Combined therapies for atherosclerosis, including atherosclerotic cardiovascular disease

Abstract

To provide combined therapies for atherosclerosis, including atherosclerotic cardiovascular disease.SOLUTION: Combinations include a first, non-PCSK9 LDL-C lowering agent (such as a statin or other non-PCSK9 LDL-C lowering therapy), combined with a second, PCSK9 inhibitor therapy (such as a PCSK9 antibody or anti-RNA). It is confirmed that the application of both therapies, at adequately elevated levels to reduce the LDL-C level of a subject to very low levels, for an adequate period of time provides an added benefit of further protection from atherosclerosis and improves the subject's cardiovascular outcomes.SELECTED DRAWING: Figure 2

Description

Technical Field

[0001] Cross - reference to Related Applications This application claims priority to U.S. Provisional Patent Application No. 62 / 421,685, filed on November 14, 2016, U.S. Provisional Patent Application No. 62 / 471,874, filed on March 15, 2017, U.S. Provisional Patent Application No. 62 / 515,117, filed on June 5, 2017, U.S. Provisional Patent Application No. 62 / 581,244, filed on November 3, 2017, and U.S. Provisional Patent Application No. 62 / 584,600, filed on November 10, 2017, the contents of each of which are hereby incorporated by reference into this specification.

[0002] Sequence Listing in Electronic Format This application is being filed with a sequence listing in electronic format. The sequence listing is submitted as a file named APMOL018WO.TXT, created on November 8, 2017, and last saved on November 13, 2017, with a size of 88,325 bytes. The information in the electronic format sequence listing is hereby incorporated by reference into this specification in its entirety.

[0003] The present invention relates to combination therapies for atherosclerosis, including atherosclerotic cardiovascular disease.

Background Art

[0004] Over the past several decades, many different LDL - lowering therapies have been developed for use in cholesterol management. These compounds and methods of using these compounds have been found to be effective in lowering LDL - C levels to various levels in various subjects.

Summary of the Invention

Means for Solving the Problem

[0005] In some embodiments, methods for treating coronary artery atherosclerotic disease are provided. The method includes a) identifying a subject who has received a first therapy including a non-PCSK9 LDL-C lowering therapy, and b) administering a second therapy to the subject. The second therapy includes a PCS K9 inhibitor therapy. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary artery atherosclerosis in the subject, and the first therapy is not the same as the second therapy. is not the same as the second therapy. is not the same as the second therapy.

[0006] In some embodiments, the first therapy is a statin, such as, but not limited to, atorvastatin (LIPITOR®), cerivastatin, fluvastatin ( LESCOL), lovastatin (MEVACOR, ALTOPREV), mevastatin, pitavastatin, pravastatin (PRAVACHOL), rosuvastatin, rosuvastatin calcium (CRESTOR) and simvastatin (ZOCOR); ADVICO R (lovastatin + niacin), CADUET (atorvastatin + amlodipine); a selective cholesterol absorption inhibitor, such as, but not limited to, ezetimibe (ZET IA); a lipid-lowering therapy (LLT), such as, but not limited to, a fibrate or a fibric acid derivative, such as, but not limited to, gemfibrozil (LOPID ), fenofibrate (ANTARA, LOFIBRA, TRICOR, TRIGLI DE) and clofibrate (ATROMID-S); a resin, such as, but not limited to However, cholestyramine (QUESTRAN, QUESTRAN LIGHT, PREV ALITE, LOCHOLEST, LOCHOLEST LIGHT), colestipol (CHOLESTID) and colesevelam HCl (WELCHOL) and / or combinations thereof, such as, but not limited to, at least one of VYTORIN (simvastatin + ezetimibe) is selected.

[0007] In some embodiments, a method of treating coronary artery atherosclerosis is provided. The method comprises a) identifying a subject having an LDL-C level of 70 mg / dL or less, and b) administering to the subject an anti-PCSK9 neutralizing antibody in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less.

[0008] In some embodiments, a method of reducing the plaque volume ratio (PAV) in a subject is provided. The method comprises a) identifying a subject who has received at least moderate-level treatment with a statin, and b) administering to the subject an anti-PCSK9 neutralizing antibody in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the plaque volume ratio (PAV) in the subject.

[0009] In some embodiments, a method of reducing the total atherosclerotic plaque volume (TAV) in a subject is provided. The method comprises a) identifying a subject who has received at least moderate-level treatment with a statin, and b) administering to the subject an anti-PCSK9 neutralizing antibody in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less. ​ administering thereto to thereby reduce the total atherosclerotic volume ratio.

[0010] In some embodiments, a method of treating coronary artery atherosclerosis is provided. This method comprises a) administering optimal statin treatment to a subject having coronary artery atherosclerosis and b) simultaneously administering to the subject an amount of an anti-PCSK9 neutralizing antibody.

[0011] In some embodiments, a method of treating coronary artery atherosclerosis is provided. This method comprises a) identifying a statin-intolerant subject, b) administering to the statin-intolerant subject at least a low dose of statin treatment, and c) administering to the subject an amount of an anti-PCSK9 neutralizing antibody thereby treating coronary artery atherosclerosis.

[0012] In some embodiments, a method of effecting regression of coronary artery atherosclerosis, comprising providing a subject receiving an optimized level of statin, and administering to the subject an anti-PCSK9 neutralizing antibody at a level sufficient to regress coronary artery atherosclerosis, wherein regression is a change of less than zero in PAV or TAV, is provided.

[0013] In some embodiments, a method of reducing the LDL-C level in a subject to 80 mg / dL or less is provided. This method comprises administering an anti-PCSK9 neutralizing antibody to the subject. The subject has coronary artery atherosclerosis. The subject has received optimized statin therapy for at least one year, and the LDL-C level of the subject decreases to an average value of 80 mg / dL or less over that at least one year.

[0014] ​​​ In some embodiments, a method is provided for reducing the relative risk of a cardiovascular event by at least 10%. This method involves administering a PCSK9 neutralizing antibody to a subject who is receiving at least a moderate-intensity statin, in an amount sufficient to lower the subject's LDL-C level by about 20 mg / dL.

[0015] In some embodiments, a method is provided for reducing the amount of atherosclerotic plaque in a subject. This method involves administering a monoclonal antibody against human PCSK9 to a subject having atherosclerotic plaque. The subject is also receiving optimized statin therapy, and the combination therapy thereby reduces the amount of atherosclerotic plaque in the subject.

[0016] In some embodiments, a method is provided for suppressing disease progression. This method involves identifying a subject having an LDL-C level of 60 mg / dL or less, administering at least a moderate-intensity statin therapy to the subject, and administering evolocumab at a level sufficient to lower the subject's LDL-C level to 30 mg / dL, thereby suppressing disease progression.

[0017] In some embodiments, a method is provided for combining evolocumab and statin therapy to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at well-tolerated doses. This method involves administering at least a moderate-intensity statin therapy to a subject, administering to the subject an amount of evolocumab sufficient to lower the subject's LDL-C level to 40 mg / dL or less, and reducing the subject's LDL-C level to 40 mg / dL or less. ​​​​​​​​​​​​​​including maintaining for at least one year.

[0018] In some embodiments, methods of treating coronary atherosclerotic heart disease are provided. The method includes: a) identifying a subject having an LDL-C level of 70 mg / dL or less; b) administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less.

[0019] In some embodiments, methods of reducing atherosclerotic plaque volume (PAV) in a subject are provided. The method includes: a) identifying a subject who has received at least moderate-level treatment with a non-PCSK9 LDL-C lowering agent; b) administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the atherosclerotic plaque volume (PAV) in the subject.

[0020] In some embodiments, methods of reducing total atherosclerotic volume (TAV) in a subject are provided. The method includes: a) identifying a subject who has received at least moderate-level treatment with a non-PCSK9 LDL-C lowering agent; b) administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the total atherosclerotic volume in the subject.

[0021] In some embodiments, methods of treating coronary atherosclerotic heart disease are provided. The method includes: a) optimal non-PCSK9 LDL- administering a low-intensity statin therapy and, b) concurrently administering an amount of a PCSK9 inhibitor to the subject comprising.

[0022] In some embodiments, a method of treating coronary artery atherosclerotic disease is provided. This method comprises a) identifying a subject with statin intolerance, b) either administering a low-intensity statin treatment or not administering a statin treatment to the subject with statin intolerance, and c) administering an amount of a PCSK9 inhibitor to the subject to thereby treat coronary artery atherosclerotic disease. including.

[0023] In some embodiments, a method of effecting regression of coronary artery atherosclerotic disease is provided. This method comprises providing a subject who is receiving an optimized level of a non-PCSK9 LDL-C lowering agent and administering a PCSK9 inhibitor to the subject at a level sufficient to effect regression of coronary artery atherosclerotic disease. Regression is a change of less than zero in PAV or TAV.

[0024] In some embodiments, a method of reducing the LDL-C level in a subject to 80 mg / dL or less is provided. This method comprises administering a PCSK9 inhibitor to the subject. The subject has coronary artery atherosclerotic disease. The subject has received an optimized non-PCSK9 LDL-C lowering therapy for at least one year. The LDL-C level in the subject decreases to an average value of 80 mg / dL or less for at least one year.

[0025] In some embodiments, a method of reducing the amount of atherosclerotic plaques in a subject is provided. This method comprises administering a PCSK9 inhibitor to atherosclerotic plaques ​​​​​​​​​​​ comprises administering to a subject having the same. The subject is also undergoing optimized non-PCSK9 LDL-C lowering therapy, thereby reducing the amount of atherosclerotic plaque in the subject to cause a decrease.

[0026] In some embodiments, a method of suppressing disease progression is provided. This method includes identifying a subject having an LDL-C level of 60 mg / dL or less, administering to the subject at least a moderate-intensity non-PCSK9 LDL-C lowering therapy, and administering a PCSK9 inhibitor at a level sufficient to lower the subject's LDL-C level to 30 mg / dL, thereby suppressing disease progression.

[0027] In some embodiments, a method of combining a PCSK9 inhibitor and a non-PCSK9 LDL-C lowering therapy is provided to produce a greater LDL-C lowering and regression of coronary artery atherosclerosis at well-tolerated doses. This method includes administering to the subject at least a moderate-intensity non- PCSK9 LDL-C lowering therapy, administering to the subject a sufficient amount of a PCSK9 inhibitor such that the subject's LDL-C level is reduced to 40 m g / dL or less, and maintaining the subject's LDL-C level at 40 mg / dL or less for at least one year thereby.

[0028] In some embodiments, a method of treating a subject who cannot tolerate a sufficient therapeutic dose of a non-PCSK9 LDL-C lowering agent is provided. This method includes identifying the subject and administering a PCSK9 inhibitor to the subject until the subject's LDL cholesterol level is reduced to 60 mg / dL or less.

[0029] ​​In some embodiments, a method of treating a subject who cannot tolerate a full therapeutic dose of a statin is provided. The method includes identifying the subject and administering a PCSK9 inhibitor to the subject until the subject's LDL cholesterol level decreases to 60 mg / dL or less. In some embodiments, a method of treating coronary atherosclerotic heart disease is provided. The method includes a) identifying a subject having an LDL-C level of 70 mg / dL or less, and b) administering to the subject a non-PCSK9 LDL-C lowering agent in an amount and for a time sufficient to lower the LDL-C level to 60 mg / dL or less.

[0030] In some embodiments, a method of treating atherosclerotic cardiovascular disease is provided. The method includes a) identifying a subject who is receiving a first therapy that includes non-PCSK9 LDL-C lowering therapy, and b) administering a second therapy to the subject. The second therapy includes PCSK9 inhibitor therapy, and both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subject. The first therapy is not the same as the second therapy. The risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c) cardiovascular death, or d) fatal and / or non-fatal MI, or e) fatal and / or non-fatal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent and / or emergent coronary artery revascularization.

[0031] ​​​​​​​​​​​​​​​​

[0032] In some embodiments, a method for reducing the risk of a cardiovascular event is provided. The method includes: a) identifying a subject receiving a first therapy that includes a non-PCSK9 LDL-C lowering therapy; and b) administering to the subject a second therapy. The second therapy may be a PCSK. Both first- and second-line therapies, including 9 inhibitors, were associated with a reduced risk of cardiovascular events in subjects The first therapy is administered to the subject in an amount and for a time sufficient to reduce The risks are: a) cardiovascular death, myocardial infarction, stroke, and hospitalization for unstable angina. or a composite of cardiovascular death, myocardial infarction, or stroke, or or c) cardiovascular death, or d) fatal and / or non-fatal MI, or e) fatality and / or non-fatal stroke, or f) transient ischemic attack, or g) unstable angina. or h) hospitalization for elective, urgent and / or impending coronary revascularization. be.

[0033] In some embodiments, a method for reducing the risk of emergency coronary revascularization is provided. The method includes: a) administering to a patient receiving a first therapy that includes a non-PCSK9 LDL-C lowering therapy; and b) administering a second therapy to the subject. The second therapy is Both the first and second therapies include a CSK9 inhibitor therapy. administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease, The therapy is not the same as the second therapy.

[0034] In some embodiments, a method for reducing the risk of a cardiovascular event is provided. The method includes: a) identifying a subject having a cardiovascular disease; and b) administering to the subject a PCSK9 inhibitor for a sufficient amount of time and in a sufficient amount to reduce at least one risk of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization, or hospitalization for unstable angina. In some embodiments, a method of reducing LDL-C levels in a subject is provided. The method includes: a) administering to the subject a first therapy including a non-PCSK9 LDL-C lowering therapy; and b) administering to the subject a second therapy including a PCSK9 inhibitor. Both the first and second therapies are administered to the subject for at least 5 years, and the first therapy is different from the second therapy, and the LDL-C level of the subject is maintained at 50 mg / dL or less. In some embodiments, a method of reducing the risk of cardiovascular events is provided. The method includes: a) identifying a subject receiving a first therapy including a non-PCSK9 LDL-C lowering therapy. The method further includes: b) administering to the subject a second therapy. The second therapy includes a PCSK9 inhibitor. Both the first and second therapies are administered to the subject in a sufficient amount and for a sufficient time to reduce the risk of cardiovascular events in the subject. The first therapy is different from the second therapy. The risk is at least one of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization. In some embodiments, a method of treating a subject is provided. The method includes treating peripheral artery disease

[0035]

[0036]

[0037] Identifying a subject having peripheral artery disease ("PAD") and reducing the level of PCSK9 activity in the subject comprises reducing the level of PCSK9 activity in a subject having PAD.

[0038] In some embodiments, a method for reducing the risk of a harmful lower extremity event in a subject is provided that comprises reducing the level of PCSK9 activity in a subject having PAD. is provided.

[0039] In some embodiments, a method for reducing the risk of a major adverse cardiovascular event ("MACE") is provided. The method comprises administering a non-statin LDL-C lowering agent to the subject and administering a statin to the subject. The subject has PAD. In some embodiments a method for reducing the risk of PAD and / or CAD and / or cerebrovascular disease is provided. The method comprises administering a non-statin LDL-C lowering agent to the subject and administering a statin to the subject.

[0040] In some embodiments, a method for reducing the risk of a major adverse lower extremity event ("MALE") is provided. The method comprises administering a non-statin LDL-C lowering agent to the subject and administering a statin to the subject. The subject has PAD.

[0041] In some embodiments, a method for reducing the risk of a cardiovascular event is provided. The method comprises providing a first therapy to the subject. The first therapy comprises a non-PCSK9 LDL -C lowering therapy. The method further comprises providing a second therapy to the subject. The second therapy comprises a PCSK9 inhibitor. The first and second therapies are administered to the subject who has an Lp(a) level of 11.8 mg / dL to 50.

[0042] In some embodiments, a method for reducing the risk of a major vascular event in a subject is provided. The method is available for patients with 1) (a) recent MI, (b) multiple prior MI, or (c) multivessel The method further comprises: 2) identifying a subject having at least one of the non-PCSK diseases; 9. The method further comprises providing to the subject a first therapy comprising an LDL-C lowering therapy. 3) providing the subject with a second therapy comprising a PCSK9 inhibitor, whereby the subject has a major vascular In some embodiments, the method further comprises reducing the risk of having a coronary artery disease. A method for treating atherosclerosis, comprising administering to a patient having an LDL-C level of greater than 70 mg / dL. in an amount sufficient to reduce LDL-C levels to 40 mg / dL or less. Methods are provided that include administering a PCSK9 inhibitor over a period of time. In an embodiment, the method comprises the steps of: reducing the risk of a cardiovascular event by administering an LD of greater than 70 mg / dL; To reduce LDL-C levels to 40 mg / dL or less in subjects with LC levels Methods are provided that include administering a PCSK9 inhibitor in a sufficient amount and for a sufficient period of time. do. [Brief description of the drawings]

[0043]

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DETAILED DESCRIPTION OF THE INVENTION

[0044] Statins can be used to manage patients with clinically evident coronary heart disease. However, many patients are unable to achieve optimal LDL-C lowering or avoid experiencing cardiovascular events despite statin therapy. Additionally, some patients have reported an inability to tolerate adequate therapeutic doses of statins. Inadequate LDL-C lowering and high residual risk require further measures to deliver more effective cardiovascular prevention. patients have reported an inability to tolerate adequate therapeutic doses of statins. Inadequate LDL-C lowering and high residual risk require further measures to deliver more effective cardiovascular prevention. suggests the need for therapy. PCSK in the regulation of hepatic LDL receptor expression Elucidation of the role of K9 provided an attractive target for therapy modulation. The fact that PCSK9 levels increase in response to statin administration further supports the therapeutic potential of PCSK9 inhibitors in reducing residual cardiovascular risk in statin-treated patients.

[0045] Herein, results of clinical trials (reported in Example 1) are provided where patients treated with a PCSK9 LDL-C lowering agent (e.g., a statin) and a PCSK9 inhibitor (e.g., evolocumab) (or optionally a PCSK9 inhibitor alone) received benefits additional to those of statin treatment alone with respect to LDL-C, atherosclerotic volume, and atherosclerotic regression. .

[0046] The presently disclosed trial results (Example 1) provided an opportunity to evaluate the impact of PCSK9 inhibitors in a number of settings. By examining the effect of PCSK9 inhibitors on atherosclerotic volume, it provided the first assessment of PCSK9 inhibition on an efficacy endpoint beyond LDL-C (and / or other lipids such as ApoB, Lp(a)), and provided evidence that LDL-C lowering (and / or other lipids) affects disease activity within the vascular wall. Interestingly, this benefit was observed at much lower LDL-C levels than typically encountered in studies of moderate- or high-intensity statin monotherapy and represents the first evidence of efficacy in patients primarily treated with moderate- or high-intensity statin therapy.

[0047] In light of the presently disclosed studies, atherosclerotic cardiovascular disease (e.g., ischemic heart disease One or more "combination therapies" are provided herein for the treatment (including CAD). " A "combination therapy" or "combined therapy" is one in which the subject receiving both therapies has a risk of atherosclerotic disease (e.g., CAD, and / or PAD, and / or cerebrovascular disease) to achieve a very low LDL-C level so as to reduce the risk. As will be outlined in more detail below, each of the two therapies to be combined is previously known, but provides only a very low level of benefit in reducing LDL-C, and the combinations thereof that then provide treatment for atherosclerotic disease have not been previously shown. There are various possible combinations of therapies for the "combination therapy" approach provided herein, but this term refers to a first therapy that can be a non-PCSK9 directed therapy (e.g., a statin) for reducing LDL-C levels, and a second therapy that can be a PCSK9-specific treatment (a PCSK9 inhibitor, e.g., a neutralizing antibody against PCSK9 and / or an antisense RNA against PCSK9). Not only are these two therapies combined, but in some embodiments, the level of treatment is set so as to be well below other typical goals attempted for cholesterol-lowering therapy (to achieve a very low level of LDL-C), and is maintained for a period appropriate for dealing with atherosclerotic disease, including ischemic heart disease. Further, as will be detailed herein, given such a low level of LDL-C value in a subject, other non-combination therapies are also provided herein. Such monotherapies achieve extremely low LDL-C levels and very beneficial levels (e.g., LDL of 50, 40, 30 or 20 mg / dL or less) ​​​​​​​ There is no need to use a second agent to reduce it to L-C), and a single agent, such as an PCSK9 neutralizing antibody such as evolocumab can be used. Such a statin-free therapy may be particularly useful in situations where the subject is intolerant to statins. In other embodiments the subject is not intolerant to statins, but monotherapy is used regardless.

[0048] Interestingly, the findings presented herein are in contradiction with the results and assumptions made in previous studies such as ASTEROID, where a reduction in LDL-C below 60.8 mg / dL was assumed to have no benefit of regression. In contrast to the findings from ASTEROID, the results presented herein indicate that regression does not plateau at 60 mg / dL. Rather, the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL. the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL. the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL. Rather, the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL. the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL. the results of Example 1 show that by reducing LDL-C to below 60 mg / dL, a surprisingly beneficial regression of atherosclerosis can be obtained. In fact, the results show the benefits from reducing LDL-C levels below 60 mg / dL to levels of 25 mg / dL and 20 mg / dL.

[0049] Furthermore, the present disclosure also provides the results and findings of the FOURIER study (e.g., Example 17). These findings demonstrate the effectiveness of combination therapies (such as evolocumab when combined with non-PCSK9 therapies (such as statins)) on cardiovascular outcomes in subjects with atherosclerotic cardiovascular disease. 17). These findings demonstrate the effectiveness of combination therapies (such as evolocumab when combined with non-PCSK9 therapies (such as statins)) on cardiovascular outcomes in subjects with atherosclerotic cardiovascular disease. 17). These findings demonstrate the effectiveness of combination therapies (such as evolocumab when combined with non-PCSK9 therapies (such as statins)) on cardiovascular outcomes in subjects with atherosclerotic cardiovascular disease.

[0050] The following section provides a series of simple definitions for the present disclosure, followed by a detailed description of various specific embodiments and aspects, and further followed by a series of examples.

[0051] Definitions and embodiments Both the foregoing general description and the following detailed description are exemplary and explanatory only and are intended to provide It should be understood that the present invention is not limited to the embodiments described in the preceding paragraphs. In this application, the use of "or" refers to the plural unless specifically stated otherwise. In addition, the terms "including" and "comprises" are used interchangeably to mean "and / or." The use of other forms such as "include" and "included" is not limiting. Terms such as "component" and "component" refer to elements and components that contain a single unit unless otherwise specified. It also includes both elements and components that contain two or more subunits. Use of the word "moiety" can include a part of a moiety or the entire moiety.

[0052] The section headings used herein are for organizational purposes only and are intended to The subject matter should not be construed as being limited to any particular subject matter. All references or portions of references cited in this application, including but not limited to, , which is expressly incorporated herein by reference in its entirety for all purposes. When used in accordance with this document, the following terms shall have the following meanings, unless otherwise indicated: It will be understood.

[0053] "Combination therapy" or "combination therapy" as these terms are used herein , non-PCSK9 LDL-C lowering therapies that lower LDL-C levels (e.g., statins The first therapy may be a PCSK9 inhibitor therapy (e.g., a PCSK9 inhibitor directed against PCSK9) (using neutralizing antibodies and / or antisense RNA against PCSK9) It is meant to be a therapy of 2. The combination therapy uses a non-PCSK9 LDL-C lowering agent and a P CSK9 inhibitor. The combination therapy can also benefit from reducing other non-LDL cholesterol particles This embodiment can also be explicitly referred to as "non-PCSK9 lipid-lowering therapy".

[0054] The term "regression" or "reversal" means that one or more of the symptoms and / or aspects of the disorder have reversed "Regression" can be defined as a decrease from the baseline of PAV or TAV

[0055] The term "very low LDL-C level" means an LDL-C level of 40 mg / dL or less. In some embodiments, very low includes 25 mg / dL or less

[0056] A "PCSK9 inhibitor" means a molecule or therapy that inhibits PCSK9 activity and thereby reduces LDL-C (and / or or other lipids, such as non-HDL-C, ApoB, Lp(a), etc.) levels. This can include, for example, neutralizing antibodies against PCSK9 and PC antisense molecules against PCSK9. PCSK9 inhibitor therapy means a method of using a PCSK9 inhibitor agent

[0057] A "non-PCSK9 LDL-C lowering agent" means a molecule that reduces LDL-C levels through a pathway other than PCSK9 Non-PCSK9 LDL-C lowering therapy means a method of using a non-PCSK9 LDL-C lowering agent. Examples of non-PCSK9 LDL-C include statins (also known as HMG CoA reductase inhibitors), atorvastatin (LIPITOR (registered trademark)), ​​​​​Trademarks), cerivastatin, fluvastatin (LESCOL), lovastatin (MEVA COR, ALTOPREV), mevastatin, pitavastatin, pravastatin (PRA VACHOL), rosuvastatin, rosuvastatin calcium (CRESTOR) and simvastatin (ZOCOR), ADVICOR (lovastatin + niacin), CAD UET (atorvastatin + amlodipine); selective cholesterol absorption inhibitors, ezet imibe (ZETIA); lipid-lowering therapy (LLT), fibrates or fibric acid derivatives such as gemfibrozil (LOPID), fenofibrate (ANTARA, LO FIBRA, TRICOR, TRIGLIDE) and clofibrate (ATROMI D-S); resins (also known as bile acid sequestrants or bile acid binding drugs), cholestyra mine (QUESTRAN, QUESTRAN LIGHT, PREVALITE, LOC HOLEST, LOCHOLEST LIGHT), cholestyramine (CHOLESTI D) and colesevelam HCl (WELCHOL) and / or combinations thereof including, for example, but not limited to, VYTORIN (simvastatin + ezetimibe). The term "non-PCSK9 LDL-C lowering agent" includes agents that do not simply lower LDL-C alone. In some embodiments, the methods provided herein that include a "non-PCSK 9 LDL-C lowering agent" may instead be practiced using a "non-PCSK9 lipid-lowering agent", which is an agent that lowers the lipids of a subject without specifically lowering LDL-C specifically.

[0058] The term "proprotein convertase subtilisin / kexin type 9" or "PCSK9" refers to Refers to the polypeptide described in SEQ ID NO: 1 and / or 3 in FIGS. 14A, 14B1 - B4 。"PCSK9" is also known as FH3, NARC1, HCHOLA3, proprotein convertase subtilisin / kexin type 9, and neuronal apoptosis regulatory convertase 1. The PCSK9 gene encodes a proprotein convertase protein belonging to the proteinase K subfamily of the secretory subtilase family. The term "PCSK9" refers to both the proprotein and the product generated after autocatalysis of the proprotein. When only referring to the autocatalytic product (e.g., for an antibody that selectively binds to cleaved PCSK9), this protein can be referred to as "mature", "cleaved", "processed", or "active" PCSK9. When only referring to the inactive form, this protein can be called the "inactive", "proform", or "unprocessed" form of PCSK9. The term "PCSK9 activity" includes the ability of PCSK9 to reduce the availability of LDLR and / or the ability of PCSK9 to increase the amount of LDL in a subject. The term "isolated protein" means that the target protein is (1) free of at least some of the other proteins that would normally be found, (2) substantially free of other proteins from the same source, e.g., the same species, (3) expressed by cells of different

[0059] species, (4) separated from at least about 50% of the polynucleotides, lipids, carbohydrates, or other substances that it would naturally bind to, (5) operably linked (by covalent or non - covalent interactions) to a polypeptide that it does not naturally bind to, or (6) present in nature 。

[0060] 。 。 。 。 。 。 。 Means not to do. Generally, an "isolated protein" constitutes at least about 5%, at least about 10%, at least about 25% or at least about 50% of a given sample. Genomic DNA, cDNA, mRNA or other RNA of synthetic origin or any combination thereof can encode such an isolated protein. An isolated protein is substantially free of proteins or polypeptides or other contaminants found in its natural environment that would interfere with its therapeutic, diagnostic, prophylactic, research or other uses. This is preferred.

[0061] An antibody is said to "specifically bind" to its target antigen when the dissociation constant (K d ) is ≦ 10 -7 M. An antibody is "high affinity" when K is ≦ 5 × 10 d M, and specifically binds to the antigen with "very high affinity" when K -9 is d ≦ 5 × 10 ≦ 5 × 10 -10 M. In one embodiment, the antibody has a K of ≦ 10 -9 M. In one embodiment, the off-rate is < 1 × d 10 10 -5 . In other embodiments, the antibody binds to human PCSK -9 9 with a K -13 of about 10 d M to 10 M, and in yet another embodiment, the antibody binds with a K d ≦ 5 × 10 -10 . As will be understood by those skilled in the art, in some embodiments, any or all of the antibodies may specifically bind to PCSK 9. An antibody is "selective" if it binds more strongly to one target than to a second target.

[0062] ​ It is.

