Journal of Cardiology 76 (2020) 395–401

Contents lists available at ScienceDirect

Journal of Cardiology
journal homepage: www.elsevier.com/locate/jjcc

Original article

Plasma kinetics of mature PCSK9, furin-cleaved PCSK9, and Lp(a) with

or without administration of PCSK9 inhibitors in acute myocardial
infarction
Akihiro Nakamura (MD, PhD, FJCC)*, Masanori Kanazawa (MD, PhD),
Yuta Kagaya (MD, PhD), Masateru Kondo (MD, PhD), Kenjiro Sato (MD, PhD),
Hideaki Endo (MD, PhD), Eiji Nozaki (MD, PhD)
Department of Cardiology, Iwate Prefectural Central Hospital, Morioka, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Background: There are two types of circulating proprotein convertase subtilisin/kexin type 9 (PCSK9),
Received 13 February 2020 mature and furin-cleaved. Most types of lipoprotein(a) [Lp(a)], an independent risk factor of
Received in revised form 22 March 2020 cardiovascular events, bind to mature PCSK9.
Accepted 11 April 2020
Objective: This study examined the effects of monoclonal anti-PCSK9 antibody on plasma PCSK9 and Lp
Available online 18 May 2020
(a) levels in acute myocardial infarction (MI).
Methods: Acute MI patients (n = 36) were randomly divided into evolocumab (140 mg; n = 17) and non-
Keywords:
evolocumab (n = 19) groups. Changes in plasma PCSK9 and Lp(a) levels were monitored before and 1, 3, 5,
Acute myocardial infarction
Evolocumab
10, and 20 days after evolocumab administration.
Lipoprotein(a) Results: In the non-evolocumab group, plasma levels of mature PCSK9, furin-cleaved PCSK9, and Lp(a)
Low-density lipoprotein cholesterol (236.4
57.3 ng/mL, 22.4
5.8 ng/mL, and 19.2.
16.5 mg/dL, respectively) significantly increased by
Pharmacokinetic change day 3 (408.8
77.1 ng/mL, p < 0.001; 47.2
15.7 ng/mL, p < 0.001; and 39.7
21.3 mg/dL, p < 0.005,
Proprotein convertase subtilisin/kexin type respectively) and returned to the baseline by day 10 or 20. In the evolocumab group, mature PCSK9
9 significantly increased by >1000 ng/mL with a simultaneous decline of furin-cleaved PCSK9 below the
measurement sensitivity level after day 3. The incremental area under the curve for plasma Lp(a) levels
was significantly smaller in the evolocumab group compared with the non-evolocumab group
(p = 0.038).
Conclusion: Mature and furin-cleaved PCSK9 are transiently upregulated after MI onset. Evolocumab
significantly increases mature PCSK9 and decreases furin-cleaved PCSK9 and might inhibit transient
increase of plasma Lp(a) in acute MI.
© 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Introduction
Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays an
important role in regulating plasma low-density lipoprotein-
cholesterol (LDL-C) levels by promoting LDL receptor (LDL-R)
degradation in the liver [1]. There are two types of circulating
PCSK9: mature and furin-cleaved. Mature PCSK9 is synthesized in
the endoplasmic reticulum and is secreted by hepatocytes. Some
* Corresponding author at: Department of Cardiology, Iwate Prefectural Central
Hospital, 1-4-1 Ueda, Morioka 020-0066, Japan.
E-mail address: AkihiroNakamura0223@msn.com (A. Nakamura).
mature PCSK9 is cut by furin between the prodomain and the
catalytic domain and is secreted in the furin-cleaved form. Mature
PCSK9 can regulate LDL-R, whereas furin-cleaved type PCSK9
cannot [2]. Mature PCSK9 has reportedly more atherogenic
properties compared with furin-cleaved PCSK9 [2].
In addition to its potential role in LDL metabolism, PCSK9 has a
direct relationship with atherosclerosis development [3,4], and
plasma PCSK9 levels also transiently increase in myocardial
infarction (MI) patients [5–7]. Although each PCSK9 subtype has
different properties with regard to biological activity (e.g. affinity
to LDL-R and atherogenic formation), little is known about each
pharmacokinetic change during acute MI and the effects of
monoclonal anti-PCSK9 antibody.

