed by examination

Cause of death, n Alirocumab
(n=94) Placebo
(n=121) Delta Pulmonary 33 47 -14 The leading cause of death is infection.
The main cause of death = malignancy 12
18 19
22 Other non-cardiovascular causes 22 28 -6 The leading cause of death is infection.
The main cause of death = malignancy 6
14 11
14 Gastrointestinal tract/liver and biliary tract/pancreas 15 19 -4 The leading cause of death is infection.
The main cause of death = malignancy 4
9 3
14 Hemorrhage
The main cause of death = malignancy 3
0 6
1 -3 Neurological process but not stroke/hemorrhage 1 4 -3 The main cause of death = malignancy 1 2 Suicide 2 5 -3 A procedure or surgery not related to the cardiovascular system 3 2 +1 The leading cause of death is infection.
The main cause of death = malignancy 1
0 0
1 Accident or injury 10 8 +2 Kidney disease 5 2 +3 The leading cause of death is infection.
The main cause of death = malignancy 2
1 0
2

c. Association between non-fatal cardiovascular events and non-cardiovascular death

[282] Overall, there were 206 fewer non-fatal CV events in the alirocumab group than in the placebo group (HR 0.83, 95% CI 0.76-0.91; p<0.0001). When non-fatal CV events and non-CV deaths were described as ordinal functions ( Table 20 ), there were numerically fewer events of both types with alirocumab than with placebo as first events, second events, and third or further events, indicating an interdependence between the two event types.

[283] Furthermore, the risk of a subsequent non-CV death was higher in the presence of a non-fatal CV event. Among patients at risk for a first event in the alirocumab and placebo groups, a non-CV death occurred as a first event in 0.8% and 0.9% of patients, respectively, in the alirocumab and placebo groups. Following the first non-fatal CV event, which occurred overall a median of 1.1 (0.4, 1.9) years after randomization, a non-CV death occurred as a second event in 1.8% and 2.0% of patients, respectively, in the alirocumab and placebo groups. Similarly, after the second non-fatal CV event, which occurred overall a median of 1.5 (0.9, 2.3) years after randomization, non-CV death occurred as a third event in 3.7% and 6.2% of patients in the alirocumab and placebo groups, respectively. Qualitatively, these data suggest that each subsequent prior non-fatal CV event is associated with an increased subsequent risk of non-CV death.

Table 20. Number and timing of non-cardiovascular deaths and non-fatal myocardial infarction, stroke, or unstable angina requiring hospitalization, according to event number

Alirocumab Placebo n (%) Median time (Q1, Q3) of the event n (%) Median time (Q1, Q3) of the event First event Non-fatal myocardial infarction, stroke, or unstable angina 761 (8.0%) 1.0 (0.4, 1.9) 917 (9.7%) 1.1 (0.5, 1.9) Fatal outcome not due to cardiovascular disorder, 74 (0.8%) 1.9 (1.2, 2.5) 90 (0.9%) 1.8 (1.2, 2.4) Second event Non-fatal myocardial infarction, stroke, or unstable angina 162 (21.3%) 1.4 (0.9, 2.2) 210 (22.9%) 1.6 (0.9, 2.4) Fatal outcome not due to cardiovascular disorder, 14 (1.8%) 2.7 (1.8, 3.3) 18 (2.0%) 1.6 (1.1, 2.4) Third and further events Non-fatal myocardial infarction, stroke, or unstable angina 111 113 Fatal outcome not due to cardiovascular disorder, 6 (3.7%) 13 (6.2%) Total non-cardiovascular deaths, 94 (1.0%) 2.0 (1.4, 2.7) 121 (1.3%) 1.8 (1.2, 2.4)

Time to event is expressed in years after randomization.

[284] To quantitatively examine this possibility, a joint semiparametric model was constructed with treatment type and enrollment region assigned to the hazard functions ( Table 21 ). This model showed that alirocumab was predictive of a reduced risk of CV-related death (p=0.043) and yielded an association parameter of 2.15 (95% CI 1.61–2.69), suggesting that patients with a higher risk of non-fatal CV events also had a higher risk of CV-related death. Thus, the association between prior non-fatal CV events and subsequent fatal CV events, coupled with the reduction in the former with alirocumab, suggested that prevention of non-fatal CV events may account for the lower number of CV-related deaths with alirocumab.

Table 21. Results from the joint semiparametric model: total nonfatal myocardial infarction, stroke or unstable angina and non-cardiovascular death, treatment type and geographic region* in the model

HR (95% CI) P-value Non-fatal myocardial infarction, stroke, or unstable angina (1034 events with alirocumab vs 1240 with placebo) Treatment with alirocumab 0.83 (0.76, 0.91) <0.0001 East Europe 0.90 (0.75, 1.09) <0.0001 North America 2.20 (1.83, 2.64) The rest of the world 1.63 (1.32, 2.00) South America 0.93 (0.75, 1.15) Western Europe 1.28 (1.06, 1.54) Non-CV death (94 events with alirocumab vs 121 with placebo) Treatment with alirocumab 0.75 (0.57, 0.99) 0.0426 East Europe 1.58 (0.92, 2.72) 0.0273 North America 1.87 (1.05, 3.34) The rest of the world 1.20 (0.60, 2.41) South America 2.09 (1.17, 3.74) Western Europe 1.13 (0.63, 2.04) Association between non-fatal and fatal events: (95% CI) = 2.15 (1.61-2.69) - 0,0001 CI - confidence interval; HR - hazard ratio.

* Asia was used as the reference for analyses by geographic region.

[285] To examine whether the strength of the association between non-fatal CV events and non-CV death was affected by adjustment for factors that were predictive of non-fatal CV events and/or non-CV death, a series of univariate joint semiparametric models were fitted with the predictors expected to be predictive of these events. After including all factors significantly associated with non-fatal CV events or non-CV death in the univariate models to allow the adjusted model to be fitted, the estimated association parameter remained significant (1.82, 95% CI: 1.08-2.55; p<0.0001), indicating a consistently strong association between non-fatal CV events and non-CV death.

d. Association of mortality with baseline and achieved LDL-C levels

[286] In a post hoc analysis, death was examined in three predefined baseline LDL-C subgroups (<80 mg/dL [2.07 mmol/L], 80 to <100 mg/dL [2.07 to <2.59 mmol/L], and ≥100 mg/dL [2.59 mmol/L]; Figures 8A–8C ). The HR for death was numerically lowest in the subgroup with baseline LDL-C ≥100 mg/dL (HR 0.71, 95% CI 0.56–0.90), but there was no significant heterogeneity in the relative risk of death with alirocumab across baseline LDL-C categories (p for interaction=0.12). In contrast, there were significant gradients in the absolute risk of death in the placebo group and in the absolute difference in death between the alirocumab and placebo groups across baseline LDL-C subgroups, with the greatest risk in the placebo group and the greatest risk reduction with alirocumab observed in the subgroup with baseline LDL-C ≥100 mg/dL (P for interaction <0.005). Using Kaplan-Meier estimates of all-cause death at 4 years for patients with baseline LDL-C ≥100 mg/dL (5.8% vs 9.6%), the absolute risk reduction was 3.8%, and the number needed to treat for 4 years to eliminate 1 death in this subgroup was 26.

[287] Additional analyses examined the association between LDL-C levels achieved at 4 months after randomization and death thereafter. In linear models according to quartile of achieved LDL-C, patients with lower achieved LDL-C values at 4 months had a lower risk of death from any cause (p=0.005) ( Table 22 ). When the study population was stratified by treatment assignment, in the placebo group, where the median LDL-C value at 4 months was 87 mg/dL (2.25 mmol/L), no association was observed between achieved LDL-C value at 4 months and subsequent death ( Table 23 ). In contrast, a strong association was seen in the alirocumab group (Table 4), where the median achieved LDL-C at 4 months was 31 mg/dL (0.80 mmol/L). A continuous spline analysis of the association of achieved LDL-C levels with the risk of all-cause death yielded similar results: the association between achieved LDL-C at 4 months and subsequent death in the entire study cohort was a nearly monotonic function (model p-value=0.007) ( Figure 19A ), which was stronger in the alirocumab group ( Figure 19C ). In contrast, the association in the placebo group was U-shaped, with higher mortality occurring in patients with either the lowest or highest achieved LDL-C levels at 4 months ( Figure 19B ).

Table 22. All-cause cardiovascular and non-cardiovascular death by LDL-C quartile at 4 months in ITT (all patients)

End point Frequency of occurrence, number/total number (%) HR (95% CI)* P-value for linear trend* Fatal outcome from any cause Q1 135/4682 (2.9) 0.73 (0.58, 0.91) 0,005 Q2 164/4733 (3.5) 0.86 (0.69, 1.05) Q3 167/4721 (3.5) 0.90 (0.73, 1.10) Q4 192/4712 (4.1) Reference Fatal outcome due to cardiovascular disorder Q1 92/4682 (2.0) 0.73 (0.56, 0.95) 0.028 Q2 116/4733 (2.5) 0.89 (0.69, 1.14) Q3 112/4721 (2.4) 0.88 (0.69, 1.14) Q4 130/4712 (2.8) Reference Fatal outcome not due to cardiovascular disorder Q1 43/4682 (0.9) 0.73 (0.50, 1.08) 0.08 Q2 48/4733 (1.0) 0.78 (0.54, 1.14) Q3 55/4721 (1.2) 0.92 (0.64, 1.32) Q4 62/4712 (1.3) Reference

*Stratified by region; ITT=intention to treat; quartiles at month 4 for LDL-C: Q1 = ≤0.80 mmol/L (≤31 mg/dL); Q2 = >0.80–1.68 mmol/L (>31–≤65 mg/dL); Q3 = >1.68–2.38 mmol/L (>65–≤92 mg/dL); Q4 = >2.38 mmol/L (>92 mg/dL)

Table 23. All-cause mortality by LDL-C quartile at 4 months in ITT in placebo and alirocumab groups

LDL-C level quartile Frequency of occurrence, number/total number (%) HR (95% CI)* P-value for linear trend* Placebo group 0.96 Q1: ≤1.86 mmol/L (≤72 mg/dL) 104/2373 (4.4) 0.99 (0.75, 1.29) Q2: >1.86 - ≤2.25 mmol/L (>72 - ≤87 mg/dL) 74/2354 (3.1) 0.73 (0.54, 0.97) Q3: >2.25 - ≤2.77 mmol/L (>87 - ≤107 mg/dL) 71/2363 (3.0) 0.68 (0.50, 0.91) Q4: >2.77 mmol/L (>107 mg/dL) 110/2336 (4.7) Standard Alirocumab group 0.027 Q1: ≤0.52 mmol/L (≤20 mg/dL) 70/2319 (3.0) 0.71 (0.52, 0.96) Q2: >0.52 - ≤0.80 mmol/L (>20 - ≤31 mg/dL) 62/2369 (2.6) 0.63 (0.46, 0.87) Q3: >0.80 - ≤1.27 mmol/L (>31 - ≤49 mg/dL) 69/2389 (2.9) 0.68 (0.50, 0.93) Q4: >1.27 mmol/L (>49 mg/dL) 98/2345 (4.2) Reference

*Stratified by region; CI=confidence interval; HR=hazard ratio; ITT=intention to treat; LDL-C=low-density lipoprotein cholesterol.

CONCLUSION

[288] Alirocumab reduced the odds of death after ACS in patients with elevated atherogenic lipoprotein levels on intensive statin treatment, with similar effects on CV and non-CV death. Patients with higher LDL-C levels at baseline or over ≥3 years of follow-up had particularly large reductions in the odds of death with alirocumab. Lower achieved LDL-C levels were associated with fewer deaths, with patients achieving lower LDL-C levels after 4 months of treatment with alirocumab having a reduced risk of death. Joint semiparametric model analysis demonstrated that the risk of non-CV death was interdependent with the risk of non-fatal CV events (eg, non-fatal MI, unstable angina requiring hospitalization, and non-fatal ischemic stroke), and alirocumab had a strong effect on non-fatal CV events. Accordingly, prevention of non-fatal CV events with alirocumab was associated with a reduction in the odds of non-CV death.

Example 7. Secondary analysis - effect of alirocumab on total fatal and nonfatal cardiovascular events

[289] The risk of non-CV death is generally considered to be independent of the risk of non-fatal CV events and is not modifiable by lowering LDL-C levels. Moreover, previous trials (FOURIER, SPIRE) failed to demonstrate an effect on non-CV death. Therefore, in an additional secondary analysis, the effect of alirocumab on total (first and subsequent) non-fatal cardiovascular (CV) events and all-cause death was analyzed using a joint vulnerability-adjusted model that takes into account the potential association between non-fatal and fatal events. This analysis included all-cause death and total non-fatal CV events (MI, stroke, hospitalization for UA or heart failure, or coronary revascularization for ischemia). Sensitivity analyses restricted non-fatal events to MI, stroke, or UA. The hazard functions for the total number of nonfatal and fatal events were estimated separately using a joint model, their interdependence was determined using a shared vulnerability that accounted for risk heterogeneity among patients, and the correlation with nonfatal events among patients was established. The model also determined whether nonfatal events were associated with an increased risk of death. The model provided accurate relative estimates of the risk of a nonfatal event when nonfatal events were associated with an increased risk of death. Treatment effects were summarized using HRs and compared relative to the results of the standard analysis of the first nonfatal CV event or death.

[290] There were 5425 deaths or non-fatal CV events, a 77% increase over first events (3064). Alirocumab produced similar relative reductions in first and total events compared with placebo. Importantly, with alirocumab, there were 385 fewer total non-fatal CV events or deaths (2905 events with placebo, 2520 events with alirocumab), and 190 fewer first non-fatal CV events or deaths (1627 events with placebo, 1437 events with alirocumab) ( Figure 23 ). Thus, the results from the analysis of first events reflected only approximately half the reduction in total events associated with alirocumab treatment over a median period of 2.8 years.

[291] After 4 years, estimates of the expected total number of nonfatal cardiovascular events for a given patient in the placebo and alirocumab groups at a given time point after randomization were 0.357 and 0.301, respectively. In contrast, the expected proportions of patients with a first nonfatal cardiovascular event in the placebo and alirocumab groups were 0.183 and 0.160, respectively. The numbers needed to treat (95% CI) over 4 years to prevent one nonfatal event were 18 (11–53) based on the total number of events and 44 (26–129) based on the number of first events.

[292] Non-fatal CV events were associated with a markedly higher risk of death, and the variance in vulnerability indicated substantial heterogeneity in risk among patients ( Table 24 ).

Table 24. Analysis of the effect of alirocumab on total non-fatal CV events and all-cause deaths

HR (95% CI) P-value Number of fatal and total number of non-fatal CV events (n=5425) HR alirocumab: placebo for nonfatal events (n=2186 vs n=2513) 0.85 (0.78-0.93) 0.0002 HR alirocumab: placebo for fatal events (n=334 vs n=392) 0.82 (0.70-0.96) 0,0158 Association between non-fatal and fatal events: 2.77 (2.48-3.10) <0.0001 Variance of vulnerability 2.42 (95% CI 2.23-2.61) - <0.0001 Number of fatal and total number of non-fatal CV events limited to MI, stroke or UA (n=2999) HR alirocumab: placebo for nonfatal events (n=1034 vs n=1239) 0.81 (0.73-0.91) 0.0002 HR alirocumab: placebo for fatal events (n=334 vs n=392) 0.81 (0.68-0.96) 0,0161 Association between non-fatal and fatal events: 3.22 (2.77-3.78) <0.0001 Variance of vulnerability 2.47 (95% CI 2.24-2.70) - <0.0001 Analysis of first event: fatal or non-fatal CV event (n=3064) HR alirocumab: placebo for first event (n=1437 vs 1627) 0.88 (0.82-0.94) 0.0002 CI - confidence interval; HR - hazard ratio.

[293] Based on the estimated proportions at 4 years, the numbers needed to treat (95% CI) to prevent 1 non-fatal event are 44 (26-129) based on first events and 18 (11-53) based on total events. Thus, taking into account the total number of events illustrated the high burden of ongoing disease in the study population and the attenuation of this burden by alirocumab ( Figure 22 ). The corresponding post hoc plots by baseline LDL-C subgroups are shown in Figures 23A and 23B . In Figure 23A, the expected number of non-fatal cardiovascular events for a given patient with baseline LDL-C ≥100 mg/dL in the placebo and alirocumab groups at 4 years was 0.489 and 0.380, respectively, and the expected proportion of patients with a first non-fatal cardiovascular event in the placebo and alirocumab groups was 0.237 and 0.183, respectively. The number needed to treat (95% CI) over 4 years to prevent one non-fatal event was 19 (12-45) based on the number of first events and 9 (5-46) based on the total number of events. The number needed to treat to prevent one non-fatal event in the baseline LDL-C ≥100 mg/dL subgroup based on the total number of events was 9 (5-46). In Figure 23B, the expected number of nonfatal cardiovascular events for a given patient with baseline LDL-C <100 mg/dL in the placebo and alirocumab groups at 4 years was 0.160 and 0.151, respectively, and the expected proportion of patients with a first nonfatal cardiovascular event in the placebo and alirocumab groups was 0.302 and 0.267, respectively. The numbers needed to treat (95% CI) over 4 years to prevent one nonfatal event was 103 (38-140) based on the number of first events and 29 (14-217) based on the total number of events (negative values in the CI reflect harm).

[294] The types and numbers of peer-reviewed nonfatal cardiovascular events after randomization are summarized in Table 25 below. Myocardial infarction and need for coronary revascularization were the most common event types, and the proportions of each event type were similar between treatment groups. Patients randomized to alirocumab had numerically fewer nonfatal cardiovascular events of each type, except heart failure requiring hospitalization.

Table 25. Categories of non-fatal cardiovascular events

Event, n (% of total) Alirocumab
(n=9462) Placebo
(n=9462) Total
(n=18924) Myocardial infarction 866 (39.6) 994 (39.6) 1860 (39.6) Stroke 131 (6.0) 181 (7.2) 312 (6.6) Unstable angina requiring hospitalization 37 (1.7) 64 (2.5) 101 (2.1) Heart failure requiring hospitalization 283 (12.9) 276 (11.0) 559 (11.9) The need for coronary revascularization procedure due to ischemia 869 (39.8) 998 (39.7) 1867 (39.7) Total 2,186 2,513 4,699

[295] Results from the joint vulnerability model for total non-fatal cardiovascular events and deaths for the overall study population and for LDL-C subgroups stratified by baseline 100 mg/dL are shown in Figure 24 . Based on the interaction p-values (p=0.02 for non-fatal events, p=0.03 for death), there was significant heterogeneity in the relative effects of alirocumab treatment on both total non-fatal cardiovascular events and deaths, with the ≥100 mg/dL subgroup at randomization receiving a larger relative benefit. This result was also consistent with the observations presented in Figures 23A and 23B .

[296] Table 26 summarizes the distribution of deaths and non-fatal cardiovascular events by event ordinal number. There were 5425 deaths or non-fatal cardiovascular events, 77% more than first events (n=3064). Although the majority of patients did not experience an event during the study, a sizable subgroup of patients experienced more than 1 event (1261 patients). Among patients at risk of a first event, death occurred as a first event in 2.2% and 2.5% of the alirocumab and placebo groups, respectively. Notably, having a first non-fatal cardiovascular event was associated with a greater risk of a subsequent death. Following the first non-fatal cardiovascular event, which occurred a median of 1.0 (0.4, 1.7) years after randomization, death occurred as a second event in 5.7% and 5.0% of patients in the alirocumab and placebo groups, respectively. Similarly, following the second non-fatal cardiovascular event, which occurred a median of 1.2 (0.6, 2.0) years after randomization overall, death occurred as a third event in 6.2% and 6.6% of patients in the alirocumab and placebo groups, respectively. Qualitatively, these data indicate that each subsequent prior non-fatal cardiovascular event is associated with an increased subsequent risk of death. A joint model accounting for individual vulnerability confirmed this observation with an association parameter (95% CI) of 2.04 (1.78–2.29) linking the risks of nonfatal cardiovascular events and death.

Table 26. Distribution of fatal and expert-confirmed non-fatal cardiovascular events by event number

Alirocumab Placebo First event qty/total qty (%) Median time (Q1, Q3) of the event qty/total qty (%) Median time (Q1, Q3) of the event Non-fatal cardiovascular 1,230/9,462 (13.0) 0.9 (0.4, 1.7) 1,392/9,462 (14.7) 1.0 (0.4, 1.8) Fatal outcome 207/9,462 (2.2) 1.5 (0.7, 2.4) 235/9,462 (2.5) 1.5 (0.8, 2.3) Second event Non-fatal cardiovascular 513/1,230 (41.7) 1.2 (0.6, 2.0) 608/1,392 (43.7) 1.3 (0.6, 2.0) Fatal outcome 70/1,230 (5.7) 1.4 (0.7, 2.4) 70/1,392 (5.0) 1.6 (1.0, 2.4) The third event Non-fatal cardiovascular 188/513 (36.7) 1.6 (1.0, 2.3) 245/608 (40.3) 1.5 (0.9, 2.4) Fatal outcome 32/513 (6.2) 1.4 (1.0, 2.7) 40/608 (6.6) 1.4 (0.7, 2.4) Fourth and additional event(s) Non-fatal cardiovascular 255 268 Fatal outcome 25 47 Total Non-fatal cardiovascular 2,186 2,513 Fatal outcome 334 392

[297] Baseline characteristics by event rate category group are summarized in Table 27 below. Patients with at least one event were older, had higher baseline LDL-C, and were more likely to have comorbidities than patients without an event during the study, including diabetes, hypertension, and MI before the defined ACS event. When comparing groups with at least one event, patients with multiple events or a single fatal event had higher baseline LDL-C than patients with a single nonfatal event, and there were some differences in comorbidities.

