Evolocumab in Acute Coronary Syndrome: A Double-Blind Randomized Placebo Controlled Study
Phase: PHASE2
Conditions: Acute Coronary Syndrome
Sponsor: Johns Hopkins University

Evolocumab in Acute Coronary Syndrome     
NCT03515304
6/5/2020

 
 
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Date: 6/5/2020  
Principal Investigator: _Dr. Thorsten Leucker_ 
Application Number: _ IRB00156313_ 
 
 
 
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1. 
Abstract 
a. Provide no more than a one page research abstract briefly stating the problem, the research 
hypothesis, and the importance of the research. 
 
Despite aggressive early intervention and current secondary prevention strategies, hundreds of 
thousands of patients who survive hospitalization for acute coronary syndrome (ACS) experience 
subsequent unfavorable outcomes, including recurrent ischemic events and unfavorable cardiac 
remodeling associated with progressive left ventricular dysfunction and congestive heart failure.  
Vascular and myocardial inflammation are significantly increased in ACS patients, are closely 
correlated to LDL-C levels, and are associated with these adverse consequences in the post-ACS 
patient population. Inflammation may also play a role in platelet aggregation one of the responsible 
mechanisms for the index and for any recurrent coronary thrombotic events. Serum proprotein 
convertase subtilisin/kerin type 9 (PCSK9) levels are also increased in ACS, may raise LDL-C, and 
our pre-clinical studies indicate that PCSK9 is also a potent inducer of vascular inflammation.  The 
addition of the PCSK9 antibody evolocumab, currently approved to lower LDL-C in certain patient 
populations, to current medical therapies would appear to be of particular benefit in an important 
subset of ACS patients, those with non-ST-elevation myocardial infarction (NSTEMI) by markedly 
reducing LCL-C, stabilizing vulnerable plaque, and limiting inflammation-associated myocardial 
cell loss and resultant dysfunction.   
 
Hypothesis: In a placebo-controlled, randomized double blind trial, the addition of evolocumab to 
standard care in NSTEMI patients (1) decreases LDL-C during hospitalization and at 30 days, (2) 
decreases vascular/plaque and myocardial inflammation as assessed by PET scanning at 30 days, 
and improves (3) serum markers of endothelial function and of platelet function at hospital 
discharge and at 30 days, and (4) echocardiographic assessment of left ventricular function at 30 
days and six months. 
 
This is the first PCSK9 inhibitor trial which examines these outcomes in the ACS patient 
population.  It will provide valuable data on the extent and time course of LDL-C reduction as well 
as the impact of inhibition on inflammatory markers and on imaging assessment of vascular and 
myocardial inflammation, all of which may significantly impact important clinical outcomes in this 
high risk patient cohort.[1]  

 
 
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2. 
Objectives (include all primary and secondary objectives): To conduct a placebo-controlled 
randomized, double blind study of the effect of the addition of evolucomab to standard care in 
NSTEMI patients  
2.1 
Primary 
The primary objective is the difference in the mean % change in LDL-C from baseline to 30 days 
in the evolocumab and placebo groups. 
 
2.2 
Secondary 
The secondary objectives are to compare in the evolocumab and placebo groups: 
 
a. Serial serum markers of inflammation, lipids, myocardial injury, and of left ventricular 
function will be collected at baseline, day 1, day 3, at hospital discharge and at 30 days follow 
up. 
 
The time points of comparison are day 3, hospital discharge and 30 days.  
 
i. 
PCSK-9 
ii. 
Soluble LOX-1 
iii. 
Interleukin-6 
iv. 
High sensitivity C-reactive protein  
v. 
HDL-cholesterol 
vi. 
Triglyceride  
vii. 
Total cholesterol  
viii. 
Troponin 
ix. 
Pro-BNP 
 
b. The change between early hospitalization or shortly following discharge   and thirty day 
assessments of 
i. 
PET-FDG assessed vascular inflammation in the most diseased segment of aorta or 
carotid artery 
ii. 
Echo assessed regional wall motion in the infarct territory 
iii. 
Echo assessed global LV function 
iv. 
Echo assessed LV systolic and diastolic volumes 
 
c. At thirty days: 
i. 
Comparison of PET-FDG assessment of vascular inflammation in the evolocumab 
versus placebo group as described in 2.2. b i 
ii. 
Echo assessed as described in 2.2. b ii-iv 
iii. 
Angina class 
iv. 
New York Heart Association functional class 
v. 
LDL-C and serum markers as described in 2.2. a  
vi. 
Determine the relationship if any among the extent of change in the serum makers, FDG-
PET results and echocardiogram results. 
 
d. At six months 
i. 
Angina class 
ii. 
New York Heart Association functional class 
iii. 
LDL-C and serum markers as described in 2.2. a  
iv. 
Echo assessment as described in 2.2. b ii-iv 
 

 
 
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e. 
 