https://doi.org/10.1016/j.jjcc.2020.04.006
0914-5087/© 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
396 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401
Lipoprotein(a) [Lp(a)], an LDL-like particle with an apolipopro-
tein B100 covalently bound to the apolipoprotein(a), apo(a), by a
single disulfide bond [8], is reportedly not only a predictive marker
for future cardiovascular events [8,9] but also a key player in
cardiovascular disease development, including MI [6,7]. Clinical
studies have shown that plasma Lp(a) levels decrease up to 30% in
patients treated with monoclonal anti-PCSK9 antibody [10,11]. Al-
though the underlying mechanism remains unclear, almost all
circulating Lp(a) reportedly binds to mature PCSK9 [12], suggesting
some effect of anti-PCSK9 antibody on Lp(a) particles without a
decrease in LDL-C levels via LDL-R degradation.
This study was to examine the kinetic changes in mature and
furin-cleaved PCSK9, and the effects of evolocumab, a PCSK9
inhibitor, on them during MI. In addition, we assessed changes in
plasma Lp(a) levels and the effects of evolocumab on them in acute
MI.
Materials and methods
Study subjects and treatment
To estimate changes in plasma PCSK9 and Lp(a) levels by PCSK9
inhibitors administered during acute ST-segment elevation MI
(STEMI), we conducted a single-center, prospective, randomized,
open-labeled study of STEMI patients. The study protocol was
approved by the ethics committee of the Iwate Prefectural Central
Hospital, Iwate, Japan (Approval No. 468), and was performed in
accordance with the principles of the Declaration of Helsinki. Written
informed consent was obtained from every patient or family member.
A total of 47 STEMI patients were admitted to our hospital
between November 2017 and March 2018 (Fig. 1). STEMI was
defined as an increased creatine kinase–myocardial isoform (CK-
MB) and/or cardiac troponin T value greater than the upper
reference limit, with the following symptoms: typical chest pain
lasting >20 min, and electrocardiogram (ECG) showing new ST-
segment elevation 2 min in at least two contiguous precordial
ECG leads or 1 mm in at least two contiguous limb ECG leads or a
Fig. 1. Flowchart of the patient recruitment and randomization.
STEMI, ST-segment elevation myocardial infarction.
newly appeared left bundle branch block [13]. All patients
underwent emergency coronary angiography to make a definitive
diagnosis and conduct percutaneous coronary intervention (PCI)
within 12 h of symptom onset.
Of the 47 patients, 9 were excluded on the basis of the following
exclusion criteria: cardiogenic shock, severe congestive heart
failure, statin intolerance or contraindications to statin therapy
(e.g. previous rhabdomyolysis or severe liver dysfunction), chronic
severe renal failure (glomerular filtration rate < 30 mL/min),
chronic infection (e.g. hepatitis B, hepatitis C, and human
immunodeficiency virus infection), chronic inflammatory disease
(e.g. rheumatoid arthritis and systemic lupus erythematosus),
coagulation abnormalities, alcohol or drug abuse, active cancer,
liver insufficiency (e.g. liver cirrhosis), steroid hormone intake,
simultaneous participation in another clinical study, no PCI after
emergency coronary angiography, and unsuccessful reperfusion.
The remaining 38 patients were randomized equally into two
groups, evolocumab (140 mg) and non-evolocumab.
Each patient’s medical history was obtained at randomization
(day 0). Cardiovascular risk factors (e.g. diabetes and arterial
hypertension) were defined in accordance with international
guidelines [14,15]. If a patient had not taken any statins, 4 mg of
pitavastatin daily was started. All patients were administrated
200 mg of aspirin, 300 mg of clopidogrel, and 100 IU/kg of heparin
prior to PCI.
Conventional PCI was performed and the exact procedure
depended on the interventional cardiologists in our hospital.
Successful PCI was defined as (1) <50% in the luminal diameter
after balloon angioplasty or <25% after coronary stent implanta-
tion, (2) Thrombolysis in Myocardial Infarction (TIMI) study
classification [16], and (3) flow recovery, estimated by visual
assessment on angiograms post-PCI once the safety and efficacy of
PCI was confirmed by the operator.
Patients with stable angina pectoris (SAP; n = 16) who
underwent elective PCI were treated as the control group in this
