Clinical trial NCT03689946
Conditions: Cardiovascular Disease Hyperlipidemia
Sponsor: Cedars-Sinai Medical Center
Start date: 2019-03-19; Completion date: 2023-05-30
Enrollment: 55 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This study will quantify changes in coronary plaque volumes and plaque composition in patients treated with evolocumab.

Previous intravascular ultrasound studies have shown that treatment with a lipid-lowering PCSK9 enzyme inhibitor, such as evolocumab, to be associated with a reduction of the fatty deposits that cause plaque in the arteries, however, it is not known how evolocumab affects specific coronary plaque types and plaque inflammation.

Investigators will use quantitative assessment of non-invasive coronary computed tomography angiography (CCTA) and positron emission tomography (PET)imaging to evaluate functional changes in plaque burden, plaque composition and vascular inflammation before and after treatment with evolocumab.

Investigators propose to show that patients treated with evolocumab in combination with statins demonstrate a greater reduction of coronary non-calcified plaque volume, thereby reducing the number of future cardiac events.

Detailed description:
To evaluate the effect of evolocumab, patients who are taking Evolocumab plus another cholesterol-lowering medication (e.g statins), will undergo diagnostic testing including non-invasive coronary CT angiographic (CCTA) scans and positron emission tomography (PET) scans. The CCTA and PET scans will be done before and after being treated with evolocumab.

At the initial visit, standard imaging eligibility screening will take place, as well as blood sampling to test cholesterol levels and presence of proteins (biomarkers) associated with heart disease. A CCTA will be done (if not done for clinical purposes within the past 90 days) and a PET scan with administration of 18F-NaF injection will take place. Patients will receive the first injection of evolocumab and will be taught how to self-inject once or twice a month for 18 months.

After the initial visit, patients will self-inject evolocumab at approximately 6, 12 and 18 months in front of a medical professional for site monitoring and re-training. Labs will be drawn to assess blood components related to heart disease.

Follow-up phone calls will be made at approximately 1,3, 9, 15 months and approximately 3-7 days after their final on-site visit (18 months) to monitor safety and drug adherence.

The final visit (18 months after the initial visit) will involve another PET scan, CCTA and blood collection for biomarker testing.

Arms: arm 1: Evolocumab self-administration for 18 months. Baseline (pre-treatment) and follow-up 18F-NaF PET and CCTA (possible beta-blocker and nitroglycerin, if medically safe).
Interventions: intervention 1: Evolocumab intervention 2: 18F-NaF PET intervention 3: CCTA intervention 4: Omnipaque intervention 5: Metoprolol intervention 6: Nitroglycerin
Intervention descriptions: intervention 1: Evolocumab: In patients without homozygous familial hypercholesterolemia (FH), evolocumab will be self-injected as follows: 140mg every 2 weeks or 420mg once a month subcutaneously.

Patients with homozygous FH will be instructed to administer 420mg subcutaneously once a month by giving 3 injections consecutively within 30 minutes using the single-use prefilled autoinjector. intervention 2: 18F-NaF PET: Baseline (pre-treatment) and follow-up dual cardiac and respiratory-gated PET- imaging of the thoracic aorta. Dose of 250 MBq 18F-NaF intravenously. intervention 3: CCTA: Baseline (pre-treatment) and follow-up CCTA. Bolus injection of 80-100 ml contrast (Omnipaque or Visipaque). Possible beta blocker(metoprolol)administered to achieve a target heart ≤70 beats/min (bpm) and/or 0.4 or 0.8 mg of sublingual nitroglycerin administered, if medical safe. intervention 4: contrast agent for CCTA intervention 5: beta blocker to optimize heart rate during CCTA intervention 6: premedication for CCTA

Protocol documents:
Prot_SAP_000.pdf: 
 
1  
 
May 3, 2024 
 
Re: Cover Letter for Clinical Trials.gov NCT03689946 
 
Study Title: Effect of Evolocumab on Coronary Artery Plaque Volume and Composition by 
CCTA and Microcalcification by F18-NaF PET” 
 
This Cover Letter accompanies the approved protocol for this trial NCT03689946 which is 
completed.  
 