[0063] The term "antibody" refers to intact immunoglobulins of any isotype and includes, for example, chimeric antibodies, humanized antibodies, human antibodies, and bispecific antibodies. An intact antibody generally includes at least two full-length heavy chains and two full-length light chains. An antibody sequence can be derived from a single species or can be "chimeric," i.e., different portions of the antibody can be derived from two different species as further described below. Unless otherwise indicated, the term "antibody" includes, when the antibody retains the same or similar binding and / or function as an antibody consisting of two full-length light chains and heavy chains, antibodies comprising two substantially full-length heavy chains and two substantially full-length light chains. For example, when the antibody retains the same or similar binding and / or function as an antibody comprising two full-length heavy chains and two full-length light chains, antibodies having substitutions, insertions, or deletions of 1, 2, 3, 4, or 5 amino acid residues at the N-terminus and / or C-terminus of the heavy chain and / or light chain are included in the definition. Further, unless explicitly excluded, antibodies include, for example, monoclonal antibodies, polyclonal antibodies, chimeric antibodies, humanized antibodies, human antibodies, bispecific antibodies, and synthetic antibodies. In some aspects of the disclosure, examples of antibodies are described herein as "number / letter / number" (e.g., 21B12) from hybridoma stock numbers. In this case, the exact name refers to a specific monoclonal

[0064] The structural unit of a typical antibody contains a tetramer. Each such tetramer usually consists of 2 identical pairs of polypeptide chains, and each pair consists of one full-length "light" (about 25 kDa in certain embodiments and one full-length "heavy" chain (about 50 - 70 kDa in certain embodiments). The amino-terminal portion of each chain usually contains a variable region consisting of about 100 - 110 or more amino acids involved in antigen recognition. The carboxy-terminal portion of each chain usually defines a constant region that can be involved in effector functions. Light chains are usually classified into kappa and lambda light chains. Heavy chains are usually classified into mu, delta, gamma, alpha or epsilon and define the isotype of the antibody as IgM, IgD, IgG, IgA and IgE respectively. IgG has several subclasses, such as IgG1, IgG2, IgG3 and IgG4 (not limited to these). IgM has subclasses including IgM1 and IgM2 (not limited to these). IgA is similarly further divided into subclasses including IgA 1 and IgA2 (not limited to these). In full-length light and heavy chains, usually the variable and constant regions are joined by a "J" region consisting of about 12 or more amino acids, and the heavy chain also contains a "D" region consisting of about 10 or more amino acids. See, for example, Fundamental Immunology, Ch.7 (Paul , W., ed., 2nd ed. Raven Press, N.Y. (1989))( which is hereby incorporated by reference in its entirety for all purposes). The variable regions of each light / heavy chain pair usually form the antigen-binding site. chain pair usually form the antigen-binding site. chain pair usually form the antigen-binding site. chain pair usually form the antigen-binding site. chain pair usually form the antigen-binding site. chain pair usually form the antigen-binding site.

[0065] The variable regions are typically connected to three hypervariable regions, also known as complementarity determining regions or CDRs, which exhibit the same general structure of relatively conserved framework regions (FRs). The CDRs from each pair of two chains are usually aligned by framework regions that can enable binding to a specific epitope. From the N-terminus to the C-terminus, both the light chain and heavy chain variable regions generally contain domains FR1, CDR1, FR2, CDR2, FR3, CDR3 . and FR4. The amino acid assignments for each domain generally follow the definitions of Kabat Sequences of Proteins of Immunological Interest (National Institutes of Health, Bethesda, Md (1987 and 1991)) or Chothia & Lesk, J . Mol. Biol., 196:901 - 917 (1987); Chothia et al., Nature, 342:878 - 883 (1989). In some embodiments, instead of a full-length antibody, an "antibody fragment" or "antigen-binding fragment" is provided. As used herein and unless otherwise specifically defined, an " antibody fragment" refers to an Fv fragment that contains at least one CDR of an immunoglobulin sufficient to confer specific antigen binding to a target protein such as Fab, Fab’, F(ab’)2, and PCSK9. Antibody fragments can be produced by recombinant DNA technology or by enzymatic or chemical cleavage of intact antibodies. In some embodiments, the antibody heavy chain binds to an antigen in the absence of the antibody light chain. Certain .

[0066] In some embodiments, instead of a full-length antibody, an "antibody fragment" or "antigen-binding fragment" is provided. As used herein and unless otherwise specifically defined, an " antibody fragment" refers to an Fv fragment that contains at least one CDR of an immunoglobulin sufficient to confer specific antigen binding to a target protein such as Fab, Fab’, F(ab’)2, and PCSK9. Antibody fragments can be produced by recombinant DNA technology or by enzymatic or chemical cleavage of intact antibodies. In some embodiments, the antibody heavy chain binds to an antigen in the absence of the antibody light chain. Certain . . .

[0067] In some embodiments, the antibody heavy chain binds to an antigen in the absence of the antibody light chain. Specific In an embodiment, the antibody light chain binds to an antigen in the absence of the antibody heavy chain. In certain embodiments , the antibody binding region binds to an antigen in the absence of the antibody light chain. In certain embodiments, the antibody bind ing region binds to an antigen in the absence of the antibody heavy chain. In certain embodiments, each variable region specifically binds to an antigen in the absence of the other variable regions.

[0068] In certain embodiments, the identification of the CDRs and the residues comprising the antibody binding site is achieved by elucidating the structure of the antibody and / or the structure of the antibody-ligand complex. In certain embodiments, it can be achieved by any of a variety of techniques known to those of skill in the art, such as X-ray crystallography. In certain embodiments, the CDR regions can be identified or approximated using a variety of analytical methods. Examples of such methods include, but are not limited to, the Kabat definition, the Chothia definition, the AbM definition, the AHo definition, and the contact definition.

[0069] The Kabat definition is a standard for numbering residues in an antibody and is commonly used to identify CDR regions. See, for example, Johnson & Wu, Nucleic Aci ds Res., 28:214-8 (2000). The Chothia definition is similar to the Kabat definition, but the Chothia definition takes into account the positions of specific structural loop regions. See, for example, Chothia et al., J. Mol. Biol., 19 6:901-17 (1986); Chothia et al., Nature, 342 :877-83 (1989). The AbM definition is for modeling antibody structures ​​​​​A computer program manufactured by Oxford Molecular Group uses an integrated suite of RAM. For example, Martin et al., Proc Na tl Acad Sci(USA), 86:9268 - 9272(1989); “AbM TM , A Computer Program for Modeling Variab le Regions of Antibodies”, Oxford, UK; Oxfo rd Molecular, Ltd. See also. The AbM definition is a combination of a knowledge database and ab initio methods, for example Samudrala et al., “Ab I nitio Protein Structure Prediction Using a Combined Hierarchical Approach”, PROTE INS, Structure, Function and Genetics Supp l., 3:194 - 198(1999) to generate the tertiary structure from the primary sequence of an antibody. The AHo definition is a residue numbering scheme based on the spatial alignment of known three - dimensional structures of immunoglobulin domains (see, for example, Honegger and Plu eckthun, J.Mol.Biol., 309:657 - 670, (2001)). The contact definition is based on the analysis of available complex crystal structures. See, for example, MacCallum et al., J.Mol.Biol., 5: 732 - 45(1996). eckthun, J.Mol.Biol., 309:657 - 670, (2001) for reference). By convention, the CDR regions in the heavy chain are generally called H1, H2, and H3, and amino acids based on the analysis of available complex crystal structures. See, for example, MacCallum et al., J.Mol.Biol., 5: 732 - 45(1996).

[0070] By convention, the CDR regions in the heavy chain are generally called H1, H2, and H3, and amino It is continuously numbered in the direction from the amino terminus to the carboxy terminus. The CDR regions in the light chain are generally referred to as L1, L2, and L3 and are continuously numbered in the direction from the amino terminus to the carboxy terminus.

[0071] The term "light chain" includes the full-length light chain and fragments thereof having a variable region sequence sufficient to confer binding specificity. The full-length light chain includes a variable region domain (V ) and a constant region domain L (C ). The variable region domain of the light chain is at the amino terminus of the polypeptide. The light chain L includes kappa chains and lambda chains.

[0072] The term "heavy chain" includes the full-length heavy chain and fragments thereof having a variable region sequence sufficient to confer binding specificity. The full-length heavy chain includes a variable region domain (V ) and three constant region domains H (C 1, C H 2, and C H 3). The V H domain is at the amino terminus H of the polypeptide, the C domain is at the carboxyl terminus, and C H 3 is closest to the carboxy H terminus of the polypeptide. The heavy chain can be any isotype including IgG (including IgG1, IgG2, IgG3, and IgG4 subtypes), IgA (including IgA1 and IgA2 subtypes), IgM, and Ig E.

[0073] Bispecific or bivalent antibodies are generally artificial hybrid antibodies having two different heavy / light chain pairs and two different binding sites. Bispecific antibodies are generated by various methods including (but not limited to) hybridoma fusion or ligation of Fab' fragments​​​​ can be obtained. For example, see Songsivilai et al., Clin. Exp. Immunol., 79:315-321 (1990); Kostelny et al., J. Immunol., 148:1547-1553 (1992). ol., 79:315-321 (1990); Kostelny et al., J. I mmunol., 148:1547-1553 (1992).

[0074] Some species of mammals also produce antibodies that have only a single heavy chain.

[0075] Each individual immunoglobulin chain generally consists of several "immunoglobulin domains", each domain consisting of approximately 90-110 amino acids and having a characteristic folding pattern. These domains are the basic units that make up the antibody polypeptide. In humans, the IgA and IgD isotypes contain four heavy chains and four light chains, the IgG and IgE isotypes contain two heavy chains and two light chains, and the Ig M isotype contains five heavy chains and five light chains. The heavy chain C region generally contains one or more domains that can be involved in effector functions. The number of heavy chain constant region domains depends on the isotype. For example, the IgG heavy chain contains three C region domains known as C 1, C 2 and C 3. The antibodies provided can have any of these isotypes and subtypes. In certain embodiments of the invention, the anti-PCS K9 antibody is of the IgG1 or IgG2 or IgG4 subtype. region generally contains one or more domains that can be involved in effector functions. The number of heavy chain constant region domains depends on the isotype. For example, the IgG heavy chain contains three C region domains known as C 1, C H 1, C H 2 and C H 3. The antibodies provided can have any of these isotypes and subtypes. In certain embodiments of the invention, the anti-PCS K9 antibody is of the IgG1 or IgG2 or IgG4 subtype. K9 antibody can be of any of these isotypes and subtypes. In certain embodiments of the invention, the anti-PCS K9 antibody is of the IgG1 or IgG2 or IgG4 subtype.

[0076] The term "variable region" or "variable domain" refers to a part of the light chain and / or heavy chain of an antibody and generally contains approximately 120-130 amino-terminal amino acids in the heavy chain and in the light chain It contains about 100 to 110 amino-terminal amino acids. In certain embodiments, the variable regions of different antibodies vary greatly in amino acid sequence even among antibodies of the same species. The variable region of an antibody generally determines the specificity of a particular antibody for its target.

[0077] The term "neutralizing antibody" as used in "anti-PCSK9 neutralizing antibody" refers to an antibody that binds to a target and inhibits or reduces the biological activity of that target. This can be done, for example, by directly blocking the binding site on the target or by binding to the target and altering (e.g., a structural or energetic change in the target) the target's ability to bind by indirect means. In the evaluation of the binding and / or specificity of an antibody or an immunologically functional fragment thereof, the amount of the binding partner to which an excess of the antibody binds is reduced by at least about 1 - 20, 20 - 30%, 30 - 40%, 40 - 50%, 50 - 60%, 60 - 70%, 70 - 80%, 80 - 85%, 85 - 90%, 90 - 95%, 95 - 97%, 97 - 98 %, 98 - 99% or more (as measured by an in vitro competitive binding assay), the antibody or fragment can substantially inhibit the binding of the target to its binding partner. In the case of a PCSK9 antibody, such a neutralizing molecule can reduce the ability of PCSK9 to bind to the LDLR. In some embodiments, the neutralizing ability is characterized and / or described by a competitive assay. In some embodiments, the neutralizing ability is described by an IC or an EC value. In some embodiments, the antibody binds to PCSK9 and prevents PCSK9 from binding to the LDLR (or PCSK9 from binding to LDL ). In some embodiments, the neutralizing ability is characterized and / or described by a competitive assay. In some embodiments, the neutralizing ability is described by an IC 50 or an EC 50 value. In some embodiments, the antibody binds to PCSK 9 and prevents PCSK9 from binding to the LDLR (or PCSK9 from binding to LDL neutralized by decreasing its ability to bind to R. In some embodiments, the antibody binds to PCSK9 and neutralizes by preventing or reducing the degradation of LDLR by PCSK9 while still allowing PCSK9 to bind to LDLR between. Thus, in some embodiments, the neutralizing antibody still allows PCSK9 / LDLR binding but prevents (or reduces) the subsequent PCSK9-mediated degradation of LDLR . In some embodiments, neutralization results in a decrease in LDL-C (and / or other lipids such as non-HDL-C, Apo B, Lp(a)).

[0078] "Antigen-binding protein" includes an antigen-binding fragment that binds to an antigen and optionally a backbone or framework portion that allows the antigen-binding fragment to adopt a conformation that promotes binding of the antigen-binding protein to the antigen . In some embodiments, the antigen is a PCSK9 protein or a fragment thereof. In some embodiments , the antigen-binding fragment includes at least one CDR derived from an antibody that binds to the antigen, and in some embodiments, includes the heavy chain CDR3 derived from an antibody that binds to the antigen. In some embodiments , the antigen-binding fragment includes all three CDRs derived from the heavy chain of an antibody that binds to the antigen or all three CDRs derived from the light chain of an antibody that binds to the antigen . In some further embodiments, the antigen-binding fragment includes all six CDRs (three from the heavy chain and three from the light chain) derived from an antibody that binds to the antigen . The antigen-binding fragment in certain embodiments is an antibody fragment . The term "compete", when used in connection with antibodies that compete for the same epitope, means a test

[0079] ​​The antibody being tested means that it interferes with or inhibits (e.g., reduces) the specific binding of a reference antibody (e.g., a ligand or reference antibody) to a common antigen (e.g., PCSK9 or a fragment thereof), as determined by an assay that measures competition between antibodies. To determine whether one antibody competes with another, for example, solid-phase direct or indirect radioimmunoassay (RIA ), solid-phase direct or indirect enzyme immunoassay (EIA), sandwich competition assay (e.g., see Stahli et al., 1983, Methods in Enzymol ogy 9:242-253); solid-phase direct biotin-avidin EIA (e.g., see Kirkland et al., 1986, J. Immunol. 137:36 14-3619); solid-phase direct labeled assay, solid-phase direct labeled sandwich assay (e.g., see Harlow and Lane, 1988, Antibodies, A Laboratory Manual, Cold Spring Harbor Pr ess); solid-phase direct labeled RIA using I-125 labeling (e.g., see Mor el et al., 1988, Molec. Immunol. 25:7-15); solid-phase direct biotin-avidin EIA (e.g., see Cheung, et al., 1990, Virology 176:546-552); and direct labeled RIA (Moldenhauer et al., 1990, Scand. J. Imm unol. 32:77-82), and many other types of competitive binding assays can be used. Generally, such assays involve the use of a purified antigen bound to a solid surface or cell having either of these, i.e., an unlabeled test antibody and a labeled reference antibody. Competition ; solid-phase direct labeled RIA using I-125 labeling (e.g., see Mor el et al., 1988, Molec. Immunol. 25:7-15); solid-phase direct biotin-avidin EIA (e.g., see Cheung, et al., 1990, Virology 176:546-552); and direct labeled RIA (Moldenhauer et al., 1990, Scand. J. Imm unol. 32:77-82) can be used. Generally, such assays involve the use of a purified antigen bound to a solid surface or cell having either of these, i.e., an unlabeled test antibody and a labeled reference antibody. Competition generally involves the use of a purified antigen bound to a solid surface or cell having either of these, i.e., an unlabeled test antibody and a labeled reference antibody. Competition Inhibition is measured by determining the amount of label bound to a solid surface or cell in the presence of the test antibody. Usually, the test antibody is present in excess. Antibodies identified by a competitive assay include antibodies that bind to the same epitope as the reference antibody and antibodies that bind to an adjacent epitope that is sufficiently close to the epitope to which the reference antibody binds such that steric hindrance occurs. Further details regarding methods for determining competitive binding are provided in the examples herein. Usually, when the competing antibody is present in excess, it inhibits (e.g., reduces) specific binding of the reference antibody to the common antigen by at least 40-45%, 45-50%, 50-55%, 55-60%, 60-65%, 65-70%, 70-75% or 75% or more. Optionally, binding is inhibited by at least 80-85%, 85-90%, 90-95%, 95-97% or 97% or more. As used herein, "substantially pure" means that the described molecular species is the predominant species present, i.e., more abundant than any other individual species in the same mixture on a molar basis. In certain embodiments, a substantially pure molecule is a composition that comprises at least 50% (on a molar basis) of all macromolecular species present in the composition. In other embodiments, a substantially pure composition comprises at least 80%, 85%, 90%, 95% or 99% of all macromolecular species present in the composition. In other embodiments, the species of interest is purified to substantial homogeneity consisting of a single detectable macromolecular species such that contaminating species cannot be detected in the composition by conventional detection methods.

[0080]

[0081] ​​​​​​​​​​​​​​As used herein, the term "biological sample" includes, but is not limited to, any amount of material from something that is alive or was previously alive. Such organisms include, but are not limited to, humans, mice, monkeys, rats, rabbits, and other animals. Such materials include, but are not limited to, blood, serum, urine, cells, organs, tissues, bone, bone marrow, lymph nodes, and skin.

[0082] As used herein, the term "pharmaceutical composition" (or agent or drug) refers to a compound, composition, agent, or drug that can induce a desired therapeutic effect when appropriately administered to a patient. It does not necessarily require more than one component.

[0083] The term "therapeutically effective amount" refers to the amount of a therapeutic substance or group of therapeutic substances (e.g., a PCSK9 inhibitor; a non-PCSK9 LDL-C lowering agent (such as a statin or other non-PCSK9 LDL-C lowering agent); and a PCSK9 inhibitor and a non-PCSK9 LDL-C lowering agent). This would be an amount sufficient to produce a therapeutic response in a mammal. Such a therapeutically effective amount can be readily determined by one of ordinary skill in the art.

[0084] The terms "patient" and "subject" are used interchangeably and include human and non-human animal subjects, as well as subjects with a formally diagnosed disorder, subjects without a formally recognized disorder, subjects undergoing treatment, subjects at risk of developing a disorder, etc.

[0085] The terms "treat" and "treatment" include therapeutic treatment, prophylactic treatment, and applications that reduce the risk of a subject developing a disorder or other risk factor. Treatment does not require complete cure of the disorder. It does not seek and includes embodiments that reduce symptoms or underlying risk factors. The treatment is regression is included.

[0086] The term "prevention" does not require eliminating the possibility of an event by 100%. Rather, it means that the likelihood of the occurrence of the event is reduced in the presence of the compound or method.

[0087] The term "atheroma volume ratio (PAV)" can be calculated as follows.

Number

[0088] EEM 面積 is the cross-sectional area of the outer elastic plate, and the lumen 面積 is the cross-sectional area of the lumen. The change in PAV can be calculated as the difference between the PAV at any specific time and the PAV at baseline and can be calculated as such.

[0089] The standardized "total atheroma volume" (TAV)" can be calculated as follows and can be calculated as such.

Number

[0090] Multiply the average plaque area of each image by the median number of images analyzed across all cohorts, and compensate for the difference in segment length between subjects. The change in standardized TAV can be calculated as the difference between the TAV at any specific time and the TAV at baseline and can be calculated as such. and can be calculated as the difference between the TAV at any specific time and the TAV at baseline.

[0091] The term "moderate-intensity" non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK 9 LDL-C lowering therapy, etc.) reduces LDL-C by approximately 30% to <50% means.

[0092] The term "high-intensity" non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK 9 LDL-C lowering therapy, etc.) means reducing LDL-C by nearly >50%. .

[0093] The terms "optimal", or "optimized", or "maximized", or "maximum" " non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK9 LDL-C low ering therapy, etc.) refer to the dose of non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK9 LDL-C lowering therapy, etc.) administered so that the subject can reach their LDL-C lowering goals. When a subject is receiving at least an amount of non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK9 LDL-C lowering therapy, etc.), the subject can be described as receiving non-PCSK9 LDL-C lowering therapy (such as statin or other non-PCSK9 LDL-C lowering therapy, etc.). In some embodiments, any of the definitions or classifications (including supplements) used for any of the levels or disorders identified in Example 17 can be used in other FOURIER-related embodiments or non-FOURIER embodiments. At the end of Example 17, placing such characterizations of these disorders, etc., is to clarify that they are the definitions used in the FOURIER trial. Such definitions (from Example 17) need not apply to all embodiments provided herein in all situations, but such

[0094] definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. definitions can be used in other FOURIER-related embodiments or non-FOURIER embodiments. At the end of Example 17, placing such characterizations of these disorders, etc., is to clarify that they are the definitions used in the FOURIER trial. Such definitions (from Example 17) need not apply to all embodiments provided herein in all situations, but such definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. definitions apply to all embodiments provided herein unless otherwise specified or contrary to other definitions. It is considered applicable to any of the provided embodiments. Definitions applied in Example 17 Unless explicitly stated otherwise that a particular definition applies, the various terms in the claims have their plain and ordinary meaning. Standard techniques can be used for recombinant DNA, oligonucleotide synthesis, and tissue culture as well as transformation (e.g., electroporation, lipofection). Enzyme reactions and purification techniques can be performed according to the manufacturer's specifications, or as commonly done in the art, or as described herein. The above techniques and procedures generally follow conventional methods well known in the art and are cited and described throughout this specification in various general and more specific references. For example, see Sambrook et al., Molecular Cloning: A Laboratory Manu al (2d ed., Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y. (1989)). This reference is hereby incorporated by reference herein for all purposes. Unless otherwise specified, the terms used in connection with analytical chemistry, synthetic organic chemistry, and medicinal chemistry and pharmaceutical chemistry described herein, as well as their experimental procedures and techniques are well known and commonly used in the art. Standard techniques can be used for chemical synthesis, chemical analysis, pharmaceutical preparation, formulation and delivery, and patient treatment. Combination therapy for reducing atherosclerosis and improving cardiovascular outcomes in patients with cardiovascular disease

[0095] ​ Lowering low-density lipoprotein cholesterol (LDL-C) with 3-hydroxy-3-methylglutaryl coenzyme A reductase (statin) inhibitors is common in the management of patients with atherosclerotic disease. Analysis of data from individual statin trials and meta-analyses has suggested a consistent relationship between achieving lower LDL-C levels and reducing major adverse cardiovascular events. Concurrently, studies using intravascular ultrasound (IVUS) have investigated the effect of statins on coronary atherosclerosis and shown a linear relationship between achieved LDL-C levels and reduction in atheroma burden. However, in major clinical outcome trials and IVUS studies, only LDL-C levels in the range up to approximately 60 mg / dL have been investigated.

[0096] Proprotein convertase subtilisin / kexin type 9 (PCSK9) plays a central role in LDL-C metabolism by interfering with LDL receptor recycling to the liver surface, thereby limiting the removal of LDL particles from the bloodstream. Monoclonal antibodies against PCSK9, when administered alone or in combination with statins, significantly lower LDL-C as well as other lipids such as non-HDL-C, ApoB, and Lp(a). Initial studies have demonstrated the feasibility of achieving even lower LDL-C levels than previously reported using combinations of statins and PCSK9 inhibitors. However, whether LDL-C lowering with PCSK9 inhibitors reduces the progression rate of coronary atherosclerosis has not been examined in previous trials, and Data evaluating whether achieving lower LDL-C levels increases the benefit of suppressing disease progression compared to statin monotherapy are not available.

[0097] This specification (Example 1) presents the results of the Global Assessment of Plaque Regression (GLAGOV) trial using PCSK9 antibodies measured by intravascular ultrasound, which addresses two major scientific questions: whether PCSK9 inhibition affects and / or suppresses the progression of atherosclerotic disease, and whether achieving very low LDL-C levels using a combination of statins (representing non-PCSK9 LDL-C lowering therapy) and PCSK9 inhibitors (e.g., evolocumab) presents an increased value in further suppressing the progression of coronary artery disease as measured by IVUS.

[0098] Considering the results of this study (Example 1), the present application provides various embodiments including combination therapies, which are based in part on the ability of moderate and / or high-intensity statin therapy (non-PCSK9 LDL-C lowering agents) to suppress the progression of atherosclerotic disease (e.g., coronary atherosclerosis) in proportion to the achieved LDL-C levels, and on the ability of proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitors to further increase the lowering of LDL-C in statin-treated patients. The results of Example 1 below show that the addition of a PCSK9 inhibitor, such as evolocumab, results in greater LDL-C lowering and coronary atherosclerosis at tolerable doses compared to statin monotherapy (a representative example of a non-PCSK9 LDL-C lowering agent). has been shown to produce a significant regression of the disease. Accordingly, provided herein are combination therapies comprising a PCSK9 inhibitor and a non-PCSK9 LDL-C lowering agent. In some embodiments, the combination therapy can be used in a subject having atherosclerotic cardiovascular disease to improve the cardiovascular outcomes of the subject.

[0099] In some embodiments, provided is a method of treating coronary atherosclerotic heart disease. This method may include identifying a subject who has received a first treatment comprising a non-PCSK9 LDL-C lowering agent (e.g., a lipid-lowering treatment such as a statin or other non-PCSK9 LDL-C lowering therapy). This method may further include administering a second therapy to the subject. The second therapy includes administering to the subject a PCSK9 inhibitor such as an anti-PCSK9 neutralizing antibody. The first and second therapies are both administered in an amount and for a time sufficient to (in combination) reverse coronary atherosclerotic heart disease in the subject. The PCSK9 inhibitor reduces the level of L DL-C in the subject. The first therapy is different from the second therapy. For example, in some embodiments, the first therapy is not an anti-PCSK9 antibody treatment but any other LDL-C lowering agent (such as a statin or other non-PCSK9 LDL-C lowering therapy). In some embodiments, the first therapy is not an antibody treatment. In some embodiments, the combination therapy can be used in a subject having atherosclerotic cardiovascular disease to improve the cardiovascular outcomes of the subject.

[0100] In some embodiments, the first therapy can be any non-antibody, LDL-C lowering therapy possible. In some embodiments, the first therapy is ezetimibe (Zetia) or a statin selected from at least one of. In some embodiments, the first therapy is optimized and / or maximized statin therapy. In some embodiments, the subject's LD L level is reduced to a level of 80 mg / dL or less from the first therapy, and then further reduced from the second therapy. In some embodiments, both treatments together reduce the LDL- C level to at least 80 mg / dL. C level to at least 80 mg / dL.

[0101] In some embodiments, a method of treating coronary artery atherosclerosis is provided. This method includes identifying a subject having an LDL-C level of 70 mg / dL or less, and b) administering to the subject an anti-PCSK9 neutralizing antibody in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less. In some embodiments, the subject is diagnosed with cardiovascular disease. diagnosed with cardiovascular disease.

[0102] In some embodiments, a method of treating coronary artery atherosclerosis is provided. This method includes identifying a subject having an LDL-C level of 70 mg / dL or less, and LD administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less. In some embodiments, the subject is a cardiovascular disease diagnosed with cardiovascular disease. diagnosed with cardiovascular disease.

[0103] In some embodiments, a method of treating coronary artery atherosclerosis is provided. This method includes identifying a subject having an LDL-C level of 80 mg / dL or less, and LD administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less. In some embodiments, the subject is administering a PCSK9 inhibitor (such as an anti-PCSK9 neutralizing antibody).

[0104] In some embodiments, a method of treating coronary artery atherosclerotic disease is provided. The method comprises administering to a subject undergoing non-PCSK9 LDL-C lowering therapy (e.g., optimized statin therapy) a PCSK9 inhibitor therapy (such as an anti-PCSK9 neutralizing antibody) in an amount and for a time sufficient to lower the LDL-C level to 80 mg / dL or less. In some embodiments, the results are achieved after at least 1 year of continuous treatment with both statin therapy and antibody therapy. In some embodiments, the subject is further identified by being diagnosed with a coronary artery atherosclerotic disease or having a high risk of developing a coronary artery atherosclerotic disease. In some embodiments, the therapy can be used in a subject having an atherosclerotic cardiovascular disease to improve the cardiovascular outcome of the subject. In some embodiments, a method of reducing the atherosclerotic volume ratio of a subject is provided. The method comprises: 1) identifying a subject undergoing moderate-intensity treatment with at least a non-PCSK9 LDL-C lowering agent (e.g., a statin); and 2) administering to the subject a PCSK9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody) in an amount and for a time sufficient to lower the LDL-C level to 100 mg / dL or less, e.g., 90 mg / dL or less.