study. They underwent optimal medical therapy including 4 mg of
pitavastatin daily and no PCSK9 inhibitors. All 16 patients
underwent successful PCI, and no periprocedural MI was
documented.
Laboratory examinations
Blood samples were collected at randomization (day 0) before
emergency coronary angiography. Plasma levels of PCSK9 and lipid
markers, that is, triglycerides (TG), LDL-C, high-density lipoprotein
cholesterol (HDL-C), and Lp(a), were measured on days 1, 3, 5,10, and
20. In SAP patients, baseline samples were obtained before PCI. Sera
were separated immediately after blood collection by low-speed
centrifugation at 3000 rpm for 15 min at 4  C and stored at 80  C
until further analysis. SRL Inc, Hachioji Laboratory (Tokyo, Japan), a
commercial laboratory, determined plasma total cholesterol and TG
levels using an enzymatic method, HDL-C levels using a direct
method, apolipoprotein A-1 and apolipoprotein B levels using an
immunoturbidity method, and Lp(a) levels using latex-enhanced
immunoturbidimetry. Plasma LDL-C levels were measured directly
at TG >400 mg/L; and otherwise, they were calculated using the
Friedewald formula. Hemoglobin A1c (HbA1c) levels were deter-
mined using high-performance liquid chromatography in our
hospital laboratory. The area under the curve (AUC) was calculated
using the trapezoidal method, and the incremental AUC (iAUC) was
calculated as (total AUC area under the basal value).
Of 19 patients in the evolocumab group, 2 were excluded
because of no blood sampling: one patient died suddenly due to
free wall cardiac rupture before PCI, whereas the other was
transferred to another hospital for coronary artery bypass surgery
after emergency coronary angiography. Therefore, 36 eligible
 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401
patients were finally analyzed in this study: evolocumab group
(n = 17) or non-evolocumab group (n = 19) (Fig. 1).
Measurement of mature and furin-cleaved PCSK9
Plasma levels of mature and furin-cleaved PCSK9 were
measured using enzyme-linked immunosorbent assay (BML Inc.,
Tokyo, Japan) at randomization (day 0) and on days 1, 3, 5, 10, and
20. The lower and upper detection limits of mature and furin-
cleaved PCSK9 were set at 3.9, 20,000 ng/mL, and 0.7, 300 ng/mL,
respectively. As previously reported, interassay and intraassay
variations were 7.7% and 2.2%, respectively, in mature PCSK9 and
5.6% and 2.1%, respectively, in furin-cleaved PCSK9 [2].
Statistical analysis
Continuous variables were expressed as mean
standard
deviation (SD) and median with interquartile ranges. Categorical
variables were expressed as numbers and percentages. Differences
between the evolocumab and non-evolocumab groups were
assessed using the unpaired Student’s t-test or the Mann–Whitney
U test for continuous variables and the chi-square test or Fisher’s
exact test for categorical variables. One-way analysis of variance
followed by Tukey–Kramer honestly significant difference test was
used to examine differences among multiple groups. Statistical
analyses were performed using SPSS Statistics ver. 14.0 (SPSS Inc.,
Chicago, IL, USA). A value of p < 0.05 was considered statistically
significant.
Results
Baseline patient characteristics
Table 1 summarizes the baseline characteristics of the
36 patients. The white blood cell count on admission was
significantly higher in the non-evolocumab group compared with
the evolocumab group (p = 0.034). We found no significant
differences in other characteristics between the two groups,
including coronary risk factors, door-to-balloon times, Killip
classification, distribution of the infarct-related artery, the number
of significantly stenotic coronary arteries, cardiac troponin T, and
peak CK-MB. The plasma TG, LDL-C, and HDL-C levels were not
significantly different between the two groups. The plasma levels
of mature PCSK9 were 291.3
71.4 mg/dL and 236.4
57.3 mg/dL
in the evolocumab and non-evolocumab groups, respectively
(p = 0.875), whereas those of furin-cleaved PCSK9 were
28.6
11.8 ng/mL and 22.4
5.8 ng/mL in the evolocumab and
non-evolocumab, respectively (p = 0.602). We found here no
significant differences in the plasma Lp(a) levels between the
two groups (p = 0.944). Table 1 also summarizes the baseline
clinical and angiographic characteristics of SAP patients (control
