Does Repatha Break Down Heart Plaque?
Repatha (evolocumab) does not directly "break down" or dissolve existing heart plaque, but it powerfully reduces LDL cholesterol levels by approximately 59%, which slows plaque progression and significantly reduces cardiovascular events including heart attacks and strokes. 1
Mechanism of Action: Prevention, Not Dissolution
Repatha works by blocking PCSK9 protein, which increases the number of LDL receptors available to clear circulating LDL cholesterol from the blood—it does not actively break apart atherosclerotic plaques. 1 The drug is a fully human monoclonal antibody that binds to PCSK9, preventing it from degrading LDL receptors on liver cells, thereby enhancing cholesterol removal from the bloodstream. 2
Clinical Evidence for Cardiovascular Benefit
The landmark FOURIER trial provides the strongest evidence for Repatha's cardiovascular benefits: 1, 3
Enrolled 27,564 patients with established atherosclerotic cardiovascular disease who were already on maximum tolerated statin therapy but still had LDL cholesterol ≥70 mg/dL 1
Reduced LDL cholesterol by 59%, from a median of 92 mg/dL to 30 mg/dL over 2.2 years of follow-up 1, 3
Reduced major cardiovascular events by 15% (composite of cardiovascular death, MI, stroke, hospitalization for angina, or revascularization: 9.8% vs 11.3%, P<0.001) 1, 3
Reduced cardiovascular death, MI, or stroke by 20% (5.9% vs 7.4%, P<0.001) 1, 3
Reduced all strokes by 21% and ischemic stroke by 25% 1
Important Clinical Context
The benefit comes from preventing new cardiovascular events through aggressive LDL lowering, not from reversing existing plaque. 3 While one study showed rosuvastatin could induce carotid plaque regression in rheumatoid arthritis patients, this was with statin therapy specifically targeting LDL-C <1.8 mmol/L, not with PCSK9 inhibitors. 1
Patients achieving LDL cholesterol levels below 30 mg/dL had the lowest cardiovascular event rates with similar safety profiles, supporting the "lower is better" paradigm for high-risk patients. 1
FDA-Approved Indications
Repatha is approved for: 1
- Reducing cardiovascular risk (MI, stroke, coronary revascularization) in adults with established atherosclerotic cardiovascular disease
- Lowering LDL cholesterol in primary hyperlipidemia and familial hypercholesterolemia as adjunct to maximally tolerated statin therapy
- Dosing: 140 mg subcutaneously every 2 weeks or 420 mg once monthly 1
Safety Profile
Repatha demonstrated excellent safety in clinical trials with no significant adverse events except injection-site reactions (2.1% vs 1.6% with placebo). 3 Importantly, there was no evidence of cognitive deficits, new-onset diabetes concerns, or safety issues even at very low LDL cholesterol levels. 1, 4, 3
Clinical Bottom Line
Think of Repatha as a powerful preventive medication that stabilizes your cardiovascular risk by dramatically lowering cholesterol, not as a treatment that reverses existing plaque. 4, 3 The cardiovascular benefit is substantial and clinically meaningful for patients with established heart disease who remain at high risk despite statin therapy. 1