This is to certify that the title of our study is, “Effect of Evolocumab on Coronary Artery 
Plaque Volume and Composition by CCTA and Microcalcification by F18-NaF PET” with a 
ClinicalTrials.gov Identifier: NCT03689946. We assure that this was a study approved by 
Institutional Review Board at Cedars-Sinai Medical Center. To the best of our knowledge all 
the information provided in this study is true and is being reported in compliance with the 
declaration of Helsinki for clinical trials. 
 
 
Sincerely,  
 
Daniel Berman, MD 


 
2  
 
  
Study Protocol  
  
Title: Effect of Evolocumab on Coronary Artery Plaque Volume and Composition by 
Coronary CTA (CCTA) and Microcalcification by F18-NaF PET 
  
 
  
BACKGROUND 
  
Atherosclerotic coronary artery disease is the major cause of morbidity and mortality in the United 
States [1], and serum cholesterol levels are a strong risk factor for development and the growth 
of atherosclerotic plaque.  The deposition of low density lipoprotein cholesterol (LDL) in the 
coronary artery wall is associated with the entry of macrophages and smooth muscle cells, setting 
the stage for atheroma formation.  Atherosclerotic lesions at risk of rupture have certain 
histopathological characteristics that include positive remodeling, microcalcification, and a large 
necrotic core [2-5].   LDL cholesterol is a key mediator of atherogenesis, and inhibition of LDL 
synthesis with statins has been shown to be associated with both plaque regression and reduction 
in adverse cardiac events.  LDL levels can be reduced by even a greater degree by the inhibition 
of PCSK9, a protease that is responsible for the degradation of LDL receptors on the cell surface, 
with monoclonal antibodies https://pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-
com/repatha/repatha_pi_hcp_english.pdf) [6, 7].   
 
Treatment with the PCSK9 inhibitor, evolocumab has been shown by intravascular ultrasound to 
be associated with a reduction of percent atheroma volume after 1.5 years of treatment; however, 
it is not known how evolocumab affects specific coronary plaque types and plaque inflammation 
[6, 7].  Although intravascular ultrasound (IVUS) can provide quantitative measurements of total 
atheroma volume, it is an invasive technique with associated procedural risks and therefore not 
practical for routine clinical monitoring of response to medical therapy.  Quantitative assessment 
of changes in plaque burden, plaque composition and vascular inflammation in response to 
treatment with a PCSK9 inhibitor with noninvasive imaging (CCTA and positron emission 
tomography (PET) can provide a comprehensive assessment of pathophysiologic changes before 
and during treatment. 
 
Our group has developed and extensively validated a semiautomatic method of comprehensive 
measurements of coronary plaque burden and plaque composition in the entire coronary artery 
tree on CCTA (Autoplaque) [8-12]. Among the many Autoplaque measurements are noncalcified 
plaque volume, low density non calcified plaque volume, the latter representing the necrotic core. 
We have shown strong correlation of noncalcified plaque volume with IVUS [10] and have 
documented excellent reproducibility of the various plaque measurements [12]. In 116 patients 
having serial studies over 3.5±1.6y, we have preliminary evidence that a 10% reduction in LDL is 
associated with an interval reduction in the volumes of all components of non-calcified plaque 
including adverse plaque characteristics associated with plaque instability and predictive of future 
cardiac events [13, 14].   
 
With PET, our co-investigators have shown that microcalcification activity within coronary arteries 
and the aorta-reflecting the rate of deposition of calcium-can be assessed by18F sodium fluoride 


 
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(NaF) PET. This process is considered to be governed by the degree of plaque inflammation, and 
as such another marker of plaque vulnerability [15]. Thus, 18F NaF PET allows the assessment 
of the effect of therapy on a measurement related to plaque inflammation.    
  
STUDY DESIGN 
 
This is an early development, single-arm, prospective, open-label study of evolocumab injection 
in patients with calcified plaque in the coronary artery detected by CCTA. Fifty-five (55) evaluable 
subjects will be enrolled in the study. 
 
OBJECTIVES 
  
1. To test the hypothesis that PCSK9 (proprotein convertase subtilisin kexin type 9) inhibitor, 
evolocumab, reduces the volume of noncalcified plaque in coronary arteries as measured 
by coronary computed tomography angiography (CCTA)  
  
2. To determine the components of non-calcified coronary artery plaque that are affected by 
treatment with evolocumab.  
  
3. To determine if lipid lowering with evolocumab is associated with changes in 
microcalcification in atherosclerotic plaque as measured by F18-NaF PET   
  
SPECIFIC AIM 
 
To quantify changes in coronary plaque volumes and plaque composition in patients treated 
with evolocumab.  
 