At 12 months 
Serum markers as described in 2.2 a 
 
 
2.3 Exploratory  
 
a. The exploratory basic science outcome is: Direct comparison of endothelial cell function in 
cells harvested from intravascular equipment in the evolocumab- and placebo-randomized 
patient groups.  
b. The exploratory imaging outcome is: To assess changes in FDG-PET-guided myocardial 
inflammation in the evolocumab and placebo groups at thirty days. Additionally, we will 
compare PET assessed vascular inflammation in the evolocumab and placebo groups on the 
exam obtained during the early hospitalization. 
c. Platelet aggregation and function studies. 
 
 
3. 
Background (briefly describe pre-clinical and clinical data, current experience with procedures, 
drug or device, and any other relevant information to justify the research) 
 
The total burden of coronary heart disease and associated mortality have decreased over the last 10 
years. Although the incidence of STEMI has decreased by 50% to 60% over the last decade [2], the 
proportion of patients with acute coronary syndrome who now present with NSTEMI has grown 
substantially and now represents approximately 70% of all acute coronary syndrome patients [3]. 
This shift is likely multifactorial, but relates to the aging population, an increase in diabetes 
mellitus, and perhaps a change in plaque characteristics with fewer of the plaque rupture events 
associated with STEMI [4]. Recent studies show that over the last decade the NSTEMI population 
is getting older with an increased prevalence of diabetes, hypertension, lung disease, chronic renal 
disease, and prior coronary revascularizations [5]. Acute myocardial infarction remains a major 
cause of morbidity and mortality in the United States, Europe and Asia [6]. Despite the majority of 
NSTEMI patients receiving guideline recommended dual antiplatelet, beta blocker, ACE or ARB 
and statin therapies in addition to coronary revascularization, in hospital mortality is 5% and six-
month mortality in NSTEMI hospital survivors is 7.6% (IBID). Six-month mortality remains above 
10% in hospital survivors with elevated baseline risk, such as advanced age and evidence of heart 
failure on admission (IBID). Long term mortality and recurrent ischemic events also remain high in 
NSTEMI patients  [7]. Recurrent ischemic events are likely related to inflammation and the degree 
of residual coronary plaque burden. The Providing Regional Observations to Study Predictors of 
Events in the Coronary Tree (PROSPECT) study evaluated the risk for recurrent ischemic events 
using three vessel intracoronary ultrasound in patients receiving percutaneous coronary intervention 
for acute coronary syndrome [8]. During the three-year follow-up, with guideline directed risk 
factor modification, recurrent ischemic events were highest in patients with lesions described as thin 
fibrous cap atheroma, plaque burden >70%, and minimal luminal area < 4.0 mm2.  Additionally, 
patients with elevated markers of inflammation (hsCRP) at six months experienced higher rates of 
recurrent ischemic events at follow-up. Although the number of high risk thin-cap fibroatheroma 
did not differ between the high-hsCRP and normal-hsCRP groups, nonculprit lesion-related 
ischemic events were independently predicted by an elevated hsCRP. These data indicate that 
inflammation increases the likelihood of vulnerable plaque rupture with result antischemic events 
[9]. These data suggest that despite aggressive risk factor modification in patients with acute 
coronary syndrome, recurrent ischemic events are frequent and are associated with non-culprit 
lesion plaque burden and ongoing inflammation.  
In addition to recurrent ischemic events, heart failure is common post myocardial infarction and a 
leading cause of death in older NSTEMI patients. In a large cohort of patients 65 years of age and 

 
 
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older suffering a first myocardial infarction, new heart failure was diagnosed in 37% during the 
index hospitalization (13% mortality) with an additional 71% of hospital survivors developing heart 
failure during the five-year follow up period, 64% of which occurred in the first year. Short- and 
long- term mortality are significantly greater in those NSTEMI patients who develop heart failure 
[10]. Inflammatory mediators are also activated in heart failure after myocardial injury and are 
associated with progressive left ventricular dysfunction [11]. 
 