group). PCI was successful in all patients, and optimal angiographic
reperfusion with TIMI flow >2 was obtained in both evolocumab
and non-evolocumab groups.
Changes in plasma PCSK9 levels
Fig. 2A and B shows changes in plasma levels of matured and
furin-cleaved PCSK9, respectively, in the three groups. The plasma
levels of mature and furin-cleaved PCSK9 were not significantly
different between groups at day 0 (mature PCSK9, p = 0.104; furin-
cleaved PCSK9, p = 0.209) (Table 1). In addition, plasma levels of
mature and furin-cleaved PCSK9 in the control group did not differ
significantly from the baseline. In the non-evolocumab group,
these levels gradually increased, reached a peak at day 3 (mature
PCSK9: from 236.4
57.3 ng/dL at day 0 to 408.8
77.1 ng/mL at
397
day 3, p < 0.001; furin-cleaved PCSK9: from 22.4
5.8 ng/mL at
day 0 to 47.2
15.7 ng/mL at day 3, p < 0.001), and returned to the
baseline by day 20 (mature PCSK9: 236.4
57.3 ng/mL at day 0 vs.
243.5
84.4 ng/mL at day 20, p = 0.837; furin-cleaved PCSK9,
22.4
5.8 ng/mL at day 1 vs. 25.1
5.1 ng/mL at day 20, p = 0.293).
Compared with the non-evolocumab group, the evolocumab group
showed a significant increase in plasma levels of mature PCSK9
after day 1 (from 291.3
71.4 ng/mL at day 0 to 480.1
194.0 ng/
mL at day 1, p = 0.022); these levels were >1000 ng/mL even after
day 20 (Fig. 2A). On the other hand, the evolocumab group showed
a significant decrease in plasma levels of furin-cleaved PCSK9 after
day 1 (from 28.6
11.8 ng/mL at day 0 to 9.7
4.8 ng/mL at day 3,
p < 0.001); these levels stayed below the measurement sensitivity
level (<7.0 ng/mL) and returned to the baseline at day 20
(28.6
11.8 ng/mL at day 0 vs. 21.0
16.4 ng/mL at day 20,
p = 0.316) (Fig. 2B).
Changes in plasma LDL-C levels
Fig. 3 shows changes in plasma LDL-C levels in the three groups.
Plasma LDL-C levels in the control group did not differ significantly
from the baseline. Fifteen patients (88%) in the evolocumab group
and 16 patients (84%) in the non-evolocumab group received 4 mg
of pitavastatin after randomization. In the non-evolocumab group,
plasma LDL-C levels gradually decreased by day 3 (from
135.4
22.8 mg/dL at day 0 to 84.9
18.8 mg/dL at day 3,
p < 0.001). After a significant temporary increase at day 5 (from
84.9
18.8 mg/dL at day 3 to 102.5
22.7 mg/dL at day 5,
p = 0.016), these levels continued to decrease again by day 20. In
the evolocumab group, we observed a continuous decrease in
plasma LDL-C levels to 30.7
18.9 mg/dL at day 10.
Changes in plasma Lp(a) levels
Fig. 4 shows changes in plasma Lp(a) levels in the three groups.
The plasma Lp(a) levels were not significantly different between
groups at day 0 (p = 0.473) (Table 1). Plasma Lp(a) levels in the
control group did not differ significantly from the baseline
(Fig. 4A). In the non-evolocumab group, plasma Lp(a) levels
gradually increased, reached a peak at day 3 (from 19.2.
16.5 mg/
dL at day 0 to 39.7
21.3 mg/dL at day 3, p < 0.005), and then
returned to baseline levels by 10 days (19.2.
16.5 mg/dL at day
0 vs. 21.5
14.8 mg/dL at day 10, p = 0.644). In contrast, in the
evolocumab group, we observed a significant decrease in plasma
Lp(a) levels during acute MI (18.7
22.0 mg/dL at day 0 vs.
25.5
18.3 mg/dL at day 3, p = 0.332; 23.8
20.1 mg/dL at day 5,
p = 0.488) (Fig. 4A). The iAUC0–20 day for plasma Lp(a) levels was
significantly smaller in the evolocumab group compared with the
non-evolocumab group (p = 0.038) (Fig. 4B). The novel finding of
significant inhibition of elevated Lp(a) levels by evolocumab
suggests a potential treatment strategy using anti-PCSK9 antibody
for acute MI.
Discussion
Plasma levels of both mature and furin-cleaved PCSK9
transiently increase in acute STEMI. PCSK9 inhibitors cause
persistent, marked augmentation of plasma levels of mature
PCSK9 with a simultaneous decrease in plasma levels of furin-
cleaved PCSK9. In addition, plasma Lp(a) levels increase in acute
STEMI and are significantly inhibited by PCSK9 inhibitors.
MI pathogenesis significantly influences lipid metabolism,
especially during acute MI [17–19]. PCSK9 is a major factor
regulating LDL-R in the liver and, consequently, plasma LDL-C
levels [20]. A few studies on PCSK9 and MI have reported that these
plasma LDL-C levels increase. Zhang et al. demonstrated that
398 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401