[0105] Thereby, the atherosclerotic volume ratio (PAV) in the subject can be reduced. In some embodiments, this sufficient amount and time is sufficient to lower the LDL-C level to 40 mg / dL or less. is sufficient to cause. In some embodiments, this period is at least 1 year and the respective amounts of the compounds are as provided herein.

[0106] In some embodiments, a method for reducing total atherosclerotic volume (TAV) in a subject is provided. The method includes: 1) identifying a subject who has been undergoing moderate treatment with at least a non-PCSK9 LDL-C lowering agent (e.g., a statin), and 2) administering to the subject a PCSK9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody) in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, e.g., 90 mg / dL or less, Thereby, it is possible to reduce the total atherosclerotic volume (TAV) in the subject. In some embodiments, this sufficient amount and time are sufficient to reduce the LDL-C level to 40 mg / dL or less. In some embodiments, this period is at least 1 year, and the respective amounts of the compounds are as provided herein. In some embodiments, the subject is diagnosed with cardiovascular disease. In some embodiments, both the subject's TAV and PAV are reduced. In some embodiments, the reduction in PAV is at least 0.1%, e.g., 0.1, 0.2,

[0107] 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1. 3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.1, 2.2, 2.3, 2.4, 2.5% reduction in PAV is achieved. In some embodiments, the reduction in TAV is at least 0.1%, e.g., 0.1, 0.2, 0.3, 0.4, 0 3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.1, 2.2, 2.3, 2.4, 2.5% 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5 , 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4, 2.5, 2 .6, 2.7, 2.8, 2.9, 3, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6 , 3.7, 3.8, 3.9, 4, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4 .7, 4.8, 4.9, 5, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7 , 5.8, 5.9, A 6% reduction in TAV is achieved. In some embodiments, the above reduction is achieved within about 3 years, 2 years, 18 months or 1 year. In some embodiments , PAV is reduced by at least 1% after 18 months of treatment. In some embodiments, P AV is reduced by at least 2% after 18 months of treatment. In some embodiments, TAV is reduced by at least 1% after 18 months of treatment. In some embodiments, TAV is, reduced by at least 2% after 18 months of treatment. In some embodiments, TAV is, 18 months of treatment is reduced by at least 3%. In some embodiments, TAV is, 18 months of treatment is reduced by at least 4%. In some embodiments, TAV is, 18 months of treatment is reduced by at least 5%. In some embodiments, TAV is, 18 months of treatment is reduced by at least 6%.

[0108] In some embodiments, a method of treating coronary artery atherosclerosis comprises: 1) administering optimal non- PCSK9 LDL-C lowering therapy (e.g., statin therapy) to a subject who has coronary artery atherosclerosis, and 2) simultaneously administering to the subject an amount of a PCS K9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody). These The steps can be performed in the same (or overlapping) time, or in a different order, successively.

[0109] In some embodiments, a method for treating coronary atherosclerotic heart disease comprises: 1) identifying a subject intolerant to a statin; 2) administering a low-intensity statin treatment to the subject intolerant to the statin; and 3) administering to the subject an amount of an anti-PCSK9 neutralizing antibody, thereby treating coronary atherosclerotic heart disease. These steps can be performed in the same (or overlapping) time, or in a different order, successively. In some embodiments, a moderate-dose statin therapy is administered. In some embodiments, a high-dose statin therapy is administered. In some embodiments, the methods provided herein, such as combination therapies and monotherapies, for reducing LDL-C levels to very low levels, reduce LDL-C (and / or non-HDL-C, which is adjusted +30 points higher) by 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80,

[0110] 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180 mg / dL or more. In some embodiments, a method for providing regression of coronary atherosclerotic heart disease comprises providing a subject who has received an optimized non-PCSK9 LDL-C lowering therapy (e.g., an optimized level of statin), and ten... ... ... to regress coronary atherosclerotic heart disease. ... ...

[0111] In some embodiments, a method for providing regression of coronary atherosclerotic heart disease, which comprises providing a subject who has received an optimized non-PCSK9 LDL-C lowering therapy (e.g., an optimized level of statin), and ... to regress coronary atherosclerotic heart disease. Administering a PCSK9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody) at a suboptimal level is provided, wherein regression is a change of zero or less in PAV or TAV. These steps can be performed in sequence, at the same (or overlapping) times, or in a different order.

[0112] In some embodiments, a method is provided for reducing the LDL-C level in a subject to 80 mg / dL or less. The method comprises administering a PCSK9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody or RNAi-PCSK9) to a subject who has coronary artery atherosclerosis and who has received non-PCSK9 LDL-C lowering therapy (e.g., optimized statin therapy) for at least one year, and the LDL-C level in the subject is reduced to an average value of 80 mg / dL or less for at least one year. These steps can be performed in sequence, at the same (or overlapping) times, or in a different order. In some embodiments, the LDL level of the subject is reduced to an average value of 60 mg / dL or less, e.g., 55, 50, 45, 40, 35, 30, 25, 20 mg / dL or less, over at least one year.

[0113] In some embodiments, a method is provided for reducing the relative risk of a cardiovascular event by at least 10%. The method comprises administering a PCSK9 inhibitor (e.g., a PCSK9 neutralizing antibody) in an amount sufficient to reduce the subject's LDL-C level to about 20 mg / dL or less in a subject who has received at least moderate treatment with a non-PCSK9 LDL-C lowering agent (e.g., a statin).

[0114] ​​​​​In some embodiments, the cardiovascular event is a non-fatal myocardial infarction, myocardial infarction (MI), stroke / transient ischemic attack (TIA), angina, arterial revascularization, coronary revascularization, fatal and non-fatal stroke, hospitalization for congestive heart failure (CHF), coronary heart disease (CH D) death, coronary death, and is selected from the group consisting of coronary death. In some embodiments, the combination therapy suppresses and / or delays the progression of atherosclerosis, delays the progression of coronary atherosclerosis disease, delays the progression of atherosclerosis in CHD patients, and delays the progression of atherosclerosis in CHD patients. In some embodiments, the combination therapy can suppress and / or delay atherosclerotic cardiovascular disease (ASCVD), CAD / CHD , cerebrovascular dz and / or peripheral arterial disease (PAD). In some embodiments, any one of the methods provided herein for combination therapy is used to reduce the risk of any one or more of these events . In some embodiments, a patient or subject having a risk of one of these events is a subject identified as receiving combination therapy.

[0115] In some embodiments, the subject has at least one of the following: high LDL-C levels, HoFH, HeFH and non-familial hypercholesterolemia. In some embodiments, the subject has primary hyperlipidemia (heterozygous familial and non-familial), or mixed dyslipidemia, or homozygous familial hypercholesterolemia. In some embodiments, a subject identified as having a risk of a cardiovascular event is receiving combination therapy. Is identified as the subject to receive. In some embodiments, the subject receiving combination therapy is a) High total cholesterol (t-C), b) high LDL-C, c) high Apo B, d) high Lp(a ) and / or e) high triglycerides (TG), f) elevated non-HDL-C, and / Or g) those with low HDL-C, as well as those with primary hyperlipidemia (heterozygous familial and And non-familial) and / or those with mixed lipid disorders. In some embodiments In, the subject has one or more of type 1 diabetes, type 2 diabetes, metabolic syndrome, prediabetes and / Or has one or more of HIV / AIDS.

[0116] In some embodiments, using the combination therapies provided herein, at least the following One or more risks can be reduced or treated: CV death, non- Fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization and Hospitalization for unstable angina.

[0117] In some embodiments, the combination therapies provided herein are clinically apparent Atherosclerotic cardiovascular (CV) disease (e.g., previous MI, stroke or symptomatic PA D) can be used in patients with to reduce one or more of the following risks: CV death , non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization Surgery and hospitalization for unstable angina. In some embodiments, the combination therapy is HF (Heart failure) can be used in patients admitted for.

[0118] In some embodiments, the combination therapies provided herein are clinically apparent For use in patients with atherosclerotic cardiovascular (CV) disease to reduce one or more risks of hospitalization for CV death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization, and unstable angina. In some embodiments, the combination therapy can be used in patients hospitalized for HF. In some embodiments, the combination therapy provided herein can be used in patients with clinically evident atherosclerotic cardiovascular (CV) disease (e.g., prior MI, stroke, or symptomatic PAD, plus one major or two minor additional risk factors) to reduce the risk of hospitalization for CV death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization, and unstable angina.

[0119] In some embodiments, the combination therapy provided herein can be used in patients with clinically evident atherosclerotic cardiovascular (CV) disease (e.g., prior MI, stroke, or symptomatic PAD, plus one major or two minor additional risk factors) to reduce the risk of hospitalization for CV death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization, and unstable angina. In some embodiments, the combination therapy is used to treat / prevent / reduce the risk of primary hyperlipidemia and / or mixed lipid disorders (e.g., heterozygous familial hypercholesterolemia (HeFH), non-familial

[0120] hypercholesterolemia, mixed lipid disorders, high-risk patients without clinical atherosclerotic cardiovascular disease (CVD) or ASCVD (asymptomatic ASCVD)), coronary atherosclerosis, and / or cardiovascular disease (e.g., hospitalization for CV death, non-fatal myocardial infarction, non- fatal stroke or transient ischemic attack (TIA), coronary artery revascularization, and unstable angina). In some embodiments, a method of reducing the amount of atherosclerotic plaque in a subject, the method comprising administering a PCSK9 inhibitor (e.g., to a subject having atherosclerotic plaque In some embodiments, a method of reducing the amount of atherosclerotic plaque in a subject, the method comprising administering a PCSK9 inhibitor (e.g., to a subject having atherosclerotic plaque

[0121] In some embodiments, a method of reducing the amount of atherosclerotic plaque in a subject, the method comprising administering a PCSK9 inhibitor (e.g., to a subject having atherosclerotic plaque including administering a monoclonal antibody against PCSK9, such as an anti-PCSK9 neutralizing antibody A method is provided. The subject has also received an optimized non-PCSK9 LDL-C lowering therapy (e.g., an optimized statin therapy), thereby reducing the amount of atherosclerotic plaque in the subject. In some embodiments, the method further includes identifying a subject in need of reducing the amount of atherosclerotic plaque. These steps can be performed in the same (or overlapping) time, or in a different order. These steps can be performed in the same (or overlapping) time, or in a different order.

[0122] In some embodiments, a method for suppressing disease progression is provided. This method includes: 1) identifying a subject having an LDL-C level of 80 mg / dL or less; 2) administering to the subject at least a high and / or moderate-intensity non-PCSK9 LDL-C lowering therapy (statin therapy); and 3) administering a PCSK9 inhibitor (e.g., evolocumab) at a level sufficient to reduce the subject's LDL-C level to 30 mg / dL, thereby suppressing disease progression. These steps can be performed in the same (or overlapping) time, or in a different order. In some embodiments, the subject has had a heart attack. In some embodiments, the subject has an LDL-C level of 60 mg / dL or less.

[0123] In some embodiments, a method for suppressing disease progression is provided. This method includes identifying a subject having an LDL-C level of 80 mg / dL or less, administering to the subject at least a moderate-intensity statin therapy, and reducing the subject's LDL-C level to 30 mg / dL. ​​​​​​administering evolocumab at a level sufficient to do so, thereby suppressing the progression of the disease In some embodiments, high-intensity statin therapy is used.

[0124] In some embodiments, a greater LDL-C reduction and coronary artery atherosclerosis regression are achieved at a well-tolerated dose by combining evolocumab and statin therapy. In some embodiments, a method is provided for combining evolocumab and statin therapy to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes administering to a subject at least moderate-intensity statin therapy, administering to the subject a sufficient amount of evolocumab such that the subject's LDL-C level is reduced to 40 mg / dL or less, and maintaining the subject's LDL-C level at 40 mg / dL or less for at least one year. In some embodiments, high-intensity statin therapy is used. In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%. In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL

[0125] In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%. In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%. In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%. In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%. In some embodiments, moderate-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately 30% to <50%. In some embodiments, high-intensity non-PCSK9 LDL-C lowering therapy (such as statins or other non-PCSK9 LDL-C lowering therapies) means reducing LDL-C by approximately ≧50%.

[0126] In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL In some embodiments, a method is provided for combining a PCSK9 inhibitor (e.g., evolocumab) and a non-PCSK9 LDL-C lowering therapy (e.g., statin therapy) to produce a greater LDL-C reduction and regression of coronary artery atherosclerosis at a well-tolerated dose. The method includes: 1) high and / or moderate-intensity non-PCSK9 LDL -C-lowering therapy (e.g., high and / or moderate intensity statin therapy) is administered to the subject; and ) a sufficient amount of PCSK9 to reduce the subject's LDL-C level to 40 mg / dL or less administering an inhibitor (e.g., evolocumab) to the subject; and 3) measuring the subject's LDL-C level. These steps include maintaining blood glucose levels at or below 40 mg / dL for at least one year. The steps may be performed sequentially, at the same (or overlapping) times, or in different orders.

[0127] In some embodiments, the present invention provides a method for treating subjects who cannot tolerate a sufficient therapeutic dose of a statin. The method includes identifying a subject and measuring the LDL cholesterol level of the subject. PCSK9 inhibitors (e.g., anti-PCSK9) are administered until teratinocyte levels are reduced to below 60 mg / dL. and administering to the subject a neutralizing antibody (SK9 neutralizing antibody). In some embodiments, the method comprises administering to the subject identifying a subject having an LDL cholesterol level of 80 mg / dL or less; A PCSK9 inhibitor (e.g., an anti-PCSK9 neutralizing antibody) is administered to the subject until the PCSK9 level is reduced to 0.05 mg / kg / day. Includes and.

[0128] In some embodiments, optionally, the first therapy is a non-PCSK9-dependent LDL -C lowering therapy, i.e., it involves the use of non-PCSK9 LDL-C lowering agents. In particular, non-PCSK9 LDL-C lowering agents lower LDL-C levels but do not increase PCS levels. In some embodiments, the first therapy is not an antibody therapy. In some embodiments, the first therapy is an antibody therapy in which the antibody does not bind to PCSK9. The non-PCSK9 LDL-C lowering agent / therapy is not a PCSK9 neutralizing antibody treatment. In some embodiments, the non-PCSK9 LDL-C lowering therapy is a small molecule treatment that can lower the subject's LDL-C level. In some embodiments, the non-PCSK9 LDL-C lowering therapy is a lipid lowering therapy excluding PCSK9-driven lipid lowering therapy. In some embodiments, the non-PCSK9 LDL-C lowering therapy is niacin; ezetimibe; or a statin (also known as an HMG CoA reductase inhibitor), atorvastatin (LIPITOR (registered trademark)), cerivastatin, fluvastatin (LESCOL), lovastatin (Mevacor, ALTOPREV), mevastatin, pitavastatin, pravastatin (PRAVACHOL), rosuvastatin, rosuvastatin calcium (CRESTOR ) and simvastatin (ZOCOR), one or more of which. Statins are also found in combination drugs including: ADVICOR (lovastatin + niacin), CADUET (atorvastatin + amlodipine); selective cholesterol absorption inhibitor, ezetimibe (ZETIA); lipid lowering therapy (LLT) fibrate or fibric acid derivative, e.g. gemfibrozil (LOPID), fenofibrate (ANTARA, LOFIB RA, TRICOR, TRIGLIDE) and clofibrate (ATROMID-S ); resin (also known as bile acid sequestrant or bile acid binder), cholestyramine (QUESTRA N, QUESTRAN LIGHT, PREVALITE, LOCHOLEST, LOC HOLEST LIGHT), cholestipol (CHOLESTID) and colesevelam Hcl (WELCHOL) and / or combinations thereof, e.g., but not limited to VYTORIN (simvastatin + ezetimibe). In some embodiments , Non-PCSK9 LDL-C lowering therapies include moderate-intensity or high-intensity statin therapies. In some embodiments, the non-PCSK9 LDL-C lowering therapy includes a maximum tolerated dose of statin . Moderate-intensity therapy means reducing LDL-C by approximately 30 to <50%. High-intensity therapy means reducing LDL-C by >50%. In some embodiments, the first therapy, the non-PCSK9-dependent therapy, generally reduces lipid levels, particularly non-HDL-C levels . Thus, even if the therapy is not just a change in LDL-C level and / or does not emphasize the LDL-C level, it is also considered possible to use non-PCSK9-dependent lipid-lowering therapy as the first therapy.

[0129] In some embodiments, the non-PCSK9 LDL-C lowering therapy (which can be statin therapy) has at least the same effect as a dose of 20 mg of atorvastatin per day or is an amount of statin equivalent to atorvastatin in the same amount. In some embodiments , the amount of statin has at least the same effect as a dose of at least 40 mg of atorvastatin per day or is equivalent to atorvastatin in the same amount. In some embodiments , the statin is at least one of atorvastatin, simvastatin, rosuvastatin, pravastatin, lovastatin, and pitavastatin. In some embodiments, the statin is 20, 40, or 80 mg of atorvastatin, 40 or 8 0 mg of simvastatin, 5, 10, 20, or 40 mg of rosuvastatin, 80 mg of pravastatin, 80 mg of lovastatin, or 4 mg of pitavastatin, at least one of which. There is one. In some embodiments, the subject has received or is ingesting at least atorvastatin 40 or 80 mg, rosuvastatin 10, 20 or 40 mg or simvastatin 80 mg. In some embodiments, the amount of statin administered is the maximum allowable amount of the statin. In some embodiments, the amount of statin corresponds to at least atorvastatin 20 mg / day. In some embodiments, the amount of statin corresponds to at least atorvastatin 40 mg / day.

[0130] In some embodiments, the statin is monotherapy. In some embodiments, the subject also receives additional lipid-lowering therapy (thus, the subject can receive a statin, a PCSK9 antibody and a third treatment). In some embodiments, the additional lipid-lowering therapy is niacin, ezetimibe or both niacin and ezetimibe. This treatment is not only an option for the first therapy, but naturally also an embodiment for the lipid-lowering therapy and / or statin therapy provided herein. In some embodiments, the additional therapy can be an inhibitor of ASGR1, such as an antibody against ASGR1 or ASGR1 siRNA. In some embodiments, the additional therapy can be an inhibitor of LDLR, such as an antibody against LDLR or LDLR siRNA. In some embodiments, the additional therapy can be an inhibitor of Lp(a), such as an antibody against Lp(a) or Lp(a) siRNA. In some embodiments, the additional therapy is an Lp(a) antagonist (e.g., a peptide, mAb and / or siRNA), an antibody or inhibitor of ANGPTL4 and / or ANGPTL3, PNPL RNA), an antibody or inhibitor of ANGPTL4 and / or ANGPTL3, PNPL ​ An inhibitor of A3 (e.g., siRNA), an inhibitor of ASGR1, an inhibitor of ASGR2 (si RNA), an inhibitor of ApoC3 (e.g., siRNA), a GLP-1 receptor agonist and / or one or more of a GIPR antagonist.

[0131] In some embodiments, a non-PCSK9 LDL-C lowering therapy (which can be statin treatment ) can be administered at any level sufficient to lower cholesterol in the blood. In some embodiments, a non-PCSK9 LDL-C lowering therapy (which can be statin treatment and / or LLT) is administered in an amount and for a time to achieve a reduction in the maximum level of LDL in the blood. In some embodiments, any one or more of the above statins are administered daily.

[0132] In some embodiments, a second therapy, a PCSK9 LDL-C lowering agent, a PCSK 9 inhibitor, a non-statin LDL-C lowering agent can be a treatment that reduces LDL-C levels by PCSK9. This can also be described as including a PCSK9 inhibitor. Such PCSK9 inhibitors can include the antibody evolocumab (CAS registration number 1256937-27 -5; WHO number 9643, IND number 105188) (REPATHA (registered trademark)) , alirocumab (PRALUENT (registered trademark)), bococizumab, REGN728, R G7652, LY3015014, LGT209, 1D05 (U.S. Patent No. 8,188,2 34), 1B20 (U.S. Patent No. 8,188,233). In some embodiments, the antibody is a neutralizing antibody. In some embodiments, the anti-PCSK 9 The neutralizing antibody is evolocumab. In some embodiments, the inhibitor is one or more (including all six) of the CDRs from the antibody constructs shown in FIGS. 6-12 and is an anti-PCSK9 antibody. In some embodiments, the PCSK9 inhibitor is an anti-PCSK9 antibody comprising one or more of the amino acid heavy and / or light chains shown in FIGS. 6-12 . In some embodiments, an antibody comprising any one or more of the CDRs of the antibodies described herein can be used . In some embodiments, an antibody comprising the variable regions of the heavy and light chains of the antibodies described herein can be used. In some embodiments, the antibody is at least 95, 96, 97, 98, 99% identical to the antibodies described herein in the amino acid sequence. In some embodiments, the anti-PCSK9 antibody is the antibody described in U.S. Patent No. 8,062,640 (e.g., HCVR / LCVR = SEQ ID NO: 90 / 92), the antibody described in U.S. Patent No. 8,501,184 (e.g., REGN728, HCVR / LCVR = SEQ ID NO: 218 / 226), the antibody described in U.S. Patent No. 8,080,243 (e.g., bococizumab, HCVR / LCVR = SEQ ID NO: 54 / 53), the antibody described in U.S. Patent No. 8,188,234 (e.g., 1D05, HCVR / LCVR = SEQ ID NO: 11 / 27), the antibody described in U.S. Patent No. 8,188,233 (e.g., 1B20, HCVR / LCVR = SEQ ID NO: 11 / 27), the antibody described in U.S. Patent No. 8,710,192 , the antibodies described in U.S. Patent Application Publication No. 2011 / 0142849 and U.S. Patent Application Publication No. 2 013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, and the antibodies described in U.S. Patent No. 8,710,192, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, such as the antibody described in U.S. Patent No. 8,188,234 (e.g., 1D05, HCVR / LCVR = SEQ ID NO: 11 / 27), the antibody described in U.S. Patent No. 8,188,233 (e.g., 1B20, HCVR / LCVR = SEQ ID NO: 11 / 27), the antibody described in U.S. Patent No. 8,710,192, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, and the antibodies described in U.S. Patent No. 8,710,192, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, 0, HCVR / LCVR = SEQ ID NO: 11 / 27), the antibody described in U.S. Patent No. 8,710,192, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, specification, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, and the antibodies described in U.S. Patent No. 8,710,192, U.S. Patent Application Publication No. 2011 / 0142849, and U.S. Patent Application Publication No. 2013 / 0315927, antibody LGT209, and the antibody RG7652 described in U.S. Patent Application Publication No. 2012 / 0195910, U.S. Patent No. 8,530, 0, and the antibody described in U.S. Patent Application Publication No. 2012 / 0195910, RG7652 The antibody LY3015014 described in the specification No. 414 (HCVR / LCVR = SEQ ID NO: 7 / 8 ) is selected from. In some embodiments, the PCSK9 inhibitor includes ALN-PCSs The specific double-stranded sequence of c (U.S. Patent No. 7,605,251, U.S. Patent No. 8,809 ,292, U.S. Patent No. 9,260,718 and U.S. Patent No. 8,273 ,869). Specifically, including the disclosure of the specifically mentioned PCSK9 inhibitors , the entirety of each of these is incorporated herein by reference. Such PCSK9 inhibition Drugs may also include RNAi therapies such as siRNA and ALN-PCSsc. Other lipids PCSK9 lipid-lowering agents capable of lowering (excluding LDL-C) are also considered herein . Of course, the above-mentioned "second therapy", "PCSK9 LDL-C lowering agent ", "PCSK9 inhibitor" and / or "non-statin LDL-C lowering agent" can lower LDL- C and other lipids as well. Generally, PCSK9 lipid-lowering agents capable of lowering lipids are further considered. All of the embodiments provided in this paragraph can be used in one or more of the combination therapies provided herein. Furthermore, in the embodiments provided herein that do not require a combination of therapies (for example, embodiments that provide a particularly large reduction in LDL- C or non-HDL-c with a single agent), this treatment method can also be used in the same way in these embodiments (even when there is no "second therapy" in relation thereto). When the amount of non-PCSK9 LDL-C lowering therapy administered is combined with the PCSK9 inhibitor therapy over a sufficient period , it should be only enough to fully achieve the desired result .

[0133] ​​​ It is possible.

[0134] In some embodiments, at least 50, 60, 70, 75, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 310, 320, 330, 340, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450 mg of a PCSK9 inhibitor (e.g., a neutralizing antibody) is administered to the subject. In some embodiments, evolocumab is at least 140 mg , for example at least 150 mg, 300 mg, 400 mg or at least 420 mg of amount is administered. In some embodiments, the anti-PCSK9 neutralizing antibody is at least 140 mg, for example at least 150 mg, 300 mg, 400 mg or at least 420 m g of amount is administered.

[0135] In some embodiments, the PCSK9 inhibitor (e.g., a neutralizing antibody, e.g., evolocumab ) is administered at a frequency of at least once a week, at least once a month, at least once every two weeks, once every three months or at least once a week.

[0136] In some embodiments, the non-PCSK9 LDL-C lowering therapy and / or the PCS K9 inhibitor therapy can be administered as is normally administered for LDL-C lowering. In some embodiments, this is done up to the maximum tolerated dose of the subject. In certain embodiments the routes of administration of the two components in combination therapy are known methods, e.g., orally, intravenously, abdominally inally, intracerebrally (intraparenchymally), intraventricularly, intramuscularly, subcutaneously, intraocularly, intraarterially, intraportally or intralesionally By injection via a route, by a sustained release system, or by an implant device.

[0137] In some embodiments, a PCSK9 inhibitor (e.g., a neutralizing antibody, e.g., evolocumab ) is administered to a subject at least once a month for at least one year. In some embodiments, it is administered for at least 0.5, 12, 18, 24, 30, 36, 42, 48 , 54, 60 months or more.

[0138] In some embodiments, the LDL-C level of a subject receiving combination therapy is at least 40%, e.g., 40, 45, 50, 55, 60, 65, 70, 75, 80, 85% or more decreases.

[0139] In some embodiments, a subject is treated with a stable non-PCSK9 LDL- C lowering agent (e.g., a statin) dose for at least 4 weeks and has an LDL- C of ≧80 mg / dL or 60 - 80 mg / dL and has one major and / or three minor cardiovascular risk factors. The major risk factors can be at least one of non-coronary atherosclerotic vascular disease, myocardial infarction or hospitalization for unstable angina in the past two years or type 2 diabetes . The minor risk factors can be at least one of current smoking, hypertension, low levels of high density lipoprotein cholesterol (HDL-C), family history of premature coronary heart disease, or high sensitivity C-reactive protein (hs-CRP) ≧2 mg / L, or at least one of male ≧50 years old and female ≧55 years old.

[0140] In some embodiments, providing regression of coronary atherosclerotic disease is PAV and / or a decrease in TAV. In some embodiments, the decrease in PAV is at least 0.1%, e.g., 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0 .7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7 , 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4 or a 2.5% decrease in PAV is achieved. In some embodiments, the decrease in TAV is at least 0.1%, e.g., 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1 , 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2 .1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3, 3.1 , 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4, 4.1, 4 .2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5, 5.1, 5.2 , 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6, 6.1, 6.2, 6 .3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7, 7.1, 7.2, 7.3 , 7.4, 7.5, 7.6, 7.7, 7.8, 7.9, 8, 8.1, 8.2, 8.3, 8 .4, 8.5, 8.6, 8.7, 8.8, 8.9, 9, 9.1, 9.2, 9.3, 9.4 , 9.5, 9.6, 9.7, 9.8, 9.9, a 10% decrease in TAV is achieved. In some embodiments, the combination therapy is for the subject's atherosclerotic disease, coronary artery atherosclerotic

[0141] sclerosis, atherosclerotic cardiovascular disease, ischemic heart disease (CAD), cardiovascular event , non-fatal myocardial infarction coronary artery revascularization, PAD and / or the risk of cerebrovascular disease . Provide a reduction. In some embodiments, in some embodiments, the combination therapy is optional death from any cause, CHD death, cardiovascular death, angina, myocardial infarction (MI), stroke, fatal and non-fatal fatal stroke arterial revascularization, coronary revascularization, hospitalization for CHF and / or or provide a reduction in the risk of one or more occurrences of unstable angina.

[0142] In some embodiments, the combination therapy reduces the LDL-C level in the subject to 80 mg / d L or less, for example 70, 60, 50, 40, 30, 20 mg / dL or less. Provide.

[0143] In some embodiments, any of the above embodiments regarding atherosclerosis (or other embodiments provided in this specification) can be applied to improve the cardiovascular events of patients with atherosclerotic cardiovascular disease. Such embodiments can be such that the subject can receive two therapies (one of which is, for example, a non-PCSK9 inhibitor such as a statin, and the other is, for example, a PCSK9 inhibitor such as evolocumab), and similar therapies (for example, combination therapies) can be used. Non-PCSK9 LDL-C lowering therapy reduces the LDL-C level.

[0144] In some embodiments, the cardiovascular method can include inhibition of PCSK9 by evolocumab in a subject receiving statin therapy. As a result, LDL cholesterol can be reduced to 30 mg / dL and the risk of cardiovascular events can be reduced. In some embodiments, this is achieved without significant safety drawbacks.