Evolocumab is a monoclonal antibody that inhibits PCSK9 and is FDA-approved as an adjunct to 
diet and maximally tolerated statins for use in certain patients who need to further significantly 
lower LDL-cholesterol level. In a large randomized clinical trial in patients with atherosclerotic 
cardiovascular disease (median of 3 years after a recent event) and LDL cholesterol levels of 70 mg 
per deciliter or higher who were receiving statin therapy, the addition of evolocumab significantly 
reduced the risk of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable 
angina, or coronary revascularization during a median follow-up of 2.2 years [12]. In this study, the 
median LDL cholesterol on statin therapy was 92 mg / dL and the addition of evolocumab reduced 
LDL cholesterol by 59% to a median of 30 mg / dL. Little is known regarding other potential 
additional benefits of PCSK9 inhibition in the setting of ACS.  
 
ACS is associated with a marked increase of serum PCSK9 that likely has an important 
pathophysiologic role in mediating vascular and myocardial inflammation, leading to plaque 
vulnerability of both culprit and non-culprit coronary vessels as well as adverse myocardial 
remodeling and resulting contractile dysfunction. Growing evidence emphasizes a potential role of 
PCSK9 antibodies beyond their LDL-cholesterol lowering capacity (pleiotropic effects), which are 
likely beneficial in managing NSTEMI [13]. The Ottawa Heart Genomics Study and the Emory 
Cardiovascular Biobank both demonstrated an association between elevated PCSK9 levels and 
adverse acute and long-term events in patients with ACS. PCSK9 levels are markedly elevated 
during an ACS, and in one study were related to the composite endpoint of death and recurrent ACS 
at 1-year follow-up.[14]  Additional data indicate that elevated PCSK9 adversely affects coronary 
plaques through several pathways, including pro-inflammatory LDL oxidation and direct 
modification of plaque composition [15-17]. Additionally, chronically elevated PCSK9 levels are 
associated with progression of atherosclerosis [14]. Finally, a recent study suggests that increased 
PCSK9 levels are associated with higher platelet reactivity and are a possible predictor of ischemic 
events in ACS patients [18].  
 
Over the past few decades, our understanding of the vascular biology of atherogenesis and its 
clinical presentations has advanced significantly. It is now apparent that inflammatory processes 
play a key role not only in the initiation and progression of ASCVD but also in the clinical events 
associated with instability of already established atherosclerotic plaques [19-21]. Traditional and 
novel cardiovascular risk factors trigger a chronic inflammatory process, which is accompanied by 
loss of vasodilatory and antithrombotic properties of the vascular endothelium [22-24]. Clinical 
studies show that this emerging biology of inflammation in atherosclerosis applies directly to 
human pathology [25]. Elevated inflammatory markers predict outcomes of ACS patients  
independently of the extent of myocardial damage [25]. In addition, low-grade chronic 
inflammation, as indicated by levels of the inflammatory marker hsCRP, prospectively 
independently defines risk of atherosclerotic complications, thus adding to the prognostic 
information provided by traditional risk factors [26, 27]. Moreover, certain treatments that reduce 
coronary risk also limit inflammation [28, 29].  
 
Identifying reliable endothelial cell (EC) function markers for in vivo testing remains a challenge. In 
this clinical trial, we propose to utilize the emerging EC function marker sLOX1. The LOX1 
receptor is an endothelial receptor for atherogenic oxidized-LDL and is implicated in the 

 
 
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pathogenesis of atherosclerosis [30]. In addition, nuclear imaging studies detecting radiolabeled 
LOX1 report significantly higher accumulation of LOX1 in grade IV atheroma than in more stable 
lesions [31]. It was recently reported that LOX1 is converted to soluble molecules by proteolytic 
cleavage at the membrane proximal site of the extracellular domain. In the same study, EC 
activation by pro-inflammatory stimuli, e.g. TNF-a, led to cell-surface expression of LOX-1 which 
precedes soluble LOX-1 production [32]. sLOX1 is also proposed as a marker of plaque instability 
in ACS patients [33]. Finally, persistently elevated sLOX1 levels in ACS patients are linked to 
adverse clinical outcomes [34]. Based on the scientific evidence, we believe that sLOX1 is a 
suitable marker for endothelial dysfunction and possibly plaque instability in the setting of ACS and 
NSTEMI.  
 
In this pilot study, we will utilize non-invasive PET imaging to assess vascular/plaque and 
myocardial inflammation. A recent review article nicely summarizes the utility of PET in the setting 
of ACS [35]. The strength of PET-guided imaging in this setting is the identification of activated 
inflammatory cells in the atherosclerotic plaque, providing important information regarding the 
mechanism of vascular instability. Furthermore, longitudinal PET studies can assess the 
effectiveness of novel anti-inflammatory therapies, such as evolocumab. Initial validation of FDG-
PET imaging in the setting of ACS was performed in mice [36], but other reports also provide proof 
of feasibility in large animals and humans [37, 38]. Ripschler et al. subsequently demonstrated that 
the extent of FDG-derived myocardial inflammation early after myocardial infarction correlated 
with infarct size and systemic inflammatory markers at that time and with LVEF and cardiac 
volumes at 6-9 month follow-up [39]. 
 