Table 27. Baseline patient characteristics by categories of number of nonfatal cardiovascular and fatal events

(A)
No events
(n=15860) (B)
Single event = fatal outcome
(n=442) (C)
Single event=non-fatal CV
(n=1361) (D)
Multiple events (n = 1261) p-value (A) versus (B) +(C)+(D) (B) versus (C) (C) versus (D) (B) versus (D) Age, years 58 (51-65) 63 (56-70) 59 (52-66) 61 (54-68) <0.0001 <0.0001 0,0004 <0.0001 Age category <0.0001 <0.0001 0,0003 0.01 <65 years 74.5 56.3 71.1 64.2 From 65 to <75 years 20.8 31.5 22.5 26.6 ≥75 years 4.7 12.2 6.4 9.2 Female gender 24.9 25.1 27.9 26.1 0.03 not significant not significant not significant Region <0.0001 <0.0001 0,0001 <0.0001 Western Europe 22.3 11.3 22.6 22.1 East Europe 29.3 36.0 25.2 22.5 North America 13.8 12.9 20.9 27.4 South America 13.9 20.6 12.3 10.6 Asia 12.8 10.4 9.6 6.3 The rest of the world 7.9 8.8 9.4 11.1 Set event <0.0001 0,005 0.02 0.01 NSTEMI 47.4 52.6 52.8 57.8 STEMI 35.6 26.5 32.3 27.2 Unstable angina 17.0 20.8 14.9 15.0 Time from set event to randomization, months 2.7 (1.7-4.4) 2.5 (1.7-3.6) 2.6 (1.7-4.2) 2.4 (1.6-3.9) <0.0001 not significant 0.03 not significant Lipid-lowering therapy at randomization <0.0001 not significant 0.003 0.004 Atorvastatin/rosuvastatin in high doses 89.3 88.7 86.5 85.9 Other LLT 10.0 9.9 12.1 11.2 Without LLT 0.7 1.4 1.4 2.9 LDL-C level, mg/dL 86 (73-103) 91 (74-109) 88 (73-107) 92 (76-113) <0.0001 not significant 0,0007 not significant LDL-C level ≥100 mg/dL 28.6 37.3 32.0 39.3 <0.0001 0.04 <0.0001 not significant Diabetic status <0.0001 <0.0001 not significant <0.0001 Diabetes 26.8 44.8 33.4 43.4 Prediabetes 44.6 34.4 42.0 36.0 Norm 28.7 20.8 24.5 20.6 Smoking status 0.02 not significant not significant not significant Smokes 24.0 22.9 24.5 25.5 I smoked before 41.0 41.6 42.1 44.2 Never smoked 35.0 35.5 33.4 30.4 Presence in the medical history of information about a previous established event Hypertension 62.4 77.2 73.2 80.7 <0.0001 not significant <0.0001 not significant Myocardial infarction 16.8 28.5 25.8 39.7 <0.0001 not significant <0.0001 <0.0001 Stroke 2.6 7.5 5.7 6.8 <0.0001 not significant not significant not significant Malignant disease 2.6 3.2 3.7 4.9 <0.0001 not significant not significant not significant COPD 3.1 11.3 5.5 10.6 <0.0001 <0.0001 <0.0001 not significant GFR, ml/min per 1.73 ^m2 78.8 (68.3-90.6) 73.2 (59.9-87.3) 76.6 (64.9-88.6) 74.5 (60.0-87.3) <0.0001 not significant <0.0001 not significant GFR, <60 ml/min at 1.73 m ² 11.9 25.3 17.0 24.6 <0.0001 0.0002 <0.0001 not significant

[298] A joint vulnerability-adjusted model was also used to analyze the different baseline LDL-C subgroups (see Figure 25 ). The interaction p-values indicated significant heterogeneity in the relative treatment effects on total non-fatal cardiovascular events and deaths across baseline LDL-C subgroups. Among 5629 patients with baseline LDL-C levels ≥100 mg/dL, alirocumab reduced the total number of non-fatal cardiovascular events and deaths by 255. In contrast, among 13,295 patients with baseline LDL-C levels <100 mg/dL, alirocumab reduced the total number of non-fatal cardiovascular events and deaths by 130.

CONCLUSION

[299] In conclusion, in patients with ACS followed for a median of 28 months, the total number of deaths and non-fatal CV events prevented by alirocumab was twice the number of first events prevented. Alirocumab reduced non-fatal CV events and deaths, with a strong association between the risk of non-fatal and fatal events. Lower achieved LDL-C levels were associated with fewer deaths.

Example 8: Secondary Analysis - Effects of Alirocumab in Diabetic and Prediabetic Patients with ACS

[300] An additional group of ACS patients of particular interest are those with diabetes and prediabetes, as most patients with ACS have glucometabolite disorders. ACS patients with diabetes have a higher risk of recurrent ischemic cardiovascular events than ACS patients without diabetes and derive greater absolute benefit from high-dose statin therapy or from ezetimibe plus statin therapy. In this prespecified analysis, the CV event efficacy and glucometabolite safety of alirocumab or placebo were compared in people with diabetes, prediabetes, or normoglycemia.

a. Initial characteristics

[301] At randomization, 5444 (28.8%) patients had diabetes, 8246 (43.6%) patients had prediabetes, and 5234 (27.7%) patients were normoglycemic. Within each glycometabolic category, baseline characteristics were well balanced between the alirocumab and placebo groups. Baseline characteristics of normoglycemic, prediabetic, and diabetic patients are presented in Table 28 , and baseline characteristics by glycemic stratum by treatment group are presented in Table 29 . Most patients had undergone coronary revascularization for an established ACS event and were receiving evidence-based treatment with two antiplatelet agents, a beta blocker, and a renin-angiotensin system inhibitor. Higher baseline values of body mass index, non-HDL cholesterol and triglyceride levels and lower HDL cholesterol levels were observed in the glycometabolic stratum. There was no gradient in LDL cholesterol levels in the glycometabolic stratum.

Table 28. Baseline characteristics in normoglycemic, prediabetic, and diabetic patients

Normoglycemia (n=5234) Prediabetes
(n=8246) Diabetes
(n=5444) Age (years) 56 (50, 63) 59 (52, 65) 59 (53, 66) Female gender 20.6% 23.6% 31.9% BMI, kg/ ^m2 , median value (Q1, Q3)* 27 (25, 30) 28 (25, 31) 29 (26, 33) Systolic BP - mmHg 125 (115, 135) 126 (117, 137) 130 (120, 140) Diastolic BP - mmHg 78 (70, 83) 79 (70, 83) 79 (70, 84) Acute coronary syndrome event identified - number (%) Non-ST-segment elevation myocardial infarction 2478 (47.4) 3921 (47.6) 2776 (51.1) ST-segment elevation myocardial infarction 1922 (36.8) 2971(36.1) 1643 (30.3) Unstable angina 826 (15.8) 1344 (16.3) 1012 (18.6) NSTEMI/STEMI/UA 47.4/36.8/15.8% 47.6/36.1/16.3% 51.1/30.3/18.6% Laboratory values, median value (Q1, Q3) LDL-C level, mg/dL 86 (74, 104) 88 (74, 104) 85 (71, 104) Non-HDL-C level, mg/dL 112 (97, 134) 115 (100, 136) 117 (101, 140) HDL-C level, mg/dL 44 (38, 52) 43 (37, 51) 41 (35, 48) Triglyceride level, mg/dL 117 (87, 164) 127 (93, 177) 147 (106, 205) A1c level, % 5.4 (5.3, 5.5) 5.9 (5.7, 6.0) 7.0 (6.5, 8.2) Fasting glucose level, mg/dL 93.7 (88.3, 99.1) 100.9 (93.7, 108.1) 133.3 (111.7, 169.4) Follow-up duration - months 2.9 (2.3, 3.5) 2.8 (2.3, 3.4) 2.7 (2.3, 3.4) Satisfied with specified criteria for ≥3 years of follow-up - number (%) 2405 (45.9) 3550 (43.1) 2287 (42.0) Cardiological intervention - no. (%) Percutaneous coronary intervention for established acute coronary syndrome 3929 (75.1) 6009 (72.9) 3739 (68.7) Preliminary coronary artery bypass grafting 228 (4.4) 395 (4.8) 424 (7.8) Cardiotropic drugs - quantity (%) Beta blocker 4285 (81.9) 7031 (85.3) 4674 (85.9) Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker 3832 (73.2) 6427 (77.9) 4457 (81.9) Aspirin 5048 (96.4) 7877 (95.5) 5161 (94.8) P2Y inhibitor ₁₂ 4633 (88.5) 7314 (88.7) 4594 (84.4) Medicines for the treatment of diabetes* - quantity (%) Insulin 0 0 1268 (23.3) Injectable medications for diabetes other than insulin 0 0 47 (0.9) Oral medications for diabetes 4 (0.1) 39 (0.5) 3276 (60.2)

NSTEMI: non-ST-segment elevation myocardial infarction; STEMI: ST-segment elevation myocardial infarction; UA: unstable angina.

Table 29. Baseline characteristics of glycemic stratum by treatment group

Normoglycemia (N=5234) Prediabetes (N=8246) Diabetes (N=5444) Alirocumab
(N=2639) Placebo
(N=2595) Alirocumab
(N=4130) Placebo
(N=4116) Alirocumab
(N=2693) Placebo
(N=2751) Age - years 56 (50-63) 56 (50-63) 59 (52-65) 59 (52-65) 59 (53-66) 59 (53-66) Female gender - number (%) 538 (20.4) 540 (20.8) 996 (24.1) 952 (23.1) 856 (31.8) 880 (32.0) Acute coronary syndrome event identified - number (%) ST-segment elevation myocardial infarction 977 (37.1) 945 (36.5) 1507 (36.6) 1464 (35.6) 817 (30.4) 826 (30.1) Non-ST-segment elevation myocardial infarction 1240 (47.1) 1238 (47.8) 1957 (47.5) 1964 (47.7) 1377 (51.3) 1399 (51.0) Unstable angina 418 (15.9) 408 (15.8) 658 (16.0) 686 (16.7) 492 (18.3) 520 (18.9) Laboratory values at randomization* LDL cholesterol level - mg/dl 86 (73-103) 87 (74-104) 88 (75-105) 87 (74-104) 85 (71-103) 85 (71-105) Non-HDL Cholesterol Level - mg/dL 112 (97-134) 113 (98-134) 116 (100-136) 115 (99-137) 117 (100-140) 117 (102-141) Total cholesterol - mg/dL 158 (141-182) 160 (142-181) 161 (144-183) 160 (142-183) 159 (141-184) 159 (141-184) HDL Cholesterol Level - mg/dL 44 (38-53) 44 (37-52) 43 (37-51) 43 (37-50) 41 (35-48) 41 (35-47) Triglyceride level - mg/dL 116 (86-161) 118 (87-166) 127 (93-177) 127 (93-177) 147 (106-205) 147 (105-204) HbA1c level - % 5.4 (5.3-5.5) 5.4 (5.3-5.5) 5.9 (5.7-6.0) 5.9 (5.7-6.0) 7.0 (6.5-8.3) 7.0 (6.5-8.2) Fasting glucose level - mg/dl 93.6 (88.2-99.0) 93.6 (88.2-97.2) 100.8 (93.6-108.0) 100.8 (93.6-109.8) 133.2 (111.6-167.4) 131.4 (109.8-169.2)

b. Cardiovascular events in the placebo group by glycometabolic status

[302] After 16 weeks of treatment (intention-to-treat population), LDL-C, non-HDL-C, HDL-C, and triglyceride levels were similar among the three subgroups of normoglycemic patients with prediabetes and diabetes in both the alirocumab and placebo groups. In the placebo group, the rates of the primary endpoint were 6.5, 3.4, and 3.1 per 100 person-years for patients with diabetes, prediabetes, and normoglycemia at baseline, respectively ( Figure 26 ). In the placebo group, despite having similar lipid parameters, patients with diabetes had an increased incidence of MACE. The corresponding unadjusted hazard ratios for the primary endpoint in patients with diabetes versus normoglycemia and patients with prediabetes versus normoglycemia were 2.09 (95% CI, 1.78-2.46) and 1.10 (95% CI, 0.93-1.30), respectively ( Figure 27 ). Similar data for the individual components of the primary endpoint are presented in Table 30 .

Table 30. Hazard ratios for individual components of the primary endpoint in the placebo group

Diabetes vs. Prediabetes Diabetes vs. Normal MACE: HR 1.90 (95% CI 1.65, 2.17); P<0.0001 HR 2.09 (95% CI 1.78, 2.46); P<0.0001 Fatal outcome due to coronary heart disease: HR 2.14 (95% CI 1.60, 2.88); P<0.0001 HR 2.54 (95% CI 1.77, 3.64); P<0.0001 Non-fatal myocardial infarction: HR 1.88 (1.59, 2.21); P<0.0001 HR 1.98 (95% CI 1.63, 2.40); P<0.0001 Ischemic stroke: HR 2.10 (95% CI 1.48, 2.99); P<0.0001 HR 2.89 (95% CI 1.84, 4.56); P<0.0001 Unstable angina: HR 1.75 (95% CI 0.98, 3.15); P=0.0573 HR 1.56 (95% CI 0.82, 2.98); P=0.1720 HR stands for hazard ratio; MACE – major adverse cardiovascular event; MI – myocardial infarction; UA – unstable angina; Q – quartile.

c. Effect of alirocumab on lipid levels

[303] Figure 26 shows median changes in lipid parameters at month 4 in each treatment group stratified by baseline glycometabolic category. Changes from baseline in LDL-C at month 4 were similar in each glycometabolic category (median -64% to -65% for alirocumab; +1.0% to 0% for placebo).

[304] In alirocumab-treated patients, median (quartile 1, quartile 3) LDL-C values at month 4 were 31 mg/dL (20, 47), 31 mg/dL (21, 49), and 31 mg/dL (21, 50) among patients with diabetes, prediabetes, and normoglycemia, respectively, compared with 87 mg/dL (71, 107), 87 mg/dL (72, 107), and 88 mg/dL (73, 107) among patients on placebo.

d. Effect of alirocumab on endpoint events according to glucometabolic status

[305] Table 31 shows the results of a prespecified analysis of MACE incidence by intention-to-treat and baseline glycometabolic status. Alirocumab provided similar relative risk reductions for the primary endpoint in patients with diabetes (HR, 0.84; 95% CI, 0.74-0.97), prediabetes (HR, 0.86; 95% CI, 0.74-1.00), and normoglycemia (HR, 0.85; 95% CI, 0.70-1.03), with no significant interaction between glycometabolic status and treatment. However, among patients with diabetes at baseline, the risk of recurrent ischemic events after ACS was high despite high-dose statin treatment. Thus, significantly higher absolute risk at baseline among patients with diabetes resulted in a larger absolute risk reduction with alirocumab (-2.3%) compared with patients with prediabetes (-1.2%) or normoglycemia (-1.2%; P _interaction = 0.0019) ( Table 31 ). Consequently, patients with recent ACS and diabetes received the greatest absolute benefit from alirocumab with the addition of the maximum tolerated dose of a statin.

Table 31. Prespecified tests for patients with diabetes, prediabetes, and normoglycemia

Category N (% of cohort) Cumulative incidence of MACE Absolute risk reduction (95%CI) Relative risk reduction (risk ratio)
(95% CI) Alirocumab
qty/total qty (%) Placebo
qty/total qty (%) All subjects 18,924 (100) 903/9462 (9.5) 1052/9462 (11.1) 1.6% (0.7%, 2.4%) 0.85 (0.78, 0.93) With diabetes 5444 (28.8) 380/2693 (14.1) 452/2751 (16.4) 2.3% (0.4%, 4.2%) 0.84 (0.74, 0.97) With prediabetes 8246 (43.6) 331/4130 (8.0) 380/4116 (9.2) 1.2% (0%, 2.4%) 0.86 (0.74, 1.00) Normoglycemia 5234 (27.7) 192/2639 (7.3) 220/2595 (8.5) 1.2% (-0.3%, 2.7%) 0.85 (0.70, 1.03)

Median follow-up time: 34 months. ARR: absolute risk reduction; NA: not applicable.

e. Glycemic safety of alirocumab

[306] Figure 28 shows the effects of alirocumab on HbA1c, fasting glucose, and incident diabetes in patients without diabetes at baseline and separately in patients with prediabetes or normoglycemia. Among patients without diabetes at baseline, alirocumab treatment resulted in lower mean HbA1c (5.78% vs 5.80%, P=0.0008), similar mean fasting glucose (5.67 vs 5.68 mmol/L, P=0.84), and no excess risk of incident diabetes (HR, 1.00; 95% CI, 0.89-1.11) compared with placebo. Results were similar when considering the separate categories of prediabetes or normoglycemia at baseline. Thus, there was no evidence of an increase in fasting serum glucose or HbA1c levels with alirocumab compared with placebo. Furthermore, there was no overall increase in new-onset diabetes, the pre-specified safety endpoint, with alirocumab compared with placebo during the study period (see Figure 28 and Table 4 ).

CONCLUSION

[307] In a prespecified analysis of diabetic, prediabetic, and normoglycemic patients with recent ACS, the largest absolute benefit from alirocumab plus the maximum tolerated dose of a statin was seen in patients with recent ACS and diabetes. In these patients with recent ACS and diabetes, treatment with alirocumab to achieve LDL-C levels of 25–50 mg/dL resulted in an approximately two-fold absolute reduction in cardiovascular events among patients with diabetes compared with patients with prediabetes or normoglycemia. With a median follow-up of 2.8 years and 2405 patients without diabetes meeting pre-defined criteria for 3-5 years of follow-up, alirocumab did not adversely affect glycemic controls (HbA1c, fasting glucose) or increase the risk of new-onset diabetes.

Example 9: Secondary analysis - effects of alirocumab in patients with peripheral arterial disease, cerebrovascular disease, or both

[308] Patients with atherosclerosis that was evident in more than one vascular bed were at high risk of major adverse cardiovascular events (MACE) and death. A secondary analysis of the ODYSSEY OUTCOMES trial examined whether the benefit of alirocumab was influenced by the presence of multivascular disease, defined as coronary artery disease with concomitant peripheral arterial disease (PAD), cerebrovascular disease (CeVD), or both. The median follow-up was 2.8 years.

a. Initial characteristics

[309] In this analysis, three subgroups of patients with recent ACS were defined by the location of other apparent vascular disease: 1) single-vessel disease (coronary artery disease without known PAD or CeVD), 2) multivessel disease in two vascular beds (coronary artery disease and either PAD or CeVD), and 3) multivessel disease in three vascular beds (coronary artery disease with both PAD and CeVD). An additional sensitivity analysis was performed with four subgroups of patients with ACS: 1) both without PAD and without CeVD; 2) PAD with or without concomitant CeVD; 3) CeVD with or without concomitant PAD; and 4) both PAD and CeVD. PAD included limb arterial disease or abdominal aortic aneurysm. CeVD was defined as a history of carotid endarterectomy, carotid stenting, stroke, or transient ischemic event.

[310] Table 32 summarizes the baseline characteristics of patients with single-vessel (coronary artery) disease, multivessel disease in two beds (divided separately into PAD and separately into CeVD), and multivessel disease in three beds. At baseline, 17,370 patients had single-vessel disease (91.8%), 1,405 patients had multivessel disease in two vascular beds (7.4%; 3.2% PAD only and 4.2% CeVD only), and 149 had multivessel disease in three vascular beds (0.8%). Compared with patients with single-vessel disease, patients with coronary artery disease and PAD, coronary artery disease and CeVD, and multivessel disease in the three beds were older (median ages 58, 62, 62, and 66 years, p<0.0001); patients with coronary artery disease and PAD or coronary artery disease and CeVD were slightly more likely to be female (26.7% and 33.2%, respectively) than those with single-vessel disease (24.7%, p<0.0001). Of all patients with CeVD, 526 (66.2%) had a history of stroke. Patients with multivascular disease in the three beds had more comorbidities, including a history of hypertension, myocardial infarction, and coronary artery bypass grafting, compared with patients with single-vessel (coronary artery) disease (all p<0.0001). Furthermore, patients with multivascular disease in the three beds compared with patients with single-vessel disease had a higher incidence of diabetes (43.6% vs. 27.7%; p<0.0001) and were more likely to be current or former smokers (81.9% vs. 64.9%; p<0.0001). More patients with multivessel disease in the three beds compared with patients with single-vessel disease had a glomerular filtration ratea (GFR) <60 mL/min/1.73 ^m2 (39.6% vs. 12.3%), with median GFR values of 78.5, 73.5, 72.3, and 67.0 mL/min/1.73 ^m2 in patients with single-vessel (coronary) disease, coronary disease and PAD, coronary disease and CeVD, and multivessel disease in the three beds, respectively (p<0.0001). Table 33 shows the baseline characteristics for the four overlapping vascular bed groups by PAD or CeVD.