[0145] ​In some embodiments, methods of treating atherosclerotic cardiovascular disease are provided and include a) identifying a subject who is receiving a first therapy comprising a non-PCSK9 LDL-C lowering therapy The method further includes b) administering a second therapy to the subject The second therapy includes PCSK9 inhibitor therapy. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subject. The first therapy is not the same as the second, and the risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c) cardiovascular death, or d ) fatal and / or non-fatal MI, or e) fatal and / or non-fatal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent and / or emergent coronary artery revascularization In some embodiments, methods of reducing the risk of cardiovascular events are provided. The method includes a) identifying a subject who is receiving a first therapy comprising non-PCSK9 LDL-C lowering therapy The method may further include b) administering a second therapy to the subject. The second therapy includes a PCSK9 inhibitor. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy. The risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c ardiovascular death, or d ) fatal and / or non-fatal MI, or e) fatal and / or non-fatal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent and / or emergent coronary artery revascularization In some embodiments, methods of reducing the risk of cardiovascular events are provided. The method includes a) identifying a subject who is receiving a first therapy comprising non-PCSK9 LDL-C lowering therapy The method may further include b) administering a second therapy to the subject. The second therapy includes a PCSK9 inhibitor. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy. The risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c

[0146] In some embodiments, methods of reducing the risk of cardiovascular events are provided. The method includes a) identifying a subject who is receiving a first therapy comprising non-PCSK9 LDL-C lowering therapy The method may further include b) administering a second therapy to the subject. The second therapy includes a PCSK9 inhibitor. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy. The risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c ardiovascular death, or d ) fatal and / or non-fatal MI, or e) fatal and / or non-fatal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent and / or emergent coronary artery revascularization The method may further include b) administering a second therapy to the subject. The second therapy includes a PCSK9 inhibitor. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy. The risk is a) a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, or c ardiovascular death, or d ) fatal and / or non-fatal MI, or e) fatal and / or non-fatal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent and / or emergent coronary artery revascularization or a stroke composite, or c) cardiovascular death, or d) lethal and / or non-lethal M I, or e) lethal and / or non-lethal stroke, or f) transient ischemic attack, or g) hospitalization for unstable angina, or h) elective, urgent, and / or emergent coronary revascularization.

[0147] In some embodiments, methods are provided for reducing the risk of emergency coronary revascularization . The method includes identifying a subject who is receiving a first therapy including a non-PCSK9 LDL-C lowering therapy . The method further includes administering a second therapy to the subject. The second therapy includes a PCSK9 inhibitor therapy. Both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subject . The first therapy is not the same as the second therapy.

[0148] In some embodiments, methods are provided for reducing the risk of cardiovascular events. The method includes a) identifying a subject having a cardiovascular disease, and b) administering to the subject a PCSK9 inhibitor for an amount and time sufficient to reduce at least one risk of cardiovascular death, non-fatal myocardial infarction , non-fatal stroke or transient ischemic attack (TIA), coronary revascularization, or hospitalization for unstable angina.

[0149] In some embodiments, methods are provided for reducing the risk of cardiovascular events. The method includes a) identifying a subject who is receiving a first therapy including a non-PCSK9 LDL-C lowering therapy, and b) administering to the subject a second therapy including a PCSK9 inhibitor. The first Both the first therapy and the second therapy are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy, and the risk is a composite of coronary revascularization, myocardial infarction, and cerebrovascular accident. The amount and time. The first therapy is not the same as the second therapy, and the risk Is a composite of coronary revascularization, myocardial infarction, and cerebrovascular accident.

[0150] In some embodiments, a method of reducing the risk of cardiovascular events is provided. This Method includes a) identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy, and b) administering to the subject a second therapy comprising a PCSK9 inhibitor. Both the first And the second therapy are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject, the first therapy is not the same as the second therapy, and the risk is A composite of fatal MI and / or non-fatal MI and fatal and / or non-fatal coronary artery Revascularization. Fatal MI and / or non-fatal MI and fatal and / or non-fatal coronary artery Revascularization.

[0151] In some embodiments, the risk is one or more of coronary revascularization, myocardial infarction, and cerebrovascular accident, a combination thereof, or a composite thereof. In some embodiments, the risk Is one or more of fatal MI and / or non-fatal MI and fatal and / or non-fatal coronary artery Revascularization, a combination thereof, or a composite thereof. Revascularization, a combination thereof, or a composite thereof.

[0152] In some embodiments, the combination therapy (or either of the monotherapy provided herein ) is for more than 6 months, such as 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 , 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 4 4, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57 , 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 8 Continued for 4 months or more and in response thereto, the risk of cardiovascular death, myocardial infarction, stroke, angina admission for stable angina or cardiovascular events such as coronary artery revascularization is at least 5 percent, 10 percent, 15 percent, 20 percent, 25 percent or more reduced. In some embodiments, the risk is of the composite of these disorders (in the first occurrence, combination of any one of these). In some embodiments , the risk is of the combination of these disorders. In some embodiments, the risk is of these individual disorders. In some embodiments , the risk is of cardiovascular death, myocardial infarction or stroke only (but as a composite) risk. In some embodiments, all of these composite risks are 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 , 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 4 9, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62 , 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84 months or more and at least 5, 10, 15, 20, 25% or more reduced. In some embodiments In that case, the reduction rate is a combination of these impairments (in the initial occurrence of any one of these, in combination). In some embodiments, the risk is the risk for a combination of these impairments. In some embodiments, the risk is the risk for each of these individual impairments. In some embodiments, the risk is the risk of only cardiovascular death, myocardial infarction or stroke (however, as a combination). In some embodiments, the risk decreases from about 16% during the first year of treatment to about 25% after the first year of treatment.

[0153] In some embodiments, the combination therapy (or any of the monotherapies provided herein) is continued for more than 6 months, such as 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 4 4, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 8 4 months or more, and upon receiving it, the risk of any cardiovascular event such as cardiovascular death, myocardial infarction or stroke is reduced by at least 5 percent, 10 percent, 15 percent, 20 percent, 25 percent or more. In some embodiments, the risk is a combination of these impairments (in the initial occurrence of any one of these, in combination). In some embodiments, the risk is a combination of these impairments. ​ risks for the thing. In some embodiments, the risks are risks for these individual impairments. In some embodiments, all of these combined risks are 6 , 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 3 4, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 , 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 7 4, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84 months or more, and are reduced by at least 5, 10, 15, 20, 25% or more. In some embodiments, the reduction rate is a combination of these impairments (in the occurrence of any one of these, in combination). In some embodiments, the risks are risks for the combination of these impairments. In some embodiments, the risks are risks for these individual impairments. In some embodiments, the risks decrease from about 16% during the first year of treatment to about 25% after the first year of treatment.

[0154] In some embodiments, any of the methods provided herein in connection with the reduction of risks can exclude the reduction of the risk of cardiovascular death over more than 12 months and up to 36 months, apart from myocardial infarction and stroke. In some embodiments, any of the methods provided herein in connection with the reduction of risks can reduce the risk of cardiovascular death over more than 12 months. can be excluded. In some embodiments, any of the methods provided herein in connection with risk reduction can include reducing the risk of cardiovascular death beyond 36 months.

[0155] In some embodiments, a combination therapy (or any of the monotherapies provided herein ) can result in a significant reduction in the risk of cardiovascular events, such as a 15 % reduction in the risk of the primary composite endpoint of cardiovascular death, myocardial infarction, stroke, hospitalization for angina pectoris, or coronary artery revascularization, either (a) individually or (b) as a composite (either one of them, but not in combination ), and a 20% reduction in the risk of clinically severe major secondary endpoints of cardiovascular death, myocardial infarction, or stroke, either (a) individually or (b) as a composite (either one of them but not in combination). In some embodiments, combination therapy can reduce the risk of myocardial infarction by 27%, stroke by 21%, and coronary artery revascularization by 22%. In some embodiments, the primary endpoint is the first occurrence of any of cardiovascular death, myocardial infarction , stroke, coronary artery revascularization, or hospitalization for unstable angina pectoris, and the composite over time up to that point (e.g., the first one of any of them, in combination ). Thus, in some embodiments, the method can reduce the risk (or increase the time until) the first occurrence of any of cardiovascular death, myocardial infarction , stroke, coronary artery revascularization, or hospitalization for unstable angina pectoris. In some embodiments , the method can result in a composite over time up to the first occurrence of any of cardiovascular death, myocardial infarction , stroke, coronary artery revascularization, or hospitalization for unstable angina pectoris (e.g., the first one of any of them, in combination ). In some embodiments, the method reduces the risk (or increases the time until) the first occurrence of any of cardiovascular death, myocardial infarction , stroke, coronary artery revascularization, or hospitalization for unstable angina pectoris. In some embodiments , the method can result in a composite over time up to the first occurrence of any of cardiovascular death, myocardial infarction ​Reduce one first thing, in combination).

[0156] In some embodiments, the method reduces the risk (or increases the time until) of any of cardiovascular death, myocardial infarction, or stroke occurring first. In some embodiments, the method reduces the composite of the time until (e.g., one first thing, in combination) any of cardiovascular death, myocardial infarction, or stroke occurs first. In some embodiments, the method reduces the composite of the time until any of cardiovascular death, myocardial infarction, or stroke occurs first. In some embodiments, the method reduces the composite of the time until (e.g., one first thing, in combination) any of cardiovascular death, myocardial infarction, or stroke occurs first. Reduce one first thing, in combination).

[0157] In some embodiments, the methods provided herein reduce LDL cholesterol by a significant amount. In some embodiments, the reduction is at least 50%, e.g., 59%, from a median of 92 - 30 mg / dL (2.4 - 0 .8 mmol / L). This effect can persist over 3 years without attenuation. Reduce one first thing, in combination).

[0158] In some embodiments, subjects seeking improvement in cardiovascular outcomes are those who (1) receive a statin having an efficacy equivalent to atorvastatin 20 mg / day or more (see, e.g., Table 17.4), and (2) have an LDL-C ≥ 70 mg / dl or a non-HDL-C ≥ 100 mg / dl in their regimen. In some embodiments, the subjects being treated have a non-HDL-c level at least as high as the corresponding LDL-C level See, e.g., Table 17.4), and (2) have an LDL-C ≥ 70 mg / dl or a non-HDL-C ≥ 100 mg / dl in their regimen. In some embodiments, the subjects being treated have a non-HDL-c level at least as high as the corresponding LDL-C level In some embodiments, this means the LDL-C level provided herein, + 30 mg / dLl (as a conversion count from non-HDL-c to LDL-c). Non HDL-C indicates its technically recognized meaning, cholesterol minus HDL-C HDL-C indicates its technically recognized meaning, cholesterol minus HDL-C It shows LDL-C, VLDL-C (determined approximately as tg / 5) and As shown in Figure 55, the reduction in non-HDL-C to approximately 30 mg / dL , reducing the event rate and therefore the risk of a subject having a widespread event As shown in Figure 55, at such very low levels (e.g., 50, 40, 30, 20 By lowering non-HDL-C to levels below 100 mg / kg / day, the target , low event rates for stroke, revascularization and hospitalization for unstable angina ("HUA"); The primary and secondary endpoints were as defined by FOURIER. The required endpoints were cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery disease. The secondary endpoint was a composite of CV death, MI, or stroke. Subjects at risk for any of the conditions shown in Figure 55 (or their subpoints) should be considered for this study. The method provided herein can be used to benefit from the LCL-C level of interest. Any of the conditions described herein that would benefit from lowering non-HDL-C Their progression can be tracked by monitoring the levels of each LD LC lowering methods can also (or instead) focus on lowering non-HDL-C Those skilled in the art will appreciate that since LDL-C is a component of non-HDL-C, will understand the overlap between roaches.

[0159] In some embodiments, the subject has clinically evident atherosclerotic cardiovascular disease. In some embodiments, this is a history of myocardial infarction, a history of non-hemorrhagic stroke. History or symptomatic peripheral arterial disease and further characteristics that place them at higher cardiovascular risk ( For example, it is defined as (as outlined in the supplementary section of Example 17). In some embodiments, the subject is on an optimized stable lipid-lowering therapy, preferably a high-intensity statin, and has fasting LDL cholesterol ≥ 70 mg / dL or non-HDL cholesterol ≥ 1 00 mg / dL, and must be on at least atorvastatin 20 mg / day or equivalent, regardless of the presence or absence of ezetimibe. In some embodiments, such subjects can receive combination therapy after identification and achieve good cardiovascular

[0160] outcomes. In some embodiments, the method reduces the risk or occurrence of a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization (e.g., the first of any one of them, in combination). In some embodiments, the risk is significantly reduced when P < 0.05. In some embodiments, the risk of recurrence of a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization (e.g., the first of any one

[0161] of them, in combination) is reduced. In some embodiments, the method reduces the risk or occurrence of a composite of cardiovascular death, myocardial infarction, or stroke (e.g., the first of any one of them, in combination). "Composite" means the first occurrence of the items listed in the event group (e.g., the time until occurrence). "Composite risk" or other similar terms indicate the risk until the first time point of the events in the list. Thus, the composite risk of cardiovascular death, myocardial infarction, or stroke describes the risk of In some embodiments, the combined risk of cardiovascular death, myocardial infarction, hospitalization for unstable angina, stroke or coronary revascularization is reduced. In some embodiments, the combined risk of cardiovascular death, myocardial infarction or stroke is reduced. As used herein, the term "combined" governs how the meaning of a list of items should be interpreted.

[0162] In some embodiments, the combination of a non-PCSK9 inhibitor and a PCSK9 inhibitor significantly reduces the rate of death, myocardial infarction, stroke, coronary revascularization or hospitalization for unstable angina: In some embodiments, the reduction rate is the combination of these disorders (the first occurrence of any one of these, in combination). In some embodiments the magnitude of the risk reduction can further increase over time, for example, from 12% (95% CI 3 - 20) in the first year to 19% (95% CI 11 - 27) after the second year. Similarly, for the secondary endpoints described herein with respect to the FOURIER results, the risk reduction went from 16% (95% CI 4 - 26) in the first year to 25% (95% CI 15 - 34) after the second year (see Figure 20 and the supplementary results of Example 17). In some embodiments, the combination therapy allows for a hazard ratio of 0.84 (95% CI, 0.74 - 0.96) in the first year in which the risk of cardiovascular death, myocardial infarction or stroke (as a combination) is reduced. In some embodiments, the combination therapy allows for a hazard ratio of 0.75 (95% CI, 0.66 - 0.85) after the first year in which the risk of cardiovascular death, myocardial infarction or stroke (as a combination) is reduced. In some embodiments, the combination therapy allows for a hazard ratio of 0.75 (95% CI, 0.66 - 0.85) after the first year in which the risk of cardiovascular death, myocardial infarction or stroke (as a combination) is reduced. In some embodiments, the combination therapy allows for a hazard ratio of 0.75 (95% CI, 0.66 - 0.85) after the first year in which the risk of cardiovascular death, myocardial infarction or stroke (as a combination) is reduced. In some embodiments, the combination therapy allows for a hazard ratio of 0.75 (95% CI, 0.66 - 0.85) after the first year in which the risk of cardiovascular death, myocardial infarction or stroke (as a combination) is reduced. In some embodiments, the combination therapy allows for a hazard ratio of 0.75 (95% The therapy enables a hazard ratio of 0.88 (95% CI, 0.80 - 0.97) in the first year with reduced risk for cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, stroke or coronary artery (as a composite) revascularization. In some embodiments, the combination therapy enables a hazard ratio of 0.81 (95% CI, 0.73 - 0.89) after the first year with reduced risk for cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, stroke or coronary artery (as a composite) revascularization. In some embodiments, the combination therapy enables a hazard ratio as shown in Table 17.2b, following the combination treatment method outlined herein. (95% CI, 0.73~0.89) for the first year after the first year with reduced risk for cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, stroke or coronary artery

[0163] In some embodiments, the combination therapy enables a hazard ratio of 0.96 (0.74 - 1.25) for cardiovascular death in the first year, following the combination treatment method outlined herein. In some embodiments, the combination therapy enables a hazard ratio of 0.80 (0.68 - 0.94) for myocardial infarction in the first year. In some embodiments, the combination therapy

[0164]

Table 1

[0165] In some embodiments, the combination therapy enables a hazard ratio of 0.96 (0.74 - 1.25) for cardiovascular death in the first year. (0.74~1.25).

[0166] In some embodiments, the combination therapy enables a hazard ratio of 0.80 (0.68 - 0.94) for myocardial infarction in the first year. In some embodiments, the combination therapy (0.68~0.94). In some embodiments, the combination therapy enables a hazard ratio of 0.65 (0.55 - 0.77) for myocardial infarction after the first year. (0.55~0.77) for myocardial infarction after the first year.

[0167] In some embodiments, the combination therapy enables a hazard ratio of 0.97 (0.77 - 1.22) for hospitalization for unstable angina in the first year. In some embodiments (0.77~1.22). In some embodiments In the state, the combination therapy enables a hazard ratio of 0.9 9 (0.75 - 1.30) for hospitalization due to unstable angina after the first year.

[0168] In some embodiments, the combination therapy enables a hazard ratio of 0.83 ( 0.63 - 1.08) for stroke in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0.76 (0.60 - 0.97) for stroke after the first year.

[0169] In some embodiments, the combination therapy enables a hazard ratio of 0.84 (0.74 - 0.96) for coronary artery revascularization in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0.72 (0.63 - 0 .82) for coronary artery revascularization after the first year.

[0170] In some embodiments, the combination therapy enables a hazard ratio of 0.84 (0.71 - 1.00) for urgent coronary artery revascularization in the first year. In some embodiments the combination therapy enables a hazard ratio of 0.63 (0.52 - 0.75) for coronary artery revascularization after the first year.

[0171] In some embodiments, the combination therapy enables a hazard ratio of 0.86 (0.72 - 1.03) for elective coronary artery revascularization in the first year. In some embodiments the combination therapy enables a hazard ratio of 0.81 ( 0.68 - 0.97) for elective coronary artery revascularization after the first year.

[0172] In some embodiments, the combination therapy enables a hazard ratio of 0.87 (0.79 - 0.97) for the CTTC composite endpoint in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0. 78 (0.71 - 0.86) for the CTTC composite endpoint in the second year.

[0173] In some embodiments, the combination therapy enables a hazard ratio of 0.86 (0.76 - 0.97) for coronary heart death, MI, ischemic stroke during or urgent revascularization as a composite in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0.76 (0.68 - 0.86) for coronary heart death, MI, ischemic stroke or urgent revascularization as a composite in the second year.

[0174] In some embodiments, the combination therapy enables a hazard ratio of 0.84 (0.73 - 0.95) for coronary heart death, MI or stroke (as a composite) in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0.73 (0.65 - 0.83) for coronary heart death, MI or stroke (as a composite) in the second year.

[0175] In some embodiments, the combination therapy enables a hazard ratio of 0.81 (0.70 - 0.93) for lethal or non - lethal MI or stroke (as a composite) in the first year. In some embodiments, the combination therapy enables a hazard ratio of 0.67 (0.59 - 0.77) for lethal or non - lethal MI or stroke (as a composite) in the second year.

[0176] ​​​​​​ In some embodiments, "reducing the risk" means either a) increasing the amount of time to any one of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization (either as a composite, individually, or in combination), or b) at least one of increasing the amount of time to any one of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination). In some embodiments, the risk reduction can be achieved over a treatment period, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months or more (either as a composite, individually, or in combination). In some embodiments, the method can reduce the risk of the primary secondary endpoint by 17% in patients whose median LDL cholesterol starts at 126 mg / dL and then decreases to 43 mg / dL by evolocumab, and can reduce the risk by 22% in patients whose median LDL cholesterol starts at 73 mg / dL and then decreases to 22 mg / dL by evolocumab. In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. In some embodiments, the risk of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination) in subjects with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%. In some embodiments, the subject's LDL cholesterol In some embodiments, "reducing the risk" means either a) increasing the amount of time to any one of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization (either as a composite, individually, or in combination), or b) at least one of increasing the amount of time to any one of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination). In some embodiments, the risk reduction can be achieved over a treatment period, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months or more (either as a composite, individually, or in combination). In some embodiments, the method can reduce the risk of the primary secondary endpoint by 17% in patients whose median LDL cholesterol starts at 126 mg / dL and then decreases to 43 mg / dL by evolocumab, and can reduce the risk by 22% in patients whose median LDL cholesterol starts at 73 mg / dL and then decreases to 22 mg / dL by evolocumab. In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. In some embodiments, the risk of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination) in subjects with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%. In some embodiments, the subject's LDL cholesterol

[0177] In some embodiments, the method can reduce the risk of the primary secondary endpoint by 17% in patients whose median LDL cholesterol starts at 126 mg / dL and then decreases to 43 mg / dL by evolocumab, and can reduce the risk by 22% in patients whose median LDL cholesterol starts at 73 mg / dL and then decreases to 22 mg / dL by evolocumab. In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. In some embodiments, the risk of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination) in subjects with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%. In some embodiments, the subject's LDL cholesterol In some embodiments, the method can reduce the risk of the primary secondary endpoint by 17% in patients whose median LDL cholesterol starts at 126 mg / dL and then decreases to 43 mg / dL by evolocumab, and can reduce the risk by 22% in patients whose median LDL cholesterol starts at 73 mg / dL and then decreases to 22 mg / dL by evolocumab. In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%.

[0178] In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. In some embodiments, the risk of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination) in subjects with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%. In some embodiments, the subject's LDL cholesterol

[0179] In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. In some embodiments, the risk of cardiovascular death, myocardial infarction, or stroke (either as a composite, individually, or in combination) in subjects with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%. In some embodiments, the subject's LDL cholesterol In some embodiments, the risk of myocardial infarction, stroke, and coronary artery revascularization (either as a composite, individually, or in combination) is reduced by 21% - 27%. The final median roll level was 43 mg / dL.

[0180] In some embodiments, the initial median LDL cholesterol is 73 mg / dL. The risk of cardiovascular death, myocardial infarction, or stroke in subjects (composite, individually, or in combination) In some embodiments, the subject's LDL cholesterol (combined) is reduced by 22%. The final median serum serum level was 22 mg / dL.

[0181] In some embodiments, the method comprises treating atherosclerotic cardiovascular disease (ASCVD). Reduce the composite of myocardial infarction, stroke, or cardiovascular death in patients with established disease. In some embodiments, the method includes administering to a patient having ASCVD who is receiving standard of care (e.g., statin therapy). Administering evolocumab to subjects receiving a combination therapy In some embodiments, the result is a reduction in myocardial infarction, ischemic stroke, and In some embodiments, the risk of cardiovascular events, including cardiovascular death, is reduced. , the quality-adjusted life years (QALYs) of the subject are increased. The quality of life (QALY) is a common measure of disease burden that includes both the quality and quantity of life lived. .

[0182] In some embodiments, the lifetime cardiovascular event rate is 1 to 4 years with standard background therapy. 00 patients, but with the addition of evolocumab (in combination therapy) In some embodiments, standard basal therapy may be combined with Evolocumab to reduce the blood glucose level to about 135. When used in combination with antibody therapy such as rivaroxaban (for combination therapy), the lifetime cardiovascular event rate is 100%. It can be about 140 - 130 - 120 per human patient. In some embodiments, the treatment is administered to patients with low - density lipoprotein (LDL) cholesterol ≥ 80 mg / dL . In some embodiments, the 2 - year risk of a first event (non - fatal myocardial infarction, non - fatal stroke or cardiovascular death) is ≤ 13.9% in subjects receiving the antibody and standard background therapy (e.g., receiving combination therapy), e.g., 13.9 - 7, 13 - 7, 12 - 7 , 11 - 7, 10 - 7, 9 - 7, 8 - 7.4%.

[0183] In some embodiments, the respective risk reduction for individual non - fatal myocardial infarction, non - fatal ischemic stroke and coronary artery revascularization can be 21%, 26% and 1 6% in the first year of combination therapy and can be 36%, 25% and 28% beyond the first year of combination therapy.

[0184] In some embodiments, the lifetime QALY can be 7.23 with standard background therapy, can increase to 7.62 with evolocumab (in combination therapy), and the difference in health impact is 0.39 QA LY. In some embodiments, the increase due to the administration of evolocumab (in combination therapy) can be at least 0.1, 0.2, 0.3, 0.4, 0.5, 0.6 QALY. In some embodiments, with the administration of evolocumab, the QALY itself exceeds 7.23, e.g., 7.23, 7.25, 7.3, 7.35, 7.4, 7.45, 7.5, 7.55, 7. 6, 7.7, 7.8 or can exceed it.

[0185] In some embodiments, even in the absence of a direct survival benefit, the method can reduce subsequent event rates, health - state utility (quality of life - years) and cardiovascular disease events as well as non - fatal events Provide a reduction in treatment costs by reducing

[0186] In some embodiments, when evolocumab is added to standard background therapy, including high-intensity or moderate-intensity statins, in patients with established atherosclerotic cardiovascular disease (ASCVD), the relative risk of the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization is reduced by 15% over a median follow-up period of 2.2 years. In some embodiments,

[0187] the risk of the composite of cardiovascular death, myocardial infarction, or stroke may be reduced by 20%. In some embodiments,

[0188] a greater clinical benefit may be observed after the first year of treatment with evolocumab. In some embodiments, the patient has been determined to have ASCVD. Additionally, the patient will benefit from further reduction in LDL cholesterol by other currently available lipid modifying therapies, such as maximally tolerated statins. Such

[0189] patients may receive evolocumab, which can promote improvement - Outline the -spline characteristics. In some embodiments, one or more of the following items may be used to assist in identifying subjects at high risk of atherosclerotic cardiovascular disease.

[0190]

Table 2

[0191] In some embodiments, the combination therapy enables an improvement (decrease) in the population event rate per 100 patients, as outlined in the table below (standard basal therapy vs. evolocumab + standard basal therapy).

[0192]

Table 3

[0193] In some embodiments, a method of reducing the risk of emergency coronary revascularization includes a) identifying subjects who have received a first therapy including a non-PCSK9 LDL-C lowering therapy, and b) administering a second therapy including a PCSK9 inhibitor to the subjects. Both the first and second therapies are administered to the subjects in amounts and for times sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subjects, and the first therapy is not the same as the second therapy. In some embodiments, except for myocardial infarction and stroke, over a period of 12 months or more and 36 months or less, the risk is not cardiovascular death.

[0194] In some embodiments, a method of reducing the risk of cardiovascular events is provided. This method includes a) identifying subjects having cardiovascular disease, and b) cardiovascular death, non-fatal myocardial infarction Occlusion, non-fatal stroke or transient ischemic attack (TIA), coronary artery revascularization or unstable Administering a PCSK9 inhibitor to a subject in an amount and for a time sufficient to reduce at least one risk of hospitalization for angina pectoris. In some embodiments, a subject having a cardiovascular disease is receiving non-PCSK9 LDL-C lowering therapy, and the non-PCSK9 LDL-C lowering therapy is not the same therapy as the PCSK9 inhibitor. The non-PCSK9 LDL- C lowering therapy and the PCSK9 inhibitor are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. In some embodiments, the non-PCSK9 L DL-C lowering therapy includes a statin. In some embodiments, myocardial infarction and stroke excepted, the risk is not cardiovascular death over 12 months or more and 36 months or less.

[0195] In some embodiments, a method of reducing LDL-C levels in a subject is provided The method includes a) administering a first therapy including non-PCSK9 LDL-C lowering therapy to the subject and b) administering a second therapy including a PCSK9 inhibitor to the subject. Both the first and second therapies are administered to the subject for at least 5 years, and the first therapy is not the same as the second therapy. In some embodiments, the LDL-C level of the subject is maintained at 50 mg / dL.

[0196] In some embodiments, a method of reducing the risk of cardiovascular events is provided. This method includes a) identifying a subject who is receiving a first therapy including non-PCSK9 LDL-C lowering treatment and b) administering a second therapy to the subject. The second therapy is PCSK ​It includes a 9-inhibitor. Both the first and second therapies are administered to the patient in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject. The first therapy is not the same as the second therapy. The risk is at least one of myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization.

