ESC HEART FAILURE ORIGINAL RESEARCH ARTICLE ESC Heart Failure 2020; 7: 118–123 Published online 55 January 2020 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.12533 Role of PCSK9 in the course of ejection fraction change after ST-segment elevation myocardial infarction: a pilot study Gema Miñana1,2, Julio Núñez1,2, Antoni Bayés-Genís2,3*, Elena Revuelta-López3, César Ríos-Navarro1, Eduardo Núñez1, Francisco J. Chorro1,2, Maria Pilar López-Lereu4, Jose Vicente Monmeneu4, Josep Lupón2,3, Juan Sanchis1,2 and Vicent Bodí1,2* 1 Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Valencia, Spain; 2CIBER Cardiovascular, Madrid, Spain; 3Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain, Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain; 4ERESA, Valencia, Spain Abstract Aims Proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as a therapeutic target for reducing plasma low-density lipoprotein cholesterol. Beyond lipid control, recent findings suggest a deleterious effect of this protein in the pathogenesis of postmyocardial infarction left ventricle remodelling and heart failure-related complications. The aim of this study was to assess the relationship between circulating PCSK9 and 6 month cardiac magnetic resonance imaging-derived left ventricular ejection fraction (LVEF) after a first ST-segment elevation myocardial infarction (STEMI). Methods and results We prospectively evaluated 40 patients with a first STEMI, LVEF < 50% and treated with primary percutaneous coronary intervention in which PCSK9 was measured 24 h postreperfusion. All patients underwent cardiac mag- netic resonance imaging 1 week and 6 months after STEMI. Baseline characteristics were compared across median values of PCSK9. The association between PCSK9 levels and LVEF at 6 months was evaluated by analysis of covariance. The mean age of the sample was 60 ± 12 years and 33 (82.5%) were male patients. The infarct location was anterior in 27 patients (67.5%), and 9 patients (22.5%) were Killip class ≥ II. The mean 1 week and 6 month LVEF were 41 ± 7% and 48 ± 10%, respectively. The mean PCSK9 was 1.93 ± 0.38 U/mL. Testing the association between serum PCSK9 and 6 month LVEF with analysis of covariance revealed an inverse relationship (r = 0.35, P = 0.028). After multivariate adjustment, circulating PCSK9 remained significant and inversely associated with 6 month LVEF (P = 0.002). Conclusions In patients with a first STEMI with reduced ejection fraction at index admission and treated with primary percutaneous coronary intervention, circulating PCSK9 was associated with lower LVEF at 6 months. Keywords PCSK9; Left ventricular ejection fraction; Cardiac magnetic resonance; ST-segment elevation myocardial infarction Received: 20 March 2019; Revised: 26 August 2019; Accepted: 17 September 2019 *Correspondence to: Vicent Bodi, MD PhD, Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de València, Valencia, Spain. Email: vicentbodi@hotmail.com Antoni Bayés-Genís, MD PhD, Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain. Email: abayesgenis@gmail.com Gema Miñana and Julio Núñez contributed similarly in the present study. “All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”. Introduction cells and ischemic hearts, playing a potential pathogenic role in infarct size, cardiac function, and autophagy.2,3 In addition, re- Inhibition of proprotein convertase subtilisin/kexin type 9 cent clinical evidence indicates that plasma PCSK9 is positively (PCSK9) has emerged as a novel and effective therapy for related to a higher risk of adverse events in a large cohort of treating hypercholesterolemia.1 Some experimental evidence patients with acute heart failure with predominantly left ven- suggests that PCSK9 is up-regulated in vascular smooth muscle tricular systolic dysfunction and ischemic heart disease.4 © 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any me- dium, provided the original work is properly cited and is not used for commercial purposes. Proprotein convertase subtilisin/kexin type 9 and left ventricular ejection fraction after STEMI 119 In this study, we sought to evaluate the relationship be- Uppsala, Sweden)7 and a high-sensitivity monoclonal sand- tween PCSK9 levels 24 h after primary percutaneous coronary wich immunoassay (Critical Diagnostic Presage ST2 assay), intervention and 6 month left ventricular ejection fraction respectively, according to the manufacturers’ instructions. (LVEF) assessed by cardiac magnetic resonance (CMR). Cardiac magnetic resonance