Early PCSK9 Inhibitor Use Correlates With Improved Outcomes in Patients With Acute Stroke Receiving Endovascular Therapy

Background The clinical benefits of early PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor use in patients with acute large vessel occlusion undergoing endovascular therapy (EVT) remain unclear. This study investigates whether early administration of PCSK9 inhibitors after EVT is associated with improved clinical outcomes. Methods In this retrospective cohort study, we consecutively screened patients with acute large vessel occlusion with successful EVT recanalization at 2 academic hospitals from January 2019 to March 2025. Participants were grouped based on receipt of evolocumab or alirocumab within 96 hours after EVT. Propensity score matching was performed to adjust for baseline covariates. The primary outcome was early artery reocclusion. Mediation analysis was conducted to explore potential links between PCSK9 inhibitors and clinical outcomes. Results Among 429 eligible patients (148 in the PCSK9 inhibitors group, 281 controls), 116 matched pairs were analyzed. The incidence of early artery reocclusion was significantly lower in the PCSK9 inhibitors group compared with controls (3.4% versus 12.9%; odds ratio [OR], 0.24 [95% CI, 0.08–0.75]; P =0.01). Moreover, a significantly greater proportion of patients in the PCSK9 inhibitors group achieved favorable outcomes at 90 days (modified Rankin Scale score 0–2: 77.6% versus 60.3%; OR, 2.28 [95% CI, 1.28–4.04]; P <0.01). Safety outcomes were comparable between the 2 groups. Mediation analysis suggested the benefit of PCSK9 inhibitors on functional outcomes was partially mediated by reduced EAR. Conclusions Early PCSK9 inhibitor use after EVT in patients with acute large vessel occlusion was linked to reduced EAR and better 90‐day outcomes without added adverse events.