Table 32. Baseline characteristics according to history of PAD or CeVD category

Monovascular disease
(coronary artery disease without PAD or CeVD)
(n=17370) Disease in two vascular beds
(coronary artery disease and PAD)
(n=610) Disease in two vascular beds
(coronary artery disease and CeVD)
(n=795) Disease in three vascular beds
(coronary artery disease, PAD and CeVD) (n=149) p-value Age, years 58 (51.65) 62 (56, 68) 62 (56, 69) 66 (60, 71) <0.0001 Age category <0.0001 <65 years 12,956 (74.6) 368 (60.3) 456 (57.4) 60 (40.3) from 65 to <75 years 3,575 (20.6) 178 (29.2) 252 (31.7) 72 (48.3) ≥75 years 839 (4.8) 64 (10.5) 87 (10.9) 17 (11.4) Female 4,298 (24.7) 163 (26.7) 264 (33.2) 37 (24.8) <0.0001 Region <0.0001 Western Europe 3,852 (22.2) 152 (24.9) 142 (17.9) 29 (19.5) East Europe 4,993 (28.7) 189 (31.0) 215 (27.0) 40 (26.8) North America 2,513 (14.5) 134 (22.0) 170 (21.4) 54 (36.2) South America 2,413 (13.9) 64 (10.5) 101 (12.7) 10 (6.7) Asia 2,170 (12.5) 22 (3.6) 92 (11.6) 9 (6.0) The rest of the world 1,429 (8.2) 49 (8.0) 75 (9.4) 7 (4.7) Set event <0.0001 NSTEMI 8,300 (47.9) 342 (56.3) 439 (55.4) 94 (63.1) STEMI 6,080 (35.1) 195 (31.1) 227 (28.6) 34 (22.8) Unstable angina 2,963 (17.1) 71 (11.7) 127 (16.0) 21 (14.1) Time from set event to randomization, months 2.6 (1.7, 4.3) 3.0 (1.8, 5.4) 2.7 (1.7, 4.8) 3.0 (2.1, 3.9) 0,0003 Lipid-lowering therapy at randomization <0.0001 Atorvastatin/rosuvastatin in high doses 15,486 (89.2) 525 (86.1) 679 (85.4) 121 (81.2) Other LLT 1,734 (10.0) 75 (12.3) 102 (12.8) 24 (16.1) Without LLT 150 (0.9) 10 (1.6) 14 (1.8) 4 (2.7) LDL-C level, mg/dL 86 (73, 103) 91 (76, 108) 90 (75, 109) 95 (80, 115) <0.0001 LDL-C level ≥100 mg/dL 5,060 (29.1) 218 (35.7) 290 (36.5) 61 (40.9) <0.0001 HDL-C level, mg/dL 42 (36, 50) 42 (36, 50) 43 (36, 51) 43 (37, 51) It doesn't matter Non-HDL-C level, mg/dL 114 (99, 136) 121 (105, 143) 120 (103, 144) 124 (108, 143) <0.0001 Triglyceride level, mg/dL 128 (94, 181) 134 (99, 187) 136 (98, 190) 135 (94, 182) 0.002 Apolipoprotein B level, mg/dl 79 (69, 93) 83 (72, 96) 83 (71, 96) 82 (75, 95) <0.0001 Lipoprotein (a) level, mg/dl 20.8 (6.6, 59.4) 25.5 (7.5, 68.1) 23.0 (7.1, 61.7) 29.4 (9.4, 74.5) 0.004 C-reactive protein level, mg/dL 0.16 (0.08, 3.73) 0.26 (0.11, 0.55) 0.22 (0.10, 0.48) 0.21 (0.11, 0.49) <0.0001 Body mass index, kg/ ^m2 27.9 (25.2, 31.1) 27.7 (24.9, 31.0) 28.1 (25.4, 31.5) 27.7 (24.5, 30.7) It doesn't matter HbA1c level, % 5.8 (5.5, 6.3) 6.0 (5.6, 6.7) 6.1 (5.7, 7.0) 6.0 (5.7, 6.7) <0.0001 GFR, ml/min per 1.73 ^m2 78.5 (68.1, 90.4) 74.1 (61.6, 86.7) 72.9 (59.5, 85.8) 67.0 (52.2, 84.4) <0.0001 GFR, <60 ml/min at 1.73 m ² 2139 (12.3) 135 (22.1) 206 (25.9) 59 (39.6) <0.0001 Diabetic status <0.0001 Diabetes 4,805 (27.7) 225 (36.9) 349 (43.9) 65 (43.6) Prediabetes 7,630 (43.9) 260 (42.6) 299 (37.6) 57 (38.3) Normoglycemia 4,935 (28.4) 125 (20.5) 147 (18.5) 27 (18.1) Smoking status <0.0001 Smokes 4,181 (24.1) 189 (31.0) 147 (18.5) 43 (28.9) I smoked before 7,095 (40.8) 302 (49.5) 335 (42.1) 79 (53.0) Never smoked 6,093 (35.1) 119 (19.5) 313 (39.4) 27 (18.1) Presence in the medical history of information about a previous established event Hypertension 10,930 (62.9) 489 (80.2) 694 (87.3) 136 (91.3) <0.0001 Myocardial infarction 3,147 (18.1) 204 (33.4) 226 (28.4) 62 (41.6) <0.0001 Stroke 0 0 526 (66.2) 85 (57.0) <0.0001 Malignant disease 458 (2.6) 28 (4.6) 34 (4.3) 12 (8.1) <0.0001 COPD 613 (3.5) 64 (10.5) 46 (5.8) 23 (15.4) <0.0001 CABG 826 (4.8) 82 (13.4) 91 (11.4) 48 (32.2) <0.0001 PAD 0 610 (100) 0 149 (100) <0.0001 CeVD 0 0 795 (100) 149 (100) <0.0001 Revascularization due to an established event 12,596 (72.5) 436 (71.5) 540 (67.9) 105 (70.5) 0.04 Medicines Aspirin 16,647 (95.8) 564 (92.5) 737 (92.7) 138 (92.6) <0.0001 P2Y antagonist ₁₂ 15,223 (87.6) 525 (86.1) 664 (83.5) 129 (86.6) 0,005 ACE/ARB inhibitor 13,444 (77.4) 494 (81.0) 655 (82.4) 123 (82.6) 0,0008 Beta blocker 14,687 (84.6) 507 (83.1) 672 (84.5) 124 (83.2) It doesn't matter Ezetimibe 473 (2.7) 38 (6.2) 30 (3.8) 13 (8.7) <0.0001 Treatment outcome measures among patients treated with alirocumab n=8,683 n=302 n=406 n=71 % transition to placebo 691 (8.0) 12 (4.0) 25 (6.2) 2 (2.8) 0.01

Values are median (quartile 1, quartile 3) or n (%). Not significant = p > 0.05. CABG = coronary artery bypass grafting; CeVD = cerebrovascular disease; COPD = chronic obstructive pulmonary disease; CV = cardiovascular disease; GFR = glomerular filtration rate; LDL-C = low-density lipoprotein cholesterol; LLT = lipid-lowering therapy; NSTEMI = non-ST-segment elevation myocardial infarction; PAD = peripheral arterial disease; STEMI = ST-segment elevation myocardial infarction.

Table 33. Baseline characteristics according to history of PAD or CeVD category

No PAD or CeVD
(N=17370) PAD
(including CeVD)
(N=759) CeVD
(including PAD)
(N=944) PAD and CeVD
(N=149) Age, years 58 (51, 65) 62 (57, 69) 63 (57, 70) 66 (60, 71) Age category <65 years 12,956 (74.6) 428 (56.4) 516 (54.7) 60 (40.3) from 65 to <75 years 3,575 (20.6) 250 (32.9) 324 (34.3) 72 (48.3) ≥75 years 839 (4.8) 81 (10.7) 104 (11.0) 17 (11.4) Female 4,298 (24.7) 200 (26.4) 301 (31.9) 37 (24.8) Region Western Europe 3,852 (22.2) 181 (23.8) 171 (18.1) 29 (19.5) East Europe 4,993 (28.7) 229 (30.2) 255 (27.0) 40 (26.8) North America 2,513 (14.5) 188 (24.8) 224 (23.7) 54 (36.2) South America 2,413 (13.9) 74 (9.7) 111 (11.8) 10 (6.7) Asia 2,170 (12.5) 31 (4.1) 101 (10.7) 9 (6.0) The rest of the world 1,429 (8.2) 56 (7.4) 82 (8.7) 7 (4.7) Set event NSTEMI 8,300 (47.9) 533 (56.6) 436 (57.6) 94 (63.1) STEMI 6,080 (35.1) 261 (27.7) 229 (30.3) 34 (22.8) Unstable angina 2,963 (17.1) 148 (15.7) 92 (12.2) 21 (14.1) Time from set event to randomization, months 2.6 (1.7, 4.3) 3.0 (1.9, 5.2) 2.8 (1.8, 4.7) 3.0 (2.1, 3.9) Lipid-lowering therapy at randomization Atorvastatin or rosuvastatin in high doses 15,486 (89.2) 646 (85.1) 800 (84.7) 121 (81.2) Other LLT 1,734 (10.0) 99 (13.0) 126 (13.3) 24 (16.1) Without LLT 150 (0.9) 14 (1.8) 18 (1.9) 4 (2.7) LDL-C level, mg/dL 86 (73, 103) 92 (77, 109) 91 (76, 110) 95 (80, 115) LDL-C level ≥100 mg/dL 5,060 (29.1) 279 (36.8) 351 (37.2) 61 (40.9) HDL-C level, mg/dL 42 (36, 50) 42 (36, 50) 43 (36, 51) 43 (37, 51) Non-HDL-C level, mg/dL 114 (99, 136) 121 (106, 143) 121 (104, 144) 124 (108, 143) Triglyceride level, mg/dL 128 (94, 181) 134 (98, 186) 136 (97, 190) 135 (94, 182) Apolipoprotein B level, mg/dl 79 (69, 93) 83 (73, 96) 83 (72, 96) 82 (75, 95) Lipoprotein (a) level, mg/dl 20.8 (6.6, 59.4) 26.3 (7.6, 69.9) 23.6 (7.3, 63.4) 29.4 (9.4, 74.5) C-reactive protein level, mg/dL 0.16 (0.08, 3.73) 0.25 (0.11, 0.53) 0.22 (0.10, 0.48) 0.21 (0.11, 0.49) Body mass index, kg/ ^m2 27.9 (25.2, 31.1) 27.7 (24.9, 30.9) 28.1 (25.2, 31.3) 27.7 (24.5, 30.7) HbA1c level, % 5.8 (5.5, 6.3) 6.0 (5.7, 6.7) 6.1 (5.7, 7.0) 6.0 (5.7, 6.7) GFR, ml/min per 1.73 ^m2 78.5 (68.1, 90.4) 73.5 (59.1, 85.9) 72.3 (57.0, 85.5) 67.0 (52.2, 84.4) GFR, <60 ml/min at 1.73 m ² 2,139 (12.3) 194 (25.6) 265 (28.1) 59 (39.6) Diabetic status Diabetes 4,805 (27.7) 290 (38.2) 414 (43.9) 65 (43.6) Prediabetes 7,630 (43.9) 317 (41.8) 356 (37.7) 57 (38.3) Normoglycemia 4,935 (28.4) 152 (20.0) 174 (18.4) 27 (18.1) Smoking status Smokes 4,181 (24.1) 232 (30.6) 190 (20.1) 43 (28.9) I smoked before 7,095 (40.8) 381 (50.2) 414 (43.9) 79 (53.0) Never smoked 6,093 (35.1) 146 (19.2) 340 (36.0) 27 (18.1) Presence in the medical history of information about a previous established event Hypertension 10,930 (62.9) 625 (82.3) 830 (87.9) 136 (91.3) Myocardial infarction 3,147 (18.1) 266 (35.0) 288 (30.5) 62 (41.6) Stroke 0 85 (11.2) 611 (64.7) 85 (57.0) Malignant disease 458 (2.6) 40 (5.3) 46 (4.9) 12 (8.1) COPD 613 (3.5) 87 (11.5) 69 (7.3) 23 (15.4) CABG 826 (4.8) 130 (17.1) 139 (14.7) 48 (32.2) PAD 0 759 (100) 149 (15.8) 149 (100) CeVD 0 149 (19.6) 944 (100) 149 (100) Revascularization due to an established event 12,596 (72.5) 541 (71.3) 645 (68.3) 105 (70.5) Medicines Aspirin 16,647 (95.8) 702 (92.5) 875 (92.7) 138 (92.6) P2Y antagonist ₁₂ 15,223 (87.6) 654 (86.2) 793 (84.0) 129 (86.6) ACE/ARB inhibitor 13,444 (77.4) 617 (81.3) 778 (82.4) 123 (82.6) Beta blocker 14,687 (84.6) 631 (83.1) 796 (84.3) 124 (83.2) Ezetimibe 473 (2.7) 51 (6.7) 43 (4.6) 13 (8.7) Treatment outcome measures among patients treated with alirocumab n=8,683 n=477 n=373 n=71 % transition to placebo 691 (8.0) 27 (5.7) 14 (3.8) 2 (2.8)

Values are median (quartile 1, quartile 3) or percentages of the column. CABG - coronary artery bypass grafting; CeVD - cerebrovascular disease; COPD - chronic obstructive pulmonary disease; GFR - glomerular filtration rate; LDL-C - low-density lipoprotein cholesterol; LLT - lipid-lowering therapy; NSTEMI - non-ST-segment elevation myocardial infarction; PAD - peripheral arterial disease; STEMI - ST-segment elevation myocardial infarction.

b. Lowering LDL-C levels

[311] At baseline, median LDL-C levels (quartile 1, quartile 3) were higher in patients with multivessel disease, with values of 86 (73, 103) in patients with single-vessel (CO) disease, 91 (76, 108) in COD and PAD, 90 (75, 109) in COD and CeVD, and 95 mg/dL (80, 115) with multivessel disease in the three beds (p<0.0001). In the placebo group, median LDL-C levels at 4 months were 87 (72, 106) in patients with single-vessel disease; 90 (73, 108) in PAD only; 90 (73, 115) with CeVD alone and 93 mg/dL (78, 118) with multivascular disease in the three beds. In patients treated with alirocumab, median LDL-C levels at 4 months were 30 (20, 47); 34 (23, 50); 34 (21, 52); and 31 (20, 42) across the same four vascular disease categories.

c. Primary endpoint of MACE and all-cause death

[312] Overall, in the ODYSSEY OUTCOMES trial, the incidence of MACE in the placebo and alirocumab groups was 11.1% and 9.5%, respectively, with a corresponding absolute risk reduction (ARR) of 1.6% (95% confidence interval [CI], 0.7%, 2.4%; p=0.0003) (13). Figure 29A shows that this overall MACE efficacy reflected a gradient in absolute risk and ARR by the number of vascular beds involved. For patients in the placebo group with one, two, or three vascular beds involved, the incidence of MACE was 10.0%, 22.2%, and 39.7%, respectively. The corresponding ARRs with alirocumab were 1.4% (0.6%, 2.3%), 1.9% (-2.4%, 6.2%), and 13.0% (-2.0, 28.0%) with a 3-way interaction p=0.0012. The corresponding numbers needed to treat (NNT) to prevent one MACE were 64 for all patients, 69 for patients with single-vessel (coronary) disease, 53 for patients with multivessel disease in two beds, and 8 for patients with multivessel disease in three beds.

[313] The overall incidence of all-cause death in the placebo and alirocumab groups was 4.1% and 3.5%, respectively, with a corresponding ARR of 0.6% (95% CI 0.2%, 1.2%). Similar to MACE, Figure 29B shows that this overall efficacy for all-cause death reflected a gradient in absolute risk and ARR with alirocumab across the number of vascular beds affected by disease. In the placebo group, the incidence of death in one, two, or three vascular beds affected by disease was 3.5%, 10.0%, and 21.8%, respectively. With alirocumab, the corresponding ARRs were 0.4% (-0.1, 1.0), 1.3% (-1.8%, 4.3%), and 16.2% (5.5, 26.8) with a 3-way interaction p=0.0025. The corresponding NNTs for preventing one death were 163 for all patients, 236 for patients with single-vessel (coronary) disease, 78 for patients with multivessel disease in two beds, and 6 for patients with multivessel disease in three beds.

[314] Detailed information on the primary endpoint of MACE and all-cause death are shown in Table 34 and Figure 30 , including the total number of events with corresponding HR and ARR for alirocumab compared with placebo for the primary endpoint and all-cause death in patients with single-vessel (coronary) disease, multivessel disease in two beds (divided into PAD or CeVD), and multivessel disease in three beds. Table 35 shows these details for the four overlapping vascular bed groups by PAD or CeVD.

Table 34. Primary endpoint of MACE and all-cause death according to history of PAD or CeVD category

Alirocumab
qty/total qty (%) Placebo
qty/total qty (%) HR (95% CI) P-value of 3-way relationship for HR ARR (95% CI) P-value of 3-way relationship for ARR NNT* Primary component Monovascular disease (coronary artery disease without PAD or CeVD) 740/8,683 (8.5) 866/8,687 (10.0) 0.84 (0.76, 0.93) 0.0153 1.4 (0.6, 2.3) 0,0012 69 Disease in two vascular beds (coronary artery disease and PAD) 69/302 (22.8) 73/308 (23.7) 0.98 (0.72, 1.34) 0.9 (-5.9, 7.6) 117 Disease in two vascular beds (coronary artery disease and CeVD) 75/406 (18.5) 82/389 (21.1) 0.92 (0.68, 1.24) 2.6 (-2.9, 8.2) 38 Disease in three vascular beds (coronary artery disease, PAD and CeVD) 19/71 (26.8) 31/78 (39.7) 0.54 (0.32, 0.89) 13.0 (-2.0, 28.0) 8 All patients 903/9,462 (9.5) 1,052/9,462 (11.1) 0.85 (0.78, 0.93) 1.6 (0.7, 2.4) 64 Fatal outcome from any cause Monovascular disease (coronary artery disease without PAD or CeVD) 268/8,683 (3.1) 305/8,687 (3.5) 0.87 (0.74, 1.03) 0.0058 0.4 (-0.1, 1.0) 0.0025 236 Disease in two vascular beds (coronary artery disease and PAD) 28/302 (9.3) 27/308 (8.8) 1.11 (0.68, 1.81) -0.5 (-5.1, 4.0) But. Disease in two vascular beds (coronary artery disease and CeVD) 34/406 (8.4) 43/389 (11.1) 0.76 (0.49, 1.17) 2.7 (-6.8, 1.4) 37 Disease in three vascular beds (coronary artery disease, PAD and CeVD) 4/71 (5.6) 17/78 (21.8) 0.20 (0.07, 0.57) 16.2 (5.5, 26.8) 6 All patients 334/9,462 (3.5) 392/9,462 (4.1) 0.85 (0.77, 0.98) 0.6 (0.1, 1.2) 163

HRs reflect stratification by geographic region in models with interactions between pre-PAD and pre-CeVD treatment. *Based on observed incidence rates over a median follow-up of 2.8 years.

ARR=absolute risk reduction; CeVD=cerebrovascular disease; CI=confidence interval; HR=hazard ratio; MACE=major adverse cardiovascular event; NNT=number needed to treat; PAD=peripheral arterial disease.

Table 35. Primary endpoint of MACE and all-cause death according to history of PAD or CeVD category

Alirocumab
qty/total qty (%) Placebo
qty/total qty (%) HR (95% CI) Log rank
p-value ARR (95% CI) NNT* Primary MACE No PAD or CeVD 740/8,683 (8.5) 866/8,687 (10.0) 0.85 (0.77, 0.93) 0,0008 1.4 (0.6, 2.3) 69 PAD (including CeVD) 88/373 (23.4) 104/386 (26.9) 0.83 (0.62, 1.10) 0.19 3.4 (-2.8, 9.5) 30 CeVD (including PAD) 94/477 (19.7) 113/467 (24.2) 0.80 (0.61, 1.05) 0.10 4.5 (-0.8, 9.8) 22 PAD and CeVD 19/71 (26.8) 31/78 (39.7) 0.63 (0.35, 1.12) 0.11 13.0 (-2.0, 28.0) 8 All patients 903/9,462 (9.5) 1,052/9,462 (11.1) 0.85 (0.78, 0.93) 0,0003 1.6 (0.7, 2.4) 64 Fatal outcome from any cause No PAD or CeVD 268/8,683 (3.1) 305/8,687 (3.5) 0.88 (0.75, 1.04) 0.12 0.4 (-0.1, 1.0) 236 PAD (including CeVD) 32/373 (8.6) 44/386 (11.4) 0.71 (0.45, 1.12) 0.14 2.8 (-1.4, 7.1) 35 CeVD (including PAD) 38/477 (8.0) 60/467 (12.8) 0.56 (0.37, 0.84) 0,0047 4.9 (1.0, 8.8) 20 PAD and CeVD 4/71 (5.6) 17/78 (21.8) 0.23 (0.08, 0.68) 0.0038 16.2 (5.5, 26.8) 6 All patients 334/9,462 (3.5) 392/9,462 (4.1) 0.85 (0.77, 0.98) 0.0261 0.6 (0.1, 1.2) 163

HR and p-values reflect stratification by geographic region.

ARR - absolute risk reduction; CeVD - cerebrovascular disease; CI - confidence interval; HR=hazard ratio; NNT - number needed to treat; PAD - peripheral arterial disease.

d. Safety Summary

[315] Overall, there were no differences in the incidence of adverse events or laboratory abnormalities between the alirocumab and placebo groups, except for local injection site reactions, which were more common in the alirocumab group. Table 36 shows all safety endpoints for alirocumab compared with placebo in patients with single-vessel (coronary) disease, two-bed multivessel disease (divided into PAD or CeVD), and three-bed multivessel disease. No significant differences were observed between groups.

