The PACMAN-AMI trial: a revolution in the treatment of acute coronary syndromes

After an acute coronary syndrome (ACS), the risk of major adverse cardiovascular events (MACE) persists despite the reperfusion of the culprit lesion. The addition of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) to standard lipid-lowering therapies has been demonstrated to effectively reduce the levels of low-density lipoprotein cholesterol (LDL-C), with a consistent decrease of MACE in large, randomized clinical trials enrolling patients at high risk of cardiovascular events. There is a strong rationale for an immediate and aggressive LDL-C lowering with the use of PCSK9i in ACS patients. The PACMAN-AMI trial tested this hypothesis demonstrating that in ACS patients, the addition of subcutaneous biweekly alirocumab, compared with placebo, to high-intensity statin therapy resulted in significantly greater coronary plaque regression in non-infarct-related arteries after 52 weeks, as assessed by novel intra-coronary imaging modalities. These findings might provide the mechanistic rationale in favour of early initiation of very intensive LDL-C-lowering therapy in the acute setting of ACS, potentially modifying the actual common pattern of treatment.