The multimodality dal-PLAQUE imaging study successfully utilized FDG-PET to assess plaque 
inflammation and burden in patients with high risk of coronary heart disease [40]. A subsequent 
study reported a functional alteration of the plaque, characterized by  activation of resident 
inflammatory cells, which can cause plaque instability and occlusive thrombus formation [41]. 
Since persistent activation of adaptive immunity in patients with unstable angina is linked to 
coronary instability [42], we propose to evaluate the impact of evolocumab on the extent and degree 
of vascular inflammation in our study cohort.  
 
4. 
Study Procedures 
 
a. Study design, including the sequence and timing of study procedures   
(distinguish research procedures from those that are part of routine care). 
 
This is a phase 2, double-blind, randomized, placebo controlled clinical trial of 420 mg 
evolocumab administered subcutaneously using an autoinjector/pen in NSTEMI patients during 
early hospitalization at the Johns Hopkins Hospital or the Johns Hopkins Bayview Medical 
Center.. The placebo and evolocumab will be given exactly the same way with the same Amgen 
provided device. All participants will receive standard care for NSTEMI, including high dose 
statin, aspirin, beta blocker, and, as appropriate, ACE-I or ARB and early intervention.  High 
dose statin therapy consists of atorvastatin 40mg or 80mg or rosuvastatin 20mg or 40mg per the 
most recent ACC/AHA guidelines. [43] After signing informed consent, subjects will be 
randomized to receive one dose of evolocumab or matching placebo subcutaneously. Research 
blood samples for LDL-C and inflammatory markers, and PET imaging assessment of vascular 
inflammation as well as echocardiographic studies for left ventricular function will be obtained. 
An independent Data and Safety Monitoring Committee will review all potential side effects 
and clinical outcomes during the twelve months of follow-up. 
 

 
 
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At the 30-day follow-up visit we will perform a physical exam and obtain a history of any 
clinical events including adverse events. We will perform a second FDG-PET study to assess 
vascular and myocardial; inflammation. Additionally, we will assess LDL-C and serum markers 
of inflammation and endothelial function as outlined in 2.2 a. 
 
At the 6-month follow-up visit will perform a physical exam and obtain a history of any clinical 
events including adverse events. Additionally, we will assess LDL-C and serum markers of 
inflammation and endothelial function as outlined in 2.2 a. 
 
At the 9-month follow-up visit, we will contact the participant by phone to learn of any adverse 
events. If the participant was admitted to the Emergency Department or Hospital we will obtain 
permission to obtain medical records.  
  
At 12-month follow-up visit we will assess lipid profile and serum markers of inflammation and 
endothelial function as outlined in 2.2 a.  
 
 
All above are research studies with the exception of the clinical echocardiogram during the 
initial hospitalization. 
 
b. Study duration and number of study visits required of research participants. 
 
The study duration for each participant is twelve-months and there are three study visits 
required. 
 
c. Blinding, including justification for blinding or not blinding the trial, if applicable. 
 
The investigators and participants are blinded.  Blinding is necessary to avoid potential bias in 
data gathering and analysis.  The Hopkins Investigational Pharmacy will have access to study 
drug assignment if there is a clinical need for the subjects’ treating physician to be aware of 
assignment. 
 
d. Justification of why participants will not receive routine care or will have current therapy 
stopped. 
 
All participants will receive routine care and will not have current therapy stopped. Evolocumab 
is not standard of care for ACS or NSTEMI patients.  
 
e. Justification for inclusion of a placebo or non-treatment group. 
 
Inclusion of a placebo, comparator group is necessary to best determine the safety and efficacy 
of evolocumab in NSTEMI patients.  As noted above, evolocumab is not considered “treatment” 
for this patient population and hence we do not believe there is a “non-treatment” group, or 
ethical concern by inclusion of a placebo group.    
 
f. Definition of treatment failure or participant removal criteria. 
 
Early stopping rules:  
 
 
 
Only participants who go to CABG (unanticipated) will be removed, because procedures 
utilizing the heart and lung machine itself are associated with markedly increased inflammation. 