Table 36. Endpoints for safety assessment

Monovascular disease
(coronary artery disease without PAD or CeVD) Disease in two vascular beds
(coronary artery disease and PAD) Disease in two vascular beds
(coronary artery disease and CeVD) Disease in three vascular beds
(coronary artery disease, PAD and CeVD) Alirocumab
(n=8672) Placebo
(n=8668) Alirocumab
(n=302) Placebo
(n=308) Alirocumab
(n=406) Placebo
(n=389) Alirocumab
(n=71) Placebo
(n=78) Any undesirable phenomenon 6,532 (75.3) 6,619 (76.4) 250 (82.8) 262 (85.1) 321 (79.1) 328 (84.3) 62 (87.3) 73 (93.6) Serious adverse event 1,905 (22.0) 2,012 (23.2) 124 (41.1) 142 (46.1) 136 (33.5) 151 (38.8) 37 (52.1) 45 (57.7) An adverse event that results in death 143 (1.6) 175 (2.0) 15 (5.0) 15 (4.9) 22 (5.4) 24 (6.2) 1 (1.4) 8 (10.3) adverse event leading to discontinuation of treatment 298 (3.4) 285 (3.3) 21 (7.0) 15 (4.9) 19 (4.7) 18 (4.6) 5 (7.0) 6 (7.7) Local reaction at the injection site 339 (3.9) 185 (2.1) 8 (2.6) 4 (1.3) 9 (2.2) 11 (2.8) 4 (5.6) 3 (3.8) General allergic reaction 670 (7.7) 643 (7.4) 31 (10.3) 38 (12.3) 41 (10.1) 45 (11.6) 6 (8.5) 10 (12.8) Exacerbation of diabetes or diabetic complication in patients with diabetes at baseline 444/2,369 (18.7) 521/2,427 (21.5) 23/99 (2.3) 28/126 (22.2) 29/188 (15.4) 32/161 (19.9) 10/32 (31.3) 2/33 (6.1) New-onset diabetes among patients without diabetes at baseline* 595/6,303 (9.4) 617/6,241 (9.9) 26/203 (12.8) 22/182 (12.1) 24/218 (11.0) 32/228 (14.0) 3/39 (7.7) 5/45 (11.1) Neurocognitive disorder 120 (1.4) 143 (1.6) 6 (2.0) 10 (3.2) 9 (2.2) 10 (2.6) 8 (11.3) 4 (5.1) Liver disorder 450 (5.2) 493 (5.7) 19 (6.3) 18 (5.8) 24 (5.9) 21 (5.4) 7 (9.9) 2 (2.6) Types of cataracts 99 (1.1) 117 (1.3) 8 (2.6) 9 (2.9) 10 (2.5) 5 (1.3) 3 (4.2) 3 (3.8) Hemorrhagic stroke confirmed by examination (fatal and non-fatal) 10 (0.1) 13 (0.1) 1 (0.3) 1 (0.3) 2 (0.5) 3 (0.8) 0 0

Values are qty/total qty (%) or n (%).

* New-onset diabetes was defined as the presence of one or more of the following with confirmation of diagnosis by a blinded external diabetes expert: report of an adverse event, new prescription for a diabetes medication, glycated hemoglobin ≥6.5% on two occasions (and baseline <6.5%), or fasting serum glucose ≥126 mg/dL (7.0 mmol/L) on two occasions (and baseline <126 mg/dL).

CONCLUSION

[316] Among patients with ACS and dyslipidemia despite intensive statin therapy, patients with multivascular disease, including a history of concomitant PAD, CeVD, or both, were associated with a significantly higher risk of MACE and death. In these patients, treatment with alirocumab resulted in a higher ARR than in patients without concomitant PAD or CeVD ( Figure 30 ). Therefore, patients with multivascular disease should be considered preferred candidates for alirocumab treatment after ACS.

Example 10. Secondary analysis - effects of alirocumab in patients with prior coronary artery bypass grafting

a. Baseline characteristics by previous CABG status

[317] Patients with prior coronary artery bypass grafting (CABG) have extensive natural coronary artery and graft atherosclerosis and are at increased risk of CV events and death. In a secondary analysis of the ODYSSEY OUTCOMES trial, patients were categorized by CABG status: (1) no CABG (n=16,896); (2) CABG after established ACS but before randomization, including 44 patients who also had prior CABG before established ACS (established CABG; n=1,025); or (3) CABG before established ACS (prior CABG; n=1,003) ( Table 37 ). Compared with patients without prior CABG or established CABG, patients with prior CABG were older, more likely to be female, and more likely to have prior MI, stroke, PAD, diabetes, and hypertension. Additionally, patients with prior CABG were more likely to have non-ST-segment elevation MI (NSTEMI) as their established ACS, were more likely to receive a renin-angiotensin system (RAS) inhibitor, and were less likely to receive a beta-blocker. Patients with prior CABG were less likely to receive a high-dose statin and more likely to receive other lipid-lowering therapy (including ezetimibe) with higher baseline LDL-C, non-HDL-C, apoB, and lipoprotein(a) levels. Within each CABG category, there were no significant differences in baseline characteristics between patients assigned to receive alirocumab or placebo. Among alirocumab-treated patients without prior CABG (27.2%), patients who underwent CABG due to established ACS (28.3%), and patients with prior CABG (34.5%), the dose was secretly increased from 75 to 150 mg after randomization per protocol ( Table 37 ). The numbers of patients who underwent a secret alirocumab dose adjustment per protocol were similar in each category ( Table 37 ).

Table 37. Baseline characteristics before CABG status

Without CABG
(n=16896) Installed by CABG
(n=1025) Pre-CABG
(n=1003) P-value Age, years 58 (51, 65) 60 (53, 65) 63 (57, 70) <0.0001 Age category <0.0001 <65 years 12563 (74.4) 726 (70.8) 551 (54.9) From 65 to <75 years 3479 (20.6) 255 (24.9) 343 (34.2) ≥75 years 854 (5.0) 44 (4.3) 109 (10.9) Female gender 4354 (25.8) 211 (20.6) 197 (19.6) <0.0001 Region <0.0001 Western Europe 3767 (22.3) 230 (22.4) 178 (17.7) East Europe 5049 (29.9) 180 (17.6) 208 (20.7) North America 2273 (13.5) 247 (24.1) 351 (35.0) South America 2293 (13.6) 180 (17.6) 115 (11.5) Asia 2196 (13.0) 56 (5.5) 41 (4.1) The rest of the world 1318 (84.5) 132 (8.5) 110 (11.0) Set event <0.0001 NSTEMI 7913 (46.9) 612 (59.8) 650 (64.9) STEMI 6156 (36.5) 214 (20.9) 166 (16.6) Unstable angina 2798 (16.6) 198 (19.3) 186 (18.6) Time from set event to randomization, months 2.6 (1.7, 4.2) 3.8 (2.7, 6.8) 2.5 (1.7, 4.1) <0.0001 Lipid-lowering therapy at randomization <0.0001 Atorvastatin/rosuvastatin in high doses 15077 (89.2) 900 (87.8) 834 (83.2) Other lipid-lowering therapies 1690 (10.0) 107 (10.4) 138 (13.8) Without lipid-lowering therapy 129 (0.8) 18 (1.8) 31 (3.1) LDL-C level, mg/dL 86 (73, 103) 87 (74, 107) 94 (78, 116) <0.0001 LDL-C level ≥100 mg/dL 4878 (28.9) 333 (32.5) 418 (41.7) <0.0001 HDL-C level, mg/dL 42 (36, 50) 42 (36, 50) 42 (35, 50) 0,0166 Non-HDL-C level, mg/dL 114 (99, 136) 117 (102, 140) 126 (107, 153) <0.0001 Triglyceride level, mg/dL 128 (94, 181) 137 (98, 192) 139 (102, 195) <0.0001 Apolipoprotein B level, mg/dl 79 (69, 92) 82 (70, 96) 85 (75, 103) <0.0001 Lipoprotein (a) level, mg/dl 20.3 (6.6, 58.1) 27.8 (7.5, 69.0) 33.2 (8.1, 79.9) <0.0001 C-reactive protein level, mg/dL 0.16 (0.08, 0.38) 0.19 (0.09, 0.47) 0.18 (0.08, 0.41) <0.0001 Body mass index, kg/ ^m2 27.9 (25.2, 31.0) 27.9 (25.2, 31.0) 29.2 (26.4, 32.4) <0.0001 Hemoglobin A1c level, % 5.8 (5.5, 6.3) 5.9 (5.5, 6.4) 6.0 (5.6, 6.7) <0.0001 Estimated GFR, <60 ml/min per 1.73 ^m2 2138 (12.7) 141 (13.8) 260 (25.9) <0.0001 Diabetic status <0.0001 Diabetes 4691 (27.8) 346 (33.8) 407 (40.6) Prediabetes 7482 (44.3) 382 (37.3) 382 (38.1) Normoglycemia 4723 (28.0) 297 (29.0) 214 (21.3) Smoking status <0.0001 Smokes 4258 (25.2) 136 (13.3) 166 (16.6) I smoked before 6795 (40.2) 526 (51.3) 490 (48.9) Never smoked 5842 (34.6) 363 (35.4) 347 (34.6) Presence in the medical history of information about a previous established event Hypertension 10672 (63.2) 703 (68.6) 874 (87.1) <0.0001 Myocardial infarction 2748 (16.3) 194 (18.9) 697 (69.5) <0.0001 Stroke 501 (3.0) 40 (3.9) 70 (7.0) <0.0001 Malignant disease 450 (2.7) 30 (2.9) 52 (5.2) <0.0001 COPD 621 (3.7) 51 (5.0) 74 (7.4) <0.0001 CABG 0 44 (4.3) 1003 (100) <0.0001 PAD 577 (3.4) 58 (5.7) 124 (12.4) <0.0001 CeVD 735 (4.4) 74 (7.2) 135 (13.5) <0.0001 Revascularization due to an established event 12070 (71.4) 1025 (100) 582 (58.0) <0.0001 CABG 0 1025 (100) 0 <0.0001 PCI 12070 (71.4) 117 (11.4) 582 (58.0) <0.0001 Medicines Aspirin 16160 (95.6) 978 (95.4) 948 (94.5) not significant P2Y antagonist ₁₂ 15280 (90.4) 410 (40.0) 851 (84.8) <0.0001 ACE inhibitor/angiotensin receptor blocker 13245 (78.4) 656 (64.0) 815 (81.3) <0.0001 Beta blocker 14227 (88.0) 895 (87.3) 868 (86.5) 0.0045 Ezetimibe 425 (2.5) 40 (3.9) 89 (8.9) <0.0001 Treatment outcome measures among patients treated with alirocumab n=8466 n=494 n=502 %, which was increased to 150 mg SC Q2W 2302 (27.2) 140 (28.3) 173 (34.5) 0.0018 % transition to placebo 665 (7.9) 37 (7.5) 28 (5.6) not significant

Values are medians (quartile 1, quartile 3) or column percentages. Not significant: p>0.05

NSTEMI - non-ST-segment elevation myocardial infarction; STEMI - ST-segment elevation myocardial infarction; LDL-C - low-density lipoprotein cholesterol; HDL-C - high-density lipoprotein cholesterol; GFR - glomerular filtration rate; COPD - chronic obstructive pulmonary disease; CABG - coronary artery bypass graft surgery; PAD - peripheral arterial disease; CeVD - cerebrovascular disease; SC - subcutaneous; Q2W - every other week.

b. Endpoints by status of previous CABG

[318] In each category, the relative hazard ratio (HR), absolute risk reduction (ARR) values, and the number needed to treat for 2.8 years (NNT) to prevent 1 primary endpoint (MACE) or death for alirocumab were determined. The cumulative incidence of the primary composite endpoint was significantly higher among patients with prior CABG (27.7%) than among patients who underwent CABG during hospitalization with established ACS (7.1%) or patients without CABG (9.5%) ( Table 38 and Figure 31 ). Patients with prior CABG also had higher rates of individual components of the primary endpoint and secondary endpoints ( Table 38 ).

Table 38. Primary and secondary endpoints by prior CABG status

n (%) Installed in comparison with
absence of CABG Previous versus
absence of CABG Without CABG
(n=16896) Installed by CABG
(n=1025) Pre-CABG
(n=1003) HR (95% CI)* HR (95% CI)* Primary endpoint 1604 (9.5) 73 (7.1) 278 (27.7) 0.56 (0.44, 0.72) 1.46 (1.27, 1.69) Fatal outcome due to CHD 347 (2.1) 17 (1.7) 63 (6.3) 0.54 (0.33, 0.89) 1.34 (1.00, 1.81) Non-lethal MI 1083 (6.4) 50 (4.9) 215 (21.4) 0.59 (0.44, 0.79) 1.62 (1.38, 1.91) Ischemic stroke 219 (1.3) 11 (1.1) 33 (3.3) 0.69 (0.37, 1.29) 1.14 (0.76, 1.71) Unstable angina 79 (0.5) 5 (0.5) 13 (1.3) 0.80 (0.31, 2.05) 1.64 (0.85, 3.17) Secondary endpoints The need for coronary revascularization procedure due to ischemia 1311 (7.8) 57 (5.6) 191 (19.0) 0.65 (0.49, 0.85) 1.57 (1.33, 1.86) Fatal outcome due to CV 415 (2.5) 22 (2.1) 74 (7.4) 0.60 (0.39, 0.93) 1.33 (1.01, 1.75) Fatal outcome from any cause 592 (3.5) 40 (3.9) 94 (9.4) 0.81 (0.58, 1.13) 1.24 (0.98, 1.58) PAD event recorded by the researcher 192 (1.1) 18 (1.8) 36 (3.6) 1.20 (0.71, 2.03) 1.05 (0.71, 1.57)

* Adjusts for sex, age, geographic region, diabetes status, smoking status, baseline LDL-C, baseline HDL-C, baseline BMI, renal function (GFR, <60 vs. >= 60 mL/min per 1.73 ^m2 ), history of MI, history of stroke, history of COPD, history of PAD, PCI for the established event

[319] Alirocumab reduced the odds of the primary endpoint in the overall study population (HR 0.85 [0.78–0.93]), with consistent relative risk reductions within each CABG category ( Table 39 and Figure 31 ). In contrast, the absolute risk reduction for the primary endpoint with alirocumab was most pronounced among patients with prior CABG (6.4% [0.9%, 12.0%], NNT _{2.8 years} = 16) compared with established CABG (0.9% [−2.3%, 4.0%]) and in patients without prior CABG (1.3% [0.5%, 2.2%]), respectively ( Table 39 and Figure 32 ).

[320] Similar results were seen for secondary endpoints. The relative risk reduction with alirocumab was without heterogeneity according to CABG category, except for cases of coronary revascularization due to ischemia. The absolute risk reductions for secondary endpoints were numerically greater among patients with prior CABG compared with the other two CABG categories, including CHD-related death (3.0% vs 0.5%, 0%), nonfatal MI (2.2% vs 1.2%, 0%), ischemic stroke (2.2% vs -0.3%, 0.4%), coronary revascularization (4.6% vs 3.7%, 0.7%), investigator-reported PAD events (2.8% vs 0.3%, 0.3%), CV-related death (3.6% vs 1.0%, 0.1%), and all-cause death (3.6% vs 0.5%, 0.4%). Among patients with prior CABG, the NNT _{of 2.8 years} to prevent one death was 28. For each secondary endpoint except CHD-related death, there was a significant interaction between treatment and CABG category in terms of absolute risk reduction ( Table 39 and Figure 32 ).

Table 39. Primary and secondary endpoints by randomized treatment and according to prior CABG status

Alirocumab
qty/total qty (%) Placebo
qty/total qty (%) HR (95% CI) HR Relationship
p-value ARR (95% CI) ARR Relationship
p-value Primary composite endpoint Without CABG 747/8466 (8.8) 857/8430 (10.2) 0.86 (0.78, 0.95) 0.71 1.3 (0.5, 2.2) 0,0007 Installed by CABG 33/494 (6.7) 40/531 (7.5) 0.85 (0.54, 1.35) 0.9 (-2.3, 4.0) Pre-CABG 123/502 (24.5) 155/501 (30.9) 0.77 (0.61, 0.98) 6.4 (0.9, 12.0) All patients 903/9462 (9.5) 1052/9462 (11.1) 0.85 (0.78, 0.93) 1.6 (0.7, 2.4) Fatal outcome due to CHD Without CABG 174/8466 (2.1) 173/8430 (2.1) 1.00 (0.81, 1.23) 0.20 0 (-0.4, 0.4) 0.09 Installed by CABG 7/494 (1.4) 10/531 (1.9) 0.73 (0.28, 1.91) 0.5 (-1.1, 2.0) Pre-CABG 24/502 (4.8) 39/501 (7.8) 0.62 (0.37, 1.03) 3.0 (0, 6.0) All patients 205/9462 (2.2) 222/9462 (2.3) 0.92 (0.76, 1.11) 0.2 (-0.2, 0.6) Non-lethal MI Without CABG 503/8466 (5.9) 580/8430 (6.9) 0.86 (0.76, 0.97) 0.87 0.9 (0.2, 1.7) 0,0161 Installed by CABG 21/494 (4.3) 29/531 (5.5) 0.74 (0.42, 1.30) 1.2 (-1.4, 3.8) Pre-CABG 102/502 (20.3) 113/501 (22.6) 0.88 (0.67, 1.15) 2.2 (-2.8, 7.3) All patients 626/9462 (6.6) 722 (7.6) 0.86 (0.77, 0.96) 1.0 (0.3, 1.8) Ischemic stroke Without CABG 94/8466 (1.1) 125 (1.5) 0.75 (0.57, 0.98) 0.37 0.4 (0, 0.7) 0,0118 Installed by CABG 6/494 (1.2) 5/531 (0.9) 1.24 (0.38, 4.05) -0.3 (-1.5, 1.0) Pre-CABG 11/502 (2.2) 22/501 (4.4) 0.49 (0.24, 1.01) 2.2 (0, 4.4) All patients 111/9462 (1.2) 152/9462 (1.6) 0.73 (0.57, 0.93) 0.4 (0.1, 0.8) Unstable angina requiring hospitalization Without CABG 29/8466 (0.3) 50/8430 (0.6) 0.57 (0.36, 0.91) 0.81 0.3 (0, 0.5) 0.0397 Installed by CABG 2/494 (0.4) 3/531 (0.6) 0.69 (0.12, 4.10) 0.2 (-0.7, 1.0) Pre-CABG 6/502 (1.2) 7/501 (1.4) 0.85 (0.28, 2.52) 0.2 (-1.2, 1.6) All patients 37/9462 (0.4) 60/9462 (0.6) 0.61 (0.41, 0.92) 0.2 (0.1, 0.5) Coronary revascularization Without CABG 629/8466 (7.4) 682/8430 (8.1) 0.92 (0.82, 1.02) 0.0319 0.7 (-0.2, 1.5) 0,0013 Installed by CABG 18/494 (3.6) 39/531 (7.3) 0.47 (0.27, 0.82) 3.7 (0.9, 6.5) Pre-CABG 84/502 (16.7) 107/501 (21.4) 0.74 (0.55, 0.98) 4.6 (-0.2, 9.5) All patients 731/9462 (7.7) 828/9462 (8.8) 0.88 (0.79, 0.97) 1.0 (0.2, 1.8) Fatal outcome due to CV Without CABG 204/8466 (2.4) 211/8430 (2.5) 0.96 (0.79, 1.16) 0.14 0.1 (-0.4, 0.6) 0.0341 Installed by CABG 8/494 (1.6) 14/531 (2.6) 0.59 (0.25, 1.42) 1.0 (-0.7, 2.8) Pre-CABG 28/502 (5.6) 46/501 (9.2) 0.61 (0.38, 0.97) 3.6 (0.4, 6.8) All patients 240/9462 (2.5) 271/9462 (2.9) 0.88 (0.74, 1.05) 0.3 (-0.1, 0.8) Fatal outcome from any cause Without CABG 278/8466 (3.3) 314/8430 (3.7) 0.88 (0.75, 1.03) 0.48 0.4 (-0.1, 1.0) 0.0304 Installed by CABG 18/494 (3.6) 22/531 (4.1) 0.85 (0.46, 1.59) 0.5 (-1.9, 2.9) Pre-CABG 38/502 (7.6) 56/501 (11.2) 0.67 (0.44, 1.01) 3.6 (0, 7.2) All patients 334/9462 (3.5) 392/9462 (4.1) 0.85 (0.77, 0.98) 0.6 (0.1, 1.2) PAD event recorded by the researcher Without CABG 82/8466 (1.0) 110/8430 (1.3) 0.74 (0.56, 0.99) 0.30 0.3 (0, 0.7) 0.0053 Installed by CABG 8/494 (1.6) 10/531 (1.9) 0.81 (0.32, 2.06) 0.3 (-1.3, 1.9) Pre-CABG 11/502 (2.2) 25/501 (5.0) 0.41 (0.20, 0.84) 2.8 (0.5, 5.1) All patients 101/9462 (1.1) 145/9462 (1.5) 0.69 (0.54, 0.89) 0.5 (0.1, 0.8)

HR and p-value of the association HR reflects stratification by geographic region.

CONCLUSION

[321] Among patients with recent ACS and elevated atherogenic lipoproteins despite intensive statin therapy, patients with prior CABG achieved a large absolute reduction in the odds of fatal and nonfatal CV events with alirocumab treatment.

Example 11. Secondary analysis - effects of alirocumab in patients with type 1 and type 2 myocardial infarctions

[322] Lowering LDL cholesterol (LDL-C) with statins and PCSK9 inhibitors reduces the risk of myocardial infarction (MI), but the effects on specific types of MI remain unclear. In a prespecified analysis of the ODYSSEY OUTCOMES trial, the incidence and outcome of MI types (using the Universal Definition, 3rd Edition) were assessed in patients with recent acute coronary syndrome (ACS) and elevated LDL-C despite intensive statin therapy who were randomized to receive the PCSK9 inhibitor alirocumab or placebo and followed for cardiovascular outcomes. Overall, 1383 (7.3%) patients experienced MI after randomization (total 1860 MI events). Among them, 991 (71.7%) patients had a total of 1223 type 1 MI events (42 were considered fatal), 287 (20.1%) had a total of 386 type 2 MI events (1 was considered fatal), 225 (16.3%) had type 4 MI, and the remaining 7 (<0.01%) had type 3 or type 5 MI.

[323] Baseline characteristics of patients with type 1 and type 2 MI are shown in Table 40 . Patients with type 1 MI, compared with patients with type 2 MI, were older, more often female, more often black, from North America or Europe, and had a history of hypertension, congestive heart failure, pulmonary disease, diabetes, and malignancy. LDL-C, Lp(a), and high-sensitivity C-reactive protein (hsCRP) levels were higher in patients with MI than in those without MI. LDL-C and hsCRP levels did not differ among patients with type 1 or type 2 MI, but Lp(a) levels were higher in patients with type 2 MI.