[0197] In some embodiments, the subject receiving combination therapy to improve cardiovascular outcomes has at least one major risk factor or at least two minor risk factors. Major risk factors: ○ Diabetes (type 1 or type 2) ○ Age ≥ 65 years at randomization (and ≥ 85 years at consent) ○ MI or non-hemorrhagic stroke within 6 months after screening ○ Additional diagnosis of MI or non-hemorrhagic stroke (excluding qualifying MI or non-hemorrhagic stroke) a ○ Current daily smoking ○ Symptomatic PAD (intermittent claudication with ABI < 0.85, or peripheral artery revascularization, or amputation due to atherosclerotic disease) if qualified by a history of MI or stroke ) Minor risk factors: ○ History of non-MI-related coronary artery revascularization a ○ Residual coronary artery disease with 40% stenosis in 2 major blood vessels ○ Latest HDL-C by central laboratory before randomization < 40 mg / dL (1.0 mmol / L) in men and < 50 mg / dL (1.3 mmol / L) in women ○ Latest hsCRP by central laboratory before randomization > 2.0 mg / L ○ Latest LDL-C by central laboratory before randomization ≥ 130 mg / dL (3.4 mmol / L) or non-HDL-C 160 mg / dL (4.1 mmol / L) ​​​​​​​ ○Metabolic syndrome b

[0198] In some embodiments, the subject receiving combination therapy to improve a cardiovascular event has a current fasting LDL-C of 7 0 mg / dL (1.8 mmol / L) or a non-HDL-C of 100 mg / dL (≥2. 6 mmol / L) after two weeks of stable lipid-lowering therapy according to the considerations of Example 17, and / or a current fasting triglyceride of 400 mg / dL (4.5 mmol / L) by the central laboratory before randomization.

[0199] Erased arterial disease In some embodiments, one or more of the various treatment methods provided herein are used for a subject having peripheral artery disease (''PAD'') or at risk of developing peripheral artery disease (''PAD''). The application of combination therapy to such subjects is outlined in Example 18. As background, the presence of peripheral artery disease (PAD) is a marker of a malignant vascular phenotype with event rates exceeding those of other stable populations with atherosclerosis, particularly in the context of systemic atherosclerotic disease. (Suarez C, Zeymer U , Limbourg T, et al. Influence of polyvascu lar disease on cardiovascular event rate s. Insights from the REACH Registry. Vasc Med 2010;15(4):259-65. Criqui MH, Aboyans V. Epidemiology of peripheral artery dise , Limbourg T, et al. Influence of polyvascular disease on cardiovascular event rates. Insights from the REACH Registry. Vasc Med 2010;15(4):259-65. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res2015;116(9):1509-26. Bonaca M lar disease on cardiovascular event rate s. Insights from the REACH Registry. Vasc Med 2010;15(4):259-65. Criqui MH, Aboyans V. Epidemiology of peripheral artery dise ase. Circ Res2015;116(9):1509-26. Bonaca M P, Bhatt DL, Storey RF, et al. Ticagrelor fo r Prevention of Ischemic Events After My ocardial Infarction in Patients With Per ipheral Artery Disease. J Am Coll Cardiol 2016;67(23):2719 - 28.) Therefore, patients with symptomatic PAD have a high risk of major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death. (Aboyans V, Ricco JB, Bartelink MEL, e t al. 2017 ESC Guidelines on the Diagnosi s and Treatment of Peripheral Arterial D iseases, in collaboration with the Europe an Society for Vascular Surgery (ESVS): Do cument covering atherosclerotic disease of extracranial carotid and vertebral, me senteric, renal, upper and lower extremity arteries Endorsed by: the European Strok e Organization (ESO) The Task Force for th e Diagnosis and Treatment of Peripheral Arterial Diseases of the European Societ y of Cardiology (ESC) and of the European Society for Vascular Surgery(ESVS).Eur H eart J 2017;Gerhard-Herman MD,Gornik HL, Barrett C,et al.2016 AHA / ACC Guideline o n the Management of Patients With Lower Extremity Peripheral Artery Disease: A Re port of the American College of Cardiolo gy / American Heart Association Task Force on Clinical Practice Guidelines.Circula tion 2016.) In addition, PAD patients are more likely to suffer from acute limb ischemia, urgent peripheral revascularization, and Patients suffer significant morbidity from major adverse lower extremity events (MALE), including amputations and major amputations. (Kumbhani DJ,Steg PG,Cannon CP,et al.Sta tin therapy and long-term adverse limb o utcomes in patients with peripheral arte ry disease:insights from the REACH regis try.Eur Heart J 2014;35(41):2864-72;Jone s WS, Baumgartner I, Hiatt WR, et al. elor Compared With Clopidogrel in Patien ts with Prior Lower Extremity Revascular ization for Peripheral Artery Disease.Ci rculation 2016;Bonaca MP,Scirica BM,Crea ger MA,et al.Vorapaxar in patients with peripheral artery disease:results from T RA2{degrees}P-TIMI50.Circulation 2013;12 7(14):1522,9,1529e1-6。)

[0200] Lipid-lowering therapy has been correlated with a reduction in MACE in stable patients with coronary heart disease or atherosclerotic risk factors, but there have been few sufficiently powered prospective randomized trials specifically for lowering low-density lipoprotein cholesterol (LDL-C) in patients with PAD. (Aung PP, Maxwell HG, Je pson RG, Price JF, Leng GC. Lipid-lowering for peripheral arterial disease of the l ower limb. Cochrane Database Syst Rev 200 7;(4)(4):CD000123.) Furthermore, these trials have not specifically examined the ability of LDL-C lowering to reduce the risk of MALE, an important cause of morbidity in patients with PAD. (Kumbhani DJ, Steg PG, Cannon CP, et al for peripheral arterial disease of the l ower limb. Cochrane Database Syst Rev 200 7;(4)(4):CD000123.) Furthermore, these trials have not specifically examined the ability of LDL-C lowering to reduce the risk of MALE, an important cause of morbidity in patients with PAD. (Kumbhani DJ, Steg PG, Cannon CP, et al of morbidity in patients with PAD. (Kumbhani DJ, Steg PG, Cannon CP, et al .Statin therapy and long-term adverse li .Statin therapy and long-term adverse li mb outcomes in patients with peripheral artery disease:insights from the REACH r Registry. Eur Heart J 2014;35(41):2864 - 72; Aronow WS, Nayak D, Woodworth S, Ahn C. Effe ct of simvastatin versus placebo on trea dmill exercise time until the onset of i ntermittent claudication in older patien ts with peripheral arterial disease at s ix months and at one year after treatmen t. Am J Cardiol 2003;92(6):711 - 2; Mohler E R,3rd, Hiatt WR, Creager MA. Cholesterol re duction with atorvastatin improves walki ng distance in patients with peripheral arterial disease. Circulation 2003;108(12 ):1481 - 6; Spring S, Simon R, van der Loo B, et al. High - dose atorvastatin in peripher al arterial disease(PAD): effect on endot helial function, intima - media - thickness a nd local progression of PAD. An open rand omized controlled pilot trial. Thromb Hae Most 2008;99(1):182-9; Schanzer A, Hevelon e N, Owens CD, Beckman JA, Belkin M, Conte M e N, Owens CD, Beckman JA, Belkin M, Conte M S. Statins are independently associated w ith reduced mortality in patients underg oing infrainguinal bypass graft surgery for critical limb ischemia. J Vasc Surg 2 008;47(4):774-81. Finally, PAD is often used simply as a risk enhancer, so little is known about PAD patients without previous MI or stroke. (Bonaca MP, Scirica BM, Creager MA, et al. Vorapaxar in patients with peripheral artery disease: results from TRA2 {degrees}P-TIMI50. Circulation 2013;127(1 4):1522,9,1529e1-6. Aung PP, Maxwell HG, Je pson RG, Price JF, Leng GC. Lipid-lowering for peripheral arterial disease of the l ower limb. Cochrane Database Syst Rev 200 7;(4)(4):CD000123; Hiatt WR, Fowkes FG, Hei zer G, et al. Ticagrelor versus Clopidogre l in Symptomatic Peripheral Artery Disea se. 7;(4)(4):CD000123; Hiatt WR, Fowkes FG, Heizer G, et al. Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease se se.N Engl J Med 2016;Anand S.et al. COMPASS PAD - Cardiovascular OutcoMes for People using Anticoagulation StrategieS trial:Results in Patients with Periphera l Artery Disease.European Society of Car diology Hotline 2017。)

[0201] FOURIER is a very large - scale cardiovascular outcomes trial of the PCSK9 inhibitor evolocumab, enrolling patients with atherosclerotic disease in any of the coronary, cerebral, or peripheral arterial beds. Thus, FOURIER enabled testing of the following hypotheses: (1) Patients with PAD have a higher risk of MACE compared with patients with coronary artery disease or cerebrovascular disease without PAD; (2) A consistent relative risk reduction in MACE with evolocumab leads to a greater absolute risk reduction in patients with PAD compared with those without PAD;

[0202] and (3) A reduction in LDL - C with evolocumab results in a large decrease in MALE and benefits reaching very low levels of LDL - C. This is tested and its application confirmed in Example 18 below. The scu was significantly and potently reduced. Similarly, combination therapies such as the addition of evolocumab to statin reduced the risk of major adverse limb events, and the relationship between the achieved LDL-C and the reduction in the risk of limb events extended to very low achievement levels of LDL. These benefits are not associated with apparent safety concerns. Therefore, reducing LDL-C to very low levels

[0203] is useful for reducing the risk of MACE and MALE in patients with PAD, regardless of the presence or absence of a history of MI or stroke. In some embodiments, a method of treating a subject is provided. The

[0204] method includes identifying a subject having peripheral artery disease and reducing the level of PCSK9 activity in the subject. In some embodiments, a method of reducing the risk of adverse limb

[0205] events in a subject is provided, the method including reducing the level of PCSK9 activity in a subject having peripheral artery disease. In some embodiments, a method of reducing the risk of major adverse

[0206] cardiovascular events ("MACE") is provided. The method includes administering a non-statin LDL-C lowering agent to the subject and administering a statin to the subject, wherein the subject has PAD. In some embodiments, a method of reducing the risk of major adverse

[0207] In the foregoing embodiments related to PAD, MACE, MALE, or combinations thereof, the combination therapies and / or compositions provided herein can be used.

[0208] In the foregoing embodiments related to PAD, MACE, MALE, or combinations thereof, the following aspects (and suitable aspects provided elsewhere in this specification) are also contemplated.

[0209] In some embodiments, the subject is further administered a non-PCSK9 LDL-C lowering therapy . In some embodiments, the non-PCSK9 LDL-C lowering therapy includes a statin. In some embodiments, any of the non-PCSK9 LDL-C lowering therapies provided herein can be used. In some embodiments, the amount of the statin can be at least atorvastatin 20 mg / day or an equivalent amount, and can be increased to achieve a reduction in LDL-C according to regional guidelines. In some embodiments, the amount of the statin can be at least atorvastatin 40 mg / day or an equivalent amount greater than that. In some embodiments, the amount of the statin can be at least atorvastatin 40 mg / day or an equivalent amount greater than that. In some embodiments, the amount of the statin can be at least atorvastatin 40 mg / day or an equivalent amount greater than that. In some embodiments, the amount of the statin can be at least atorvastatin 40 mg / day or an equivalent amount greater than that.

[0210] In some embodiments, the adverse lower extremity events are selected from the group consisting of at least one of acute lower limb ischemia, major amputation, and urgent peripheral revascularization.

[0211] In some embodiments, the subject does not have a history of myocardial infarction or stroke. Nevertheless, the subject can still benefit from treatment. In some embodiments, the subject has a history of myocardial infarction and / or stroke and still benefits from treatment. In some embodiments, the subject does not have a prior MI or stroke. In some embodiments, the subject has a history of myocardial infarction and / or stroke and still benefits from treatment. In some embodiments, the subject does not have a prior MI or stroke. In some embodiments, the subject has a prior MI or stroke.

[0212] In some embodiments, if the subject has intermittent claudication and the ankle brachial index is <0. 85, or if the subject has a history of peripheral surgery (lower extremity revascularization or amputation), or if the subject has both, the subject is identified as being under treatment.

[0213] In some embodiments, the therapy reduces the composite risk of cardiovascular death, myocardial infarction, stroke, unstable angina for hospitalization or coronary artery revascularization.

[0214] In some embodiments, reduction of PCSK9 activity levels in the subject is achieved by an antibody against PCSK9. In some embodiments, any PCSK9 inhibitor or PCSK9 LDL-C lowering agent or lowering therapy can be used. In some embodiments, any PCSK9 inhibitor or PCSK9 LDL -C lowering agent or lowering therapy provided herein can be used. In some embodiments, the PCS K9 LDL-C lowering agent comprises an antibody. In some embodiments, the PCSK9 LDL -C lowering agent comprises evolocumab. In some embodiments, the amount of PCSK9 LDL-C lowering agent administered is as outlined herein. In some embodiments, the amount of P CSK9 LDL-C lowering agent, when used in combination with a non-PCSK9-LDL-C lowering agent, is an amount sufficient to lower the subject's LDL-C level to 70, 60, 50, 40, 30, 20 or 10 mg / dL or less. In some embodiments, the amount of evolocumab administered is 100 - 840 mg, such as 120 - 700 mg, 140 - 600 mg, 140 - 400 mg, 160 - 300 mg, or 180 - 240 mg. 400 mg, 160 - 300 mg, or 180 - 240 mg. at 500 mg, 140 - 420 mg, 210 - 630 mg, 140 mg, or 420 mg In some embodiments, the amount of evolocumab administered is 140 mg once every two weeks or 420 mg once a month. In some embodiments, combination therapy (provided in the present specification ) can be administered to a subject having an LDL-C level above 70 mg / dL such that the subject's L DL-C level is reduced to a very low level, such as 60 or less, such as 55, 50, 45, 40, 35, 30, 25, 20, 15, or 10 mg / dL or less (including the range between any two of the foregoing values ). This method can be applied to the symptoms and / or goals presented herein, such as, but not limited to, major vascular events, cardiovascular events , major adverse cardiovascular events, major adverse limb events, adverse limb events, PAD, fatal MI and / or non-fatal MI, fatal and / or non-fatal coronary revascularization, a) a composite of coronary revascularization, b) myocardial infarction, and c) cerebrovascular attack, a) cardiovascular death, b ) myocardial infarction, c) stroke, d) hospitalization for unstable angina, or e) a composite of coronary revascularization , a composite of emergency coronary revascularization, a) cardiovascular death, b) myocardial infarction, c) stroke, d) unstable angina hospitalization, or e) coronary revascularization, or at least one of cardiovascular events to reduce the risk of at least one of the above by at least 10%. This method can be used to treat atherosclerotic heart disease, treat coronary atherosclerosis , regress coronary atherosclerosis, treat subjects who cannot tolerate a sufficient therapeutic dose of statin , treat subjects who cannot tolerate a sufficient therapeutic dose of non-PCSK9 LDL-C ​Treating subjects who cannot tolerate a lowering agent, in combination with PCSK9 inhibitor therapy and non-PCSK 9 LDL-C lowering therapies, to produce a greater reduction in LDL-C and regression of coronary artery atherosclerosis at a well-tolerated dose, to suppress disease progression and to reduce the amount of atherosclerotic plaque in a subject, and in combination with evolocumab and statin therapy, to produce a greater reduction in LDL-C and regression of coronary artery atherosclerosis at a well-tolerated dose, to lower the LDL-C level in a subject to 80 mg / dL or less, to reduce the total atherosclerotic volume (TAV) in a subject, to reduce the atherosclerotic volume ratio (PAV) in a subject for reducing the LDL-C level and suppressing disease progression, or to be applicable to a combination of these. Accordingly, in some embodiments, for any of these applications, the combination therapy provided herein is used at a level effective to lower the LDL-C level of a subject having an LDL-C level of at least 70 mg / dL to a low level of 60, 55, 50, 45, 40, 35, 30, 25, 20, 15 or 10 or less to achieve one or more of these aspects. With respect to the combination therapies mentioned, this can be any of those described herein, for example a first therapy (e.g., a non-PCSK9 LDL-C lowering agent, a statin, an optimized amount of a statin) and a second therapy (e.g., a PCSK9 LDL-C lowering agent, a PCSK9 inhibitor, a non-statin LDL-C lowering agent, an anti-PCSK9 neutralizing antibody, evolocumab). In some embodiments, this therapy can be administered in an amount of at least 140 mg every two weeks or 420 mg once a month. In some embodiments ​​​​​​​ In embodiments, LDL-C levels are below 70 mg / dl (or other levels as provided herein). If the value exceeds 100%, instead of receiving combination therapy, the subjects will be selected based on alternative indicators such as non-HDL. Combination therapy is available. Surrogate indices are 100 (at 70 mg / dL) HDL) or higher.

[0215] In some embodiments, the reduced risk for a subject is greater than a subject without PAD. greater in subjects with PAD.

[0216] In some embodiments, the subject has PAD and after treatment, the subject is diagnosed with MACE, MAL E or MACE and MALE are reduced.

[0217] In some embodiments, the MALE is used in the treatment of acute limb ischemia (ALI), major amputation (above the knee (AK) A) or below the knee (BKA), excluding the front of the foot or toes), or emergency revascularization (blood In some embodiments, MA is a combination of MA and / or MA. CE is a composite of CV death, MI or stroke.

[0218] In some embodiments, the subject's LDL-C level is at least 50 mg / dL, e.g. For example, it may fall to below 50, 40, 30, 25, 20, 15, or 10 mg / dL. In some embodiments, the cardiovascular risk is at least 10%, for example at least also be reduced by 10, 15, 20, 25, 30, 35, 40, 45 or 50%.

[0219] In some embodiments, the MALE risk is at least 10% of the risk, e.g., at least At least 10, 15, 20, 25, 30, 35, 40, 45 or 50% reduction. In one embodiment, the MACE risk is reduced by at least 10% of the risk, such as at least 1 0, 15, 20, 25, 30, 35, 40, 45 or 50%. In some embodiments the risks of MALE and MACE are reduced by at least 5%, such as at least 5, 10, 15, 20, 25 or 30%.

[0220] In some embodiments, the subject to be treated is identified as having a risk of MACE, MALE or both MACE and MALE. In some embodiments, the subject to be treated has a risk of or actually has PAD.

[0221] In some embodiments, subjects with PAD are in the highest risk patient group and thus particularly benefit from one or more of the methods provided herein. That is, subjects with PAD are considered difficult to treat by other methods. Accordingly, the present method may be particularly advantageous over other less effective methods.

[0222] In some embodiments, the subject has PAD and / or one or more recent myocardial infarctions ( "MI").

[0223] As shown in Example 19, in some embodiments, the methods provided herein are more effective in subjects with fewer such risk factors. For example, in some embodiments, the subject to be treated has three or fewer such risk factors, such as two, one or zero of these risk factors. In some embodiments, the risk factors are at least one of a change in PAV, HbA1c and / or apolipoprotein A-I​​ Yes. In some embodiments, an undesirable systolic blood pressure can be a risk factor. In some embodiments, factors associated with a greater tendency towards ongoing plaque progression include the presence of additional atherogenic factors and thus, in some embodiments, the subject to be treated does not have an excessive number of additional atherogenic factors (e.g., three or less, two or less, one or less, or none at all). In some embodiments, any of the combination therapies provided herein can be used to assist a subject having a recent and / or multiple myocardial infarctions. In some embodiments, the MI is within 4 weeks or more. In some embodiments, the MI is 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 months or less. In some embodiments, the subject has had two or more MIs, such as 2, 3, 4 or more MIs. In some embodiments, the subject has multivessel disease. In some embodiments, the subject has one or more of 1) a recent MI (within 2 years), 2) multiple MIs (two or more) and / or some combination of multivessel disease. In some embodiments, a subject having one or more of these can then undergo treatment as described herein and thereafter the risk of CVD, MI, and / or stroke can be reduced. In some embodiments, this further screening or selection process can be used to identify subjects to receive one or more of the combination therapies provided herein, such as any of those described in the summary or claims. In some Reduced by at least 1%, such as 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 2 7, 28, 29, 30% or more. In some embodiments, a subject having recently or multiple MIs is administered (or continues to receive) a first therapy including a non-PCSK9 LDL-C lowering therapy, and a second therapy is also administered to the subject. The second therapy includes a P CSK9 inhibitor therapy. In some embodiments, both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary

[0224] atherosclerosis in the subject. As shown in the results of Example 20, in some embodiments, any of the methods provided herein can be selectively applied to a subject having an Lp(a) level greater than 11.8 mg / dL. In some embodiments, the subject has an Lp(a) level greater than 11.8 mg / dL and can thus receive a greater benefit with respect to plaque regression. In some embodiments, the subject has an Lp(a) level of at least (or between any of the following two values) 11.8, 12, 13, 14, 15, 16, 17, 18, 19, 20, 2 5, 30, 35, 40, 45 or 49 or 50 mg / dL. In some embodiments, the Lp(a) level is greater than 30 mg / dL. In some embodiments, this further screening or selection process is used to identify a subject who receives any one or more of the combination therapies provided herein, such as those described in the summary or claims. In some embodiments, the The method is such that after a subject is identified as having an Lp(a) level above 11.8 mg / dL (but optionally below 30 mg / dL), a first therapy comprising a non-PCSK9 LDL-C lowering therapy is provided (or continued to be provided) to the subject, and a second therapy is administered to the subject. The second therapy comprises a PCSK9 inhibitor therapy. In some embodiments, both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary atherosclerotic disease in the subject. In some embodiments, both the first and second therapies are administered to the subject in an amount and for a time sufficient to suppress plaque formation. In some embodiments, any of the configurations numbered below can be used. 1. A method of treating coronary atherosclerotic disease, comprising: a. Identifying a subject who is receiving a first therapy comprising a non-PCSK9 LDL-C lowering therapy,