imaging Material and methods Detailed information about the CMR technique is described in Supporting Information, File S1.5 Briefly, 1 week and 6 month Study population LVEF were calculated using manual planimetry of endocardial and epicardial borders on short-axis cine images. Infarct size This study stems from a prospective observational study was assessed as the percentage of left ventricular mass with carried out from June 2009 to December 2010 that included late gadolinium enhancement. Intraobserver and interob- 203 consecutive patients with a first ST-segment elevation server variability for all CMR indices analysed in the present acute myocardial infarction (STEMI) in which a CMR at 1 week study were previously evaluated and reported by our group and 6 months was performed.5,6 In a subgroup of this cohort as being less than 5%.5 (those with LVEF < 50% at 1 week CMR), PCSK9 levels were analysed from frozen samples. After applying the exclusion criteria (Figure 1), the final sample included 40 patients. Endpoint Baseline characteristics were recorded prospectively in all cases at admission. Informed consent was obtained from The CMR-derived LVEF at 6 months was selected as the each patient. The study protocol conformed to the ethical endpoint of this study. guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution’s human research committee. Statistical analysis Continuous variables were expressed as the mean ± 1 SD or median (interquartile range) when appropriate. Discrete Biomarker assays variables were summarized as percentages. Baseline charac- teristics were compared across median values of PCSK9. The Manipulation and storage of samples were performed for association between PCSK9 levels and LVEF at 6 months expert investigators. Blood samples were isolated 24 h after was evaluated by analysis of covariance. For multivariate coronary revascularization, centrifuged at 2300 rpm for 15 regression analyses, candidate covariates were chosen based min, and serum was immediately refrigerated at 80°C under on previous medical knowledge, independent of their P value. the strict control of the temperature. PCSK9 and soluble A reduced and parsimonious model was derived using back- interleukin-1 receptor-like 1 (ST2) were measured using the ward stepwise selection. During this selection process, the Proseek Multiplex CVD III panel (Olink Proteomics AB, linearity assumption for continuous variables was tested and transformed, if appropriate, with fractional polynomials.8 The following covariates were included in the final analysis Figure 1 Flow chart.CMR, cardiac magnetic resonance; LVEF, left ventric- ular ejection fraction; STEMI, ST-segment elevation acute myocardial of covariance model: 1 week CMR-derived LVEF, age, gender, infarction. infarct size at 1 week CMR, ST2, and low-density lipoprotein (LDL) cholesterol. Moreover, the regression model was clustered on statin treatment in order to capture potential differences in the association between PCSK9 and LVEF at 6 months driven by this treatment. A two-sided P value < 0.05 was considered significant for all analyses, which were performed using STATA 15.1. Results The mean age of the sample was 60 ± 12 years, and 33 (82.5%) were male patients. The infarct location was anterior in 27 patients (67.5%), and 9 patients (22.5%) were Killip class ESC Heart Failure 2020; 7: 118–123 DOI: 10.1002/ehf2.12533 120 G. Miñana et al. ≥ II. The mean LVEF at 1 week was 41 ± 7%. Mean PCSK9 was Proprotein convertase subtilisin/kexin type 9 and 1.93 ± 0.38 U/mL. 6 month left ventricular ejection fraction The baseline characteristics of patients with PCSK9 values below and above the median (1.94 U/mL) are presented in Compared with baseline, the mean LVEF significantly in- Table 1. Patients with PCSK9 above the median exhibited no creased from 41 ± 7% to 48 ± 10% (P < 0.001) at 6 months. relationship with a worse baseline risk profile except for PCSK9 values were inversely related to 6 month LVEF (r = higher rates of dyslipidemia and prescription of statins. 