 
Hypothesis: Patients treated with evolocumab demonstrate a reduction of coronary non-
calcified plaque volume, including a preferential reduction in volume of low density non-calcified 
plaque components   
  
EXPLORATORY AIMS 
 
To evaluate whether patients treated with evolocumab demonstrate reduced microcalcification 
activity in the coronary arteries as assessed by 18F NaF.  
 
    Hypothesis: Treatment with evolocumab will be associated with reduced rate of coronary 
plaque inflammation which may be detected as a reduction in the rate of microcalcification 
activity.  
 
 
 
SUBJECT DESCRIPTION 
  
Treatment Group 


 
4  
 
 
Inclusion Criteria  
Treatment group will be comprised of 55 adult male and female patients who satisfy the following 
enrollment criteria:   
• Evidence by CCTA of noncalcified coronary artery plaque (>440 mm3)   
 
• On-label indications for evolocumab treatment which includes the following criteria:  
                Those who have established cardiovascular disease defined as acute coronary 
syndrome, history of myocardial infarction, stable angina or unstable angina, coronary 
or other arterial revascularization, stroke, transient ischemic attack, or peripheral 
arterial disease presumed to be of atherosclerotic origin.  
 
• Non-calcified plaque (NCP) volume of 250 mm3 or more in any single plaque in patients 
who do not have a total NCP >440 mm3 
  
Exclusion Criteria  
• 
Creatinine > 1.5 mg/dL prior to imaging  
• 
History of allergy to iodine contrast agents  
• 
Allergy to evolocumab or any other ingredients contained in study drug, including latex  
• 
Pregnancy  
• 
Women who are breastfeeding   
• 
Active atrial fibrillation  
• 
History of coronary artery bypass graft  
• 
Inability to lie flat  
• 
Inability or unwilling to give informed consent  
• 
Major illness or life expectancy <1 year  
• 
Planned coronary revascularization or major non-cardiac surgery in the next 12 
months  
• 
Previously or currently on evolocumab  
• 
Specific to beta-blocker administration: hypersensitivity or allergy to metoprolol or 
other beta-blockers, SBP <100mmHg, serious heart problems, such as cardiac failure 
(hypertension and angina), congestive heart failure, heart block, severe sick sinus 
syndrome, circulation problems, asthma or other breathing problems, peripheral artery 
circulatory disorders. 
  
 
Recruitment and Enrollment  
  
Treatment group 
  
Investigators and/or the study coordinator will perform a weekly review of patients who have had 
a coronary calcium screening in the past month with coronary artery calcium (CAC), patients who 
have had a coronary CT angiogram with atherosclerotic plaque, and those who have plaque as 
documented during invasive angiography in the catherization lab at Cedars-Sinai Medical Center. 


 
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Among these patients, those who meet the inclusion criteria will be recruited to participate. Any 
information available in the patient’s Cedars-Sinai medical records that can help determine 
eligibility will be viewed. The patient’s cardiologist or other medical provider who ordered the 
CCTA or the invasive angiogram will be approached regarding appropriateness of recruiting the 
patient. The patient will then be contacted by an investigator or study coordinator for potential 
consent and participation.” 
  
All potential participants will be given enough time to consider the study. It will be explained that 
their participation is voluntary and will not affect their clinical care should they agree to participate 
or decline. We will provide a copy of the consent form to patients prior to the day of the study.    
  
The subject’s clinical status will be monitored for any adverse change prior to signing informed 
consent as well as prior to beginning any research procedures.  
 
Feasibility: As of October 2017, we identified from our database 160 patients who have undergone 
sequential CCTA in whom total cholesterol and LDL values are also known, and who met 
indications for evolocumab.  
  
DESCRIPTION OF PROCEDURES (Treatment Group) 
The study protocol is comprised of a first CCTA (obtained clinically within 90 days prior to 
enrollment or at the first imaging visit for research purposes) and 18F-NaF PET, treatment with 
evolocumab for 18 months and a follow up CCTA and 18F-NaF PET.  
 
All subjects will receive blood sampling and 18F-NaF PET scan during their initial visit. Subjects 
can expect to be at CSMC for approximately 5 hours.   
  