[0225] and . b. Administering to the subject a second therapy comprising a PCSK9 inhibitor therapy, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary atherosclerotic disease in the subject, and the first therapy is not the same as the second therapy. 2. The first therapy is a statin, such as, but not limited to, atorvastatin (LIPITOR (registered trademark)), cerivastatin, fluvastatin (LESCOL), lovastatin (MEVACOR, ALTOPREV), mevastatin, pitavastatin, pravastatin (PRAVACHOL), rosuvastatin, rosuvastatin calcium (CRESTOR), and simvastatin (ZOCOR); ADVICOR (lovastatin + niacin); b. Administering to the subject a second therapy comprising a PCSK9 inhibitor therapy, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary atherosclerotic disease in the subject, and the first therapy is not the same as the second therapy. 3. The method according to item 1 or 2, wherein the second therapy is administered to the subject after the first therapy has been administered to the subject for at least 12 weeks. . 2. The first therapy is a statin, such as, but not limited to, atorvastatin (LIPITOR (registered trademark)), cerivastatin, fluvastatin (LESCOL), lovastatin (MEVACOR, ALTOPREV), mevastatin, pitavastatin, pravastatin (PRAVACHOL), rosuvastatin, rosuvastatin calcium (CRESTOR), and simvastatin (ZOCOR); ADVICOR (lovastatin + niacin); 3. The method according to item 1 or 2, wherein the second therapy is administered to the subject after the first therapy has been administered to the subject for at least 12 weeks. 4. The method according to any one of items 1 to 3, wherein the PCSK9 inhibitor therapy is administered by subcutaneous injection. 5. The method according to any one of items 1 to 4, wherein the PCSK9 inhibitor is alirocumab, evolocumab, or bococizumab. 6. The method according to any one of items 1 to 5, wherein the subject has an Lp(a) level above 11.8 mg / dL (but optionally below 30 mg / dL). (atorvastatin), CADUET (atorvastatin + amlodipine); selective cholesterol absorption inhibitors, for example, but not limited to, ezetimibe (ZETIA); lipid-lowering therapy (LLT), for example, but not limited to, fibrates or fibric acid derivatives, for example, but not limited to, gemfibrozil (LOPID), fenofibrate (ANTARA, LOFIBRA, TRICOR, TRIGLIDE) and clofibrate lates (ATROMID-S); resins, for example, but not limited to, cholestyramine (QUESTRAN, QUESTRAN LIGHT, PREVALITE, LOCHO LEST, LOCHOLEST LIGHT), cholesty pol (CHOLESTID) and colesevelam HCl (WELCHOL) and / or combinations thereof, for exam ple, but not limited to, at least one selected from VYTORIN (simvastatin + ezetimibe) of Configuration 1. 3. The first therapy is optimized statin therapy, any of the numbered configurations of this section described method. 4. The LDL level of the subject is reduced to a level of 80 mg / dL or less, any of the numbered configurations of this section described method. 5. A method for treating coronary atherosclerotic heart disease, a. identifying a subject having an LDL-C level of 70 mg / dL or less, b. administering an anti-P CSK9 neutralizing antibody to the subject in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less including the method. 6. The subject is further identified by being diagnosed with coronary atherosclerotic heart disease any of the numbered configurations of this section described method. 7. A method for reducing the atherosclerotic volume ratio (PAV) in a subject, comprising: a. Identifying a subject who has received at least a moderate level of treatment with a statin; b. Administering an anti-PCSK9 neutralizing antibody to the subject in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the atherosclerotic volume ratio (PAV) in the subject; and including the method. 8. The method according to any of the numbered configurations of this section, wherein the amount and time are sufficient to reduce the LDL-C level to 40 mg / dL or less. 9. A method for reducing the total atherosclerotic volume (TAV) in a subject, comprising: a. Identifying a subject who has received at least a moderate level of treatment with a statin; b. Administering an anti-PCSK9 neutralizing antibody to the subject in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the total atherosclerotic volume in the subject; and including the method. 10. The method according to any of the numbered configurations of this section, wherein the amount and time are sufficient to reduce the LDL-C level to 40 mg / dL or less. 11. The method according to any of the numbered configurations of this section, wherein administering an anti-PCSK9 neutralizing antibody to the subject reduces the atherosclerotic volume ratio in the subject. 12. The method according to any of the numbered configurations of this section, wherein at least a 0.1 percent reduction in PAV is achieved. 13. The method according to any of the numbered configurations of this section, wherein the reduction is achieved within 18 months. 14. The PAV is reduced by at least 1% 18 months after treatment, according to any of the numbered configurations of this section. The method according to any one of the above. 15. PAV decreases by at least 2% 18 months after treatment, for the numbered configurations of this section The method according to any one of the above. 16. A method for treating coronary atherosclerotic heart disease, a. administering optimal statin treatment to a subject having coronary atherosclerotic heart disease; b. simultaneously administering a certain amount of an anti-PCSK9 neutralizing antibody to the subject comprising the method. 17. A method for treating coronary atherosclerotic heart disease, a. identifying a subject with statin intolerance; b. administering at least a low dose of statin treatment to the subject with statin intolerance; c. administering a certain amount of an anti-PCSK9 neutralizing antibody to the subject, thereby treating coronary atherosclerotic disease comprising the method. 18. A method for effecting regression of coronary atherosclerotic heart disease, providing a subject receiving an optimized level of statin; administering an anti-PCSK9 neutralizing antibody to the subject at a level sufficient to regress coronary atherosclerotic heart disease to the subject comprising, wherein regression is a change of less than zero in PAV or TAV, the method. 19. A method for reducing the LDL-C level in a subject to 80 mg / dL or less, comprising administering an anti-PCSK9 neutralizing antibody to the subject, the subject having coronary atherosclerotic heart disease and the subject having received optimized statin therapy for at least one year, and the LDL-C level in the subject decreases to an average value of 80 mg / dL or less over at least that one year comprising the method. 20. The subject decreases to an average value of 60 mg / dL or less over at least one year, The method according to any one of the numbered configurations of this section. 21. The subject is reduced to an average value of 40 mg / dL or less over at least one year, by the method according to any of the numbered configurations of this section. 22. A method for reducing the relative risk of cardiovascular events by at least 10%, wherein at least in a subject receiving at least moderate-intensity statin, administering a PCSK9 neutralizing antibody in an amount sufficient to lower the subject's LDL-C level by about 20 mg / dL comprising the method. 23. The cardiovascular event is one selected from the group consisting of non-fatal myocardial infarction, myocardial infarction (MI), stroke / TIA, angina pectoris, arterial revascularization, coronary artery revascularization, fatal and non-fatal stroke, hospitalization for CHF, CHD death, coronary artery death, and is one of the methods according to configuration 22. selected from the cardiovascular group. Method. 24. A method for reducing the amount of atherosclerotic plaque in a subject, comprising administering a monoclonal antibody against human PCSK9 to a subject having atherosclerotic plaque, wherein the subject is receiving optimized statin therapy, thereby reducing the amount of atherosclerotic plaque in the subject. Method. 25. The method according to configuration 24, further comprising identifying a subject in need of reducing the amount of atherosclerotic plaque in the subject. 26. A method for suppressing the progression of a disease, comprising identifying a subject having an LDL-C level of 60 mg / dL or less, administering at least moderate-intensity statin therapy to the subject, administering evolocumab at a level sufficient to lower the subject's LDL-C level to 30 mg / dL, thereby suppressing the progression of the disease and comprising the method. 27. The subject has had a heart attack, any of the numbered configurations of this section ​​The method described in 28. A method of combining evolocumab and statin therapy to produce a greater reduction in LDL-C and regression of coronary atherosclerotic lesions at a well-tolerated dose, comprising: administering at least moderate-intensity statin therapy to a subject; administering to the subject a sufficient amount of evolocumab such that the subject's LDL-C level is reduced to 40 mg / dL or less; and maintaining the subject's LDL-C level at 40 mg / dL or less for at least one year. and A method comprising the above. 29. A method of treating coronary atherosclerotic disease, comprising: a. identifying a subject having an LDL-C level of 70 mg / dL or less; b. administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less. and A method comprising the above. 30. A method of reducing atherosclerotic volume percentage (PAV) in a subject, comprising: a. identifying a subject who has received at least moderate-level treatment with a non-PCSK9 LDL-C lowering agent; b. administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less, thereby reducing the atherosclerotic volume percentage (PAV) in the subject. and A method comprising the above. 31. A method of reducing total atherosclerotic volume (TAV) in a subject, comprising: a. identifying a subject who has received at least moderate-level treatment with a non-PCSK9 LDL-C lowering agent; b. administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less. and A method comprising the above. b. administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 100 mg / dL or less, such as 90 mg / dL or less. administering a PCSK9 inhibitor to the subject in an amount and for a time sufficient to thereby reduce the total atherosclerotic volume in the subject and A method comprising: 32. A method for treating coronary artery atherosclerotic disease, comprising: a. administering to a subject having coronary artery atherosclerotic disease an optimal non-PCSK9 LDL-C lowering therapy and b. simultaneously administering to the subject an amount of a PCSK9 inhibitor A method comprising: 33. A method for treating coronary artery atherosclerotic disease, comprising: a. identifying a subject with statin intolerance, b. administering to the subject with statin intolerance at least a low-intensity statin treatment, c. administering to the subject an amount of a PCSK9 inhibitor to thereby treat coronary artery atherosclerotic disease and A method comprising: 34. A method for providing regression of coronary artery atherosclerotic disease, comprising: providing a subject receiving an optimized level of a non-PCSK9 LDL-C lowering agent and administering to the subject a PCSK9 inhibitor at a level sufficient to regress coronary artery atherosclerotic disease and wherein regression is a change of zero or less in PAV or TAV. A method. 35. A method for reducing the LDL-C level in a subject to 80 mg / dL or less, comprising: administering a PCSK9 inhibitor to the subject, wherein the subject has coronary artery atherosclerotic disease and the subject has received an optimized non-PCSK9 LDL-C lowering therapy for at least one year and the LDL-C level in the subject has been reduced to an average value of 80 mg / d L or less over that at least one year. A method. 36. A method for reducing the amount of atherosclerotic plaques in a subject, comprising PC administering an SK9 inhibitor to a subject having atherosclerotic plaque, the subject being undergoing optimized non-PCSK9 LDL-C lowering therapy, thereby reducing the amount of atherosclerotic plaque in the subject. 37. A method of suppressing disease progression, comprising: identifying a subject having an LDL-C level of 60 mg / dL or less; administering to the subject at least a moderate-intensity non-PCSK9 LDL-C lowering therapy; administering a PCSK9 inhibitor at a level sufficient to reduce the subject's LDL-C level to 30 mg / dL, thereby suppressing disease progression. 38. A method of combining PCSK9 inhibitor therapy and non-PCSK9 LDL-C lowering therapy to produce greater LDL-C lowering and regression of coronary atherosclerosis at a well-tolerated dose, comprising: administering to the subject at least a moderate-intensity non-PCSK9 LDL-C lowering therapy; administering to the subject a sufficient amount of a PCSK9 inhibitor such that the subject's LDL-C level is reduced to 40 mg / dL or less; maintaining the subject's LDL-C level at 40 mg / dL or less for at least one year. 39. A method of treating a subject who cannot tolerate a sufficient therapeutic dose of a non-PCSK9 LDL-C lowering agent, comprising: identifying the subject; administering a PCSK9 inhibitor to the subject until the subject's LDL cholesterol level is reduced to 60 mg / dL or less. 40. The PCSK9 inhibitor comprises any one of the six CDR sequences shown in FIGS. 6-12. ​​​​​The method described in any of the numbered configurations in this section. 41. The first therapy is medium-intensity or high-intensity statin therapy, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 42. A statin at an effective dose level of at least 20 mg / day of atorvastatin or an equivalent amount of an equivalent of atorvastatin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 43. The amount of statin is at least an effective dose of at least 40 mg of atorvastatin or an equivalent amount of an equivalent of atorvastatin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 44. The statin is at least one of atorvastatin, simvastatin, rosuvastatin, pravastatin, lovastatin, and pitavastatin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 45. The statin is at least one of 20, 40, or 80 mg of atorvastatin, 40 or 80 mg of simvastatin, 5, 10, 20, or 40 mg of rosuvastatin, 80 mg of pravastatin, 80 mg of lovastatin, or 4 mg of pitavastatin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 46. The subject is receiving at least 40 or 80 mg of atorvastatin, 10, 20, or 40 mg of rosuvastatin, or 80 mg of simvastatin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 47. The statin is monotherapy with a statin, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 48. The subject is also receiving additional lipid-lowering therapy, the method described in any of the numbered configurations in this section. The method described in any of the numbered configurations in this section. 49. Further lipid-lowering therapies are niacin, ezetimibe, or both niacin and ezetimibe, and are methods according to any of the numbered configurations of this section. 50. The PCSK9 inhibitor or anti-PCSK9 antibody is evolocumab, and evolocumab is administered in an amount of at least 140 mg, and is a method according to any of the numbered configurations of this section. 51. Evolocumab is administered in an amount of at least 420 mg, and is a method according to any of the numbered configurations of this section. 52. The PCSK9 inhibitor or anti-PCSK9 antibody is evolocumab, and evolocumab is administered at a frequency of at least once a month, and is a method according to any of the numbered configurations of this section. 53. Providing regression of coronary atherosclerotic lesions means a decrease in PAV, and is a method according to any of the numbered configurations of this section. 54. The LDL-C level in the subject is reduced to 60 mg / dL or less, and is a method according to any of the numbered configurations of this section. 55. The LDL-C level in the subject is reduced to 50 mg / dL or less, and is a method according to any of the numbered configurations of this section. 56. The LDL-C level in the subject is reduced to 40 mg / dL or less, and is a method according to any of the numbered configurations of this section. 57. The LDL-C level in the subject is reduced to 30 mg / dL or less, and is a method according to any of the numbered configurations of this section. 58. The LDL-C level in the subject is reduced to 20 mg / dL or less, and is a method according to any of the numbered configurations of this section. 59. For the subject, CV death, non-fatal myocardial infarction, non-fatal stroke, or transient ischemic attack ( The risk of hospitalization for TIA), coronary artery revascularization, and unstable angina is reduced, this method according to any of the numbered configurations of this section. 60. The amount of the anti-PCSK9 neutralizing antibody is at least 140 mg, the method according to any of the numbered configurations of this section. 61. The amount of the anti-PCSK9 neutralizing antibody is at least 150 mg, the method according to any of the numbered configurations of this section. 62. The amount of the anti-PCSK9 neutralizing antibody is at least 300 mg, the method according to any of the numbered configurations of this section. 63. The amount of the anti-PCSK9 neutralizing antibody is at least 400 mg, the method according to any of the numbered configurations of this section. 64. The amount of the anti-PCSK9 neutralizing antibody is 420 mg, the method according to any of the numbered configurations of this section. 65. The method according to any of the numbered configurations of this section, further comprising evolocumab. 66. Evolocumab is administered subcutaneously, the method according to any of the numbered configurations of this section . 67. Evolocumab is administered to the subject at least monthly for at least 1 year, the method according to any of the numbered configurations of this section. 68. The atherosclerotic volume ratio in the subject is reduced by 0.1 to 2.5%, the method according to any of the numbered configurations of this section. 69. The standardized total atherosclerotic volume is reduced by 0.1 to 10%, the method according to any of the numbered configurations of this section. 70. The LDL-C level of the subject is reduced by at least 40%, the method according to any of the numbered configurations of this section. 71. The LDL-C level of the subject is reduced by at least 60%, the method according to any of the numbered configurations of this section. 72. The subject is treated with a stable statin dose for at least 4 weeks and has one major or three minor cardiovascular risk factors and has LDL-C of ≧80 mg / dL or 60 - 80 m g / dL, according to the method described in any of the numbered configurations of this section. 73. A method according to any of the numbered configurations of this section, comprising an anti-PCSK9 neutralizing antibody. 74. The anti-PCSK9 neutralizing antibody is evolocumab, according to any of the numbered configurations of this section described. 75. The major risk factor includes at least one of non-coronary atherosclerotic vascular disease, myocardial infarction or hospitalization for unstable angina within the past 2 years or type 2 diabetes, according to any of the numbered configurations of this section. 76. The minor risk factor includes current smoking, hypertension, low levels of high-density lipoprotein cholesterol (HDL-C), family history of premature coronary heart disease, or high-sensitivity C-reactive protein (hs-CRP) ≧2 mg / L, or at least one of men ≧50 years old and women ≧55 years old, according to any of the numbered configurations of this section. 77. A method for treating a subject who cannot tolerate a sufficient therapeutic dose of a statin, comprising identifying the subject, administering a PCSK9 inhibitor to the subject until the LDL cholesterol level of the subject decreases to 60 mg / dL or less and . 78. A method for treating coronary atherosclerotic heart disease, comprising a. identifying a patient having an LDL-C level of 70 mg / dL or less, b. administering a non-PCSK9 LDL-C lowering agent to the subject in an amount and for a time sufficient to lower the LDL-C level to 60 mg / dL or less and . 79. A method according to any of the numbered configurations of this section, wherein a high-intensity statin is administered to a subject. Method. 80. A method according to any of the numbered configurations of this section, wherein a human is diagnosed with cardiovascular death. Method. 81. A method according to any of the numbered configurations of this section, wherein evolocumab is administered every two weeks. Method. 82. A method for treating atherosclerotic cardiovascular disease, comprising: a. Identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and b. Administering a second therapy comprising a PCSK9 inhibitor therapy to the subject, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subject, the first therapy is different from the second therapy, and the risk is a) a composite of hospitalization or coronary artery revascularization for cardiovascular death, myocardial infarction, stroke, unstable angina, or b) a composite of cardiovascular death, myocardial infarction, or stroke. Method. 83. The method according to configuration 82, wherein the first and second therapies are continued for at least two years. Method. 84. The method according to configuration 83, wherein the risk of a composite of hospitalization or coronary artery revascularization for cardiovascular death, myocardial infarction, stroke, unstable angina is reduced by at least 15%. 85. The method according to configuration 82, wherein the risk of a composite of cardiovascular death, myocardial infarction, or stroke is reduced by at least 20%. Method. 86. A method for reducing the risk of cardiovascular events, comprising: a. Identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and b. Administering a second therapy comprising a PCSK9 inhibitor therapy to the subject. Method. a. Identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and b. Administering a second therapy comprising a PCSK9 inhibitor therapy to the subject. comprising, both the first and second therapies being administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject, the first therapy being different from the second therapy, the risk being a composite of a) cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke, method. 87. A cardiovascular event is selected from at least one of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary revascularization, the first and second therapies being continued for at least 2 years, the method according to composition 86. 88. The risk of a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary revascularization is reduced by at least 15%, the method according to composition 86. 89. The risk of a composite of cardiovascular death, myocardial infarction or stroke is reduced by at least 20%, the method according to composition 86. 90. The hazard ratio in the first year for reducing the risk of cardiovascular death, myocardial infarction or stroke is 0 .84 (95% CI, 0.74 - 0.96), the method according to composition 86. 91. The hazard ratio in the second year for reducing the risk of cardiovascular death, myocardial infarction or stroke is 0.75 (95% CI, 0.66 - 0.85), the method according to composition 86. 92. The hazard ratio in the first year for reducing the risk of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary revascularization is 0.88 (95% CI, 0.80 - 0.9 7), the method according to composition 86. 93. The hazard ratio in the second year for reducing the risk of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary revascularization is 0.81 (95% CI, 0.73 - 0. 89), the method according to composition 86. ​​​​​ 94. Reducing the risk means either a) increasing the amount of time until the first of any one of hospitalization for cardiovascular death, myocardial infarction, stroke, unstable angina, or coronary artery revascularization, or b) increasing the amount of time until the first of any one of cardiovascular death, myocardial infarction, or stroke, which means at least one of the methods of configurations 82 to 93. 95. The risk of myocardial infarction, stroke, and coronary artery revascularization is reduced by 21% to 27%, the method according to configuration 86. 96. The risk of cardiovascular death, myocardial infarction, or stroke in a subject with an initial median LDL cholesterol of 126 mg / dL is reduced by 17%, the method according to configuration 86. 97. The final median of the subject's LDL cholesterol level is 43 mg / dL, the method according to configuration 96. 98. The risk of cardiovascular death, myocardial infarction, or stroke in a subject with an initial median LDL cholesterol of 73 mg / dL is reduced by 22%, the method according to configuration 86. 99. The final median of the subject's LDL cholesterol level is 22 mg / dL, the method according to configuration 98. 100. A method for reducing the risk of emergency coronary artery revascularization, comprising: a. identifying a subject who has received a first therapy including a non-PCSK9 LDL-C lowering therapy, and b. administering a second therapy including a PCSK9 inhibitor therapy to the subject, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of atherosclerotic cardiovascular disease in the subject, and the first therapy is not the same as the second therapy. 101. A method for reducing the risk of cardiovascular events, comprising: a. identifying a subject having a cardiovascular disease,​​​​​ b. Cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA), Reducing at least one risk of coronary artery revascularization or hospitalization for unstable angina by administering to a subject a PCSK9 inhibitor in a sufficient amount and for a sufficient time comprising a method. 102. A subject having a cardiovascular disease is undergoing a non-PCSK9 LDL-C lowering therapy, The non-PCSK9 LDL-C lowering therapy is not the same therapy as the PCSK9 inhibitor, non-PCS Both the K9 LDL-C lowering therapy and the PCSK9 inhibitor are administered to the subject in a sufficient amount and for a sufficient time to reduce the risk of cardiovascular events in the subject, according to the method described in Composition 101. described method. 103. The non-PCSK9 LDL-C lowering therapy is the method described in Composition 102, comprising a statin. method. 104. The risk is the risk for the composite of cardiovascular death, myocardial infarction or stroke, according to any one of Compositions 82 to 103. 105. The risk is the risk for the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, according to any one of Compositions 82 to 103. described method. 106. A method for reducing the LDL-C level in a subject, a. Providing a first therapy to the subject, the first therapy comprising a non-PCSK9 LDL-C lowering therapy and, b. Administering a second therapy to the subject, the second therapy comprising a PCSK9 inhibitor both the first and second therapies being administered to the subject for at least 5 years, the first therapy being different from the second therapy, and the LDL-C level of the subject being maintained below 50 mg / dL. method. 107. A method for reducing the risk of cardiovascular events, a. Identifying a subject who is receiving a first therapy including a non-PCSK9 LDL-C lowering therapy and b. Administering a second therapy including a PCSK9 inhibitor therapy to the subject wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject, the first therapy is not the same as the second therapy, and the risk is at least one of myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization. A method. 108. A method for reducing the risk of cardiovascular events, comprising: a. Identifying a subject who is receiving a first therapy including a non-PCSK9 LDL-C lowering therapy and b. Administering a second therapy including a PCSK9 inhibitor to the subject wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject, the first therapy is not the same as the second therapy, and the risk is a composite of coronary artery revascularization, myocardial infarction, and cerebrovascular attack. A method. 109. A method for reducing the risk of cardiovascular events, comprising: a. Identifying a subject who is receiving a first therapy including a non-PCSK9 LDL-C lowering therapy and b. Administering a second therapy including a PCSK9 inhibitor to the subject wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of cardiovascular events in the subject, the first therapy is not the same as the second therapy, and the risk is a composite of fatal MI and / or non-fatal MI and fatal and / or non-fatal coronary artery revascularization. A method. 110. A method of treating a subject, comprising: identifying a subject having obliterative arterial disease​​ Reducing the PCSK9 activity level in a subject and A method comprising the steps of: 111. A method for reducing the risk of adverse lower limb events in a subject, comprising reducing the PCSK9 activity level in a subject having peripheral arterial disease A method comprising the steps of: 112. The method according to Configuration 111, wherein the subject is further administered a non-PCSK9 LDL-C lowering therapy The method described above. 113. The method according to Configuration 112, wherein the non-PCSK9 LDL-C lowering therapy comprises a statin The method described above. 114. The method according to Configuration 113, wherein the adverse lower limb event is selected from the group consisting of at least one of acute lower limb ischemia, major amputation, and emergency peripheral revascularization The method described above. 115. The method according to Configuration 113, wherein the subject has no history of myocardial infarction or stroke 116. The method according to Configuration 113, wherein the subject is identified if the subject has intermittent claudication and an ankle-brachial index < 0.85, if the subject has a history of peripheral surgery (lower limb revascularization or amputation), or if the subject Has both The method described above. 117. The method according to Configuration 113, wherein the composite risk of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization is reduced The method described above. 118. The method according to any one of Configurations 110 to 117, wherein the reduction of the PCSK9 activity level in the subject is achieved by an antibody against PCSK9 The method described above. 119. The method according to Configuration 118, wherein the antibody comprises evolocumab 120. The method according to any one of Configurations 110 to 119, wherein the reduction of the risk to the subject is greater in a subject having PAD than in a subject not having PAD The method described above. 121. The subject has PAD, and after the method, the subject has a reduced risk of MACE, Configuration The method according to any one of 110 to 119. 122. The subject has no prior MI or stroke, and the method according to any one of 110 to 119. one. 123. A method for reducing the risk of major adverse lower extremity events ("MALE"), administering a non-statin LDL-C lowering agent to a subject, administering a statin to a subject having peripheral artery disease ("PAD") and a method comprising 124. MALE is a composite of acute limb ischemia (ALI), major amputation (above knee (AKA) or below knee ( BKA), excluding the forefoot or toes), or emergency revascularization (thrombolysis or emergency vascular intervention for ischemia), the method according to composition 123. 125. A method for reducing the risk of major adverse cardiovascular events ("MACE"), administering a non-statin LDL-C lowering agent to a subject, administering a statin to a subject having PAD and a method comprising 126. MACE is a composite of CV death, MI or stroke, the method according to composition 125 . 127. The subject had no prior MI or stroke, and any one of compositions 110 to 126 the method described in one. 128. The LDL-C level of the subject is reduced to at least 50 mg / dL, and composition 11 the method according to any one of 0 to 127. 129. The LDL-C level of the subject is reduced to at least 10 mg / dL, and composition 11 the method according to any one of 0 to 128. 130. The cardiovascular risk is reduced by at least 10%, and any one of compositions 110 to 129 the method described in one. 131. The cardiovascular risk is reduced by at least 40%, and any one of compositions 110 to 129 The method described in one The risk of 132.MALE is reduced by at least 10%, any one of configurations 111 to 124 The method described in any one of them The risk of 133.MALE is reduced by at least 20%, any one of configurations 111 to 124 The method described in any one of them The composite risk of 134.MALE and MACE is reduced by at least 10%, configuration 1 The method described in any one of 110 to 134 The composite risk of 135.MALE and MACE is reduced by at least 20%, configuration 1 The method described in any one of 110 to 134 A method for reducing the risk of cardiovascular events, Providing a first therapy including a non-PCSK9 LDL-C lowering therapy to a subject, Providing a second therapy including a PCSK9 inhibitor to a subject Including, both the first and second therapies are administered to the subject, and the subject has an Lp(a) level of 11.8 mg / dL to 50, method A method for reducing the risk of major vascular events in a subject, 1) (a) Identifying a subject having at least one of (a) a recent MI, (b) multiple previous MIs, or (c) multivessel disease And, 2) Providing a first therapy including a non-PCSK9 LDL-C lowering therapy to a subject, 3) Providing a second therapy including a PCSK9 inhibitor to the subject, thereby reducing the risk that the subject has a major vascular event And Including method 138. The major vascular event consists of at least one of CVD, MI, or stroke The method according to configuration 137, selected from the group 139. The recent MI is within 2 years, the method according to configuration 137 or 138 140. The plurality of prior MIs is at least two, and any one of Configurations 137 to 139 The method described therein. 141. The subject has at least two of (a) a recent MI, (b) a plurality of prior MIs, or (c) multivessel disease, and is the method according to any one of Configurations 137 to 140. 142. The subject has all three of (a) a recent MI, (b) a plurality of prior MIs, or (c) multivessel disease, and is the method according to any one of Configurations 137 to 140. 143. The first therapy, or non-PCSK9 LDL-C lowering agent, or statin consists of or contains an optimized amount of statin, and the second therapy, PCSK9 LDL- C lowering agent, PCSK9 inhibitor, non-statin LDL-C lowering agent or anti-PCSK9 neutralizing antibody consists of or contains evolocumab, alirocumab, or an antibody that competes with evolocumab or alirocumab, and is the method according to any one of Configurations 1, 16, 18, 19, 32, 34, 35, 36, 82, 86, 100, 106, 107, 108, 109, 123, 125, 136 and 137. 144. The second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin L DL-C lowering agent or anti-PCSK9 neutralizing antibody consists of or contains evolocumab, alirocumab, or an antibody that competes with evolocumab or alirocumab, and is the method according to any one of Configurations 5, 7 9, 17, 18, 19, 22, 29, 30, 31, 33, 37, 38, 39, 77 and 101. 145. The statin is 20, 40 or 80 mg of atorvastatin, 40 or 8 0 mg of simvastatin, 5, 10, 20 or 40 mg of rosuvastatin; 80 mg at least one of pravastatin, 80 mg of rosuvastatin, or 4 mg of pitavastatin, or the first therapy or non-PCSK9 LDL-C lowering agent is ezetimibe as described in Configuration 143 or 144 146. The PCSK9 inhibitor or anti-PCSK9 antibody is evolocumab, and evolocumab is administered in an amount of at least 140 mg every two weeks as described in Configuration 143 or 144 147. Evolocumab is administered in an amount of at least 420 mg once a month as described in Configuration 1 43 or 144 148. The amount of the anti-PCSK9 neutralizing antibody is at least 150 mg as described in Configuration 143 or 144 149. The amount of the anti-PCSK9 neutralizing antibody is at least 300 mg as described in Configuration 143 or 144 150. The first therapy, or non-PCSK9 LDL-C lowering agent, or statin consists of or includes an optimized amount of statin, and the second therapy, PCSK9 LDL- C lowering agent, PCSK9 inhibitor, non-statin LDL-C lowering agent or anti-PCSK9 neutralizing antibody consists of or includes evolocumab, and evolocumab is administered in an amount of at least 1 40 mg every two weeks or at least 420 mg once a month as described in any one of Configurations 1, 16, 1 8, 19, 32, 34, 35, 36, 82, 86, 100, 106, 107, 108, 1 09, 123, 125, 136 and 137 151. The second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin L DL-C lowering agent or anti-PCSK9 neutralizing antibody consists of or includes evolocumab ​​​See, evolocumab is administered in an amount of at least 140 mg every two weeks or at least 42 0 mg once a month, according to the method described in any one of Configurations 5, 7, 9, 17, 18, 19, 22, 29, 30, 31 , 33, 37, 38, 39, 77 and 101. 152. The subject has clinical atherosclerotic cardiovascular disease, and the method reduces the risk of myocardial infarction, stroke and / or coronary artery revascularization, according to the method described in Configuration 150 or 151 . 153. The subject has primary (heterozygous familial and non-familial) hyperlipidemia, according to the method described in Configuration 150 or 151. 154. Evolocumab is administered by a self-injector having a pre-filled cartridge or an on-body infusor, according to the method described in any one of Configurations 150 to 153 . 155. A method for treating atherosclerotic cardiovascular disease and / or primary (heterozygous familial and non-familial) hyperlipidemia, comprising providing a treatment comprising a statin and evolocumab to a subject, wherein evolocumab is provided in an amount of at least 140 mg every two weeks or at least 420 mg once a month. 156. A method for treating atherosclerotic cardiovascular disease and / or primary (heterozygous familial and non-familial) hyperlipidemia, comprising receiving at least one of 20, 40 or 80 mg of atorvastatin; 40 or 80 mg of simvastatin; 5, 10, 20 or 40 mg of rosuvastatin; 80 mg of pravastatin, 80 mg of lovastatin or 4 mg of pitavastatin, and receiving evolocumab in an amount of at least 140 mg every two weeks or at least 420 mg once a month. ​ 157. A method for treating atherosclerotic cardiovascular disease and / or primary (heterozygous familial and and non-familial) hyperlipidemia, comprising providing or administering at least one of 20, 40 or 80 mg of ator vastatin; 40 or 80 mg of simvastatin; 5, 10, 20 or 40 mg of rosuvastatin; 80 mg of pravastatin, 80 mg of lovastatin or 4 mg of pitavastatin, and providing or administering evolocumab in an amount of at least 14 0 mg every two weeks or at least 420 mg once a month. A method as described above. 158. A method for treating coronary atherosclerotic heart disease, comprising identifying a subject having an LDL -C level of more than 70 mg / dL, and administering to the subject an anti-PCSK9 neutralizing antibody in an amount and for a time sufficient to reduce the LDL-C level to 40 mg / dL or less, 3 0 mg / dL or less, or 20 mg / dL or less. 159. In any one of the above configurations, the symptoms and / or goals are, instead, A) major vascular events, cardiovascular events, major adverse cardiovascular events, major adverse lower limb events, adverse lower limb events, fatal MI and / or non-fatal MI and fatal and / or non-fatal coronary revascularization, a) coronary revascularization, b) myocardial infarction, and c) cerebrovascular attack composite, a) cardiovascular death, b) myocardial infarction, c) stroke, d) hospitalization for unstable angina, or e) coronary revascularization composite, emergency coronary revascularization, a) cardiovascular death, b) myocardial infarction, c) stroke, d) hospitalization for unstable angina, or e) at least one of coronary revascularization, or at least one of cardiovascular events, or reducing the risk of at least one of or B) treating atherosclerotic heart disease, treating coronary atherosclerotic disease, regressing coronary atherosclerotic disease, treating subjects who cannot tolerate a sufficient therapeutic dose of statin, treating subjects who cannot tolerate a sufficient therapeutic dose of non-PCSK9 LDL-C lowering agent, combining PCSK9 inhibitor therapy and non-PCSK9 LDL-C lowering therapy to produce a greater reduction in LDL-C and regression of coronary atherosclerotic disease at a dose that can be sufficiently tolerated, suppressing disease progression, reducing the amount of atherosclerotic plaque in a subject, combining evolocumab and statin therapy to produce a greater reduction in LDL-C and regression of coronary atherosclerotic disease at a dose that can be sufficiently tolerated, reducing the LDL-C level in a subject to 80 mg / dL or less, reducing the total atherosclerotic volume (TAV) in a subject, reducing the atherosclerotic volume ratio (PAV) in a subject for reducing the LDL-C level and suppressing disease progression, or at least one of these combinations, to at least one of the methods described in any one of the above configurations. 161. a) identifying statin-intolerant subjects; b) administering a low dose or no-dose statin treatment to statin-intolerant subjects; c) Reduce to or below L, thereby treating coronary atherosclerotic heart disease comprising administering to a subject an amount of an anti-PCSK9 neutralizing antibody for treating coronary atherosclerotic heart disease. 162. The non-HDL-C level of the subject is reduced to 100, 90, 80, 70, 60, 50 or 4 0 or less, any of the methods of the configuration provided above. 163. The risk of hospitalization for the subject's primary, secondary, CVD, MI, stroke, revascularization and / or unstable angina pectoris ("HUA") is reduced, the method according to the configuration of 162. 164. The second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin L DL-C lowering agent or anti-PCSK9 neutralizing antibody comprises at least one of the six CDRs of evolocumab, in any one of configurations 1, 16, 18, 19, 32, 34, 35, 36, 82, 86, 10 0, 106, 107, 108, 109, 123, 125, 136, 137, 7, 9, 17 18, 19, 22, 29, 30, 31, 33, 37, 38, 39, 77 and 101 The method according to any one of the above. 165. The second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin L DL-C lowering agent or anti-PCSK9 neutralizing antibody comprises all of the six CDRs of evolocumab The method according to the configuration of 164. 166. The six CDRs are the six CDRs of the construct named 21B12 in FIGS. 8-11 The method according to the configuration of 165. 167. The second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin L DL-C lowering agent or anti-PCSK9 neutralizing antibody comprises the heavy chain and light chain amino acid sequences of evolocumab, the method according to the configuration of 164. 168. Second therapy, PCSK9 LDL-C lowering agent, PCSK9 inhibitor, non-statin LDL-C lowering agent or anti-PCSK9 neutralizing antibody is the method according to Configuration 167, including the evolocumab heavy chain and light chain as shown in Figure 12.