0.35, P = 0.028). The mean PCSK9 values were significantly higher in patients with LVEF < 50% at 6 months (2.06 ± 0.29 vs. 1.80 ± 0.41 U/mL, P = 0.028). After multivariate adjust- ment including well-established determinants of left ventricle Proprotein convertase subtilisin/kexin type 9 and remodelling (1 week LVEF, infarct size, and ST2 levels) and po- 1 week cardiac magnetic resonance parameters tential confounders (age, gender, lipoprotein status, and statin treatment), circulating PCSK9 remained significant and For the CMR imaging variables at 1 week, no significant inversely associated with 6 month LVEF (P = 0.002; Figure 2). differences were found across median PCSK9 values and LVEF, left ventricular end-diastolic volume index, left ventric- ular end-systolic volume index, microvascular obstruction, and infarct size (Table 1). PCSK9 values did not correlate with Discussion LVEF (r = 0.20, P = 0.206), left ventricular end-diastolic vol- ume index (r = 0.02, P = 0.895), left ventricular end-systolic In this cohort of patients with a first STEMI and reduced ejec- volume index (r = 0.14, P = 0.384), microvascular obstruction tion fraction at 1 week, we found an independent association (r = 0.20, P = 0.207), or infarct size (r = 0.29, P = 0.073). between PCSK9 levels and 6 month CMR-derived LVEF. This Table 1 Baseline characteristics across PCSK9 values PCSK9 below median PCSK9 above median (<1.94 U/mL) (>1.94 U/mL) Variables (n = 20) (n = 20) P Demographics and medical history Age (years) 59 ± 12 60 ± 12 0.638 Male, n (%) 17 (85) 16 (80) 0.677 Hypertension, n (%) 12 (60) 10 (50) 0.525 Diabetes mellitus, n (%) 4 (20) 4 (20) 1 Dyslipidemia, n (%) 4 (20) 11 (55) 0.022 Smoker, n (%) 13 (65) 11 (55) 0.519 Anterior infarction, n (%) 15 (75) 12 (60) 0.311 GRACE score 137 ± 28 147 ± 38 0.321 TIMI risk scorea 3 (1.5–4) 2 (1.5–3.5) 0.499 Laboratory data Killip class ≥ II, n (%) 6 (30) 3 (15) 0.256 Peak hsTnT (ng/mL)a 3631 (1772–4987) 3702 (2892–7627) 0.159 ST2 (pg/mL)a 86.7 (37.9–113.8) 103.9 (63.2–135.9) 0.083 PCSK9 (U/mL) 1.64 ± 0.25 2.22 ± 0.23 <0.001 CMR at 1 week LVEF (%) 42 ± 7 41 ± 7 0.641 2 LVEDVI (mL/m ) 84 ± 18 78 ± 20 0.445 2 LVESVI (mL/m ) 48 ± 11 48 ± 17 0.953 Infarct size (%)a 28 (19–34) 30 (26–41) 0.206 MVO (%) 2.1 ± 0.4 2.6 ± 0.6 0.482 Medical treatment at discharge Aldosterone receptor blockers, n (%) 8 (40) 4 (20) 0.168 ACEI/ARB, n (%) 13 (65) 18 (90) 0.058 Beta blockers, n (%) 13 (65) 13 (65) 1 Statins, n (%) 13 (65) 19 (95) 0.018 ACEI, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blockers; CMR, cardiac magnetic resonance; GRACE, Global Registry of Acute Coronary Events; hsTnT, high-sensibility troponin T; LVEDVI, left ventricular end-diastolic volume index; LVEF, left ven- tricular ejection fraction; LVESVI, left ventricular end-systolic volume index; MVO, microvascular obstruction; PCSK9, proprotein convertase subtilisin/kexin type 9; ST2, soluble interleukin-1 receptor-like 1; TIMI, Thrombolysis in Myocardial Infarction. Values for continuous variables are expressed as mean ± SD unless otherwise specified. a Values expressed as median (interquartile range). ESC Heart Failure 2020; 7: 118–123 DOI: 10.1002/ehf2.12533 Proprotein convertase subtilisin/kexin type 9 and left ventricular ejection fraction after STEMI 121 Figure 2 Adjusted effect of PCSK9 on 6 month left ventricular ejection fraction.LVEF, left ventricular ejection fraction; PCSK9, proprotein convertase subtilisin/kexin type 9. association was independent of crucial determinants of left plasma PCSK9 was significantly associated with a higher risk of ventricle remodelling (1 week CMR–LVEF, infarct size, and mortality and/or heart failure-related readmission beyond ST2) and important potential confounders. well-known prognosticators in a large European cohort including 2174 patients with acute heart failure with predominant ischaemic aetiology and left ventricular systolic dysfunction.4 Proprotein convertase subtilisin/kexin type 9 as a Thus, and in agreement with our findings, we postulate marker of left ventricular remodelling and heart up-regulation of PCSK9 during an acute myocardial infarction failure-related complications may be implicated on pathophysiological processes causally linked to adverse remodelling, such as inflammation and/or PCSK9 is a well-established target for treating hypercholester- autophagy. olemia and atherosclerosis progression.1,9 Although the major source of PCSK9 is the liver, in a recent experimental study in mice and explanted human hearts, Ding et al. Proprotein convertase subtilisin/kexin type 9 as a reported that PCSK9 is up-regulated in the zone bordering potential therapeutic target for preventing left the infarct area and determines, at least in part, infarct size, ventricular remodelling cardiac function, and autophagy.3 The same group reported that PCSK9 is highly expressed in vascular smooth muscle Several effects of PCSK9 antibodies have been postulated in cells, and its expression and development of autophagy are patients