 
 
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a. Description of what happens to participants receiving therapy when study ends or if a 
participant’s participation in the study ends prematurely. 
 
Participants will only receive one dose of the study drug and will not receive any additional 
study related therapy. 
 
5. 
Inclusion/Exclusion Criteria 
5.1 
Inclusion Criteria 
a. Age 25 to 90 years. 
b. NSTEMI with troponin I > 5.0 ng/dL, with compatible symptoms and ECG changes. 
c. Permission of attending physician. 
d. Ability to understand the risk, benefits, and alternatives of participation. 
 
 
5.2 
Exclusion Criteria 
a. STEMI 
b. Patients requiring invasive support because of compromised hemodynamics. 
d. Scheduled for cardiac surgery. 
e. Current or prior treatment with a PCSK9 antibody. 
f. Current participation in an intervention clinical trial. 
g. Female of childbearing potential. This is a female subject who has not used acceptable 
method(s) of birth control (see below) for at least one month prior to screening, unless the 
subject is sterilized or postmenopausal. Menopause is defined as: 12 months of spontaneous 
and continuous amenorrhea in a female > 55 year of age. 
Ø Acceptable method(s) of birth control definition: One highly effective method 
(methods that can achieve a failure rate of less than 1% per year when used 
consistently and correctly)  
• Combined hormonal (estrogen and progestogen) contraception associated with 
inhibition of ovulation (oral, intravaginal, transdermal) 
• Progestogen-only hormonal contraception associated with inhibition of ovulation 
(oral, injectable, implantable) 
• Intrauterine device (IUD) 
• Intrauterine hormone-releasing system (IUS) 
• Bilateral tubal occlusion 
• Vasectomized partner 
• Sexual abstinence 
 
h. Contraindication to statin therapy.  
i. Subject likely not to be available to complete all protocol-related study visits or 
procedures. 
j. Latex allergy 
k. History of severe hypersensitivity to any monoclonal antibody. 
 
 
6. 
Drugs/ Substances/ Devices 
a. The rationale for choosing the drug and dose or for choosing the device to be used. 
 
The drug evolocumab was chosen because of studies indicating that it reduces inflammation and 
improves lipid profile in patients already on statin therapy. [12] The dose was chosen based on 

 
 
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that approved by the FDA for clinical use in patients with stable coronary disease, available in 
the United States and reduces LDL cholesterol. [44] 
 
b. Justification and safety information if FDA approved drugs will be administered for non-FDA 
approved indications or if doses or routes of administration or participant populations are 
changed. 
 
Evolocumab is an FDA approved medication that will be administered for a non-FDA approved 
indication, hospitalized patients with NSTEMI. This is justified based on clinical and pre-
clinical data indicating that vascular and myocardial inflammation is increased in NSTEMI 
patients, that inflammation is associated with adverse outcomes in this patient group, that in 
stable CAD patients, anti-inflammatory interventions improve outcomes, and that evolocumab 
has anti-inflammatory properties.  The dose and route of administration are the same as that 
administered for FDA approved indications.  
 
We are applying for an exemption from the FDA such that an IND is not needed for the 
proposed mechanistic study in NSTEMI patients.  Safety information on the use of these drugs 
is detailed above.  
 
An IND exemption request will be submitted to the FDA. 
 
7. 
Study Statistics 
a. Primary outcome variable. 
 
The primary outcome will assess the difference of LDL-C serum concentration between the 
placebo and evolocumab groups at 30 days. To assess the primary endpoint of the mean percent 
change from baseline in LDL-C at day 30, a repeated measures linear effects model will be used 
in comparing the efficacy of evolocumab vs placebo.  
 
b. Secondary outcome variables. 
 
For the secondary outcome of comparing the changes in target to background ratio (TBR) over 
time (30-day FDG PET scan minus early hospitalization or shortly following discharge FDG 
PET scan) between the groups, the following statistical approach will be used consistent with 
the prior literature.[45] Specifically, difference in the percent change in TBR at 30 days from 
early hospitalization (30 day – early hospitalization TBR) between the two randomized groups 
will be compared with ANCOVA using the baseline TBR as a covariate. The percent difference 
between the index vessel MDS TBR in the placebo and evolocumab groups at 30 days will be 
analyzed using Kruskal Walis testing.   
The non-parametric biomarkers of the secondary endpoint will be log transformed, and the 
results interpreted as the difference in geometric means between the groups. The analysis will be 
performed in the primary evaluable population, defined as data from subjects that provided 
imaging/laboratory data at the indicated time points.  
A one-sided p-value ≤0.05 will be considered significant, based on the assumption that 
evolocumab will reduce, and not increase, inflammation.  
 