Following the 18F-NaF PET scan, the first injection of evolocumab will be administered by a nurse 
at CSMC. Patients will be given instructions on how to prepare and administer evolocumab prior 
to use and will be provided a 6 months’ supply of evolocumab for self-administration at each onsite 
visit.    
  
In patients without homozygous familial hypercholesterterolemia (FH), evolocumab will be self-
injected as follows: 140mg every 2 weeks or 420mg once a month subcutaneously.  
 
Patients with homozygous FH will be instructed to administer 420mg subcutaneously once a 
month by giving 3 injections consecutively within 30 minutes using the single-use prefilled 
autoinjector.  
 
Patients will undergo monitoring for adverse effects and for adherence with treatment every 3 
months (phone calls at 1,3, 9, and 15 months of treatment and on-site visit with a nurse practitioner 
(NP) or MD at 6, 12 and 18 months of treatment. Patients will also receive a sharps container to 
safely discard all used syringes immediately after administration of the dose. The filled container 
will be returned during each on-site follow-up visits for drug accountability and proper disposal. 
After 18 months of treatment with evolocumab, patients will undergo a CCTA and 18F-NaF 
PETCT. Acquisition protocols will be identical to their baseline study.    


 
6  
 
  
Blood testing (estimated procedure time = 15 minutes)  
  
Prior to beginning any imaging, patients will have blood drawn from a peripheral vein (<30 cc) to 
check creatinine (I-STAT® (Abbott Laboratories).  Plasma and serum samples will be drawn for 
assessment of plasma and serum biomarkers including inflammatory, cardiac, and lipid markers, 
which may include C-reactive protein, IgM, interleukin-12 p70, tumor necrosis factor α, erythrocyte 
sedimentation rate, lipoprotein-associated phospholipase (Lp-PLA2), brain natriuretic peptide, 
oxidized low-density lipoprotein (LDL), high-sensitivity troponin as well as novel biomarkers being 
developed in the laboratory of co-investigator Dr. Jennifer Van Eyk, PhD.  
  
18F-NaF PET Scan (estimated procedure time = 4 hours from time of 18F NaF injection)  
   
1) Study subjects will be administered a dose of 250 MBq 18F-NaF intravenously.  
2) All subjects will undergo dual cardiac and respiratory-gated PET-CT imaging of the 
thoracic aorta with a GE Discovery PET/CT 710 (GE Medical Systems) 180 minutes after 
injection. Scanning will utilize an attenuation correction CT scan (non-enhanced 120 kV 
and 50 mA), followed by PET imaging of the thorax in list-mode for 30 minutes.   
 
 
CCTA (estimated procedure time = 0.5 hours)  
  
The protocol used is the standard clinical protocol for CCTA that was employed in the baseline 
CCTA. The typical protocol is as follows:  
  
1) CCTA will be performed using a SOMATOM Definition scanner (Force, Siemens Medical) 
as previously described [16].  When needed, oral and/or intravenous beta blockers 
(metoprolol) is administered to achieve a target heart ≤70 beats/min (bpm).  Immediately 
before CTA scanning, 0.4 or 0.8 mg of sublingual nitroglycerin (ScielePharma, Alpharetta, 
Georgia) is administered. Images are acquired after a bolus injection of 80-100 ml contrast 
(Omnipaque or Visipaque, GE Healthcare, Princeton, New Jersey) at a rate of 5-6 ml/s, 
using either axial or helical scanning with dose modulation. Scanning parameters will 
include: tube voltage of 120 or 100 kVp, tube current 600 to 800 mA, depending on patient 
size; table feed/scan 3.8 mm; and pitch factor 0.2-0.4 (Heart rate dependent).  Real-time 
bolus-tracking technique is used to trigger scan initiation.  Axial images will be 
reconstructed at 0.6-mm slice thickness, 0.3-mm slice increment, 250-mm field-of-view, 
and 512 × 512 matrix.   
  
Follow-up calls and visits  
  
Phone Calls: At the beginning of the 3rd, 9th, and 15th month of treatment with evolocumab, 
patients will be contacted by phone to determine if they have had any adverse effects from 
evolocumab and to assess their adherence to monthly injections.  A final phone call will also be 
made 3-7 days after the last dose and scan to determine adverse events and concomitant 
medications.  
 