Table 40. Baseline characteristics of patients with type 1 and type 2 myocardial infarctions

Characteristics (A)
No event
(n=17719) (B)
First event=1st type
(n=963) (C)
First event=2nd type
(n=242) (A) compared to (B) compared to (C)
P-value (B) versus (C), P-value Age, years 58 (52, 65) 59 (52, 66) 65 (59, 72) <0.0001 <0.0001 Age category <0.0001 <0.0001 <65 years 13069 (73.8) 651 (67.6) 120 (49.6) From 65 to <75 years 3757 (21.2) 243 (25.2) 77 (31.8) ≥75 years 893 (5.0) 69 (7.2) 45 (18.6) Female gender 4416 (24.9) 267 (27.7) 79 (32.6) 0.0039 not significant Race <0.0001 not significant Caucasoids 14039 (79.2) 788 (81.8) 197 (81.4) Mongoloids 2390 (13.5) 86 (8.9) 22 (9.1) Negroids 411 (2.3) 44 (4.6) 18 (7.4) Other 879 (5.0) 45 (4.7) 5 (2.1) Region <0.0001 0,0290 Western Europe 3894 (22.0) 232 (24.1) 49 (20.2) East Europe 5185 (29.3) 199 (20.7) 53 (21.9) North America 2555 (14.4) 234 (24.3) 82 (33.9) South America 2469 (13.9) 103 (10.7) 16 (6.6) Asia 2194 (12.4) 80 (8.3) 19 (7.9) The rest of the world 1422 (8.0) 115 (11.9) 23 (9.5) Set event <0.0001 not significant NSTEMI 8443 (47.7) 587 (61.0) 145 (59.9) STEMI 6209 (35.1) 259 (26.9) 68 (28.1) Unstable angina 3037 (17.2) 116 (12.1) 29 (12.0) Time from set event to randomization, months 2.6 (1.7, 4.4) 2.5 (1.7, 3.9) 2.5 (1.7, 4.2) 0.0369 not significant Lipid-lowering therapy at randomization <0.0001 not significant Atorvastatin/rosuvastatin in high doses 15766 (89.0) 845 (87.7) 200 (82.6) Other LLT 1802 (10.2) 98 (10.2) 35 (14.5) Without LLT 151 (0.9) 20 (2.1) 7 (2.9) LDL-C level, mg/dL 86 (73, 103) 91 (76, 113) 91 (75, 109) <0.0001 not significant LDL-C level ≥100 mg/dL 5177 (29.2) 365 (37.9) 87 (36.0) <0.0001 not significant HDL-C level, mg/dL 43 (36, 50) 41 (35, 49) 45 (37, 54) <0.0001 <0.0001 Non-HDL-C level, mg/dL 114 (99, 136) 123 (105, 149) 121 (103, 137) <0.0001 not significant Triglyceride level, mg/dL 128 (94, 181) 138 (100, 201) 130 (90, 178) <0.0001 0,0117 ApoB level, mg/dL 79 (69, 92) 84 (72.101) 82 (71, 95) <0.0001 not significant Lp(a) level, mg/dl 20.8 (6.6, 59.0) 25.4 (7.3, 70.0) 34.9 (9.3, 76.8) <0.0001 not significant CRP level, mg/dL 0.16 (0.08, 0.38) 0.23 (0.10, 0.53) 0.26 (0.11, 0.58) <0.0001 not significant BMI, kg/ ^m2 27.9 (25.2, 31.0) 28.6 (25.7, 31.7) 28.7 (25.7, 32.8) <0.0001 not significant HbA1c level, % 5.8 (5.5, 6.3) 6.0 (5.6, 6.8) 6.0 (5.6, 6.9) <0.0001 not significant GFR, ml/min per 1.73 ^m2 78.5 (67.8, 90.4) 76.0 (62.5, 88.3) 67.4 (53.5, 83.7) <0.0001 <0.0001 GFR, <60 ml/min at 1.73 m ² 2256 (12.7) 199 (20.7) 84 (34.7) <0.0001 <0.0001 Active smoker 4261 (24.0) 252 (26.2) 47 (19.4) not significant 0.0305 Presence in the medical history of information about a previous established event Diabetes 4924 (27.8) 404 (42.0) 116 (47.9) <0.0001 not significant Hypertension 11277 (63.6) 758 (78.1) 214 (88.4) <0.0001 0,0005 Myocardial infarction 3174 (17.9) 373 (38.7) 92 (38.0) <0.0001 not significant PCI 2805 (15.8) 347 (36.0) 89 (36.8) <0.0001 not significant CABG 844 (4.8) 162 (16.8) 41 (16.9) <0.0001 not significant Stroke 541 (3.1) 55 (5.7) 15 (6.2) <0.0001 not significant Malignant disease 475 (2.7) 36 (3.7) 21 (8.7) <0.0001 0.0033 COPD 637 (3.6) 68 (7.1) 41 (16.9) <0.0001 <0.0001 PAD 628 (3.5) 89 (9.2) 42 (17.4) <0.0001 0,0007 CHF 2542 (14.3) 195 (20.2) 78 (32.2) <0.0001 0,0001 Revascularization due to an established event 12886 (72.7) 630 (65.4) 161 (66.5) <0.0001 not significant PCI 12024 (67.9) 595 (61.8) 150 (62.0) <0.0001 not significant CABG 976 (5.5) 38 (3.9) 11 (4.5) not significant not significant Medicines Aspirin 16960 (95.7) 910 (94.5) 216 (89.3) <0.0001 0.0054 P2Y antagonist ₁₂ 15482 (87.4) 855 (88.8) 204 (82.3) not significant not significant ACE/ARB inhibitor 13728 (77.5) 793 (82.3) 195 (80.6) 0.0011 not significant Beta blocker 14951 (84.4) 833 (86.5) 206 (85.1) not significant not significant Ezetimibe 472 (2.7) 68 (7.1) 14 (5.8) <0.0001 not significant Randomized to placebo group 8808 (49.7) 512 (53.2) 142 (58.7) 0.0028 not significant

Values are medians (quartile 1, quartile 3) or column percentages. Not significant: p>0.05

ACE - angiotensin-converting enzyme; ARB - angiotensin II receptor blocker; CABG - coronary artery bypass grafting; CHF - congestive heart failure; COPD - chronic obstructive pulmonary disease; CV - cardiovascular disorder; LDL-C=low-density lipoprotein cholesterol; LLT - lipid-lowering therapy; NSTEMI - non-ST-segment elevation myocardial infarction; PAD - peripheral arterial disease; PCI - percutaneous coronary intervention; STEMI - ST-segment elevation myocardial infarction.

[324] Figure 33 shows the Kaplan-Meier curve of the incidence of type 1 and type 2 MI over time in patients treated with alirocumab and placebo. For type 1 MI, the risk was highest in the first 12 months, followed by a divergence of the curves and subsequent lower annual risk. For type 2 MI, the risk was relatively constant over time with a divergence beginning at approximately 6 months.

[325] The effects of alirocumab on each type of MI are presented in Table 41. Overall, alirocumab reduced the incidence of all MIs compared with placebo (7.9% placebo vs 6.8% alirocumab, HR 0.85, 95% CI 0.77-0.95, p=0.003). The incidence of both type 1 MI (HR 0.87, 95% CI 0.77-0.99, p=0.0317) and type 2 MI (HR 0.77, 95% CI 0.61-0.97, p=0.0251) was reduced. No treatment effect of alirocumab was observed on types 3–5 MI. In the case of MI type 4, the HR was 0.94 (CI 0.72–1.22, p=0.62).

[326] The majority of MIs (82.7%) were non-STEMI (non-ST-segment elevation myocardial infarction), and alirocumab significantly reduced the incidence of these MIs (HR 0.82 (CI 0.72, 0.93), p=0.0020. There was no significant effect on the incidence of STEMI. The incidence of Q-wave MI was small (10.5%) in patients with interpretable ECGs. There was no observed effect of alirocumab on Q-wave MI, whereas non-Q-wave MI was reduced by alirocumab (HR 0.86, CI 0.76, 0.97), p=0.0130.table 42shown Results of a sensitivity analysis of different types of myocardial infarction event rates and alirocumab effects, which included patients who died on day 1 (n=7 alirocumab; n=11 placebo).

Table 41. Incidence of different types of myocardial infarction and effects of alirocumab

Alirocumab Placebo HR of treatment (95% CI) ^1.2 P-value ^1.2 Patients with MI ¹
n (%) Total MI cases Patients with MI ¹
n (%) Total MI cases Any myocardial infarction (MI) 639 (6.8) 866 744 (7.9) 994 0.85 (0.77, 0.95) 0.0031 Universal classification 1st type: spontaneous 463 (4.9) 560 528 (5.6) 663 0.87 (0.77, 0.99) 0,0317 Type 2: Imbalance between demand and supply 125 (1.3) 180 162 (1.7) 206 0.77 (0.61, 0.97) 0.0251 Type 3: Cardiac death suggestive of MI without elevated biomarker levels 2 0 - - Type 4A: Pericutaneous coronary intervention 22 (0.2) 23 28 (0.3) 29 0.94 (0.72, 1.22) 0.62 Type 4B: stent thrombosis 50 (0.5) 55 46 (0.5) 49 4C type: restenosis 37 (0.4) 44 42 (0.4) 44 Type 5: peri-aorto-coronary bypass grafting 2 3 - - ECG classification NSTEMI 437 (4.6) 576 529 (5.6) 692 0.82 (0.72, 0.93) 0,0020 STEMI 92 (0.5) 96 109 (1.2) 116 0.84 (0.64, 1.11) 0.22 ECG is uninterpretable or unavailable 161 (1.7) 194 162 (1.7) 186 1.01 (0.81, 1.25) 0.96 Classification by Q wave With Q wave 52 (0.5) 52 71 (0.9) 73 0.73 (0.51, 1.04) 0.08 No Q wave 483 (5.1) 634 560 (5.9) 725 0.86 (0.76, 0.97) 0,0130 ECG is uninterpretable or unavailable 146 (1.5) 180 165 (1.7) 196 0.88 (0.71, 1.10) 0.27

¹ Consistent with traditional time-to-first-event analysis

² Reflects stratification by geographic region.

NSTEMI - non-ST-segment elevation myocardial infarction; STEMI - ST-segment elevation myocardial infarction

Table 42. Results of sensitivity analyses of different types of myocardial infarction events and the effects of alirocumab, including the number of events at the date of death

Alirocumab Placebo Patients with MI ¹
n (%) Patients with MI ¹
n (%) HR treatments
(95% CI) ¹ P-value ¹ Any myocardial infarction (MI) 646 (6.8) 755 (8.0) 0.85 (0.77, 0.94) 0.0023 1st type: spontaneous 464 (4.9) 534 (5.6) 0.86 (0.76, 0.98) 0.0215 Type 2: Imbalance between demand and supply 126 (1.3) 163 (1.7) 0.77 (0.61, 0.97) 0.0256 Type 3: Cardiac death suggestive of MI without elevated biomarker levels 10 (<0.1) 5 (<0.1) - - Type 4A: Pericutaneous coronary intervention 22 (0.2) 28 (0.3) 0.94 (0.72, 1.22) 0.62 Type 4B: stent thrombosis 50 (0.5) 46 (0.5) 4C type: restenosis 37 (0.4) 42 (0.4) Type 5: peri-aorto-coronary bypass grafting 2 (<0.1) 3 (<0.1) - -

[327] Table 43 shows the effect of alirocumab on biomarker levels, primarily cardiac troponin (92%), at various cut-off points. Alirocumab treatment was associated with no clear reduction at lower MIs (with peak biomarker levels <3 times the upper limit of normal), with greater reductions at higher MIs, as defined by the peak biomarker value.

Table 43. First MI by level of biomarker increase ^a .

Multiple of the upper limit of normal Alirocumab Placebo Number of events
n (%) Patients with MI ¹
n (%) Number of patients with MI ^a
n (%) HR treatments
(95% CI) ^b P-value ^b from 1 to <3 406 (29.4) 200 (2.1) 206 (2.2) 0.97 (0.79-1.17) 0.72 from 3 to <10 304 (22.0) 133 (1.4) 171 (1.8) 0.77 (0.62-0.97) 0.026 from 10 to <100 468 (33.8) 213 (2.3) 255 (2.7) 0.83 (0.69-1.00) 0.044 ≥100 167 (12.1) 73 (0.8) 94 (1.0) 0.77 (0.57-1.04) 0.09 Absent 38 (2.7) 20 (0.2) 18 (0.2) 1.10 (0.58-2.08) 0.77

^a In 1383 first MIs: troponin level available in 1272 (92.0%); CK-MB in 73 (5.3%); both troponin and CKMB absent in 38 (2.7%).

^b Analysis using Cox proportional hazards models stratified by geographic region.

CI - confidence interval; HR - hazard ratio; MI - myocardial infarction.

a. Prognostic factors for type 1 and type 2 myocardial infarction

[328] Potential predictors for type 1 MI include age category, race, region, established event, lipid-lowering therapy at randomization, LDL-C, HDL-C, Lp(a), BMI, GFR, diabetes status, hypertension, MI, stroke, PCI, COPD, CABG, PAD, CHF, revascularization due to established event, and alirocumab treatment (significant predictors (p<0.05) in the traditional Cox model).

[329] Potential predictors for type 2 MI include age category, female sex, race, region, established event, lipid-lowering therapy at randomization, LDL-C, HDL-C, Lp(a), BMI, GFR, current smoking status, diabetes status, hypertension, MI, stroke, malignancy, PCI, COPD, CABG, PAD, CHF, revascularization due to established event, and alirocumab treatment (significant predictors (p<0.05) in the traditional Cox model). Tables 44 and 45 show the multivariable predictive models for type 1 and type 2 MI, respectively.

Table 44. Multivariable prognostic model for MI type 1

MI type 1 Characteristic HR (95% CI) p-value History of PCI 1,505 (1,266, 1,790) <0.0001 History of CABG 1,739 (1,446, 2,091) <0.0001 History of diabetes 1,572 (1,379, 1,793) <0.0001 History of PAD 1,609 (1,294, 2,002) <0.0001 History of hypertension 1,539 (1,307, 1,811) <0.0001 Region <0.0001 Western Europe Reference East Europe 0.504 (0.413, 0.614) North America 0.930 (0.769, 1.125) South America 0.654 (0.512, 0.835) Asia 2,028 (0,966, 4,260) The rest of the world 1,161 (0,924, 1,457) LDL-C level, increase of 1 mg/dL 1,004 (1,003, 1,006) <0.0001 History of myocardial infarction 1,463 (1,230, 1,740) <0.0001 History of CHF 1,327 (1,121, 1,571) 0,0010 GFR, <60 ml/min at 1.73 m ² 1,368 (1,167, 1,603) 0,0001 Revascularization due to an established event 0.796 (0.696, 0.910) 0,0009 Active smoker 1,228 (1,062, 1,420) 0.0055 Race 0.0085 Caucasoids Reference Mongoloids 0.376 (0.185, 0.765) Negroids 1,369 (1,005, 1,865) Other 0.968 (0.703, 1.333) Treatment with alirocumab 0.870 0.768, 0.986) 0.0288 History of stroke 1,336 (1,023, 1,746) 0.0337

Table 45. Multivariable prognostic model for type 2 MI

MI type 2 Characteristic HR (95% CI) p-value GFR, <60 ml/min at 1.73 m ² 2,048 (1,569, 2,673) <0.0001 History of PAD 2,487 (1,826, 3,388) <0.0001 History of PCI 1,477 (1,089, 2,005) 0,0123 History of COPD 2,263 (1,629, 3,145) <0.0001 History of CHF 2,359 (1,803, 3,087) <0.0001 History of diabetes 1,761 (1,379, 2,249) <0.0001 Region <0.0001 Western Europe Reference East Europe 0.445 (0.304, 0.652) North America 1,163 (0,825, 1,637) South America 0.436 (0.250, 0.761) Asia 1.233 (0.361, 4.211) The rest of the world 1,220 (0,768, 1,938) History of hypertension 2,661 (1,785, 3,966) <0.0001 Age category <0.0001 <65 years Reference From 65 to <75 years 1,455 (1,108, 1,913) ≥75 years 2,263 (1,584, 3,232) Race 0,0211 Caucasoids Reference Mongoloids 0.758 (0.243, 2.358) Negroids 1,915 (1,215, 3,016) Other 0.621 (0.265, 1.451) History of myocardial infarction 1,491 (1,105, 2,011) 0,0089 HDL-C level, increase of 1 mg/dL 1,011 (1,002, 1,021) 0,0173 Treatment with alirocumab 0.770 (0.610, 0.973) 0.0288

[330] Most significant factors were similar for both types of MI. However, LDL-C level, revascularization at the established event, smoking status, race, and previous stroke were significant for type 1 MI but not significant for type 2 MI. In addition, age categories, history of chronic obstructive pulmonary disease, and baseline HDL-C levels were significant for type 2 MI but not for type 1 MI.

b. Fatal outcome in patients with type 1 and type 2 myocardial infarction

[331] The mortality rate in patients with type 2 MI after randomization (n=283, 25.4%) was more than twice that in patients with type 1 MI after randomization (n=73, 11.9%). Alirocumab reduced the incidence of type 2 MI but did not reduce the incidence of death after type 2 MI (24.8% vs 25.9%). In contrast, alirocumab reduced the incidence of death after type 1 MI compared with placebo (10.2% vs 13.4%).

[332] Figure 34 shows the forest plot of type 1 MI or type 2 MI during follow-up as prognostic factors for all-cause death. After adjustment for treatment type and prognostic factors, a significant effect was observed for type 1 MI, p=0.03, but not for type 2 MI, p=0.61.

[333] Figure 35 shows a forest plot of all-cause death, cardiovascular death, and non-cardiovascular death before and after type 1 or type 2 MI. The incidence of all-cause death before MI was similar for both type 1 and type 2 MI, but was approximately twice as high after type 2 MI than after type 1 MI. The reduction in all-cause death after type 1 MI with alirocumab was 47/463 (10.2%) compared with 71/528 (13.4%) in the placebo group, HR 0.69 (CI 0.48, 1.00). After type 2 MI, alirocumab had no significant effect on death: 31/125 alirocumab (24.8%) vs 42/162 (25.9%), HR 0.98 (CI 0.62, 1.56).

[334] The rates of cardiovascular death before MI were similar in both type 1 and type 2 MI. The rates of cardiovascular death after type 2 MI were higher than after type 1 MI. There was no effect of alirocumab on the rates of cardiovascular death after any type of MI. For non-cardiovascular death, rates were similar before MI in both type 1 and type 2 MI. After MI, the rates of non-cardiovascular death were 3-4 times higher in patients with type 2 MI than in patients with type 1 MI. There was no effect of alirocumab on non-CV deaths in type 1 or type 2 MI.

CONCLUSION

[335] In patients with ACS and elevated LDL-C despite intensive statin therapy, alirocumab reduced the incidence of both type 1 and type 2 MI and reduced the number of deaths in type 1 MI, indicating that lowering LDL-C levels below levels achieved with statin treatment was an effective preventive strategy for both types of MI.

Example 12. Cardiovascular efficacy of alirocumab after acute coronary syndrome events in high-risk versus very-high-risk patients

[336] The incidence of composite ischemic events and the efficacy of PCSK9 inhibition with alirocumab were examined in patients from ODYSSEY OUTCOMES who were classified as having “very high risk” for future atherosclerotic cardiovascular disease (ASCVD) events according to the 2018 ACC/AHA guidelines. (Grundy SM, et al. JACC (2018) (in press - available online November 10, 2018)).

[337] Based on the 2018 ACC/AHA guideline criteria, a total of 11,935 (63%) patients were classified as “very high risk” and 6,989 (37%) were classified as “not very high risk.” Criteria for the “very high risk” category included prior (before the defined ACS event) ischemic events (of which 19.2% of patients had prior myocardial infarction (MI), 2.8% had prior ischemic stroke, and 4.0% had prior PAD) or the presence of multiple high-risk clinical conditions (26.9% were ≥65 years of age, 28.8% had diabetes mellitus, 13.4% had chronic kidney disease, and 24.1% were active smokers).

[338] Treatment with alirocumab was associated with a consistent relative reduction in the risk of MACE events in patients with very-high-risk features compared with patients without very-high-risk features ( Table 46 ). However, the absolute risk of MACE and the absolute reduction in MACE events with alirocumab were greater among patients classified as very-high-risk, with a strong absolute benefit among patients with multiple prior ischemic events compared with patients who only had all other high-risk clinical features.

Table 46. Time to first occurrence of primary endpoint

Population Placebo
qty/total qty (%) Alirocumab
qty/total qty (%) Risk ratio
(95% CI) Interrelation
p-value No additional very high risk indicators 198/3525 (5.6%) 168/3464 (4.8%) 0.86 (0.70-1.06) 0.83 Additional signs of very high risk 854/5937 (14.4%) 735/5998 (12.3%) 0.84 (0.76-0.92) Previous events associated with ASCVD 458/2241 (20.4%) 398/2209 (18.0%) 0.86 (0.75-0.98) 0.62 Myocardial infarction 378/1843 (20.5%) 333/1790 (18.6%) 0.87 (0.75-1.01) Ischemic stroke 63/256 (24.6%) 54/268 (20.1%) 0.77 (0.54-1.12) PAD 104/386 (26.9%) 88/373 (23.6%) 0.83 (0.62-1.10) ≥1 high-risk clinical condition (without prior ASCVD-related event) 396/3696 (10.7%) 337/3789 (8.9%) 0.82 (0.71-0.95)

CONCLUSION

[339] Application of the 2018 ACC/AHA Cholesterol Guidelines' "very high risk" criteria allows for the precise identification of patients with ACS and dyslipidemia who would benefit greatly from alirocumab treatment. Patients classified as "very high risk" based on multiple prior ischemic events would benefit particularly greatly from this approach.

