Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?   

Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg...

The VESALIUS-CV trial did include subjects with calcium scores >100. Hence, there is now RCT data demonstrating reductions in major adverse cardiovascular events for individuals with elevated CAC and elevated LDLc. There is, however, no head-to-head data between PCSK9-i/statins/ezetimibe/bempedoi...

Statins are still foundational therapy, so I would not start a PCSK9 inhibitor in lieu of a statin. The only case would be if there was statin intolerance or statin reluctance (some patients are fixed on not taking a statin, and I wouldn't deny them alternative effective therapies, if so).The decisi...