 
7  
 
Visits to Cedars-Sinai: At the beginning of the 6th, and 12th months of treatment with evolocumab, 
patients will be seen by a NP at Cedars Sinai for on-site follow-up safety visits.  Adherence to 
treatment and adverse effects will be assessed at these visits. Blood will be drawn at these visits 
to measure serum total cholesterol, LDL, HDL and TG as well as to confirm that patient is not 
pregnant.  Patient will return the sharps container with the used syringes to CSMC research staff 
and new container will be dispensed. An additional 6 months’ supply of evolocumab will also be 
dispensed at the follow-up visits (months 6 and 12), and re-training of injection technique/disposal 
will be provided as needed.   
 
There will also be a final visit at the end of 18 months of treatment at which time adverse events 
and adherence will also be assessed and blood will be collected for a lipid panel and to confirm 
pregnancy status; samples will be stored for biomarker assessment.  Patients will undergo a 
CCTA and PET-CT at that time as described above.  
 
Patients who discontinue the study after 12 months of treatment with evolocumab will be 
encouraged to undergo CCTA and 18F-NaF PET, which will be the EOS (end-of-study) imaging 
for this group. 
 
 Study Schedule  
 
 
 


 
8  
 
 
COLLECTION OF CLINICAL INFORMATION 
 
Clinical information including age, sex, BMI, ASCVD risk factors, medications and dose of statin 
and antiplatelet therapy and laboratory data will be collected. 
 
DATA PROCESSING AND ANALYSIS 
I. 
Data anonymization/blinding 
a. Anonymization 
i. DICOM files of each CCTA and PET for each subject who completed the 
follow-up scan were anonymized of all identifiers except for the Series 
Description, using “diconymize”. A randomization generator randomized all 
baseline and follow-up scans and provided new subject IDs (prefix “EVO”) 
and procedure IDs (prefix CT or PET, depending on the procedure).  
ii. CTs and PETs related to the same visit have the same 4 alpha-numeric ID 
with the CT or PET prefix to signify which studies were evaluated together. A 
linking file was accessible only to the study manager who were unblinded to 
which scans are baseline and follow-up.  
iii. Once all scans are anonymized, the folder was zipped and uploaded to a 
BOX folder, accessible to the PIs and readers. 
b. Blinding 
i. In order to blind readers to the order of the scans, a linking file was created to 
randomize the subject’s ID, order of enrolment and order of scan  
II. 
CCTA image analysis 
i. The CCTA imaging core lab (Cedars-Sinai Medical Center, Los Angeles, CA, 
USA) performed qualitative and quantitative measurements of CCTA using AI 
enabled plaque quantification research software (Autoplaque, Cedars-Sinai 
Medical Center, Los Angeles, CA, USA). All qualitative and quantitative 
analyses were reported as per-patient and per-lesion level. 
ii. All coronary segments ≥2 mm according to the 18-segment SCCT model 
were evaluated by level III-experienced readers blinded to clinical and PET 
data. Two serial scans (date blinded) were assessed at the same time. 
Overall study quality was recorded using a 5-point image quality assessment 
tool (excellent/good/fair/poor/non-diagnostic). The presence of coronary 


 
9  
 
plaque was defined as any tissue structure <1mmm2 that existed either within 
the coronary artery lumen or adjacent to the coronary artery lumen that could 
be discriminated from surrounding pericoronary tissue or the vessel lumen 
itself. Between two serial scans, lesions were matched between two serial 
CCTAs using lesion location (involved coronary segment) and branch points 
as landmarks.  
iii. Qualitative APC measurements 
1. Stenosis severity was visually graded according to the CAD-RADS 
(Coronary Artery Disease – Reporting and Data System). All plaques 
were qualitatively assessed for the presence of adverse plaque 
characteristics: positive remodeling, low attenuation plaque, spotty 
calcification, and napkin-ring sign. Positive remodeling was defined by 
a vessel remodeling index >1.1. Low attenuation plaque was defined 
by the presence of any voxel <30 Hounsfield units (HU). Spotty 
calcification was defined as visually detectable calcification <3 mm in 
any direction within a plaque. Napkin-ring sign was defined as 
noncalcified plaque with a central area of hypoattenuation surrounded 
by a peripheral rim of hyperattenuation. High risk plaque was defined 
as presence of two or more APCs. 
iv. Quantitative measurements 
1. In axial and multiplanar views, the expert level III reader placed a 
region of interest in the ascending aorta to define normal blood pool 
and control points in the coronary lumen to define the centerline. The 
proximal and distal limits of lesions was manually defined, following 
which adaptive scan-specific Hounsfield Unit (HU) thresholds for 
plaque components were automatically generated. Automatic 
segmentation of the vessel wall and lumen were performed with 
manual adjustment as required. Plaque volume (mm3) was calculated 
on a per-lesion level for the following components: total plaque, 
calcified plaque, noncalcified plaque, and low-attenuation plaque 
(defined by a fixed attenuation threshold <30 HU). Quantitative 
diameter stenosis (%) was calculated as the ratio of minimal lumen 