A one-sided p-value ≤0.05 will be considered significant, based on the assumption that 
evolocumab will reduce, and not increase, inflammation.  
 
c. Statistical plan including sample size justification and interim data analysis. 
 

 
 
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We are providing power calculations for the primary as well as key secondary endpoints (see Tables 
1-4).  
 
Primary endpoint: 
For calculation of power for the primary endpoint, we anticipate median baseline presentation LDL-
C of 110 (90 – 130) mg/dL in our patient population.  This number is informed by prior ACS trials 
(i.e. TIMI-22) as well as local experience with the ACS population at the Johns Hopkins Hospital 
(with approximately 25%-35% of the population already on baseline statin therapy).  We expect this 
LDL-C value to be reduced by approximately 50% by high intensity statin therapy in the standard 
treatment arm (i.e. LDL-C of 55 (40- 70) mg/dL at 30 days).  We anticipate a further 50% lowering 
of LDL-C at 30 days after the administration of evolocumab (i.e. LDL-C of 28 (14 – 42) mg/dL.  As 
is shown below (Table 1), using a one-sided p-value of 0.05, the study has nearly 100% power to 
detect this difference, and will have 80% power to detect an absolute LDL-C reduction of 9.5 
mg/dL (17% reduction in LDL-C at 30 days). Additionally, Table 2 presents the expected mean ± 
SD baseline and 30-day LDL-C levels and the expected percent LDL-C change in the placebo and 
evolocumab arms.  
 
Table 1 
 
 
N in each group 
 
Median (IQR) LDL-C  
in ACS Population at 
baseline 
Anticipated 
Percent LDL-C 
Reduction in the 
Standard of Care 
Arm 
Estimated Power 
to Detect a 50% 
Additional LDL 
Lowering 
Detectable 
Point Estimate 
at 80% Power 
N = 30 
110 (90-130) 
50% (40 – 60%) 
99+% 
 
-9.5 mg/dL 
 
 
Table 2: Expected mean ± SD LDL-C levels at baseline and thirty days and the percent change from 
baseline to 30 days in the placebo and evolocumab groups.   
 
Groups: 
LDL-C, mg/dl 
% change from baseline, 
mean (SD) 
Baseline, mean (SD) 
30 day, mean (SD) 
Atorvastatin 
80mg 
+Placebo 
110 (±14) 
55 (±11) 
-50 (±12) 
+Evolocumab 
28 (±10) 
-75 (±14) 
 
Secondary Endpoint: 
Previously published clinically relevant, drug-induced TBR changes are reported in the range of 
5%-15%. [46] The power calculations for a 10% and 15% TBR difference based on a sample size of 
30 patients per study arm are outlined in Table 3 & 4 below. The primary outcome for this 
calculation of sample is the % difference in TBR between the groups at 30 days in the most 
diseased segment of aorta or carotid artery.  Table 1 uses a 1-sided p-value of 0.05, under the 
hypothesis that evolocumab will lower inflammation and will not raise it, consistent with the 
approach used in the Dal-PLAQUE study.  For completeness, we replicated the analysis in Table 4 
using a 2-sided p-value of 0.05.  Calculations are performed using non-parametric statistics 
accounting for the possibility of non-normally distributed TBR data; calculations using parametric 
statistics and the following anticipated means and standard deviations yield similar results, as 
shown in Table 5 below:  
 
Table 3: Power calculations using a 1-sided p-value, i.e. only assumes that PCSK9 inhibition will 
lower TBR in the most diseased segment (MDS) and will not raise TBR.  
 
 
 
 
 
Estimated Power 
Detectable 

 
 
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N in each group 
Median (IQR) TBR in 
ACS Population at 30 
days 
at 10% & 15% 
TBR Difference 
Point Estimate 
at 70% & 80% 
Power 
Aorta MDS 
N = 30 
3.2 (2.7 – 4.0) 
66% 
93% 
-10.6% 
-12.0% 
Carotid MDS 
N = 30 
2.5 (2.1 – 3.0) 
78% 
98%  
-9.0% 
-10.2% 
 
Table 4: Power calculations using a standard 2-sided p-value of 0.05 
 
 
 
N in each group 
 
Median (IQR) TBR in 
ACS Population at 30 
days 
Estimated Power 
at 10% & 15% 
TBR Difference 
Detectable 
Point Estimate 
at 70% & 80% 
Power 
Aorta MDS 
N = 30 
3.2 (2.7 – 4.0) 
54% 
87% 
-12.0% 
-13.6% 
Carotid MDS 
N = 30 
2.5 (2.1 – 3.0) 
68% 
95%  
-10.4% 
-11.6% 
 
The tables above show fair to good power to demonstrate a difference of 10%, and an excellent 
power to show a difference of 15% in the primary outcome. 
 