Example 13. Effects of alirocumab according to background statin treatment

[340] This analysis compared the efficacy of alirocumab or placebo in ODYSSEY OUTCOMES patients with different background statin therapy. All 18,924 patients were categorized according to background statin therapy at randomization: high-intensity therapy (atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day) (n=16,811, 88.8%); low- or moderate-intensity therapy (atorvastatin <40 mg/day or rosuvastatin <20 mg/day) (n=1,653, 8.7%); or no statin (n=460, 2.4%). This study did not allow background statin therapy in cases of statin intolerance, which was defined as documented intolerance to ≥2 statins. Relative risk (hazard ratio [HR]) and absolute risk reduction (ARR) values for MACE were determined for all patient groups.

[341] The hazard ratios (HRs) were consistent across statin categories ( Table 47 ). Baseline LDL-C increased across the high-intensity, low/moderate-intensity, and no-statin categories. There was a gradient in the risk of MACE among these categories in the placebo group (10.8%, 10.7%, and 26%, respectively). With alirocumab, the mean reduction in LDL-C from baseline to month 4 was greater across these three categories (-1.37 mmol/L, -1.47 mmol/L, and -2.27 mmol/L, respectively), and the ARRs for MACE among the categories were 1.3%, 3.2%, and 8.0%, respectively (P _{for interaction} < 0.001).

Table 47. LDL-C values and MACE events stratified by intensity of statin therapy

All patients High intensity statin Low/moderate intensity statin No statins P-value of the relationship N=18924 (100%) N=16811 (88.8%) N=1653 (8.7%) N=460 (2.4%) PBO ALI PBO ALI PBO ALI PBO ALI LDL-C level (SE) (mmol/L) at baseline [mg/dL] 2.39 (0.01) [92 (31)] 2.39 (0.01)
[92 (31)] 2.35 (0.01) [91 (29)] 2.35 (0.01) [91 (29)] 2.41 (0.03) [93 (29)] 2.43 (0.03) [94 (29] 3.76 (0.08) [145 (48)] 3.82 (0.08) [148 (45)] LDL-C level (SE) (mmol/L): change from baseline to month 4 [mg/dL] 0.03 (0.01) [1 (0)] -1.4 (0.01) [-54 (0)] 0.03 (0.01) [1 (0)] -1.37 (0.01) [-53 (0)] 0.01 (0.02) [0 (1)] -1.47 (0.02) [-56 (1)] -0.004 (0.06) [0 (2)] -2.27 (0.06) [-86 (2)] <0.001 MACE, n (%) 1052 (11.1) 903 (9.5) 907 (10.8) 797 (9.5) 86 (10.7) 64 (7.5) 59 (26.0) 42 (18.0) HR (95% CI) 0.85 (0.78-0.93) 0.88 (0.80-0.96) 0.69 (0.50-0.95) 0.65 (0.43-0.96) 0.14 ARR (%) (95% CI) 1.6 (0.7-2.4) 1.3 (0.3-2.2) 3.2 (0.4-5.9) 8.0 (0.4-15.5) <0.001

CONCLUSION

Among ODYSSEY OUTCOMES patients, statin-naïve patients had a higher mean baseline LDL-C level (3.82 mmol/L) and a greater mean absolute reduction in LDL-C level (-2.27 mmol/L) with alirocumab than statin-naïve patients. Statin-naïve patients also had a greater absolute reduction in the risk of MACE (8.0% (0.4–15.5)) compared with high-intensity statin-treated patients (1.3% (0.3–2.2) P _interaction < 0.001). Thus, statin-naïve patients, including those with statin intolerance or for whom a statin is contraindicated, may be an important group to consider for treatment with alirocumab after ACS.

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<223> Description of the artificial sequence: Synthetic peptide

<400> 27

Ala Arg Asp Ile Val Leu Met Val Tyr His Met Asp Tyr Tyr Tyr Tyr

1 5 10 15

Gly Met Asp Val

20

<210> 28

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 28

Gln Ser Leu Leu His Ser Asn Gly Asn Asn Tyr

1 5 10

<210> 29

<211> 3

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 29

Leu Gly Ser

1

<210> 30

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 30

Met Gln Thr Leu Gln Thr Pro Leu Thr

1 5

<210> 31

<211> 8

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 31

Gly Phe Thr Phe Ser Ser His Trp

1 5

<210> 32

<211> 8

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 32

Ile Asn Gln Asp Gly Ser Glu Lys

1 5

<210> 33

<211> 20

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 33

Ala Arg Asp Ile Val Leu Met Val Tyr His Met Asp Tyr Tyr Tyr Tyr

1 5 10 15

Gly Met Asp Val

20

<210> 34

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 34

Gln Ser Leu His His Ser Asn Gly Asn Asn Tyr

1 5 10

<210> 35

<211> 3

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 35

Leu Gly Ser

1

<210> 36

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 36

Met Gln Thr Leu Gln Thr Pro Leu Thr

1 5

<210> 37

<211> 131

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

VH;m2CX1D05

<400> 37

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ser

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Gly Thr Phe Asn Ser His

20 25 30

Ala Ile Ser Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Gly Ile Asn Pro Ile Leu Gly Ile Ala Asn Tyr Ala Gln Lys Phe

50 55 60

Gln Gly Arg Val Thr Ile Thr Ala Asp Glu Ser Thr Ser Thr Ala Tyr

65 70 75 80

Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg His Tyr Glu Ile Gln Ile Gly Arg Tyr Gly Met Asn Val Tyr

100 105 110

Tyr Leu Met Tyr Arg Phe Ala Ser Trp Gly Gln Gly Thr Leu Val Thr

115 120 125

Val Ser Ser

130

<210> 38

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 VH; m2CX1D05

<400> 38

Gly Gly Thr Phe Asn Ser His Ala Ile Ser

1 5 10

<210> 39

<211> 20

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR2 VH; m2CX1D05

<400> 39

Trp Met Gly Gly Ile Asn Pro Ile Leu Gly Ile Ala Asn Tyr Ala Gln

1 5 10 15

Lys Phe Gln Gly

20

<210> 40

<211> 22

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 VH; m2CX1D05

<400> 40

His Tyr Glu Ile Gln Ile Gly Arg Tyr Gly Met Asn Val Tyr Tyr Leu

1 5 10 15

Met Tyr Arg Phe Ala Ser

20

<210> 41

<211> 213

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

LC; m2CX1D05

<400> 41

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Ser Ala

20 25 30

Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Asn Gly Ser Thr Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Phe Ala Val Tyr Tyr Cys Gln Gln Phe Asp Gly Asp Pro Thr

85 90 95

Phe Gly Gln Gly Thr Lys Val Glu Ile Lys Arg Thr Val Ala Ala Pro

100 105 110

Ser Val Phe Ile Phe Pro Pro Ser Asp Glu Gln Leu Lys Ser Gly Thr

115 120 125

Ala Ser Val Val Cys Leu Leu Asn Asn Phe Tyr Pro Arg Glu Ala Lys

130 135 140

Val Gln Trp Lys Val Asp Asn Ala Leu Gln Ser Gly Asn Ser Gln Glu

145 150 155 160

Ser Val Thr Glu Gln Asp Ser Lys Asp Ser Thr Tyr Ser Leu Ser Ser

165 170 175

Thr Leu Thr Leu Ser Lys Ala Asp Tyr Glu Lys His Lys Val Tyr Ala

180 185 190

Cys Glu Val Thr His Gln Gly Leu Ser Ser Pro Val Thr Lys Ser Phe

195 200 205

Asn Arg Gly Glu Ala

210

<210> 42

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 VL; m2CX1D05

<400> 42

Arg Ala Ser Gln Gly Ile Arg Ser Ala Leu Asn

1 5 10

<210> 43

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR2 VL; m2CX1D05

<400> 43

Leu Leu Ile Tyr Asn Gly Ser Thr Leu Gln Ser

1 5 10

<210> 44

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 VL; m2CX1D05

<400> 44

Gln Gln Phe Asp Gly Asp Pro

1 5

<210> 45

<211> 119

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

VH;1B20

<400> 45

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Glu

1 5 10 15

Ser Leu Lys Ile Ser Cys Lys Gly Ser Gly Tyr Ser Phe Thr Asn Tyr

20 25 30

Trp Ile Ser Trp Val Arg Gln Met Pro Gly Lys Gly Leu Glu Trp Met

35 40 45

Gly Ile Ile Tyr Pro Gly Asp Ser Tyr Thr Asn Tyr Ser Pro Ser Phe

50 55 60

Gln Gly Gln Val Thr Ile Ser Ala Asp Lys Ser Ile Ser Thr Ala Tyr

65 70 75 80

Leu Gln Trp Ser Ser Leu Lys Ala Ser Asp Thr Ala Met Tyr Tyr Cys

85 90 95

Ala Arg Asp Tyr Trp Tyr Lys Pro Leu Phe Asp Ile Trp Gly Gln Gly

100 105 110

Thr Leu Val Thr Val Ser Ser

115

<210> 46

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 VH;1B20

<400> 46

Gly Tyr Ser Phe Thr Asn Tyr Trp Ile Ser

1 5 10

<210> 47

<211> 20

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR2 VH;1B20

<400> 47

Trp Met Gly Ile Ile Tyr Pro Gly Asp Ser Tyr Thr Asn Tyr Ser Pro

1 5 10 15

Ser Phe Gln Gly

20

<210> 48

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 VH;1B20

<400> 48

Asp Tyr Trp Tyr Lys Pro Leu Phe Asp Ile

1 5 10

<210> 49

<211> 220

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

LC; 1B20

<400> 49

Asp Ile Val Met Thr Gln Ser Pro Asp Ser Leu Ala Val Ser Leu Gly

1 5 10 15

Glu Arg Ala Thr Ile Asn Cys Arg Ser Ser Gln Ser Val Leu Tyr Ser

20 25 30

Ser Asn Asn Lys Asn Tyr Leu Ala Trp Tyr Gln Gln Lys Pro Gly Gln

35 40 45

Pro Pro Lys Leu Leu Ile Tyr Trp Ala Ser Thr Arg Glu Ser Gly Val

50 55 60

Pro Asp Arg Phe Ser Gly Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr

65 70 75 80

Ile Ser Ser Leu Gln Ala Glu Asp Val Ala Val Tyr Tyr Cys Gln Gln

85 90 95

Tyr Ser Ser Phe Pro Ile Thr Phe Gly Gln Gly Thr Lys Val Glu Ile

100 105 110

Lys Arg Thr Val Ala Ala Pro Ser Val Phe Ile Phe Pro Pro Ser Asp

115 120 125

Glu Gln Leu Lys Ser Gly Thr Ala Ser Val Val Cys Leu Leu Asn Asn

130 135 140

Phe Tyr Pro Arg Glu Ala Lys Val Gln Trp Lys Val Asp Asn Ala Leu

145 150 155 160

Gln Ser Gly Asn Ser Gln Glu Ser Val Thr Glu Gln Asp Ser Lys Asp

165 170 175

Ser Thr Tyr Ser Leu Ser Ser Thr Leu Thr Leu Ser Lys Ala Asp Tyr

180 185 190

Glu Lys His Lys Val Tyr Ala Cys Glu Val Thr His Gln Gly Leu Ser

195 200 205

Ser Pro Val Thr Lys Ser Phe Asn Arg Gly Glu Ala

210 215 220

<210> 50

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 VL;1B20

<400> 50

Arg Ser Ser Gln Ser Val Leu Tyr Ser Ser Asn Asn Lys Asn Tyr Leu

1 5 10 15

Ala

<210> 51

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR2 VL;1B20

<400> 51

Leu Leu Ile Tyr Trp Ala Ser Thr Arg Glu Ser

1 5 10

<210> 52

<211> 8

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 VL;1B20

<400> 52

Gln Gln Tyr Ser Ser Phe Pro Ile

1 5

<210> 53

<211> 120

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

antibody heavy chain variable region polypeptide

<400> 53

Glu Val Gln Leu Leu Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Lys Ala Ser Gly Tyr Thr Phe Ser Ser Tyr

20 25 30

Gly Met Tyr Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Ile

35 40 45

Gly Trp Ile Asp Pro Gly Ser Gly Gly Thr Lys Tyr Asn Glu Lys Phe

50 55 60

Lys Gly Lys Ala Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Arg Tyr Gly Tyr Tyr Phe Asp Tyr Trp Gly Gln Gly Thr

100 105 110

Leu Val Thr Val Ser Ser Ala Ser

115 120

<210> 54

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR1 regions of the AX132 antibody

<400> 54

Lys Ala Ser Gly Tyr Thr Phe Ser Ser Tyr Gly Met Tyr Trp Val Arg

1 5 10 15

<210> 55

<211> 23

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR2 regions of the AX132 antibody

<400> 55

Trp Ile Gly Trp Ile Asp Pro Gly Ser Gly Gly Thr Lys Tyr Asn Glu

1 5 10 15

LysPheLysGlyLysAlaThr

20

<210> 56

<211> 15

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR3 regions of the AX132 antibody

<400> 56

Cys Ala Arg Glu Arg Tyr Gly Tyr Tyr Phe Asp Tyr Trp Gly Gln

1 5 10 15

<210> 57

<211> 108

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

antibody light chain variable region polypeptide

<400> 57

Glu Ile Val Leu Thr Gln Ser Pro Ala Thr Leu Ser Leu Ser Pro Gly

1 5 10 15

Glu Arg Ala Thr Ile Thr Cys Arg Ala Ser Gln Tyr Val Gly Ser Tyr

20 25 30

Leu Asn Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Arg Leu Leu Ile

35 40 45

Tyr Asp Ala Ser Asn Arg Ala Thr Gly Ile Pro Ala Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Glu Pro

65 70 75 80

Glu Asp Phe Ala Val Tyr Tyr Cys Gln Val Trp Asp Ser Ser Pro Pro

85 90 95

Val Val Phe Gly Gly Gly Thr Lys Val Glu Ile Lys

100 105

<210> 58

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

light chain CDR1 regions of antibodies AX213 and AX132

<400> 58

Ile Thr Cys Arg Ala Ser Gln Tyr Val Gly Ser Tyr Leu Asn Trp Tyr

1 5 10 15

Gln

<210> 59

<211> 13

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

light chain CDR2 regions of antibodies AX213 and AX132

<400> 59

Leu Ile Tyr Asp Ala Ser Asn Arg Ala Thr Gly Ile Pro

1 5 10

<210> 60

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 region of the light chain of antibodies AX132 and AX213

<400> 60

Tyr Tyr Cys Gln Val Trp Asp Ser Ser Pro Pro Val Val Phe Gly Gly

1 5 10 15

<210> 61

<211> 120

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

antibody heavy chain variable region polypeptide

<400> 61

Glu Val Gln Leu Leu Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Lys Ala Ser Gly Tyr Thr Phe Ser Arg Tyr

20 25 30

Gly Ile Asn Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Ile

35 40 45

Gly Arg Ile Asp Pro Gly Asn Gly Gly Thr Arg Tyr Asn Glu Lys Phe

50 55 60

Lys Gly Lys Ala Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Ala Asn Asp Gly Tyr Ser Phe Asp Tyr Trp Gly Gln Gly Thr

100 105 110

Leu Val Thr Val Ser Ser Ala Ser

115 120

<210> 62

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR1 regions of the AX213 antibody

<400> 62

Lys Ala Ser Gly Tyr Thr Phe Ser Arg Tyr Gly Ile Asn Trp Val Arg

1 5 10 15

<210> 63

<211> 23

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR2 regions of the AX213 antibody

<400> 63

Trp Ile Gly Arg Ile Asp Pro Gly Asn Gly Gly Thr Arg Tyr Asn Glu

1 5 10 15

LysPheLysGlyLysAlaThr

20

<210> 64

<211> 15

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

heavy chain CDR3 regions of the AX213 antibody

<400> 64

Cys Ala Arg Ala Asn Asp Gly Tyr Ser Phe Asp Tyr Trp Gly Gln

1 5 10 15

<210> 65

<211> 108

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

antibody light chain variable region polypeptide

<400> 65

Glu Ile Val Leu Thr Gln Ser Pro Ala Thr Leu Ser Leu Ser Pro Gly

1 5 10 15

Glu Arg Ala Thr Ile Thr Cys Arg Ala Ser Gln Tyr Val Gly Ser Tyr

20 25 30

Leu Asn Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Arg Leu Leu Ile

35 40 45

Tyr Asp Ala Ser Asn Arg Ala Thr Gly Ile Pro Ala Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Glu Pro

65 70 75 80

Glu Asp Phe Ala Val Tyr Tyr Cys Gln Val Trp Asp Ser Ser Pro Pro

85 90 95

Val Val Phe Gly Gly Gly Thr Lys Val Glu Ile Lys

100 105

<210> 66

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

light chain CDR1 regions of antibodies AX213 and AX132

<400> 66

Ile Thr Cys Arg Ala Ser Gln Tyr Val Gly Ser Tyr Leu Asn Trp Tyr

1 5 10 15

Gln

<210> 67

<211> 13

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

light chain CDR2 regions of antibodies AX213 and AX132

<400> 67

Leu Ile Tyr Asp Ala Ser Asn Arg Ala Thr Gly Ile Pro

1 5 10

<210> 68

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 region of the light chain of antibodies AX132 and AX213

<400> 68

Tyr Tyr Cys Gln Val Trp Asp Ser Ser Pro Pro Val Val Phe Gly Gly

1 5 10 15

<210> 69

<211> 119

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic polypeptide VH antibody AX1

<400> 69

Glu Val Gln Leu Leu Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Lys Ala Ser Gly Phe Thr Phe Thr Ser Tyr

20 25 30

Tyr Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Ile

35 40 45

Gly Arg Ile Asn Pro Asp Ser Gly Ser Thr Lys Tyr Asn Glu Lys Phe

50 55 60

Lys Gly Arg Ala Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Gly Gly Arg Leu Ser Trp Asp Phe Asp Val Trp Gly Gln Gly

100 105 110

Thr Leu Val Thr Val Ser Ser

115

<210> 70

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR1 VH antibody AX1

<400> 70

Lys Ala Ser Gly Phe Thr Phe Thr Ser Tyr Tyr Met His Trp Val Arg

1 5 10 15

<210> 71

<211> 23

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR2 VH antibody AX1

<400> 71

Trp Ile Gly Arg Ile Asn Pro Asp Ser Gly Ser Thr Lys Tyr Asn Glu

1 5 10 15

LysPheLysGlyArgAlaThr

20

<210> 72

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR3 VH antibody AX1

<400> 72

Cys Ala Arg Gly Gly Arg Leu Ser Trp Asp Phe Asp Val Trp Gly Gln

1 5 10 15

<210> 73

<211> 109

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic polypeptide VL antibody AX

<400> 73

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Ile Ser Arg Tyr

20 25 30

Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Phe Ala Thr Tyr Tyr Cys Ala Ala Tyr Asp Tyr Ser Leu Gly

85 90 95

Gly Tyr Val Phe Gly Asp Gly Thr Lys Val Glu Ile Lys

100 105

<210> 74

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR1 VL antibody AX1

<400> 74

Arg Ala Ser Gln Asp Ile Ser Arg Tyr Leu Ala

1 5 10

<210> 75

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR2 VL antibodies AX1, AX9, AX189

<400> 75

Ala Ala Ser Ser Leu Gln Ser

1 5

<210> 76

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR3 VL antibody AX1

<400> 76

Ala Ala Tyr Asp Tyr Ser Leu Gly Gly Tyr Val

1 5 10

<210> 77

<211> 121

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic polypeptide VH antibodies AX9, AX189

<400> 77

Glu Val Gln Leu Leu Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Lys Ala Ser Gly Tyr Thr Phe Ser Ser Tyr

20 25 30

Trp Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Ile

35 40 45

Gly Arg Ile Asp Pro Tyr Asn Gly Gly Thr Lys Tyr Asn Glu Lys Phe

50 55 60

Lys Gly Lys Ala Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Tyr Gly Tyr Tyr Leu Gly Ser Tyr Ala Met Asp Tyr Trp Gly

100 105 110

Gln Gly Thr Leu Val Thr Val Ser Ser

115 120

<210> 78

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR1 VH antibodies AX9, AX189

<400> 78

Lys Ala Ser Gly Tyr Thr Phe Ser Ser Tyr Trp Met His Trp Val Arg

1 5 10 15

<210> 79

<211> 23

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR2 VH antibodies AX9, AX189

<400> 79

Trp Ile Gly Arg Ile Asp Pro Tyr Asn Gly Gly Thr Lys Tyr Asn Glu

1 5 10 15

LysPheLysGlyLysAlaThr

20

<210> 80

<211> 18

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR3 VH antibodies AX9, AX189

<400> 80

Cys Ala Arg Tyr Gly Tyr Tyr Leu Gly Ser Tyr Ala Met Asp Tyr Trp

1 5 10 15

Gly Gln

<210> 81

<211> 109

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic polypeptide VL antibody AX189

<400> 81

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Val Ser Arg Tyr

20 25 30

Leu Thr Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Ala Tyr Asp Tyr Ser Leu Ser

85 90 95

Gly Tyr Val Phe Gly Gly Gly Thr Lys Val Glu Ile Lys

100 105

<210> 82

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR1 VL antibody AX189

<400> 82

Arg Ala Ser Gln Asp Val Ser Arg Tyr Leu Thr

1 5 10

<210> 83

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR2 VL antibodies AX1, AX9, AX189

<400> 83

Ala Ala Ser Ser Leu Gln Ser

1 5

<210> 84

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Sequence

synthetic peptide CDR3 VL antibody AX189

<400> 84

Gln Ala Tyr Asp Tyr Ser Leu Ser Gly Tyr Val

1 5 10

<210> 85

<211> 115

<212> PROTEIN

<213> Homo sapiens

<400> 85

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Leu Thr Ser Tyr

20 25 30

Gly Ile Ser Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Trp Val Ser Phe Tyr Asn Gly Asn Thr Asn Tyr Ala Gln Lys Leu

50 55 60

Gln Gly Arg Gly Thr Met Thr Thr Asp Pro Ser Thr Ser Thr Ala Tyr

65 70 75 80

Met Glu Leu Arg Ser Leu Arg Ser Asp Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Gly Tyr Gly Met Asp Val Trp Gly Gln Gly Thr Thr Val Thr