 
10  
 
diameter to the mean of 2 (proximal and distal) non-diseased 
reference points. The contrast density difference is defined as the 
maximum percent difference in contrast density (the luminal 
attenuation per unit area over 1-mm cross-sections) within the plaque, 
with respect to the proximal normal reference cross-section. 
 
III. 
PET image analysis 
i. PET reconstruction  
1. PET images was reconstructed into 4 cardiac phases using a vendor 
provided software (JS-Recon12, Siemens, Knoxville, TN, USA). All 
PET image reconstructions were performed with corrections for time-
of-flight and point-spread function. Using 4 cardiac gates, we 
reconstructed the data on a 256 × 256 matrix (109 slices, slice 
thickness 2.027 mm) using 2 iterations, 21 subsets and 5-mm Gausian 
filter.  
ii. Cardiac Motion correction  
1. Cardiac motion corrected images were obtained from the gated PET 
reconstructions through PET-PET image co-registration using a 
diffeomorphic registration and dedicated software (FusionQuant 
version 1.19.2.7, Cedars-Sinai Medical center). 
iii. Image registration 
1. Prior to image analysis, the PET reconstructions were registered to the 
CCTA images, using a rigid translation of the PET images. The PET to 
CCTA registration was ensured using five key points of reference; 
sternum, vertebrae, blood pool in the left and right ventricle (based 
upon high 18F-NaF activity in the blood pool in comparison to the 
surrounding myocardium), and the great vessels. 
iv. Blood clearance correction  
1. To minimize the impact of variations in background blood pool activity 
introduced by the injection-to-scan delays, we standardized the 
background blood pool activity to an injection-to-scan delay of 180 
minutes using a previously described correction factor: 


 
11  
 
SUVBackground corrected = SUVBackground*e(−0.004*(60−t)) 
 
where t represents the injection-to-scan delay in minutes. 
v. CMA quantification   
1. To obtain the CMA values, two distinct steps were performed. First, 
we selected the proximal and distal end of the vessel (>2 mm) and 
applied a vessel tracking algorithm to extract whole-vessel tubular 3D 
volumes of interest from CCTA using dedicated Autoplaque software  
(version 3, Cedars-Sinai Medical Center, Los Angeles, CA). These 
encompassed all the main epicardial coronary vessels and their 
immediate surroundings (4-mm radius) facilitating per-vessel and per-
patient uptake quantification. In a tubular VOI, along the extracted 
centerlines, with 4-mm radius, we measured the CMA on the 
PET/CCTA co-registered images. For this study, we evaluated 18F-
NaF activity along the entire course of coronary arteries regardless of 
the presence of coronary stents, and we included the left main in the 
left anterior descending artery VOI. CMA was defined as the average 
SUV within the activity volume above threshold of background SUV 
mean +2 standard deviations. The background activity was measured 
in the right atrium.  
vi. TBRMAX quantification  
1. On the co-registered PET and CTA images, 18F-NaF PET uptake was 
measured in all coronary segments with a vessel diameter ≥2 mm as 
defined by CTA. The 18F-NaF uptake in these lesions were evaluated 
in a 3D spherical volume of interest (VOI) (radius 5 mm). In all 
plaques meeting these criteria, the maximum standardized uptake 
values (SUVMAX) were measured within manually drawn regions of 
interest. TBRMAX values were calculated by dividing the coronary 
SUVMAX by the blood pool activity measured in the right atrium 
(cylindrical volume of interest radius 10 mm and thickness 5 mm) at 
the level of the right coronary artery ostium.  
vii. Diagnostic Evaluation of CMA and TBRMAX  


 
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1. Using CMA, the individual coronary arteries were marked as high 18F-
NaF if CMA>1.56. We assessed the burden of activity on a per-vessel 
and per-patient level. To allow a per-patient analysis, we added the 
CMA activity of all major epicardial vessels (CMAtotal).  For TBR, PET 
uptake was quantified based on the CCTA lesion position, with lesions 
categorized as 18F-NaF-positive (TBRMAX ≥1.3) or 18F-NaF-negative 
(TBRMAX <1.3).  
 