Mean and standard deviations of anticipated TBR in ACS population at 30 days: 
• Aorta MDS: 3.3 ± 0.6 
• Carotid artery MDS: 2.6 ± 0.4 
 
 
 
 
 
Table 5: Power calculations using a 1-sided p-value of 0.05 and assuming a normal distribution. 
 
 
 
N in each group 
 
Mean (SD) TBR in 
ACS Population at 30 
days 
 
Estimated Power 
at 10% & 15% 
TBR Difference 
Detectable 
Point Estimate 
at 70% & 80% 
Power 
Aorta MDS 
N = 30 
3.3 (0.6) 
69% 
94% 
-10.3% 
-11.8% 
Carotid MDS 
N = 30 
2.6 (0.4) 
81% 
98%  
-8.7% 
-10.0% 
 
d. Early stopping rules. 
 
The Johns Hopkins DSMB will perform any interim analysis they require to monitor patient 
safety and provide reports advising continuation of the study.  
 
 
8. 
Risks 
a. Medical risks, listing all procedures, their major and minor risks and expected frequency. 
 
Study drug: 
Evolocumab is supplied as a sterile, single-use, preservative free solution for subcutaneous 
injection in a disposable, spring-based prefilled autoinjector/pen (AI/pen).  The AI/pen contains 
a 1.0 mL deliverable volume of 140 mg/mL evolocumab or placebo and three 140mg/ml 
AI/pens will be dispensed by the Johns Hopkins Investigational Drug Service  and will be 
administered by one of the investigators to each study participant. Evolocumab is well tolerated 
with few side effects.  A prior clinical trial reported no significant differences in adverse events 
(AEs) and serious adverse events (SAEs) between those participants receiving evolocumab and 

 
 
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those receiving placebo in a randomized, placebo- controlled trial over three months of 
administration (Rutherford 2) [47]. Other trials reported no SAEs and no differences in AEs 
between treatment with the PCSK9 inhibitor and placebo[48].  The most common reasons for 
withdrawal were unrelated to the study drug. The GAUSS-3 randomized trial comparing 
evolocumab and ezetimibe reported no difference in AEs between the study arms and no SAEs 
reported over 24 weeks [49]. A recent large metanalysis of PCSK9 inhibitor trials showed no 
difference in treatment-emergent AEs or SAEs in evolocumab-treated and placebo-administered 
patients[50].  Overall, injection site reactions are manageable and rarely lead to discontinuation 
of the PCSK9 antibody. Other side effects are all comparable to those reported in the placebo 
groups. Importantly, very few musculoskeletal side effects are reported in major clinical trials, 
and are comparable to those seen in placebo-treated patients, and there is no difference in 
laboratory abnormalities reflective of liver or kidney damage over 12 weeks of treatment in the 
evolocumab vs. placebo groups. [50] 
 
Table 6: The most common adverse effects of evolocumab are listed below and do not differ from 
those which occurred in patients who received placebo. [50] 
Most Common Safety 
Endpoints 
Evolocumab (12 week) 
Placebo (12 
week) 
P 
value 
  
Pooled event rate (95% CI)   
  
Musculoskeletal disorders 
9.8 (4.1-15.4) 
7.1 (1.6-12.6) 
0.74 
Nasopharyngitis 
6.2 (3.6-8.8) 
4.2 (2.1-6.3) 
0.11 
Gastrointestinal disorders 
5.6 (2.7-8.4) 
5.3 (1.9-8.7) 
0.73 
Upper respiratory tract 
infection 
4.2 (2.5-5.9) 
2.9 (0.3-5.6) 
0.96 
Headache 
3.4 (2.2-4.6)  
2.6 (1.5-3.7) 
0.33 
Injection site reactions 
2.2 (1.3-3.1) 
1.7 (0.9-2.5) 
0.82 
 
PET studies: 
Intravenous Line during PET study: can cause some slight discomfort when the needle is 
inserted into the arm vein. The potential side effects of taking blood samples may include 
dizziness, soreness and/or bruising of the skin for several days. In very rare circumstances, 
bleeding or infection can develop at the needle puncture site. However, because the procedure is 
performed by a trained specialist using sterile and standard medical practices, that is very 
unlikely. 
 