100 105 110

Val Ser Ser

115

<210> 86

<211> 5

<212> PROTEIN

<213> Homo sapiens

<400> 86

Ser Tyr Gly Ile Ser

1 5

<210> 87

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 87

Trp Val Ser Phe Tyr Asn Gly Asn Thr Asn Tyr Ala Gln Lys Leu Gln

1 5 10 15

Gly

<210> 88

<211> 6

<212> PROTEIN

<213> Homo sapiens

<400> 88

Gly Tyr Gly Met Asp Val

1 5

<210> 89

<211> 109

<212> PROTEIN

<213> Homo sapiens

<400> 89

Gln Ser Ala Leu Thr Gln Pro Ala Ser Val Ser Gly Ser Pro Gly Gln

1 5 10 15

Ser Ile Thr Ile Ser Cys Thr Gly Thr Ser Ser Asp Val Gly Gly Tyr

20 25 30

Asn Ser Val Ser Trp Tyr Gln Gln His Pro Gly Lys Ala Pro Lys Leu

35 40 45

Met Ile Tyr Glu Val Ser Asn Arg Pro Ser Gly Val Ser Asn Arg Phe

50 55 60

Ser Gly Ser Lys Ser Gly Asn Thr Ala Ser Leu Thr Ile Ser Gly Leu

65 70 75 80

Gln Ala Glu Asp Glu Ala Asp Tyr Tyr Cys Asn Ser Tyr Thr Ser Thr

85 90 95

Ser Met Val Phe Gly Gly Gly Thr Lys Leu Thr Val Leu

100 105

<210> 90

<211> 14

<212> PROTEIN

<213> Homo sapiens

<400> 90

Thr Gly Thr Ser Ser Asp Val Gly Gly Tyr Asn Ser Val Ser

1 5 10

<210> 91

<211> 7

<212> PROTEIN

<213> Homo sapiens

<400> 91

Glu Val Ser Asn Arg Pro Ser

1 5

<210> 92

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 92

Asn Ser Tyr Thr Ser Thr Ser Met Val

1 5

<210> 93

<211> 123

<212> PROTEIN

<213> Homo sapiens

<400> 93

Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Lys Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Ser Tyr

20 25 30

Ser Met Asn Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ser Ser Ile Ser Ser Ser Ser Ser Tyr Ile Ser Tyr Ala Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Asn Ser Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Phe Cys

85 90 95

Ala Arg Asp Tyr Asp Phe Trp Ser Ala Tyr Tyr Asp Ala Phe Asp Val

100 105 110

Trp Gly Gln Gly Thr Met Val Thr Val Ser Ser

115 120

<210> 94

<211> 10

<212> PROTEIN

<213> Homo sapiens

<400> 94

Gly Phe Thr Phe Ser Ser Tyr Ser Met Asn

1 5 10

<210> 95

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 95

Ser Ile Ser Ser Ser Ser Ser Tyr Ile Ser Tyr Ala Asp Ser Val Lys

1 5 10 15

Gly

<210> 96

<211> 14

<212> PROTEIN

<213> Homo sapiens

<400> 96

Asp Tyr Asp Phe Trp Ser Ala Tyr Tyr Asp Ala Phe Asp Val

1 5 10

<210> 97

<211> 111

<212> PROTEIN

<213> Homo sapiens

<400> 97

Gln Ser Val Leu Thr Gln Pro Pro Ser Val Ser Gly Ala Pro Gly Gln

1 5 10 15

Arg Val Thr Ile Ser Cys Thr Gly Ser Ser Ser Asn Ile Gly Ala Gly

20 25 30

Tyr Asp Val His Trp Tyr Gln Gln Leu Pro Gly Thr Ala Pro Lys Leu

35 40 45

Leu Ile Ser Gly Asn Ser Asn Arg Pro Ser Gly Val Pro Asp Arg Phe

50 55 60

Ser Gly Ser Lys Ser Gly Thr Ser Ala Ser Leu Ala Ile Thr Gly Leu

65 70 75 80

Gln Ala Glu Asp Glu Ala Asp Tyr Tyr Cys Gln Ser Tyr Asp Ser Ser

85 90 95

Leu Ser Gly Ser Val Phe Gly Gly Gly Thr Lys Leu Thr Val Leu

100 105 110

<210> 98

<211> 14

<212> PROTEIN

<213> Homo sapiens

<400> 98

Thr Gly Ser Ser Ser Asn Ile Gly Ala Gly Tyr Asp Val His

1 5 10

<210> 99

<211> 7

<212> PROTEIN

<213> Homo sapiens

<400> 99

Gly Asn Ser Asn Arg Pro Ser

1 5

<210> 100

<211> 11

<212> PROTEIN

<213> Homo sapiens

<400> 100

Gln Ser Tyr Asp Ser Ser Leu Ser Gly Ser Val

1 5 10

<210> 101

<211> 114

<212> PROTEIN

<213> Homo sapiens

<400> 101

Gln Val Gln Leu Val Glu Ser Gly Gly Gly Val Ala Gln Pro Gly Arg

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Ser Tyr

20 25 30

Gly Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ala Val Ile Tyr Tyr Asp Gly Ile Asn Lys His Tyr Ala Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Asp Arg Gly Leu Asp Trp Gly Gln Gly Thr Leu Val Thr Val

100 105 110

Ser Ser

<210> 102

<211> 10

<212> PROTEIN

<213> Homo sapiens

<400> 102

Gly Phe Thr Phe Ser Ser Tyr Gly Met His

1 5 10

<210> 103

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 103

Val Ile Tyr Tyr Asp Gly Ile Asn Lys His Tyr Ala Asp Ser Val Lys

1 5 10 15

Gly

<210> 104

<211> 5

<212> PROTEIN

<213> Homo sapiens

<400> 104

Asp Arg Gly Leu Asp

1 5

<210> 105

<211> 113

<212> PROTEIN

<213> Homo sapiens

<400> 105

Asp Ile Val Met Thr Gln Ser Pro Asp Ser Leu Ala Val Ser Leu Gly

1 5 10 15

Glu Arg Ala Thr Ile Asn Cys Lys Ser Ser Gln Ser Val Leu Tyr Ser

20 25 30

Ser Asn Ser Lys Asn Tyr Leu Val Trp Tyr Gln Gln Lys Pro Gly Gln

35 40 45

Pro Pro Lys Leu Leu Ile Tyr Trp Ala Ser Thr Arg Glu Ser Gly Val

50 55 60

Pro Asp Arg Phe Ser Gly Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr

65 70 75 80

Ile Ser Ser Leu Gln Ala Glu Asp Val Ala Val Tyr Tyr Cys Gln Gln

85 90 95

Tyr Tyr Ser Thr Pro Trp Thr Phe Gly Gln Gly Thr Lys Val Glu Ile

100 105 110

Lys

<210> 106

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 106

Lys Ser Ser Gln Ser Val Leu Tyr Ser Ser Asn Ser Lys Asn Tyr Leu

1 5 10 15

Val

<210> 107

<211> 7

<212> PROTEIN

<213> Homo sapiens

<400> 107

Trp Ala Ser Thr Arg Glu Ser

1 5

<210> 108

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 108

Gln Gln Tyr Tyr Ser Thr Pro Trp Thr

1 5

<210> 109

<211> 118

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

heavy chain variable region polypeptide (FR1-FR4) Vh

monoclonal antibody pJG04 to PCSK9 (clones LGT-209 and LGT-210)

<400> 109

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Phe Ser Thr Met

20 25 30

Tyr Met Ser Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Arg Ile Asp Pro Ala Asn Glu His Thr Asn Tyr Ala Gln Lys Phe

50 55 60

Gln Gly Arg Val Thr Met Thr Arg Asp Thr Ser Ile Ser Thr Ala Tyr

65 70 75 80

Met Glu Leu Ser Arg Leu Thr Ser Asp Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Ser Tyr Tyr Tyr Tyr Asn Met Asp Tyr Trp Gly Gln Gly Thr

100 105 110

Leu Val Thr Val Ser Ser

115

<210> 110

<211> 5

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 of the heavy chain of monoclonal antibodies to PCSK9 clones LGT-209,

LGT-210 and LGT-211

<400> 110

Thr Met Tyr Met Ser

1 5

<210> 111

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR2 of the heavy chain of monoclonal antibodies to PCSK9 clones LGT-209,

LGT-210 and LGT-211

<400> 111

Arg Ile Asp Pro Ala Asn Glu His Thr Asn Tyr Ala Gln Lys Phe Gln

1 5 10 15

Gly

<210> 112

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

complementarity determining region 3 (CDR3) of the Vh heavy chain

monoclonal antibody pJG04 to PCSK9 (clones LGT-209 and LGT-210)

<400> 112

Ser Tyr Tyr Tyr Tyr Asn Met Asp Tyr

1 5

<210> 113

<211> 106

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

variable region polypeptide (FR1-FR4) Vk light chain

monoclonal antibody pJG04 to PCSK9 (clones LGT-209 and LGT-211)

<400> 113

Gln Ile Val Leu Thr Gln Ser Pro Ala Thr Leu Ser Val Ser Pro Gly

1 5 10 15

Glu Arg Ala Thr Leu Ser Cys Arg Ala Ser Gln Ser Val Ser Tyr Met

20 25 30

His Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Arg Leu Leu Ile Tyr

35 40 45

Gly Val Phe Arg Arg Ala Thr Gly Ile Pro Asp Arg Phe Ser Gly Ser

50 55 60

Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Gly Arg Leu Glu Pro Glu

65 70 75 80

Asp Phe Ala Val Tyr Tyr Cys Leu Gln Trp Ser Ser Asp Pro Pro Thr

85 90 95

Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys

100 105

<210> 114

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 of the light chain of monoclonal antibodies to PCSK9 clones LGT-209,

LGT-210 and LGT-211

<400> 114

Arg Ala Ser Gln Ser Val Ser Tyr Met His

1 5 10

<210> 115

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR1 of the light chain of monoclonal antibodies to PCSK9 clones LGT-209,

LGT-210 and LGT-211

<400> 115

Gly Val Phe Arg Arg Ala Thr

1 5

<210> 116

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR3 of the light chain of mouse monoclonal antibody LFU720 to PCSK9

and monoclonal antibody to PCSK9 clones LGT-209,

LGT-210 and LGT-211

<400> 116

Leu Gln Trp Ser Ser Asp Pro Pro Thr

1 5

<210> 117

<211> 118

<212> PROTEIN

<213> Homo sapiens

<400> 117

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Ser Tyr

20 25 30

Tyr Met His Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Glu Ile Ser Pro Phe Gly Gly Arg Thr Asn Tyr Asn Glu Lys Phe

50 55 60

Lys Ser Arg Val Thr Met Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr

65 70 75 80

Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Arg Pro Leu Tyr Ala Ser Asp Leu Trp Gly Gln Gly Thr

100 105 110

Thr Val Thr Val Ser Ser

115

<210> 118

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 118

Gly Tyr Thr Phe Thr Ser Tyr

1 5

<210> 119

<211> 6

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 119

Ser Pro Phe Gly Gly Arg

1 5

<210> 120

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the heavy chain variable region

<400> 120

Glu Arg Pro Leu Tyr Ala Ser Asp Leu

1 5

<210> 121

<211> 107

<212> PROTEIN

<213> Homo sapiens

<400> 121

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Ser Ser Ala

20 25 30

Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Ser Ala Ser Tyr Arg Tyr Thr Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Arg Tyr Ser Leu Trp Arg

85 90 95

Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys

100 105

<210> 122

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the light chain variable region

<400> 122

Arg Ala Ser Gln Gly Ile Ser Ser Ala Leu Ala

1 5 10

<210> 123

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the light chain variable region

<400> 123

Ser Ala Ser Tyr Arg Tyr Thr

1 5

<210> 124

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the light chain variable region

<400> 124

Gln Gln Arg Tyr Ser Leu Trp Arg Thr

1 5

<210> 125

<211> 118

<212> PROTEIN

<213> Homo sapiens

<400> 125

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Ser Tyr

20 25 30

Tyr Met His Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Glu Ile His Pro Ser Gly Gly Arg Thr Asn Tyr Asn Glu Lys Phe

50 55 60

Lys Ser Arg Val Thr Met Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr

65 70 75 80

Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Arg Pro Leu Tyr Ala Met Asp Tyr Trp Gly Gln Gly Thr

100 105 110

Thr Val Thr Val Ser Ser

115

<210> 126

<211> 10

<212> PROTEIN

<213> Homo sapiens

<400> 126

Gly Tyr Thr Phe Thr Ser Tyr Tyr Met His

1 5 10

<210> 127

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 127

Glu Ile His Pro Ser Gly Gly Arg Thr Asn Tyr Asn Glu Lys Phe Lys

1 5 10 15

Ser

<210> 128

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 128

Glu Arg Pro Leu Tyr Ala Met Asp Tyr

1 5

<210> 129

<211> 107

<212> PROTEIN

<213> Homo sapiens

<400> 129

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Lys Ala Ser Gln Asp Val His Thr Ala

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr His Ala Ser Tyr Arg Tyr Thr Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Arg Tyr Ser Leu Trp Arg

85 90 95

Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys

100 105

<210> 130

<211> 11

<212> PROTEIN

<213> Homo sapiens

<400> 130

Lys Ala Ser Gln Asp Val His Thr Ala Val Ala

1 5 10

<210> 131

<211> 7

<212> PROTEIN

<213> Homo sapiens

<400> 131

His Ala Ser Tyr Arg Tyr Thr

1 5

<210> 132

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 132

Gln Gln Arg Tyr Ser Leu Trp Arg Thr

1 5

<210> 133

<211> 118

<212> PROTEIN

<213> Homo sapiens

<400> 133

Gln Val Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Ser Tyr

20 25 30

Tyr Met His Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met

35 40 45

Gly Glu Ile His Pro Ser Gly Gly Arg Thr Asn Tyr Asn Glu Lys Phe

50 55 60

Lys Ser Arg Val Thr Met Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr

65 70 75 80

Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Arg Pro Leu Tyr Ala Ser Asp Leu Trp Gly Gln Gly Thr

100 105 110

Thr Val Thr Val Ser Ser

115

<210> 134

<211> 10

<212> PROTEIN

<213> Homo sapiens

<400> 134

Gly Tyr Thr Phe Thr Ser Tyr Tyr Met His

1 5 10

<210> 135

<211> 17

<212> PROTEIN

<213> Homo sapiens

<400> 135

Glu Ile His Pro Ser Gly Gly Arg Thr Asn Tyr Asn Glu Lys Phe Lys

1 5 10 15

Ser

<210> 136

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 136

Glu Arg Pro Leu Tyr Ala Ser Asp Leu

1 5

<210> 137

<211> 107

<212> PROTEIN

<213> Homo sapiens

<400> 137

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Lys Ala Ser Gln Asp Val His Thr Ala

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr His Ala Ser Tyr Arg Tyr Thr Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Arg Tyr Ser Leu Trp Arg

85 90 95

Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys

100 105

<210> 138

<211> 11

<212> PROTEIN

<213> Homo sapiens

<400> 138

Lys Ala Ser Gln Asp Val His Thr Ala Val Ala

1 5 10

<210> 139

<211> 7

<212> PROTEIN

<213> Homo sapiens

<400> 139

His Ala Ser Tyr Arg Tyr Thr

1 5

<210> 140

<211> 9

<212> PROTEIN

<213> Homo sapiens

<400> 140

Gln Gln Arg Tyr Ser Leu Trp Arg Thr

1 5

<210> 141

<211> 118

<212> PROTEIN

<213> Mus musculus

<400> 141

Gln Val Gln Leu Gln Gln Pro Gly Ala Glu Leu Val Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Leu Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Ser Tyr

20 25 30

Trp Met His Trp Val Lys Gln Arg Pro Gly Gln Gly Leu Glu Trp Ile

35 40 45

Gly Glu Ile Asn Pro Ser Asn Gly Arg Thr Asn Tyr Asn Glu Lys Phe

50 55 60

Lys Ser Lys Ala Thr Leu Thr Val Asp Lys Ser Ser Ser Thr Ala Tyr

65 70 75 80

Met Gln Leu Ser Ser Leu Thr Ser Glu Asp Ser Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Arg Pro Leu Tyr Ala Met Asp Tyr Trp Gly Gln Gly Thr

100 105 110

Ser Val Thr Val Ser Ser

115

<210> 142

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 142

Gly Tyr Thr Phe Thr Ser Tyr

1 5

<210> 143

<211> 6

<212> PROTEIN

<213> Mus musculus

<400> 143

Asn Pro Ser Asn Gly Arg

1 5

<210> 144

<211> 9

<212> PROTEIN

<213> Mus musculus

<400> 144

Glu Arg Pro Leu Tyr Ala Met Asp Tyr

1 5

<210> 145

<211> 108

<212> PROTEIN

<213> Mus musculus

<400> 145

Asp Ile Val Met Thr Gln Ser His Lys Phe Met Ser Thr Ser Val Gly

1 5 10 15

Asp Arg Val Ser Ile Thr Cys Lys Ala Ser Gln Asp Val Ser Thr Ala

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Gln Ser Pro Lys Leu Leu Ile

35 40 45

Tyr Ser Ala Ser Tyr Arg Tyr Thr Gly Val Pro Asp Arg Phe Thr Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Val Gln Ala

65 70 75 80

Glu Asp Leu Ala Val Tyr Tyr Cys Gln Gln Arg Tyr Ser Thr Pro Arg

85 90 95

Thr Phe Gly Gly Gly Thr Lys Leu Glu Ile Lys Arg

100 105

<210> 146

<211> 11

<212> PROTEIN

<213> Mus musculus

<400> 146

Lys Ala Ser Gln Asp Val Ser Thr Ala Val Ala

1 5 10

<210> 147

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the light chain variable region

<400> 147

Ser Ala Ser Tyr Arg Tyr Thr

1 5

<210> 148

<211> 9

<212> PROTEIN

<213> Mus musculus

<400> 148

Gln Gln Arg Tyr Ser Thr Pro Arg Thr

1 5

<210> 149

<211> 115

<212> PROTEIN

<213> Mus musculus

<400> 149

Glu Val Gln Leu Gln Gln Ser Gly Pro Glu Leu Val Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Ile Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Asp Tyr

20 25 30

Tyr Met Asn Trp Val Lys Gln Ser His Gly Lys Ser Leu Glu Trp Ile

35 40 45

Gly Asp Ile Asn Pro Asn Asn Gly Gly Thr Thr Tyr Asn Gln Lys Phe

50 55 60

Lys Gly Lys Ala Thr Leu Thr Val Asp Lys Ser Tyr Ser Thr Ala Tyr

65 70 75 80

Met Glu Leu Arg Ser Leu Thr Ser Glu Asp Ser Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Trp Leu Leu Phe Ala Tyr Trp Gly Gln Gly Thr Leu Val Thr

100 105 110

Val Ser Ala

115

<210> 150

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 150

Gly Tyr Thr Phe Thr Asp Tyr

1 5

<210> 151

<211> 6

<212> PROTEIN

<213> Mus musculus

<400> 151

Asn Pro Asn Asn Gly Gly

1 5

<210> 152

<211> 6

<212> PROTEIN

<213> Mus musculus

<400> 152

Trp Leu Leu Phe Ala Tyr

1 5

<210> 153

<211> 108

<212> PROTEIN

<213> Mus musculus

<400> 153

Asp Ile Val Met Thr Gln Ser Gln Lys Phe Met Ser Thr Ser Val Gly

1 5 10 15

Asp Arg Val Ser Val Thr Cys Lys Ala Ser Gln Asn Val Gly Thr Asn

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Gln Ser Pro Lys Ala Leu Ile

35 40 45

Tyr Ser Ala Ser Tyr Arg Tyr Ser Gly Val Pro Asp Arg Phe Thr Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Asn Val Leu Ser

65 70 75 80

Glu Asp Leu Ala Glu Tyr Phe Cys Gln Gln Phe Tyr Ser Tyr Pro Tyr

85 90 95

Thr Phe Gly Gly Gly Thr Lys Leu Glu Ile Lys Arg

100 105

<210> 154

<211> 11

<212> PROTEIN

<213> Mus musculus

<400> 154

Lys Ala Ser Gln Asn Val Gly Thr Asn Val Ala

1 5 10

<210> 155

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 155

Ser Ala Ser Tyr Arg Tyr Ser

1 5

<210> 156

<211> 9

<212> PROTEIN

<213> Mus musculus

<400> 156

Gln Gln Phe Tyr Ser Tyr Pro Tyr Thr

1 5

<210> 157

<211> 123

<212> PROTEIN

<213> Mus musculus

<400> 157

Glu Val Gln Leu Gln Gln Ser Gly Pro Glu Leu Val Lys Pro Gly Ala

1 5 10 15

Ser Val Lys Ile Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Asp Tyr

20 25 30

Tyr Met Asn Trp Val Lys Gln Ser His Gly Lys Ser Leu Glu Trp Ile

35 40 45

Gly Asp Ile Asn Pro Asn Asn Gly Gly Thr Ser Tyr Asn Gln Lys Phe

50 55 60

Lys Gly Lys Ala Thr Leu Thr Val Asp Lys Ser Ser Ser Thr Ala Tyr

65 70 75 80

Met Glu Leu Arg Ser Leu Thr Ser Glu Asp Ser Ala Val Tyr Tyr Cys

85 90 95

Ala Gly Gly Gly Ile Tyr Tyr Arg Tyr Asp Arg Asn Tyr Phe Asp Tyr

100 105 110

Trp Gly Gln Gly Thr Thr Leu Thr Val Ser Ser

115 120

<210> 158

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 158

Gly Tyr Thr Phe Thr Asp Tyr

1 5

<210> 159

<211> 6

<212> PROTEIN

<213> Mus musculus

<400> 159

Asn Pro Asn Asn Gly Gly

1 5

<210> 160

<211> 14

<212> PROTEIN

<213> Mus musculus

<400> 160

Gly Gly Ile Tyr Tyr Arg Tyr Asp Arg Asn Tyr Phe Asp Tyr

1 5 10

<210> 161

<211> 107

<212> PROTEIN

<213> Mus musculus

<400> 161

Asp Ile Gln Met Thr Gln Thr Thr Ser Ser Leu Ser Ala Ser Leu Gly

1 5 10 15

Asp Arg Val Thr Ile Ser Cys Ser Ala Ser Gln Gly Ile Ser Asn Tyr

20 25 30

Leu Asn Trp Tyr Gln Gln Lys Pro Asp Gly Thr Val Lys Leu Leu Ile

35 40 45

Tyr Tyr Thr Ser Ser Leu His Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Tyr Ser Leu Thr Ile Ser Asn Leu Glu Pro