with acute coronary syndromes. In addition to the regulated by well-known inflammation mediators, such as li- reduction of LDL cholesterol, PCSK9 antibodies would popolysaccharide, tumour necrosis factor α (TNFα), and reac- contribute to plaque stabilization via several mechanisms.9,14 tive oxygen species.2,10,11 However, a direct myocardial effect can also be envisioned. Other authors have also reported PCSK9 is associated with Glick et al. found that treatment of primary cardiomyocytes the inflammatory response.12 Ricci et al. showed, in a recent re- with recombinant mPCSK9 resulted in prompt expression of port, that human recombinant PCSK9 drives an inflammatory re- well-known markers of autophagy. Interestingly, PCSK9 sponse on macrophages by inducing the pro-inflammatory inhibition was associated with the attenuation of these cytokines TNFα, interleukin-1, and interleukin-6, and the markers.15 Moreover, Ding et al. reported that PCSK9 chemokines monocyte chemoattractant protein-1 and C-X-C inhibition in mice by chemical inhibitors or gene deletion re- Motif Chemokine Ligand 2 (CXCL2). In addition, they reported sults in a significant improvement in infarct size and cardiac a positive correlation between PCSK9 and TNFα plasma function, with a significant decrease in autophagy activity.3 levels of healthy subjects. These authors suggest the pro- In view of the available data, and accordingly to our re- inflammatory action of PCSK9 on macrophages is mainly depen- sults, we hypothesize that, in patients with STEMI, treatment dent on the LDL receptor .12 Moreover, a role of PCSK9 on with PCSK9 inhibitors might play a role by limiting adverse left pathogen lipids (such as lipopolysaccharide) removal regulation ventricular postmyocardial infarction remodelling beyond its has also been suggested; thus, reduced PCSK9 function should beneficial effects on the lipid profile and plaque stabilization. be associated with increased pathogen lipid clearance via the These myocardial effects could also explain part of the LDL receptor, a decreased inflammatory response, and improved beneficial clinical effects found with PCSK9 inhibitors.1 septic shock outcome.13 In agreement with prior postulates, Further studies are warranted to test this hypothesis. ESC Heart Failure 2020; 7: 118–123 DOI: 10.1002/ehf2.12533 122 G. Miñana et al. Limitations Funding This study has some limitations. First, as this is an observa- This work was supported in part by grants from CIBER CV tional study, we cannot rule out selection bias or the absence [grant numbers 16/11/00420, 16/11/00486, and 16/11/ of unmeasured confounding factors. Second, as no serial 00403], Instituto de Salud Carlos III-FEDER [grant numbers PCSK9 measurements were performed, we could not evalu- (PIE15/00013 and, PI17/01836)], Madrid, Spain, and ate the significance of changes over time. However, available Generalitat Valenciana [GV/2018/116]. The authors have no data in mice in the context of coronary artery disease show other funding, financial relationships, or conflicts of interest that the plasma PCSK9 concentration is mostly elevated in to disclose relative to this work. the early hours after onset of acute coronary syndrome.3 Abbreviation list CMR: cardiac magnetic resonance Conclusion LDL: low-density lipoprotein LVEDVI: left ventricular end-diastolic volume index In patients with a first STEMI with LVEF < 50% and treated LVEF: left ventricular ejection fraction with primary percutaneous coronary intervention, PCSK9 LVESVI: left ventricular end-systolic volume index levels in the acute phase predict the LVEF at 6 months. MVO: microvascular obstruction Further studies are warranted to confirm these findings and PCSK9: proprotein convertase subtilisin/kexin type 9 to explore the causative role of PCSK9 in post-STEMI ST2: soluble interleukin-1 receptor-like 1 ventricular remodelling and its potential as a therapeutic STEMI: ST-segment elevation myocardial infarction target. TNFα: tumour necrosis factor α Supporting information Conflict of interest Additional supporting information may be found online in the Supporting Information section at the end of the article. J.N. received board membership fees and travel expenses from AMGEN. J.S. reports grants from Biotronik, Prosmedica, Data S1. Supporting information and Bayer outside of the submitted work. References 1. Sabatine MS, Giugliano RP, Keech AC, 4. Bayes-Genis A, Núñez J, Zannad F, Monmeneu JV, Lupón J, Bodí V. 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