Isotope (F-18 fluorodeoxyglucose (FDG) Injections (PET-scans):  
This research study includes exposure to radiation from x-rays or gamma rays. This radiation 
exposure is for research purposes only and is not part of medical care. X-rays and gamma rays 
from natural or medical sources can damage the genetic material (DNA) in cells. At low doses, 
the body is usually able to repair the damage.  
 
The radiation exposure that a study participant will get in this research study is 3.1 rem. This is 
more than the 0.3 rem that the average person in the United States gets each year from natural 
sources like the sun, outer space, air, food and soil. It is less than the 5 rems of radiation that is 
allowed each year for people who are exposed to radiation in their jobs. 
 
The radiation exposure described here is what the study participant will get from this research 
study only. It does not include any exposure the patient may have received or will receive from 
other tests outside of this study that are a part of medical care. Radiation risk builds up with 
each exposure. The study participant should think about his history of radiation exposure from 

 
 
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tests (like x-rays or CT scans) in deciding about the radiation in this study. We encourage all 
study participants to ask questions about the total amount of radiation he/she will be receiving. 
 
 
b. Steps taken to minimize the risks. 
 
To protect against and minimize the potential risks of evolocumab treatment, study participants 
will undergo a careful history as well as physical examinations at baseline to identify any 
condition which might increase their risk from the medication but not known to the patients or 
documented in their medical records. The subcutaneous injections of the study drug 
(evolocumab or placebo) will be administered by one of the physician investigators. In addition, 
patients will be evaluated closely at regular intervals following the injection for side-effects. 
Patients who experience significant symptoms will be evaluated.  
 
Trained personnel will perform the blood collection procedure and will make every effort to 
minimize any risks or discomfort. 
 
c. Plan for reporting unanticipated problems or study deviations. 
 
All clinically significant unanticipated problems or study deviations will be reported to the 
DSMB and the IRB according to The Johns Hopkins Medicine Institutional Review Boards 
published guidelines. The DSMB will include a cardiologist familiar with the management of 
patients with acute coronary symptoms, a statistician and an individual with a background in 
medical ethics. The DSMB will have access to study drug assignment and will make 
recommendations to Dr. Leucker regarding any safety concerns and continuation of the study.  
 
 
d. Legal risks such as the risks that would be associated with breach of confidentiality. 
 
Once the data are acquired, they will be assigned a code for each subject with identification 
secured and accessible only to the principal and other investigators, and the research 
coordinator.  Patient clinical information such as copies of clinical studies and imaging reports 
will be filed in a locked filing cabinet with access under control of Dr. Leucker or one of the 
other investigators and study coordinators. Patient information summarized and/or converted 
into electronic form (tables, images, etc.) will be identified by the assigned code. We will abide 
by the Johns Hopkins Institutional policy that all identifiers in images and data acquired under 
IRB-approved research protocols must be removed if they leave the institution, for example in 
presentations.   
 
e. Financial risks to the participants. 
 
All study related costs will be paid from research sources, as stated in the consent form. 
 
 
9. 
Benefits 
a. 
Description of the probable benefits for the participant and for society. 
 
Results from this study may benefit patients with an ACS in the future by providing 
information on the role of lipid lowering and anti-inflammatory medications in patients with 
an ACS. This would support the use of PCSK9 inhibitors to complement existing ACS 
treatment strategies in this population. However, we do not currently know whether subjects 

 
 
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will have an immediate benefit. It could be that this agent (evolocumab) reduces 
inflammation and LDL cholesterol and improves vascular and/or myocardial inflammation 
and this would, at least in the short term, benefit the patients receiving that drug. In prior 
non-ACS studies, the risks of receiving evolocumab were not different from placebo. In 
addition, the risks would be relatively short term since study participants will be only 
receiving a one-time dose of evolocumab. The low risk is reasonable in relation to the 
potential knowledge gained that may guide future therapeutic studies.   
 
10. 
Payment and Remuneration 
a. 
Detail compensation for participants including possible total compensation, proposed bonus, 
and any proposed reductions or penalties for not completing the protocol. 
 
For every outpatient visit study participants will receive $75. For study participants who have to 
travel > 75 miles, or have an early morning heart scan, a hotel room for one night may be 
provided. Additionally, study participants will be reimbursed for transportation and parking 
expenses and given a $10 meal voucher following procedures requiring prior fasting. 
 
 
11. 
Costs 
a. 
Detail costs of study procedure(s) or drug (s) or substance(s) to participants and identify 
who will pay for them. 
 
There is no cost to the participants related to the study procedures or drugs.  

 
 
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