65 70 75 80

Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Tyr Ser Lys Leu Pro Phe

85 90 95

Thr Phe Gly Ser Gly Thr Lys Leu Glu Ile Lys

100 105

<210> 162

<211> 11

<212> PROTEIN

<213> Mus musculus

<400> 162

Ser Ala Ser Gln Gly Ile Ser Asn Tyr Leu Asn

1 5 10

<210> 163

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 163

Tyr Thr Ser Ser Leu His Ser

1 5

<210> 164

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 164

Gln Gln Tyr Ser Lys Leu Pro Phe Thr

1 5

<210> 165

<211> 117

<212> PROTEIN

<213> Mus musculus

<400> 165

Glu Val Lys Leu Val Glu Ser Glu Gly Gly Leu Val Gln Pro Gly Ser

1 5 10 15

Ser Met Lys Leu Ser Cys Thr Ala Ser Gly Phe Thr Phe Ser Asp Tyr

20 25 30

Tyr Met Ala Trp Val Arg Gln Val Pro Glu Lys Gly Leu Glu Trp Val

35 40 45

Ala Asn Ile Asn Tyr Asp Gly Ser Asn Thr Ser Tyr Leu Asp Ser Leu

50 55 60

Lys Ser Arg Phe Ile Ile Ser Arg Asp Asn Ala Lys Asn Ile Leu Tyr

65 70 75 80

Leu Gln Met Ser Ser Leu Lys Ser Glu Asp Thr Ala Thr Tyr Tyr Cys

85 90 95

Ala Arg Glu Lys Phe Ala Ala Met Asp Tyr Trp Gly Gln Gly Thr Ser

100 105 110

Val Thr Val Ser Ser

115

<210> 166

<211> 7

<212> PROTEIN

<213> Mus musculus

<400> 166

Gly Phe Thr Phe Ser Asp Tyr

1 5

<210> 167

<211> 6

<212> PROTEIN

<213> Mus musculus

<400> 167

Asn Tyr Asp Gly Ser Asn

1 5

<210> 168

<211> 8

<212> PROTEIN

<213> Mus musculus

<400> 168

Glu Lys Phe Ala Ala Met Asp Tyr

1 5

<210> 169

<211> 108

<212> PROTEIN

<213> Mus musculus

<400> 169

Asp Ile Val Met Thr Gln Ser His Lys Phe Met Ser Thr Ser Phe Gly

1 5 10 15

Asp Arg Val Ser Ile Thr Cys Lys Ala Ser Gln Asp Val Ser Asn Ala

20 25 30

Leu Ala Trp Tyr Gln Gln Lys Pro Gly His Ser Pro Lys Leu Leu Ile

35 40 45

Phe Ser Ala Ser Tyr Arg Tyr Thr Gly Val Pro Asp Arg Phe Thr Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Val Gln Ala

65 70 75 80

Glu Asp Leu Ala Val Tyr Tyr Cys Gln Gln His Tyr Ser Thr Pro Trp

85 90 95

Thr Phe Gly Gly Gly Thr Lys Leu Glu Ile Lys Arg

100 105

<210> 170

<211> 11

<212> PROTEIN

<213> Mus musculus

<400> 170

Lys Ala Ser Gln Asp Val Ser Asn Ala Leu Ala

1 5 10

<210> 171

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

CDR of the light chain variable region

<400> 171

Ser Ala Ser Tyr Arg Tyr Thr

1 5

<210> 172

<211> 9

<212> PROTEIN

<213> Mus musculus

<400> 172

Gln Gln His Tyr Ser Thr Pro Trp Thr

1 5

<210> 173

<211> 121

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 173

Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Thr Arg His

20 25 30

Thr Ile His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ala Arg Ile Ser Pro Ala Asn Gly Asn Thr Asn Tyr Ala Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Ala Asp Thr Ser Lys Asn Thr Ala Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Trp Ile Gly Ser Arg Glu Leu Tyr Ile Met Asp Tyr Trp Gly

100 105 110

Gln Gly Thr Leu Val Thr Val Ser Ser

115 120

<210> 174

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 174

Gly Phe Thr Phe Thr Arg His Thr Ile His

1 5 10

<210> 175

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 175

Arg Ile Ser Pro Ala Asn Gly Asn Thr Asn Tyr Ala Asp Ser Val Lys

1 5 10 15

Gly

<210> 176

<211> 12

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 176

Trp Ile Gly Ser Arg Glu Leu Tyr Ile Met Asp Tyr

1 5 10

<210> 177

<211> 108

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 177

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Val Ser Thr Ala

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Ser Ala Ser Phe Leu Tyr Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Tyr Arg Ile Gln Pro

85 90 95

Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys Arg

100 105

<210> 178

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 178

Arg Ala Ser Gln Asp Val Ser Thr Ala Val Ala

1 5 10

<210> 179

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 179

Ser Ala Ser Phe Leu Tyr Ser

1 5

<210> 180

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 180

Gln Gln Ser Tyr Arg Ile Gln Pro Thr

1 5

<210> 181

<211> 121

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 181

Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Ser Thr

20 25 30

Ala Ile His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ala Arg Ile Ser Pro Ala Asn Gly Asn Thr Asn Tyr Ala Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Ala Asp Thr Ser Lys Asn Thr Ala Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Trp Ile Gly Ser Arg Glu Leu Tyr Ile Met Asp Tyr Trp Gly

100 105 110

Gln Gly Thr Leu Val Thr Val Ser Ser

115 120

<210> 182

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 182

Gly Phe Thr Phe Ser Ser Thr Ala Ile His

1 5 10

<210> 183

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 183

Arg Ile Ser Pro Ala Asn Gly Asn Thr Asn Tyr Ala Asp Ser Val Lys

1 5 10 15

Gly

<210> 184

<211> 12

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 184

Trp Ile Gly Ser Arg Glu Leu Tyr Ile Met Asp Tyr

1 5 10

<210> 185

<211> 108

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 185

Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly

1 5 10 15

Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Val Ser Thr Ala

20 25 30

Val Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile

35 40 45

Tyr Ser Ala Ser Phe Leu Tyr Ser Gly Val Pro Ser Arg Phe Ser Gly

50 55 60

Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro

65 70 75 80

Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Tyr Pro Ala Leu His

85 90 95

Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys Arg

100 105

<210> 186

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 186

Arg Ala Ser Gln Asp Val Ser Thr Ala Val Ala

1 5 10

<210> 187

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 187

Ser Ala Ser Phe Leu Tyr Ser

1 5

<210> 188

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 188

Gln Gln Ser Tyr Pro Ala Leu His Thr

1 5

<210> 189

<211> 125

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 189

Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Lys Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Pro Phe Ser Lys Leu

20 25 30

Gly Met Val Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ser Thr Ile Ser Ser Gly Gly Gly Tyr Thr Tyr Tyr Pro Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Asn Ser Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Arg Glu Gly Ile Ser Phe Gln Gly Gly Thr Tyr Thr Tyr Val Met

100 105 110

Asp Tyr Trp Gly Gln Gly Thr Leu Val Thr Val Ser Ser

115 120 125

<210> 190

<211> 10

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 190

Gly Phe Pro Phe Ser Lys Leu Gly Met Val

1 5 10

<210> 191

<211> 17

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 191

Thr Ile Ser Ser Gly Gly Gly Tyr Thr Tyr Tyr Pro Asp Ser Val Lys

1 5 10 15

Gly

<210> 192

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 192

Glu Gly Ile Ser Phe Gln Gly Gly Thr Tyr Thr Tyr Val Met Asp Tyr

1 5 10 15

<210> 193

<211> 112

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic

polypeptide

<400> 193

Asp Ile Val Met Thr Gln Ser Pro Leu Ser Leu Pro Val Thr Pro Gly

1 5 10 15

Glu Pro Ala Ser Ile Ser Cys Arg Ser Ser Lys Ser Leu Leu His Arg

20 25 30

Asn Gly Ile Thr Tyr Ser Tyr Trp Tyr Leu Gln Lys Pro Gly Gln Ser

35 40 45

Pro Gln Leu Leu Ile Tyr Gln Leu Ser Asn Leu Ala Ser Gly Val Pro

50 55 60

Asp Arg Phe Ser Gly Ser Gly Ser Gly Thr Asp Phe Thr Leu Lys Ile

65 70 75 80

Ser Arg Val Glu Ala Glu Asp Val Gly Val Tyr Tyr Cys Tyr Gln Asn

85 90 95

Leu Glu Leu Pro Leu Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys

100 105 110

<210> 194

<211> 16

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 194

Arg Ser Ser Lys Ser Leu Leu His Arg Asn Gly Ile Thr Tyr Ser Tyr

1 5 10 15

<210> 195

<211> 7

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 195

Gln Leu Ser Asn Leu Ala Ser

1 5

<210> 196

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: Synthetic peptide

<400> 196

Tyr Gln Asn Leu Glu Leu Pro Leu Thr

1 5

<210> 197

<211> 2076

<212> DNA

<213> Homo sapiens

<400> 197

atgggcaccg tcagctccag gcggtcctgg tggccgctgc cactgctgct gctgctgctg 60

ctgctcctgg gtcccgcggg cgcccgtgcg caggaggacg aggacggcga ctacgaggag 120

ctggtgctag ccttgcgttc cgaggaggac ggcctggccg aagcacccga gcacggaacc 180

acagccacct tccaccgctg cgccaaggat ccgtggaggt tgcctggcac ctacgtggtg 240

gtgctgaagg aggagaccca cctctcgcag tcagagcgca ctgcccgccg cctgcaggcc 300

caggctgccc gccggggata cctcaccaag atcctgcatg tcttccatgg ccttcttcct 360

ggcttcctgg tgaagatgag tggcgacctg ctggagctgg ccttgaagtt gccccatgtc 420

gactacatcg aggaggactc ctctgtcttt gcccagagca tcccgtggaa cctggagcgg 480

attacccctc cacggtaccg ggcggatgaa taccagcccc ccgacggagg cagcctggtg 540

gaggtgtatc tcctagacac cagcatacag agtgaccacc gggaaatcga gggcagggtc 600

atggtcaccg acttcgagaa tgtgcccgag gaggacggga cccgcttcca cagacaggcc 660

agcaagtgtg acagtcatgg cacccacctg gcaggggtgg tcagcggccg ggatgccggc 720

gtggccaagg gtgccagcat gcgcagcctg cgcgtgctca actgccaagg gaagggcacg 780

gttagcggca ccctcatagg cctggagttt attcggaaaa gccagctggt ccagcctgtg 840

gggccactgg tggtgctgct gcccctggcg ggtgggtaca gccgcgtcct caacgccgcc 900

tgccagcgcc tggcgagggc tggggtcgtg ctggtcaccg ctgccggcaa cttccgggac 960

gatgcctgcc tctactcccc agcctcagct cccgaggtca tcacagttgg ggccaccaat 1020

gcccaagacc agccggtgac cctggggact ttggggacca actttggccg ctgtgtggac 1080

ctctttgccc caggggagga catcattggt gcctccagcg actgcagcac ctgctttgtg 1140

tcacagagtg ggacatcaca ggctgctgcc cacgtggctg gcattgcagc catgatgctg 1200

tctgccgagc cggagctcac cctggccgag ttgaggcaga gactgatcca cttctctgcc 1260

aaagatgtca tcaatgaggc ctggttccct gaggaccagc gggtactgac ccccaacctg 1320

gtggccgccc tgccccccag cacccatggg gcaggttggc agctgttttg caggactgta 1380

tggtcagcac actcggggcc tacacggatg gccacagccg tcgcccgctg cgccccagat 1440

gaggagctgc tgagctgctc cagtttctcc aggagtggga agcggcgggg cgagcgcatg 1500

gaggcccaag ggggcaagct ggtctgccgg gcccacaacg cttttggggg tgaggtgtc 1560

tacgccattg ccaggtgctg cctgctaccc caggccaact gcagcgtcca cacagctcca 1620

ccagctgagg ccagcatggg gacccgtgtc cactgccacc aacagggcca cgtcctcaca 1680

ggctgcagct cccactggga ggtggaggac cttggcaccc acaagccgcc tgtgctgagg 1740

ccacgaggtc agcccaacca gtgcgtgggc cacagggagg ccagcatcca cgcttcctgc 1800

tgccatgccc caggtctgga atgcaaagtc aaggagcatg gaatcccggc ccctcaggag 1860

caggtgaccg tggcctgcga ggagggctgg accctgactg gctgcagtgc cctccctggg 1920

acctcccacg tcctgggggc ctacgccgta gacaacacgt gtgtagtcag gagccggggac 1980

gtcagcacta caggcagcac cagcgaaggg gccgtgacag ccgttgccat ctgctgccgg 2040

agccggcacc tggcgcaggc ctcccaggag ctccag 2076

<210> 198

<211> 692

<212> PROTEIN

<213> Homo sapiens

<400> 198

Met Gly Thr Val Ser Ser Arg Arg Ser Trp Trp Pro Leu Pro Leu Leu

1 5 10 15

Leu Leu Leu Leu Leu Leu Leu Gly Pro Ala Gly Ala Arg Ala Gln Glu

20 25 30

Asp Glu Asp Gly Asp Tyr Glu Glu Leu Val Leu Ala Leu Arg Ser Glu

35 40 45

Glu Asp Gly Leu Ala Glu Ala Pro Glu His Gly Thr Thr Ala Thr Phe

50 55 60

His Arg Cys Ala Lys Asp Pro Trp Arg Leu Pro Gly Thr Tyr Val Val

65 70 75 80

Val Leu Lys Glu Glu Thr His Leu Ser Gln Ser Glu Arg Thr Ala Arg

85 90 95

Arg Leu Gln Ala Gln Ala Ala Arg Arg Gly Tyr Leu Thr Lys Ile Leu

100 105 110

His Val Phe His Gly Leu Leu Pro Gly Phe Leu Val Lys Met Ser Gly

115 120 125

Asp Leu Leu Glu Leu Ala Leu Lys Leu Pro His Val Asp Tyr Ile Glu

130 135 140

Glu Asp Ser Ser Val Phe Ala Gln Ser Ile Pro Trp Asn Leu Glu Arg

145 150 155 160

Ile Thr Pro Pro Arg Tyr Arg Ala Asp Glu Tyr Gln Pro Pro Asp Gly

165 170 175

Gly Ser Leu Val Glu Val Tyr Leu Leu Asp Thr Ser Ile Gln Ser Asp

180 185 190

His Arg Glu Ile Glu Gly Arg Val Met Val Thr Asp Phe Glu Asn Val

195 200 205

Pro Glu Glu Asp Gly Thr Arg Phe His Arg Gln Ala Ser Lys Cys Asp

210 215 220

Ser His Gly Thr His Leu Ala Gly Val Val Ser Gly Arg Asp Ala Gly

225 230 235 240

Val Ala Lys Gly Ala Ser Met Arg Ser Leu Arg Val Leu Asn Cys Gln

245 250 255

Gly Lys Gly Thr Val Ser Gly Thr Leu Ile Gly Leu Glu Phe Ile Arg

260 265 270

Lys Ser Gln Leu Val Gln Pro Val Gly Pro Leu Val Val Leu Leu Pro

275 280 285

Leu Ala Gly Gly Tyr Ser Arg Val Leu Asn Ala Ala Cys Gln Arg Leu

290 295 300

Ala Arg Ala Gly Val Val Leu Val Thr Ala Ala Gly Asn Phe Arg Asp

305 310 315 320

Asp Ala Cys Leu Tyr Ser Pro Ala Ser Ala Pro Glu Val Ile Thr Val

325 330 335

Gly Ala Thr Asn Ala Gln Asp Gln Pro Val Thr Leu Gly Thr Leu Gly

340 345 350

Thr Asn Phe Gly Arg Cys Val Asp Leu Phe Ala Pro Gly Glu Asp Ile

355 360 365

Ile Gly Ala Ser Ser Asp Cys Ser Thr Cys Phe Val Ser Gln Ser Gly

370 375 380

Thr Ser Gln Ala Ala Ala His Val Ala Gly Ile Ala Ala Met Met Leu

385 390 395 400

Ser Ala Glu Pro Glu Leu Thr Leu Ala Glu Leu Arg Gln Arg Leu Ile

405 410 415

His Phe Ser Ala Lys Asp Val Ile Asn Glu Ala Trp Phe Pro Glu Asp

420 425 430

Gln Arg Val Leu Thr Pro Asn Leu Val Ala Ala Leu Pro Pro Ser Thr

435 440 445

His Gly Ala Gly Trp Gln Leu Phe Cys Arg Thr Val Trp Ser Ala His

450 455 460

Ser Gly Pro Thr Arg Met Ala Thr Ala Val Ala Arg Cys Ala Pro Asp

465 470 475 480

Glu Glu Leu Leu Ser Cys Ser Ser Phe Ser Arg Ser Gly Lys Arg Arg

485 490 495

Gly Glu Arg Met Glu Ala Gln Gly Gly Lys Leu Val Cys Arg Ala His

500 505 510

Asn Ala Phe Gly Gly Glu Gly Val Tyr Ala Ile Ala Arg Cys Cys Leu

515 520 525

Leu Pro Gln Ala Asn Cys Ser Val His Thr Ala Pro Pro Ala Glu Ala

530 535 540

Ser Met Gly Thr Arg Val His Cys His Gln Gln Gly His Val Leu Thr

545 550 555 560

Gly Cys Ser Ser His Trp Glu Val Glu Asp Leu Gly Thr His Lys Pro

565 570 575

Pro Val Leu Arg Pro Arg Gly Gln Pro Asn Gln Cys Val Gly His Arg

580 585 590

Glu Ala Ser Ile His Ala Ser Cys Cys His Ala Pro Gly Leu Glu Cys

595 600 605

Lys Val Lys Glu His Gly Ile Pro Ala Pro Gln Glu Gln Val Thr Val

610 615 620

Ala Cys Glu Glu Gly Trp Thr Leu Thr Gly Cys Ser Ala Leu Pro Gly

625 630 635 640

Thr Ser His Val Leu Gly Ala Tyr Ala Val Asp Asn Thr Cys Val Val

645 650 655

Arg Ser Arg Asp Val Ser Thr Thr Gly Ser Thr Ser Glu Gly Ala Val

660 665 670

Thr Ala Val Ala Ile Cys Cys Arg Ser Arg His Leu Ala Gln Ala Ser

675 680 685

Gln Glu Leu Gln

690

<---

Claims (30)

1. A method for reducing the risk of death from any cause in a patient with hypercholesterolemia who has a serum LDL-C level greater than or equal to 100 mg/dL, who is receiving therapy with the maximum tolerated dose of a statin and has had an acute coronary syndrome (ACS), comprising: administering to the patient a therapeutically effective amount of the antibody for at least 3 years, where the antibody specifically binds proprotein convertase subtilisin/kexin type 9 (PCSK9), where the PCSK9 antibody is alirocumab. 2. The method according to claim 1, wherein the patient has a concomitant polyvascular disease, wherein the polyvascular disease includes coronary artery disease with concomitant: (a) peripheral arterial disease (PAD); (b) cerebrovascular disease (CeVD); or (c) PAD and CeVD. 3. The method according to item 1 or 2, wherein the patient has previously undergone coronary artery bypass grafting (CABG). 4. The method according to claim 1, wherein the antibody comprises HCDR1 comprising the amino acid sequence set forth in SEQ ID NO: 2; HCDR2 comprising the amino acid sequence set forth in SEQ ID NO: 3; HCDR3 comprising the amino acid sequence set forth in SEQ ID NO: 4; LCDR1, comprising the amino acid sequence set forth in SEQ ID NO: 7; LCDR2, comprising the amino acid sequence set forth in SEQ ID NO: 8; LCDR3, comprising the amino acid sequence set forth in SEQ ID NO: 10. 5. The method according to any one of paragraphs 1-4, wherein the step of administration comprises administration to the patient: (a) one or more 75 mg doses of antibody every two weeks for 4 to 8 weeks; and (b) one or more 150 mg doses of antibody every two weeks if the patient's LDL-C level after stage (a) is greater than or equal to the threshold level. 6. The method of claim 5, wherein the threshold level is 50 mg/dL. 7. The method according to any one of paragraphs 1-4, wherein the step of administration comprises administration to the patient: (a) one or more doses of 75 mg of antibody every two weeks; or (b) one or more doses of 150 mg of antibody every two weeks; or (c) one or more doses of 300 mg of antibody every four weeks. 8. The method according to any one of paragraphs 1-7, wherein therapy with the maximum tolerated dose of statins comprises: (a) atorvastatin at a daily dose of 40 to 80 mg; (b) rosuvastatin at a daily dose of 20 to 40 mg. 9. The method according to any one of claims 1-4 or 7, 8, wherein the administering step comprises administering to the patient one or more doses of 75 mg of alirocumab every two weeks for at least 3 years. 10. The method of any one of claims 1 to 8, wherein the administering step comprises administering to the patient one or more doses of 150 mg of alirocumab every two weeks for at least 3 years. 11. The method according to any one of claims 1-10, wherein alirocumab is administered subcutaneously into the thigh, abdomen or upper arm.

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