[0226] In some embodiments, a method of treating coronary atherosclerotic heart disease is provided. This method includes a) identifying a statin-intolerant subject, b) administering a low-dose or no-dose statin treatment to the statin-intolerant subject, and c) lowering the LDL-C level of the statin-intolerant subject to 60 mg / dL or less, thereby treating coronary atherosclerotic heart disease, by administering to the subject at least one of an amount of a PCSK9 LDL-C lowering agent, a PCSK9 inhibitor, a non-statin LDL-C lowering agent, an anti-PCSK9 neutralizing antibody, evolocumab, alirocumab, and / or an antibody that competes with evolocumab or alirocumab. In some embodiments, the subject is treated with a sufficient amount of an anti-PCSK9 neutralizing antibody for a sufficient time to lower its LDL-C to 55, 50, 45, 40, 35, 30, 25, 20 mg / dL or lower. In some embodiments, the antibody is evolocumab. If only a single therapy is used, that therapy is not considered a "combination therapy" as used herein. However, any of the embodiments provided herein for combination therapy can be appropriately modified and considered for this very low LDL-C therapy. In particular, the use of at least one of a PCSK9 LDL-C lowering agent, a PCSK9 inhibitor, a non-statin LDL-C lowering agent, an anti-PCSK9 neutralizing antibody, evolocumab, alirocumab, and / or an antibody that competes with evolocumab or alirocumab is also considered. for the therapy. , bring about extremely low LDL-C levels in the subject, which will provide a great benefit (for that particular embodiment) .

[0227] In some embodiments, a composition for achieving any of the above methods is provided. In some embodiments, the composition can be a combination of a first therapy and a second therapy . In some embodiments, the therapies can be provided as separate components, and each component can be administered to the subject separately or simultaneously. In some embodiments, the secondary therapy is administered to the abdomen, thigh, or upper arm.

[0228] In some embodiments, using one or more of the methods provided herein, the clinical risk of myocardial infarction, stroke, and coronary artery revascularization in adults with atherosclerotic cardiovascular disease can be reduced.

[0229] In some embodiments, one or more of the methods provided herein are used as dietary adjuncts, alone or in combination with other lipid-lowering therapies (e.g., statins, ezetimibe), to lower low-density lipoprotein cholesterol (LDL-C) in adults with primary (heterozygous familial and non-familial) hyperlipidemia.

[0230] In some embodiments, one or more of the methods provided herein are used as adjuncts to diet and other LDL-lowering therapies (e.g., statins, ezetimibe, LDL apheresis therapy) in patients with homozygous familial hypercholesterolemia (HoFH) who require further reduction of LDL-C. In some embodiments, non-PC ​​​​​SK9 lipid-lowering therapy includes procedures such as apheresis therapy. Thus, in some embodiments, the combination therapies provided herein may include non-PCSK9 lipid lowering treatment, and / or statin therapy, and / or PCSK9 therapy. In some embodiments, the combination therapies provided herein may include non-PCSK9 lipid lowering treatment and / or PCSK9 therapy. In some embodiments, the combination therapies provided herein may include non-PCSK9 lipid-lowering treatment and / or statin therapy.

[0231] In some embodiments, a 420 mg dose of REPATHA can be administered by using a disposable on-body injector with a prefilled cartridge over 9 minutes, or by using a disposable prefilled autoinjector or a disposable prefilled syringe to perform three consecutive injections within 30 minutes.

[0232] In some embodiments, for subjects receiving combination therapy to reduce plaque, the subjects have no or relatively few risk factors (as outlined, for example, in FIGS. 39 and Example 19). In some embodiments, the subjects lack changes in PAV, HbA1c, and apolipoprotein A-I that indicate risk or at-risk systolic blood pressure (p = 0.01).

[0233] In some embodiments, subjects treated by any of the methods provided herein have Lp(a) levels of 11.8 - 49 mg / dL. In some embodiments The combination therapies provided herein can be applied to subjects having normal Lp(a) levels, and the subjects can still benefit from the reduction in atherosclerotic risk resulting from the potent lipid lowering provided by the combination therapies. Thus, the subjects can further benefit from a reduction in LDL-C levels to 70 mg / dL or less, 60 mg / dL or less, 50 mg / dL or less, 40 mg / dL or less, or, for example, 30 mg / dL or less. In some embodiments, the subjects can experience a greater absolute reduction in major CV events. This conclusion can be supported, for example, by Example 22. In some embodiments, high-risk subjects receive a combination therapy (e.g., a statin and evolocumab) provided herein such that the subject's LDL-C level is reduced to 70 mg / dL or less, 60 mg / dL or less, 50 mg / dL or less, 40 mg / dL or less, or, for example, 30 mg / dL or less. The risk for intermediate-risk subjects (intermediate risk of atherosclerotic CV disease; TRS2°P score = 24; 79% of the population) can have an absolute risk reduction (ARR) of at least 1.9% in CV death, MI, or stroke after 3 years with EvoMab as compared to Pbo alone. The risk for high-risk subjects (high risk of atherosclerotic CV disease, score ≥5; 16%) can have an ARR of 3.6% in CV death, MI, or stroke (see, for example, FIGS. 52 and Example 22). In some embodiments, using any of the methods provided herein, a first agent

[0234]

[0235] ​ Not only the risk of the vent, but also the total number of major vascular events in the subject can be reduced This conclusion can be supported, for example, by Example 23. In some embodiments Subjects receiving one of the combination therapies provided herein may have an LDL-C level Reduced to 70 mg / dL or less, 60 mg / dL or less, 50 mg / dL or less, 40 mg / dL or less Or, for example, 30 mg / dL or less, thereby reducing the risk not only of the first major Cardiovascular events, but also, if they occur, the risk of subsequent cardiovascular events This can be 2, 4, 6, 8, 10, 12 months or 1, 1.2, 1.4, 1.6, 1.8, 2, 2, 2.2, 2.4, 2.6, 2 .8, 3 years or more. In some embodiments, the risk of subsequent MI, stroke or Coronary artery revascularization is reduced both in terms of the likelihood of such events occurring in the subject And the time to such events And both are reduced

[0236] In some embodiments, using any of the methods provided herein, plaque MI associated with rupture, smaller MI and larger MI, both STEMI and NSTE MI, as well as / or the risk of MI across various subtypes of types 1-4 can be reduced This can be supported, for example, by Example 24. In some Embodiments, subjects receiving one of the combination therapies provided herein may have an LDL -C level reduced to 70 mg / dL or less, 60 mg / dL or less, 50 mg / dL or less, 40 mg / dL or less or, for example, 30 mg / dL or less, thereby reducing the plaque MI associated with aortic rupture, smaller MI and larger MI and / or STE across various subtypes of MI, NSTEMI, type 1, type 2, type 3 and / or type 4 can reduce the risk of MI. In some embodiments, it is particularly useful for STEMI, NSTEMI, type 1 and / or type 4 subtypes. In some embodiments, the risk of MI at various troponin thresholds can also be reduced. In some embodiments, any of the combination methods provided herein are particularly useful for subjects with elevated troponin. As outlined in the following examples, in some embodiments, combination therapy can be used to reduce MI in subjects with high values of Tn10×ULN. Thus, these methods can be particularly advantageous in subjects with elevated troponin, which can be used as a screening for subjects who have further benefits from this method (e.g., 10 times higher levels of troponin, etc.).

[0237] In some embodiments, a method of treating a subject is provided. The method includes providing a first therapy to the subject that includes non-PCSK9 LDL-C lowering therapy and administering a second therapy to the subject that includes a PCSK9 inhibitor. The subject has a history of stroke and / or diabetes. This method can be combined with any of the other combination embodiments provided herein.

[0238] In the embodiments provided herein with respect to "stroke", the disclosure of "stroke" includes "fatal stroke", "non-fatal stroke" and the combination of "fatal stroke" and Discloses all embodiments related to both. Similarly, the disclosure of "fatal stroke" is also intended for use of the method in non-fatal stroke or for broad use in both.

[0239] In the embodiments provided herein with respect to "MI", the disclosure of "MI" discloses all embodiments related to "fatal MI", "non-fatal MI", and both "fatal MI" and "non-fatal MI". Similarly, the disclosure of "fatal MI" is also intended for use of the method in non-fatal MI or for broad use in both.

[0240] In the embodiments provided herein with respect to "coronary revascularization", the disclosure of "coronary revascularization" discloses all embodiments related thereto, including: "emergency coronary revascularization", "non-emergency coronary revascularization", and both "emergency coronary revascularization" and "non-emergency coronary revascularization". Similarly, the disclosure of "emergency coronary revascularization" is also intended for use of the method in coronary revascularization or for broad use in both. intends.

Example

[0241] Example 1: Introduction This example outlines and presents the results of the Global Assessment of Plaque Regression (GLAGOV) trial using PCSK9 antibodies measured by intravascular ultrasound. In this trial, several aspects were investigated, including whether PCSK9 inhibition suppresses the progression of atherosclerosis, and whether achieving very low LDL-C levels with the combination of a statin and a PCSK9 inhibitor presents an increase in values that further suppress the progression of coronary artery disease, as measured by IVUS. including whether it presents an increase in values that further suppress the progression of coronary artery disease, as measured by IVUS.​​​​​ evaluated the main scientific problems. The results showed that the combination therapy (achieving a very low LDL-C level) not only suppressed the progression but also actually led to the recovery of the disorder.

[0242] Method Trial Design The GLAGOV trial was randomized, multi-center, and double-blind, with the institutional review board of each site approving the trial protocol, and patients provided written informed consent. The trial protocol and statistical analysis plan are available on JAMAnetwork.com, and the trial design has been previously described.

[0243] Patients aged ≥18 years were eligible if they had at least one epicardial coronary artery stenosis ≥20% shown by clinically indicated coronary angiography and had a target vessel suitable for imaging diagnosis with a visual occlusion of ≤50%. Patients had been treated with a stable statin dose for at least 4 weeks and were required to have an LDL-C of ≥80 mg / dL or 60 - 80 mg / dL and either one major or three minor cardiovascular risk factors. Major risk factors included non-coronary atherosclerotic vascular disease, hospitalization for myocardial infarction or unstable angina within the past 2 years, or type 2 diabetes. Minor risk factors included current smoking, hypertension, low levels of high-density lipoprotein cholesterol (HDL-C), family history of premature coronary heart disease, high-sensitivity C-reactive protein (hs-CRP) ≥2 mg / L or men aged ≥50 years and women aged ≥55 years. In the design, patients with an entry LDL-C of 60 - 80 mg / dL were limited to 25% of the total patient cohort. At screening, lipid-lowering therapy ​​​Patients who were not currently receiving therapy were included in a 4-week lipid-stabilization period. The inclusion of patients intolerant to statins was limited to 10% of the total cohort. Patients were excluded if they had poorly controlled diabetes or hypertension or heart failure, renal insufficiency, or liver disease. Patients were asked to identify their race according to certain categories determined by the study protocol in order to assess potential differences in concomitant treatments and disease progression. Patients were randomized in a 1:1 ratio with a block size of 4 using an interactive voice response system to receive either 420 mg of evolocumab or placebo by subcutaneous injection once monthly for 76 weeks. During the treatment period, patients were seen at weeks 4, 12, 24, 36, 52, 64, and 76, and IVUS imaging was repeated at week 78. A clinical events committee, for which treatment assignment was blinded, adjudicated cardiovascular events. An independent blinded unblinding data monitoring committee, chaired by an academic cardiologist, reviewed the safety of the clinical trial during the study. Acquisition and analysis of ultrasound images Baseline intravascular ultrasound examination was performed following coronary angiography. Previous reports have described the methods of image acquisition

[0244] and analysis. Imaging was performed in a single artery and screened at a core clinical laboratory. Patients who met predefined requirements regarding image quality were eligible for randomization. At week 78, patients underwent a second ultrasound examination in the same artery. Using digitized images, staff who were unaware of the treatment status measured the lumen and external elastic membrane in images within matched arterial segments. The measurers were unaware of the order of the imaging tests (baseline versus follow-up).

[0245] versus follow-up). The accuracy and reproducibility of this method have been previously reported. It has been done.

[0246] The primary efficacy measure, percent atheroma volume (PAV), was calculated as follows:

number

number

[0247] Efficacy Endpoints The primary efficacy endpoint was PAV from baseline to week 78, as described above. The secondary efficacy endpoints were the nominal changes in the order of the trials. Nominal change in TAV from baseline to week 78, decrease in PAV from baseline, and and reduction in TAV from baseline. Exploratory endpoints included adjudicated Events (all-cause mortality, cardiovascular death, myocardial infarction, hospitalization for unstable angina, coronary vascular Incidence of stroke, reconstructive surgery, stroke, transient ischemic attack [TIA], and hospitalization for heart failure) and Included were changes in lipid parameters. Additional exploratory post hoc analyses included comparisons of changes in PAV and the proportion of patients who had PAV regression in patients with baseline LDL -C of 70 mg / dL or less or greater than 70 mg / dL. Local weighted polynomial regression (LOESS ) curve fitting was performed to examine the relationship between the resulting LDL-C levels and disease progression . .

[0248] Statistical Analysis All statistical analyses were performed using SAS version 9.4 (SAS Inc., Cary NC) . Means and standard deviations were reported for continuous variables with approximately normal distributions . Medians and interquartile ranges were reported for variables that were not normally distributed. IVUS effectiveness parameters were reported as least squares means (95% confidence intervals [CI]), and treatment groups were compared using analysis of covariance (ANCOVA) of rank-transformed data with adjustment for baseline values and geographic region . Time-weighted means (95% confidence intervals [CI ) were reported for lipoprotein levels during treatment and compared using ANCOVA with adjustment for treatment group and geographic region . The time-weighted mean for each test parameter was created by summing the products of each measurement and the time interval between visits divided by the total time . .

[0249] To examine the primary and secondary endpoints, a step-down statistical approach was applied . First, the primary endpoint was tested at a 0.05 significance level, and then the secondary endpoints were tested at a 0.05 significance level in the order described in section 4.1.2 of the statistical analysis plan . Sensitivity analyses using multiple imputations were performed to complete missing primary endpoint data. The imputation model included treatment group, statin-based as covariates Variables of intensive primary care, region, baseline LDL, baseline PAV, age, and sex were included. Subgroup analyses for the primary endpoint were performed using the subgroups specified in section 7.4 of the statistical analysis plan. Subgroups by treatment interaction were tested. Additional exploratory analyses were performed in patients with baseline LDL-C of 70 mg / dL or less or greater than 70 mg / dL.

[0250] For the change in the primary efficacy parameter PAV, a sample size of 356 subjects per treatment group was required to provide 90% power at a two-sided alpha of 0.05 to detect a nominal treatment difference of 0.71% assuming a standard deviation of 2.9%. A difference of 0.5% has been previously reported to distinguish patients who experienced cardiovascular events from those who did not. Assuming a discontinuation rate of 25%, 950 randomized patients were required. All reported p-values were two-sided. A p-value < 0.05 was considered statistically significant.

[0251] Results Subject Characteristics The breakdown of patients enrolled in the trial is shown in Figure 1. From May 3, 2013, to January 12, 2015, 970 patients were randomized at 197 sites, and 968 patients were administered the study drug (484 in the evolocumab treatment group and 484 in the placebo group). 846 patients (87.2%) had IVUS imaging that was evaluable at both baseline and follow-up. Of these patients, 423 were in the placebo group and 423 were in the evolocumab group. The mean exposure period to the study drug was 17.6 months. Table 1 reports the baseline characteristics of the randomized patients.

[0252] ​​​​​​​​​​​​​ [Table 4]

[0253] Table 1 (above) shows baseline and follow-up data for patients treated with placebo or evolocumab. The clinical characteristics and concomitant medical treatments of patients who underwent evaluable imaging were summarized. Results are presented as means and standard deviations for continuous variables and frequencies (percentages) for categorical variables. ACE, angiotensin-converting enzyme; ARB, agiotensin-converting enzyme; angiotensin receptor blockers; BMI, i.e., body mass index; MI, i.e., myocardial infarction; PCI, or percutaneous coronary intervention.

[0254] At the time of randomization, 58.9% were receiving high-intensity statins and 39.4% were receiving moderate-intensity statins. At baseline, 1.4% of patients were not taking statins. The mean LDL-C was 92.5 ± 27.2 mg / dL, and the median hsCRP was 1.6 (interquartile range 0.8, 3.4) mg / L. Evaluable follow-up IVUS imaging No significant differences were observed in these parameters between patients who received and did not receive (See Table 1.1).

[0255] [Table 5]

[0256] biochemical measurements Table 2 below shows the baseline and follow-up IVUS imaging data for 846 patients. The time-weighted mean LDL-C levels over the 78-week treatment period were significantly higher than those in placebo. In the placebo group, it was 93.0 mg / dL (a 3.9% change from baseline, resulting in an LDL-C of 90 mg / dL), and in the evolocumab group, it was 36.6 mg / dL (a -59 .8% change from baseline, resulting in an LDL-C of 29 mg / dL) (P<0.001). The LDL-C decreased by 56.1 mg / dL in the evolocumab group, while it increased by 0. 5 mg / dL in the placebo group. The difference between the groups was -56.5 mg / dL (95% CI -59.7, -5 3.4, P<0.001). (Figure 2) Patients treated with evolocumab had a greater decrease in apoB (-38.8 vs +2.7 mg / dL, between-group difference -40.6 mg / dL [95% CI -42 .9, -38.3], P<0.001), triglycerides (-9.6 vs +5.6 mg / d L, between-group difference -19.1 mg / dL [95% CI -27.5, -10.6], P<0.0 01), and Lp(a) (-3.8 vs -0.2 mg / dL, between-group difference -6.7 mg / dL [95% CI -7.9, -5.5], P<0.001), and a greater increase in HDL-C levels (+4.0 vs +1.2 mg / dL, between-group difference 2.5 mg / dL [95% CI 1.7 , 3.4], P<0.001). The median value of hsCRP levels during treatment was 1.4 mg / L (IQR 0.7, 3.0) in the placebo group and 1. 4 mg / L (IQR 0.7, 3.0) in the evolocumab group, with P = 0.48.

[0257]

Table 6

[0258]

Table 7

[0259] Primary and secondary IVUS endpoints The changes in the IVUS measurements of plaque area ratio are summarized in Table 3 below. Table 3 presents the primary and secondary endpoints evaluated by intravascular ultrasound at baseline and at 78-week follow-up, along with the changes from the baseline. Results are presented as mean SD and median (95% confidence interval) for continuous variables, and as percentages for categorical variables at baseline and follow-up. The change in parameters was represented by the least-squares mean standard error. (95% confidence interval) and as percentages for categorical variables at baseline and follow-up. The change in parameters was represented by the least-squares mean standard error.

[0260] [Table 8]

[0261] [Table 9]

[0262] PAV, a primary efficacy measure, did not change in the placebo group (+0.05% compared to baseline, P = 0.78), but decreased by 0.95% in the evolocumab group (P < 0.001 compared to baseline; between-group difference -1.01% (95% CI -1.78, 0.64 ) P < 0.001). TAV, a secondary efficacy measure, did not change in the placebo group (-0.9 mm3 compared to baseline, P = 0.45), but decreased by 5.8 mm 3 in the evolocumab group (P < 0.001 compared to baseline; between-group difference -4.9 mm3 (95% C I -7.3, 2.5) P < 0.001). Patients treated with more evolocumab showed a PAV regression of 64.2% vs 47.3%, P < 0.001), and a TAV regression of 61.3% vs 48.9 %, P < 0.001). In all pre-specified subgroups ​​​​​​There was no statistical evidence of interaction (Figure 3). Specifically, no difference in treatment effect was observed among patients stratified according to baseline LDL-C. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001. Among patients stratified according to baseline LDL-C, no difference in treatment effect was observed. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001. In the imputation modeling of patients who did not undergo IVUS imaging at follow-up, similar results were shown, with PAV decreasing with placebo (-0.02%) and evolocumab (-1.05%), and the difference between groups being -1.03% (95% CI -1.51, -0.55), P < 0.001.

[0263] Exploratory post hoc analysis In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). In this subgroup, the proportion of patients with regression of PAV with evolocumab compared with placebo was 81.2% vs 48.0%, and the difference between groups was 33.2% [95% CI 18.6, 47.7] P < 0.001]. (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). The change in PAV with statin monotherapy was 0.05%, and the change in PAV with statin + evolocumab was -0.95% (across all treatment groups). A similar association was also observed for the secondary endpoint of TAV. (Figure 4B, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). The change in TAV with statin monotherapy was -0.9%, and the change in TAV with statin + evolocumab was -5.8% (across all treatment groups). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). In 144 patients with baseline LDL-C of 70 mg / dL or less, evolocumab treatment was associated with a favorable effect on the change in PAV compared with placebo (-1.97% vs -0.35%, difference between groups -1.62% [95% CI -2.50, -0.74], P < 0.001). (Figure 4A, black bars represent statin combined with evolocumab, and white bars represent statin monotherapy). (across the treatment groups). The right panel of Figure 4A shows the percentage of subjects with PAV regression. (the sum of <70 and ≥70 is for monotherapy: 47.3% regressors, 52.7% progressors; and for statin + evolocumab: 64.3% regressors and 35.7% progressors). The right panel of Figure 4B shows the percentage of subjects with TAV regression.

[0264] Figure 4C shows data for an exploratory subgroup of subjects with baseline LDL-C <70 mg / dL. The mean LDL-C was 70.6 mg / dL with monotherapy (a 16.4% change from baseline and ultimately 65.5 mg / dL), and 24.0 mg / dL with combination therapy (a -58.3% change and ultimately 15.0 mg / dL). Figure 4D shows data from an exploratory subgroup with baseline LDL-C <70 mg / dL, showing a -0.35% change in PAV with statin monotherapy and a -1.97% change with combination therapy, with 48.0% showing regression with monotherapy and 81.2% showing regression with

[0265] The LOESS plot showed a linear relationship between the resulting LDL-C and PAV progression at LDL-C levels ranging from 110 mg / dL to 20 mg / dL . (Figure 5, the plot shows 95% confidence limits).

[0266] Exploratory clinical events and adverse events by laboratory values Table 4 shows centrally adjudicated clinical events, clinically adverse events, laboratory abnormalities, and reasons for study discontinuation. Table 4 summarizes clinically adverse events and adverse events by laboratory values and reasons for discontinuation in the safety population. Results are presented as frequency (percentage).

[0267]

Table 10

[0268]

Table 11

[0269] This trial did not have the power to evaluate the impact on cardiovascular events, but when comparing the evolocumab group with the placebo group, exploratory analysis revealed numerically fewer adverse cardiovascular outcomes (12.2% vs 15.3%), non-fatal myocardial infarction (2.1% vs 2.9%) and coronary revascularization (10.3% vs 13. 6%). The administration of evolocumab was , and the incidences of injection site reactions (0.4% vs 0%), muscle pain (7.0% vs 5.8%) and neurocognitive vents (1.4% vs 1.2%) did not become significantly excessive and were well tolerated. The incidence of abnormal test values was low in both groups. Only 1 patient (0.2%) developed anti-evolocumab antibodies, and no neutralizing antibodies were detected. Glycated hemoglobin levels did not change in any treatment group.

[0270] Discussion of Example 1 The above trial showed that adding the PCSK9 inhibitor evolocumab (combination therapy) to patients treated with moderate or high-intensity statin therapy had a favorable effect on the progression of coronary atherosclerosis measured by IVUS. Both primary and secondary IVUS efficacy measurement items were the regression of atherosclerotic lesions during 18 months of treatment in patients treated with the combination of evolocumab and statin and in patients treated with statin alone showed the absence of regression. Compared to the baseline, in PA V, patients in the placebo treatment group did not show a decrease in atherosclerotic burden (+0.05 %, P = 0.78), while patients in the evolocumab group showed a significant decrease in PAV (-0.95%, P <0.001), -1.01%, and showed a between-group difference of P < 0.001. Similar results were observed in TAV, the main secondary endpoint (between-group difference -4.9 mm3, P < 0.00 1). These findings provide evidence that PCSK9 inhibition leads to an increased benefit on the progression of coronary artery disease in statin-treated patients.

[0271] The proportion of patients showing regression of coronary atherosclerosis, defined as a change in PAV or TAV less than zero, was evaluated. Using this definition, for PAV, the primary endpoint, 67% of the treatment group receiving the combination of statin and PCSK9 inhibitor experienced regression (between-group difference 17.0%, P < 0.001), while approximately 47% of the patients in the placebo group experienced regression. Similar results were observed for TAV, and more patients achieved regression with combination therapy (between-group difference 12.5%, P < 0.001). This is the first clinical trial showing an increased effect on regression in patients who had been treated with moderate or potent statin therapy before participating in the trial. It is also the first demonstration of a decrease in the progression of atherosclerotic arterial disease by IVUS for non-statin LDL-lowering therapy. After major clinical benefits were demonstrated in multiple large-scale outcome trials, statins are now in the global guidelines for managing patients with clinically manifest coronary heart disease.

[0272] After major clinical benefits were demonstrated in multiple large-scale outcome trials, statins are now in the global guidelines for managing patients with clinically manifest coronary heart disease. It is considered necessary. However, many patients are unable to achieve optimal LDL-C lowering despite statin therapy and are experiencing cardiovascular events. Furthermore, some patients have reported being unable to tolerate adequate therapeutic doses of statins. Since the reduction of LDL-C is insufficient and the residual risk is high, the possibility of additional therapy being useful is suggested. The regulation of hepatic LDL receptor expression by PCSK9 provides a potentially useful target for therapeutic modulation to address the residual cardiovascular risk in statin-treated patients, particularly based on the observation that PCSK9 levels increase in response to statin administration. In this trial, almost all patients were treated with statins before participating in the trial, and when the PCSK9 inhibitor evolocumab was added, the reduction in LDL-C levels and atherosclerotic volume increased. In the trial summarized in Example 1, a favorable effect on disease progression was observed without an increase in the incidence of muscle pain, an increase in liver transaminases, or new-onset diabetes. However, the number of treated patients was relatively small. Subcutaneous injection site reactions were reported only in two evolocumab-treated patients, the detection rate of anti-drug antibodies was low, there were no neutralizing antibodies, and it was well tolerated. These safety findings are consistent with previous observations showing no clear excess of adverse events in statin-treated patients who achieved very low LDL-C levels. Subgroup analysis did not show heterogeneity in the favorable effect of PCSK9 inhibition on disease progression. Regardless of baseline LDL-C levels, evolocumab

[0273]

[0274] ​​​​​​​​​​​​​​Regression was observed. An LDL-C of 70 mg / dL represents the most stringent target level recommended by the ACC / AHA global guidelines. In patients with baseline LDL-C below 70 mg / dL, post hoc analysis of this trial showed that PAV regressed in >80% of patients who received combination therapy. This observation supports current treatment guidelines that recommend intensive lipid lowering in patients with high cardiovascular risk. These findings are reassuring from a safety perspective. The ACC / AHA global guidelines recommend the most stringent target level. In patients with baseline LDL-C below 70 mg / dL, post hoc analysis of this trial showed that PAV regressed in >80% of patients who received combination therapy. This observation supports current treatment guidelines that recommend intensive lipid lowering in patients with high cardiovascular risk. These findings are reassuring from a safety perspective. Decisive evidence to support PCSK9 inhibitors as a clinically effective treatment strategy depends on their ability to reduce cardiovascular adverse events. Previous reports have shown an association between both coronary atherosclerotic burden and rate of progression and cardiovascular outcomes. Current knowledge of the effect of evolocumab on disease progression is promising, but completion of ongoing large-scale cardiovascular outcome trials of PCSK9 inhibitors will provide further confirmation of the efficacy and safety of these drugs.

[0275] Decisive evidence to support PCSK9 inhibitors as a clinically effective treatment strategy depends on their ability to reduce cardiovascular adverse events. Previous reports have shown an association between both coronary atherosclerotic burden and rate of progression and cardiovascular outcomes. Current knowledge of the effect of evolocumab on disease progression is promising, but completion of ongoing large-scale cardiovascular outcome trials of PCSK9 inhibitors will provide further confirmation of the efficacy and safety of these drugs. Most patients (about two-thirds) achieved regression of atheroma despite achieving very low LDL-C levels with evolocumab. However, the trial in Example 1 evaluated patients after 18 months of treatment, which was a relatively short treatment period compared to other recent studies of high-intensity statin treatment that treated patients for 24 months. There remains a possibility that a higher proportion of patients will show regression at these low LDL levels with longer-term treatment. Most patients (about two-thirds) achieved regression of atheroma despite achieving very low LDL-C levels with evolocumab. However, the trial in Example 1 evaluated patients after 18 months of treatment, which was a relatively short treatment period compared to other recent studies of high-intensity statin treatment that treated patients for 24 months.

[0276] There remains a possibility that a higher proportion of patients will show regression at these low LDL levels with longer-term treatment. However, the trial in Example 1 evaluated patients after 18 months of treatment, which was a relatively short treatment period compared to other recent studies of high-intensity statin treatment that treated patients for 24 months. There remains a possibility that a higher proportion of patients will show regression at these low LDL levels with longer-term treatment. The above trial presented clinically demonstrated coronary angiograms of patients' disease progression with PCS There remains a possibility that a higher proportion of patients will show regression at these low LDL levels with longer-term treatment.