 
 
  
BENEFITS 
  
Evolocumab is clinically indicated for patients with ASCVD as defined in the inclusion criteria.  We 
are not aware of any direct benefit for subjects from quantification of plaque volumes or 
microcalcification.  
  
OFF-LABEL USE OF SODIUM FLUORIDE F-18-NaF 
  
Sodium Fluoride F-18 Injection is a radioactive diagnostic agent for PET approved to use in 
imaging of bone to define areas of altered osteogenic activity. Sodium Fluoride F-18 Injection is 
not, however, approved for the indication of cardiac imaging.   
  
The prescribed dose for an adult bone study is 300-450 MBq (approved dose for bone scanning). 
This study will employ a lower dose of 250 MBq. This follows the recommendation that the dose 
be minimized consistent with the objectives of the procedure and the nature of the radiation 
detection devices employed. The use of this lower dose has been shown to be effective in 
previous studies conducted at CSMC. 
  
The 18F-NaF for this study will be manufactured by PetNet (Culver City, CA) and will be received 
by our radiopharmacy in the S. Mark Taper Imaging Center, Nuclear Medicine division. Our 
radiopharmacist will prepare the doses for administration for the cardiac imaging procedures.   
  
Use of 18F-NaF in this study does not involve a route of administration, dose, patient population, 
or other factor that significantly increases the risk (or decreases the acceptability of the risk) 
associated with the use of 18F-NaF for the approved use in bone scanning.   
  
The investigators have no intention of reporting data from this study to the FDA for change in 
indications or labeling.   
   
RISKS 
  


 
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18F-NaF PET: According to the package insert, there are no contraindications and no adverse 
reactions have been reported for Sodium Fluoride F 18 Injection based on a review of the 
published literature, publicly available reference sources, and adverse drug reaction reporting 
systems. As with any injectable drug product, allergic reactions and anaphylaxis may occur. This 
research procedure is being conducted in a clinical setting and emergency resuscitation 
equipment and personnel are immediately available.   
  
As with other radiopharmaceuticals, this injection has the potential to cause harm to an unborn 
child. Pregnant women will not be enrolled. Department policy states that all females of child 
bearing age (10-60yo) are screened to determine pregnancy status. If the female volunteer is of 
child bearing age and the first day of their last menstrual cycle is not within the past 30 days, we 
will administer a one-step HCG urine test (QuickVue®, Quidel Corp) in the department to 
determine their pregnancy status. To minimize the risks to a nursing infant, it is recommended 
that mothers interrupt nursing for at least 24 hours.  
  
CCTA: The physical procedure of CCTA and administration of intravenous contrast are generally 
considered low-risk in patients without significant renal dysfunction and other contraindications to 
intravenous contrast. We will be performing the CCTA at least 48 hours after the initial dye load 
in the cath lab (if they have been enrolled from the cath lab), the risk of renal dysfunction is 
minimal.  
  
Beta-Blocker and Nitroglycerin: Administration of metoprolol and sublingual nitroglycerin is 
associated with minimal risk since patients with clinical contraindications will be excluded.  
  
Radiation: Estimated total radiation exposure from 18F-NaF is approximately 0.81 Rem from the 
combined 18F-NaF and associated attenuation scans.  This calculation is based on 0.0027 
Rem/MBq dose equivalent for 18F-NaF and 0.138 Rem average radiation for cine-CT attenuation 
scan [22], and approximately 0.8 rem from the coronary CTA.  
 
The study includes a baseline and a final 18F-NaF as well as a baseline and a final CCTA. The 
baseline CTA may be eligible if done clinically within 60 days prior to enrollment. 
 
Evolocumab:  
Hypersensitivity reactions (e.g., rash, urticaria) have been reported in patients treated with 
evolocumab, including some that led to discontinuation of therapy. If signs or symptoms of serious 
allergic reactions occur, discontinue treatment with evolocumab, treat according to the standard 
of care, and monitor until signs and symptoms resolve.  Please see section 6 of the appendix 
Repatha_prescribing information.pdf.  
  
PRIMARY ENDPOINT 
  
1. Change in noncalcified coronary artery plaque volume from baseline to month 18 of 
treatment with Evolocumab. 
2. Change in plaque composition (low density non-calcified and calcified) from baseline to 
month 18 of treatment with Evolocumab.    
  


 
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STATISTICAL ANALYSIS PLAN 
 
For all statistical analyses, two-sided tests will be conducted and p-values < 0.05 will be 
considered significant.  Continuous variables will be presented as mean ± standard deviation (SD) 
or median (interquartile range) as appropriate. Annualized rate of change in total plaque volume, 
and the volume of non-calcified plaque, specifically, low density non calcified plaque components 
will be analyzed. .  Mean values will be compared using a paired Student’s t-test median values 
will be compared using the Wilcoxon rank-sum (Mann-Whitney) test. The relationship between 
decrease in LDL and changes in plaque volume and individual plaque components per year will 
be evaluated after adjusting for the effects of confounding variables including age, diabetes, 
hypertension, smoking, family history of premature coronary artery disease, statin use, baseline 
LDL and baseline plaque volume. Reproducibility of measurements of, volume of plaque 
components and total plaque volume will be assessed using intra-class correlations and 
coefficients of variation.  
 
SAMPLE SIZE POWER CALCULATIONS 
 
In a study of 116 patients who underwent sequential CTA, we observed a reduction in total plaque 
volume and NCPV among patients who experienced a reduction in LDL of >10% of their baseline 
LDL level under the influence of statins alone.  Based on this preliminary work, we expect to detect 
a difference of at least 50mm3/year in non-calcified plaque volume (∆NCPV = NCPVpre-treatment – 
NCPVpost-treatment) among patients who were treated with evolocumab. From our data, we estimate 
the population standard deviation for measurement of (∆NCPV/year) to be 115mm3.  Using a 
paired t-test with a power of 80% and an alpha value of 0.05, we would need 44 patients in our 
treatment group.    
 
After accounting for approximately 10 patients who might withdraw from the study, we propose to 
enroll 55 patients in our treatment group.  
  
INSTITUTIONAL REVIEW BOARD (IRB) 
 
Prior to study initiation and when amended, the protocol and any applicable advertisement for 
patient recruitment will be submitted for review and approval to the IRB charged with this 
responsibility. Site personnel must provide reports of the progress, or completion, termination or 
discontinuation of the study to the IRB at appropriate intervals.  The investigator will verify that 
each subject has consented, in writing, to direct access to his/her original medical records for trial-
related monitoring, audit, IRB/IEC review, and regulatory inspection. 
 
DATA COLLECTION AND MANAGEMENT 
 
All information from the 18F-NaF PET scan and CCTA scan performed while the subject is at 
CSMC may be used for research analysis including the actual images, acquisition parameters of 
the imaging protocol, any information collected at the time of the test, and information from the 
patient’s medical record.   


 
15  
 
 
DATA AND SAFETY MONITORING 
 
All suspected unexpected serious adverse reactions (SUSARs) related or possibly related to 
evolocumab and their follow-up reports will be reported to Amgen within 24 hours of submission 
to the regulatory agency, IRB or IEC. A copy of any safety report involving an Amgen drug (e.g. 
evolocumab) submitted to the regulatory agency, IRB or IEC, will be faxed to Amgen, within 24 
hours of such submission.   
 
The sponsor will report all pregnancies and pregnancies occurring in the partner of a patient 
participating in the study or potential infant exposure through lactation within 10 calendar days of 
sponsor’s awareness to Amgen.  
  
DATA REPORTING 
 
Routine reporting of recruitment, protocol compliance and data collection is planned annually to 
the IRB once recruitment begins. Occurrence of safety incidences including adverse events are 
reported according to CSMC compliance requirements. The investigators will provide direct 
access to source data/documents for trial-related monitoring, audits, IRB/IEC review, and 
regulatory inspection. The investigators have no intention of reporting data from this study to the 
FDA for change in indications or labeling.   
 
PATIENT CONFIDENTIALITY 
 
The data source files will be kept in a locked room in the office of the cardiovascular imaging 
research team in the Mark Taper Imaging Institute building at Cedars Sinai Medical Center.  The 
data will be stored in a de-identified manner.  The identifiable information will not be reused or 
disclosed except as consistent with this protocol and signed HIPAA Authorization for Research.  


 
16  
 
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