[0277] The above trial presented clinically demonstrated coronary angiograms of patients' disease progression with PCS The effect of SK9 inhibition was tested. In asymptomatic patients with overt atherosclerotic disease a similar effect is thought to be observed. The retention of patients (87%) was better than in previous IVUS studies, but in both studies the results may have been influenced by patients who did not complete the trial.

[0278] Over the 20 years following the original observation that statins reduce adverse cardiovascular outcomes, a continuing search has been conducted to identify additional therapies to increase clinical benefit. The PCSK9 inhibitor evolocumab has been shown to lower LDL-C to very low levels and produce significant regression of coronary atherosclerotic plaques. Large-scale outcome trials of PCSK9 inhibitors are ongoing, but current knowledge indicates that combining PCSK9 inhibitors with statins produces a substantial progressive inhibition of disease progression across a wide range of baseline LDL levels.

[0279] Summarizing the results of Example 1, of 968 treated patients (mean age, 59.8 [9.2]; 269 [27.8%] women; LDL-C 92.5 mg / dL [27.2]), 846 received evaluable imaging at follow-up. Compared with placebo, the evolocumab group had lower mean time-weighted LDL-C levels of 93.0 vs 36.6 mg / dL, with a difference of -56.5 mg / dL (95% confidence interval [CI] -59.7, -53.4), P < 0 .001. The PAV, a key efficacy parameter, increased by 0.05% with placebo and decreased by 0.95% with evolocumab, with a difference of -1.01% (95% CI -1.78, 0.64 ) was P < 0.001. Standardized TAV, a secondary efficacy parameter, decreased by 0.9 mm3 in the placebo and by 5.8 mm3 in evolocumab, and the difference was -4.9 mm3 (95% CI -7.3, 2.5), P < 0.001). Evolocumab caused plaque regression in a higher percentage of patients, 64.3% vs. 47.3% for PAV, P < 0.00 1, and 61.5% vs. 48.9% for TAV, P < 0.001. In patients with angiographically proven coronary artery disease treated with statins, addition of evolocumab led to a greater decrease in PAV after 78 weeks compared to placebo, and evolocumab had low rates of safety abnormalities on clinical examinations and cardiovascular events and was well tolerated. The combination therapy

[0280] not only suppressed disease progression but actually reversed it with respect to PAV and TAV. From the above results, a low LDL-C level was observed in the evolocumab combination therapy group (36.6 mg / dL vs. 93.0 mg / dL), which was associated with a decrease in the atheroma volume ratio of evolocumab ( -0.95%) but not with placebo (+0.05%), and the percentage of patients showing plaque regression was higher (64.3% vs. 47.3%). Thus, adding the PCSK9 inhibitor, evolocumab, to statin therapy led to a greater decrease in LDL-C and a greater atheroma regression. Furthermore, the data support the approach that treatment to achieve a low LD

[0281] L-C level of 20 mg / dL provides benefit to the subjects. Furthermore, the above benefits are also supported by the approach in which benefit is achieved by reducing the LDL-C level below the currently recommended minimum level ( <70 mg / dL) according to the global guidelines. Thus, adding evolocumab to statin therapy led to a greater decrease in LDL-C and a greater atheroma regression. Furthermore, the data support the approach that treatment to achieve a low LDL-C level of 20 mg / dL provides benefit to the subjects. Furthermore, the above benefits are also supported by the approach in which benefit is achieved by reducing the LDL-C level below the currently recommended minimum level ( <70 mg / dL) according to the global guidelines. <70 mg / dL) according to the global guidelines. At an average LDL-C level of 36.6 mg / dL obtained in the test, there was no excessive new-onset diabetes, no myalgia, and no neurocognitive side effects, etc., and no safety issues were confirmed.

[0282] Example 2: Use of a PCSK9 antibody and a statin for reducing atherosclerosis Identify human subjects at risk of developing atherosclerosis. Administer to the subject a therapeutically effective amount of evolocumab together with a statin at an optimized level of statin administration. Maintain this combination therapy for at least one year. Throughout the year, the subject's LDL-C level is reduced to 90 mg / dL or less, thereby reducing the risk of atherosclerosis compared to patients who have not received treatment.

[0283] Example 3: Identify patients with clinically evident atherosclerotic cardiovascular (CV) disease. Administer to the patient a therapeutically effective amount of evolocumab together with 40 mg / day of atorvastatin (or its equivalent ). Maintain this combination therapy for at least one year. Throughout the year, the subject's LDL-C level is reduced to 90 mg / dL or less, thereby reducing the risk of CV death, non-fatal myocardial infarction, non-fatal stroke or transient ischemic attack (TIA) and the risk of coronary artery revascularization.

[0284] Example 4: Identify patients with clinically evident atherosclerotic cardiovascular (CV) disease. Administer to the patient 420 mg / month of evolocumab together with 80 mg / day of atorvastatin (or its equivalent ). Maintain this combination therapy for at least one year. Thereby, ​​​​​​​​This combination therapy reduces the risk of CV death, non-fatal myocardial infarction, non-fatal stroke, or transient ischemic attack (T IA), coronary artery revascularization, and hospitalization for unstable angina.

[0285] Example 5: Identify patients with atherosclerotic plaques. Administer evolocumab to the patients in combination with a statin corresponding to 40 mg / day or alternatively 80 mg / day of atorvastatin. Maintain this combination therapy for at least one year. Thereby, this combination therapy reduces the PAV of the patient.

[0286] Example 6: Identify patients with atherosclerotic plaques. Administer evolocumab to the patients in combination with a statin corresponding to 40 mg / day or alternatively 80 mg / day of atorvastatin (or its equivalent). Maintain this combination therapy for at least one year. Thereby, this combination therapy reduces the TAV of the patient.

[0287] Example 7: Identify patients with atherosclerosis. The patients are receiving non-PCK9 LDL-C lowering therapy (e.g., statin). Administer PCSK9 inhibitor therapy to the patients. The amount and duration of PCSK9 inhibitor therapy (e.g., anti-PCSK9 neutralizing antibody) are sufficient to reverse coronary atherosclerosis in the subject in combination with the continued application of non-PCK9 LDL- C lowering therapy.

[0288] Example 8: Identify patients with ischemic heart disease. Administer a certain amount of anti-PCSK9 neutralizing antibody and the maximum tolerated amount of statin to the patients. Maintain this combination therapy for at least one year. Thereby, Thereby, this combination therapy reduces the patient's TAV and PAV.

[0289] Example 9: Identify patients with atherosclerosis. Administer to the patients a certain amount of anti-PCSK9 neutralizing anti- body and the maximum tolerated dose of statin. Maintain this combination therapy for at least one year such that the patient's LDL-C level is maintained at 90 mg / dL or less. Thereby, this combination therapy reduces the patient's TAV and PAV.

[0290] Example 10: Identify patients with plaque and / or atherosclerosis. Administer to the patients a certain amount of PCSK9 inhibitor and the maximum tolerated dose of statin. Maintain this combination therapy for at least one year such that the patient's LD L-C level becomes 60 mg / dL or less. Thereby, the combination therapy results in plaque regression and regression of atherosclerosis .

[0291] Example 11: Identify patients with atherosclerosis. Administer to the patients a certain amount of PCSK9 inhibitor and the optimized dose of statin. Maintain this combination therapy for at least one year such that the patient's LDL-C level is 60 mg / dL or less. Thereby, the combination therapy results in regression of atherosclerosis.

[0292] Example 12: Identify subjects at risk of developing atherosclerosis. Administer to the subjects a certain amount of PC SK9 inhibitor and the optimized dose of statin. Maintain this combination therapy for at least one year such that the subject's LD L-C level becomes 60 mg / dL or less. This combination therapy thus results in a reduced risk of the subject developing atherosclerosis. Result in.

[0293] Example 13: Identify patients with atherosclerosis. Administer a certain amount of a PCSK9 inhibitor to the patients in an amount and for a time such that the patients' LDL-C level is maintained at 60 mg / dL or less for at least one year. This combination therapy thus results in the regression of atherosclerosis. Maintained at 60 mg / dL or less for at least one year in an amount and for a time such that a certain amount Of PCSK9 inhibitor is administered. This combination therapy thus results in the regression of atherosclerosis Result in regression.

[0294] Example 14: Identify patients with atherosclerotic plaques. Administer a certain amount of a PCSK9 inhibitor to the patients in an amount and for a time such that the patients' LDL-C level is maintained at 20 mg / dL to 40 mg / dL for at least one year. This combination therapy thus results in the regression of atherosclerotic plaques. Level is maintained at 20 mg / dL to 40 mg / dL for at least one year in an amount and at a time When a certain amount of PCSK9 inhibitor is administered. This combination therapy thus results in the regression of atherosclerotic Plaques.

[0295] Example 15: Identify patients with atherosclerotic plaques. Administer a certain amount of a statin to the patients in an amount and for a time such that the patients' LDL-C level is maintained at 20 mg / dL to 40 mg / dL for at least one year. This combination therapy thus results in the regression of atherosclerotic plaques. Level is maintained at 20 mg / dL to 40 mg / dL for at least one year in an amount and at a time When a certain amount of statin is administered. This combination therapy thus results in the regression of atherosclerotic Plaques.

[0296] Example 16: Identify patients with atherosclerotic cardiovascular disease. Administer a certain amount of a statin to the patients in an amount and for a time such that the patients' LDL-C level is maintained at 20 mg / dL to 50 mg / dL for at least two years. As a result, the treatment is associated with a reduction in cardiovascular death, myocardial infarction, Level is maintained at 20 mg / dL to 50 mg / dL for at least two years in an amount and Time when a certain amount of statin is administered. As a result, the treatment is associated with a reduction in cardiovascular death, myocardial infarction, A 15% reduction in the composite risk of hospitalization for stroke, unstable angina, or coronary artery revascularization and a 20% reduction in the risk of cardiovascular death, myocardial infarction, or stroke. resulting in a 20% reduction in the risk of cardiovascular death, myocardial infarction, or stroke.

[0297] Example 17: A randomized double-blind placebo-controlled trial was conducted in 27,564 patients with atherosclerotic cardiovascular disease who were receiving statin therapy with LDL cholesterol ≥ 70 mg / dL or non-HDL ≥ 100. Patients were randomly assigned to receive subcutaneous injections of evolocumab (140 mg every 2 weeks or 420 mg once monthly) or the corresponding placebo. The primary efficacy endpoint was the first occurrence of the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization. The primary secondary efficacy endpoint was the first occurrence of the composite of cardiovascular death, myocardial infarction, or stroke. The median follow-up was 2.2 years. Regardless of which occurred first, that composite. Regardless of which occurred first, that composite. The median follow-up was 2.2 years.

[0298] Summary of results: Evolocumab reduced LDL cholesterol by 59% from a median of 92 mg / dL to 30 mg / dL (P < 0.001). Evolocumab significantly reduced the risk of the primary endpoint [1344 patients (9.8%) vs. 1563 patients (11.3%); HR 0 .85, 95% CI 0.79 - 0.92, P < 0.001] and the primary secondary endpoint [816 patients (5.9%) vs. 1013 patients (7.4%); HR 0.80, 95% CI 0.73 - 0.88, P < 0.001]. The results included those at the lower quartile of baseline LDL cholesterol (median 74 mg / dL). CI 0.73 - 0.88, P < 0.001]. The results included those at the lower quartile of baseline LDL cholesterol (median 74 mg / dL), including those. It was consistent across the major subgroups. The incidence of adverse events, including musculoskeletal, diabetes, and neurocognitive, was similar in the two groups.

[0299] Summary of conclusions: Inhibition of PCSK9 by evolocumab, with statin therapy as background, reduced LDL cholesterol by 30 mg / dL and reduced the risk of cardiovascular events without major safety concerns. These findings suggest that patients with atherosclerotic cardiovascular disease benefit from lowering LDL cholesterol below current targets.

[0300] In this example, the results of the study named "Further cardiovascular Outcomes Research with PCSK9 Inhibition in subje cts with Elevated Risk" (FOURIER) are summarized. FOURIER was a dedicated cardiovascular outcomes trial that tested the clinical efficacy and safety of adding evolocumab to high-intensity or moderate-intensity statin therapy in patients with clinically evident atherosclerotic vascular disease.

[0301] Detailed consideration of the method of Example 17 Study design This example (the "FOURIER trial") was a randomized, double-blind, placebo-controlled, multinational clinical trial that randomized patients at 1,242 sites in 49 countries.

[0302] Study population Eligible patients were 40 to 85 years old and had clinically evident atherosclerotic cardiovascular disease, defined as a history of myocardial infarction, non-hemorrhagic stroke, or symptomatic peripheral artery disease, and had additional characteristics (full eligibility criteria in the supplement) that put them at higher cardiovascular risk. Patients were to receive optimized stable lipid-lowering therapy, preferably a high-intensity statin, to have fasting LDL cholesterol ≥ 70 mg / dL or non-HDL cholesterol ≥ 100 mg / dL, regardless of the presence or absence of ezetimibe, and must have received at least 20 mg of atorvastatin or its equivalent per day.

[0303] Randomization and study treatment Eligible patients were randomly assigned 1:1 to receive subcutaneous injections of evolocumab (either 140 mg / every 2 weeks or 420 mg / month, according to the patient's preference) or the corresponding placebo. Random assignment of study treatment was done by a central computer system that included stratification by final screening LDL cholesterol (< 85 vs ≥ 85 mg / dL) and region, and was double-blind. 85 vs ≥ 85 mg / dL) and region, and was double-blind. was done by a central computer system that included stratification by final screening LDL cholesterol (<

[0304] Endpoint The primary efficacy endpoint was defined as the composite of major cardiovascular events, which was cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization. The main secondary efficacy endpoint was the composite of cardiovascular death, myocardial infarction, or stroke. Other efficacy endpoints are listed in the supplementary section of Example 17. Safety was evaluated by collection of adverse events and central laboratory testing (see the supplementary section of Example 17). efficacy endpoint was the composite of cardiovascular death, myocardial infarction, or stroke. Other efficacy endpoints are listed in the supplementary section of Example 17. Safety was evaluated by collection of adverse events and central laboratory testing (see the supplementary section of Example 17). Endpoint descriptions are provided in the supplementary section of Example 17. Endpoint descriptions are provided in the supplementary section of Example 17. Safety was evaluated by collection of adverse events and central laboratory testing (see the supplementary section of Example 17). Endpoint descriptions are provided in the supplementary section of Example 17.

[0305] Statistical considerations The primary efficacy analysis was of any element of the primary composite endpoint from the randomized treatment assignment Based on the time to the first occurrence. If the primary endpoint was significantly reduced (P<0 .05), the major secondary endpoints and then cardiovascular death were tested at a significance level of 0.05 in a hierarchical manner . For further details, see the supplementary section of Example 17. All efficacy analyses were performed on an intention-to-treat basis . For safety evaluation, all randomized patients who received at least one study treatment and for whom post-dose data were available were included . The number of study samples was based on the major secondary assessment items, and 1630 such endpoints were estimated to be required to provide 90% power to detect a 15% relative risk reduction with evolocumab . (Sabatine MS, Giugliano RP, Keech A, et al. Rationale and design of the Further cardiovascular Outcomes Research with PCSK9 Inhibition in subjects with Elevated Risk trial. Am Heart J 2016;173:94-101.). Hazard ratios and 95% confidence intervals were created using a Cox proportional hazards model with stratifying factors as covariates, and the P-values for event time-to-occurrence analysis were from the log-rank test .

[0306] Results of Example 17 Patients A total of 27,564 patients were randomized from February 2013 to June 2015. The baseline characteristics of the patients in the two groups were well-matched and are shown in Table 17.1

[0307]

Table 12

[0308]

Table 13

[0309] The mean age of the patients was 63 years, 25% were female, and 81% had a history of myocardial infarction, 19% had a history of non-hemorrhagic stroke, and 13% had symptomatic peripheral arterial disease. At baseline, a total of 69.3% of the patients were on high-intensity statin therapy (defined according to the ACC / AHA guidelines (Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC / AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:S1-45), see Supplementary Section of Example 17), 30.4% were on moderate statin therapy, and 5.2% were also taking ezetimibe. During the study period, only 9.8% of the patients changed their lipid-lowering basic treatment (see the results in the Supplementary Section of Example 17 for details). The use of secondary preventive therapies was high. At the time of study enrollment, 93% of the patients were on antiplatelet therapy, 76% were taking beta-blockers, and 78% were taking ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin II receptor blockers). At baseline, a total of 69.3% of the patients were on high-intensity statin therapy (defined according to the ACC / AHA guidelines (Stone NJ, Robinson JG, Lichtenstein AH, et al.2013 ACC / AHA guideline on the treatm ent of blood cholesterol to reduce ather osclerotic cardiovascular risk in adults :a report of the American College of Car diology / American Heart Association Task Force on Practice Guidelines.Circulation 2014;129:S1-45), see Supplementary Section of Example 17), 30.4% were on moderate statin therapy, and 5.2% were also taking ezetimibe. During the study period, only 9.8% of the patients changed their lipid-lowering basic treatment (see the results in the Supplementary Section of Example 17 for details). The use of secondary preventive therapies was high. At the time of study enrollment, 93% of the patients were on antiplatelet therapy, 76% were taking beta-blockers, and 78% were taking ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin II receptor blockers). see Supplementary Section of Example 17), 30.4% were on moderate statin therapy, and 5.2% were also taking ezetimibe. During the study period, only 9.8% of the patients changed their lipid-lowering basic treatment (see the results in the Supplementary Section of Example 17 for details). The use of secondary preventive therapies was high. At the time of study enrollment, 93% of the patients were on antiplatelet therapy, 76% were taking beta-blockers, and 78% were taking ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin II receptor blockers). (see the results in the Supplementary Section of Example 17 for details). The use of secondary preventive therapies was high. At the time of study enrollment, 93% of the patients were on antiplatelet therapy, 76% were taking beta-blockers, and 78% were taking ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin II receptor blockers). At the time of study enrollment, 93% of the patients were on antiplatelet therapy, 76% were taking beta-blockers, and 78% were taking ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin had taken a sinus receptor blocker) and / or an aldosterone antagonist.

[0310] A total of 27,525 patients (99.9%) received at least one dose of the study drug. Early permanent discontinuation of the study drug occurred in 12.5% of patients (5.7% per year), withdrawal of consent in 0.7% ( 0.3% per year), and loss to follow-up in <0.1% (0.03% per year), and the same rates were shown in the two study groups (Figure 17). The median follow-up period was 26 months (IQR 22 - 30), and the follow-up person-years were 59,865 person-years. Confirmation of the primary endpoint was completed in 99% of the potential follow-up person-years.

[0311] Lipid data The median baseline LDL cholesterol was 92 mg / dL (IQR 80 - 109 m g / dL). Evolocumab reduced LDL cholesterol by an average of 59% (95% CI 58 - 60; P < 0.001) at week 48 compared with placebo, with an average absolute reduction of 56 mg / dL (95% CI 55 - 57) and a median reduction to 30 mg / dL (IQR 19 - 46 mg / dL). The reduction in LDL cholesterol persisted over the long term (Figure 1 5 and Figure 18). At week 48, LDL cholesterol decreased to ≤70 mg / dL in 87 % of the evolocumab group, ≤40 mg / dL in 67%, and ≤25 mg / dL in 42%, whereas in the placebo group they were 18%, 0.5%, and <0.1%, respectively (P < 0.001 for all treatment comparisons). Similarly, evolocumab reduced the related atherogenic lipid measurements, and the reduction compared with placebo at week 48 was 52% for non-HDL cholesterol and 49% for apolipoprotein B (P < 0.001 for both). For further details, refer to the supplementary results of Example 17 and Figure 19.

[0312] Efficacy endpoint Evolocumab significantly reduced the risk of the primary composite endpoint of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary artery revascularization. The primary endpoint was observed in 1344 cases (9.8%) in the evolocumab group and 1563 cases (11.3 %) in the placebo group (HR 0.85, 95% CI 0.79 - 0.92, P < 0.001) ( Table 17.2a and Figure 16A). In Figures 16A and 16B, the Kaplan - Meyer rates of the primary endpoint at 1, 2, and 3 years were 5.3% (95% CI 4.9 - 5.7) vs. 6.0% (95% CI 5.6 - 6. 4), 9.1% (95% CI 8.6 - 9.6) vs. 10.7% (95% CI 10.1 - 1 1.2), and 12.6% (95% CI 11.7 - 13.5) vs. 14.6% (95% C I 13.8 - 15.5) in the evolocumab and placebo groups, respectively. The Kaplan - Meyer rates of the major secondary endpoints at 1, 2, and 3 years were 3.1% (95 % CI 2.8 - 3.4) vs. 3.7% (95% CI 3.4 - 4.0), 5.5% (95 % CI 5.1 - 5.9) vs. 6.8% (95% CI 6.4 - 7.3), and 7.9% ( 95% CI 7.2 - 8.7) vs. 9.9% (95% CI 9.2 - 10.7) in the evolocumab and placebo groups, respectively. The P - value was calculated using the log - rank test. The P - value was calculated using the log - rank test.

[0313]

Table 14

[0314] CTTC stands for Cholesterol Treatment Trialists C ollaboration and represents the composite endpoint of coronary heart death, non-fatal MI, stroke, or coronary revascularization. Considering the hierarchical nature of the statistical tests, the P-values for the primary and major secondary endpoints should be considered statistically significant, while all other P-values should be considered exploratory.

[0315] Similarly, evolocumab significantly reduced the rate of the major secondary composite endpoint of cardiovascular death, myocardial infarction, or stroke. The major secondary endpoint occurred in 81 6 cases (5.9%) in the evolocumab group and 1013 cases (7.4%) in the placebo group (HR 0.80, 95% CI 0.73–0.88, P<0.001) (Table 17.2 and Figure 16B). The magnitude of risk reduction for the primary endpoint increased over time from 12% (95% CI 3–20) at year 1 to 19% (95% CI 11–27) after year 2. Similarly, for the major secondary endpoint, the risk reduction was 16% (95% CI 4 –26) at year 1 and 25% (95% CI 15–34) after year 2 (see Figure 20, Table 1 7.2b and Supplementary Results of Example 17). The risk of MI, stroke, and coronary revascularization was reduced by 21–27%, but there was no effect on hospitalizations for unstable angina, hospitalizations for worsening heart failure, or death from any cause.

[0316]

Table 15

[0317] The risk of MI, stroke, and coronary revascularization was reduced by 21–27%, but the impact on hospitalization for un...

Claims

**Claim 1** A method for treating coronary atherosclerotic heart disease, comprising: a. identifying a subject who has received a first therapy including a non-PCSK9 LDL-C lowering therapy; and b. administering a second therapy including a PCSK9 inhibitor therapy to the subject, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reverse coronary atherosclerotic heart disease in the subject, and the first therapy is different from the second therapy. **Claim 2** A method for treating coronary atherosclerotic heart disease, comprising: a. identifying a subject having an LDL-C level of 70 mg / dL or less; b. administering an anti-PCSK9 neutralizing antibody to the subject in an amount and for a time sufficient to lower the LDL-C level to 60 mg / dL or less. **Claim 3** A method for reducing the plaque atherosclerotic volume (PAV) in a subject, comprising: identifying a subject who has received at least a moderate level of treatment with a statin; administering an anti-PCSK9 neutralizing antibody to the subject in an amount and for a time sufficient to lower the LDL-C level to 90 mg / dL or less, thereby reducing the plaque atherosclerotic volume (PAV) in the subject. **Claim 4** A method for reducing the total atherosclerotic volume (TAV) in a subject, comprising: a. identifying a subject who has received at least a moderate level of treatment with a statin; b. administering an anti-PCSK9 neutralizing antibody to the subject in an amount and for a time sufficient to lower the LDL-C level to 90 mg / dL or less, thereby reducing the total atherosclerotic volume in the subject. **Claim 5** A method for treating coronary atherosclerotic heart disease, comprising: a. identifying a subject intolerant to statins; b. administering at least a low dose of statin treatment to the subject intolerant to statins; c. administering an amount of anti-PCSK9 neutralizing antibody to the subject, thereby treating coronary atherosclerotic heart disease. **Claim 6** A method for reducing the amount of atherosclerotic plaques in a patient, comprising administering a monoclonal antibody against human PCSK9 to a subject having atherosclerotic plaques, wherein the subject has received optimized statin therapy, thereby reducing the amount of atherosclerotic plaques in the subject. **Claim 7** ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ A method of combining evolocumab and statin therapy to produce a greater LDL-C reduction and regression of coronary atherosclerosis at a well-tolerated dose, comprising: administering at least a moderate-intensity statin therapy to a subject; administering to the subject a sufficient amount of evolocumab such that the LDL-C level of the subject is reduced to 40 mg / dL or less; maintaining the LDL-C level of the subject at 40 mg / dL or less for at least one year. A method for treating coronary atherosclerosis, comprising: identifying a subject having an LDL-C level of 70 mg / dL or less; administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 60 mg / dL or less. A method for reducing atherosclerotic volume percentage (PAV) in a subject, comprising: identifying a subject who has received at least a moderate level of treatment with a non-PCSK9 LDL-C lowering agent; administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 90 mg / dL or less, thereby reducing the atherosclerotic volume percentage (PAV) in the subject. A method for reducing total atherosclerotic volume (TAV) in a subject, comprising: identifying a subject who has received at least a moderate level of treatment with a non-PCSK9 LDL-C lowering agent; administering to the subject a PCSK9 inhibitor in an amount and for a time sufficient to reduce the LDL-C level to 90 mg / dL or less, thereby reducing the total atherosclerotic volume in the subject. A method for suppressing disease progression, comprising: identifying a subject having an LDL-C level of 60 mg / dL or less; administering to the subject at least a moderate-intensity non-PCSK9 LDL-C lowering therapy; administering a PCSK9 inhibitor at a level sufficient to reduce the LDL-C level of the subject to 30 mg / dL, thereby suppressing disease progression. A method of combining PCSK9 inhibitor therapy and non-PCSK9 LDL-C lowering therapy to produce a greater LDL-C reduction and regression of coronary atherosclerosis at a well-tolerated dose, comprising: ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ administering at least moderately intensive non-PCSK9 LDL-C lowering therapy; administering to the subject a sufficient amount of a PCSK 9 inhibitor such that the LDL-C level of the subject is reduced to 40 mg / dL or less; maintaining the LDL-C level of the subject at 40 mg / dL or less for at least one year ; and a method comprising the steps of: **Claim 13** A method of reducing the risk of a cardiovascular event, comprising: identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and 、 administering to the subject a second therapy comprising a PCSK9 inhibitor, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of a cardiovascular event in the subject, the first therapy is different from the second therapy, and the risk is a composite of a) cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or coronary artery revascularization, or b) a composite of cardiovascular death, myocardial infarction or stroke. **Claim 14** A method of reducing the risk of a cardiovascular event, comprising: identifying a subject who has received a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and administering to the subject a second therapy comprising a PCSK9 inhibitor, wherein both the first and second therapies are administered to the subject in an amount and for a time sufficient to reduce the risk of a cardiovascular event in the subject, the first therapy is different from the second 、 therapy, and the risk is a composite of lethal MI and / or non-lethal MI and lethal and / or non-lethal coronary artery revascularization. **Claim 15** A method of reducing the risk of major adverse limb events ("MALE"), comprising: administering a non-statin LDL-C lowering agent to a subject; and administering a statin to the subject having peripheral artery disease ("PAD"). **Claim 16** A method of reducing the risk of major adverse cardiovascular events ("MACE"), comprising: administering a non-statin LDL-C lowering agent to a subject; and administering a statin to the subject having PAD. **Claim 17** A method of reducing the risk of a cardiovascular event, comprising: providing to a subject a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and providing to the subject a second therapy comprising a PCSK9 inhibitor, wherein both the first and second therapies are administered to the subject, and the subject has a... ... risk of 11.

8. **Claim 18** A method of reducing the risk of a cardiovascular event, comprising: providing to a subject a first therapy comprising a non-PCSK9 LDL-C lowering therapy; and providing to the subject a second therapy comprising a PCSK9 inhibitor, wherein both the first and second therapies are administered to the subject, and the subject has a... A method having an Lp(a) level of mg / dL to 50. **Claim 18** A method for reducing the risk of major vascular events in a subject, comprising: 1) identifying a subject having at least one of (a) a recent MI, (b) multiple prior MIs, or (c) multivessel disease; 2) providing to the subject a first therapy comprising a non-PCSK9 LDL-C lowering therapy; 3) providing to the subject a second therapy comprising a PCSK9 inhibitor, thereby reducing the risk that the subject will have a major vascular event. A method comprising. **Claim 19** A method for reducing the risk of a cardiovascular event, comprising administering to a subject having an LDL-C level of 70 mg / dL or higher an amount and for a time sufficient to lower the LDL-C level to 40 mg / dL or lower of a PCSK9 inhibitor. A method comprising.

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