Table 1
Baseline characteristics of patients in this study.

SAP STEMI; STEMI; p-Value

(n = 16) evolocumab non-evolocumab evolocumab vs.
group (n = 17) group (n = 19) non-evolocumab group

Clinical characteristics
Age, years 61.6
13.1 64.2
14.8 62.3
10.7 0.60
Male, n (%) 15 (94) 14 (82) 12 (63) 0.20
Height, cm 165.8
6.6 166.6
9.7 161.7
9.6 0.13
Body mass index, kg/m2 24.9
4.2 24.0
2.4 24.4
3.5 0.70
Systolic BP, mmHg 128.8
18.9 135.8
33.0 144.6
38.3 0.46
Diastolic BP, mmHg 73.6
16.1 85.8
24.3 84.5
17.3 0.85
Heart rate, beats/min 78
15 72
22 75
16 0.66
Coronary risk factor
Hypertension, n (%) 11 (69) 12 (71) 13 (68) 0.89
Diabetes mellitus, n (%) 6 (38) 6 (35) 6 (32) 0.81
Familial history of IHD, n (%) 5 (31) 4 (24) 5 (26) 0.85
Smoking, n (%) 11 (69) 11 (65) 14 (74) 0.56
Previous history
Previous MI, n (%) 3 (19) 1 (6) 2 (11) 0.62
Previous CABG, n (%) 1 (6) 0 (0) 1 (5) 0.35
Previous PCI, n (%) 6 (38) 2 (12) 2 (11) 0.91
Onset-to-Door time, median (25th, 75th) (min) – 108 (60, 213) 155 (94, 326) 0.21
Door-to-Balloon time, median (25th, 75th) (min) – 81 (68, 93) 80 (71, 88) 0.62
Killip class 2, n (%) – 3 (18) 4 (21) 0.80
Angiographic characteristics
Multivessel disease, n (%) 9 (56) 10 (59) 13 (68) 0.55
PCI target lesion
RCA, n (%) 5 (31) 6 (35) 7 (42) 0.92
LMT, n (%) 1 (6) 0 (0) 1 (5) 0.34
LAD, n (%) 7 (44) 9 (53) 8 (42) 0.52
LCX, n (%) 4 (25) 2 (12) 3 (16) 0.73
Biochemical data
White blood cell count, 103/mL 6.79
2.2 9.94
3.4 13.1
4.8 0.03
AST, IU/L 22.6
7.6 54.8
71.0 44.6
49.3 0.64
ALT, IU/L 23.0
11.2 35.7
22.9 31.6
21.8 0.60
CPK, median (25th, 75th) (IU/L) 78 (64, 105) 158 (109, 280) 120 (78, 249) 0.25
CK-MB, median (25th, 75th) (IU/L) 4.0 (4.0, 5.2) 7.2 (4.6, 13.6) 8.8 (4.6, 27.5) 0.64
Troponin T, median (25th, 75th) (ng/mL) – 0.33 (0.02, 2.52) 0.12 (0.01, 0.29) 0.27
Peak CPK, median (25th, 75th) (IU/L) – 4107 (783, 6268) 3963 (862, 5842) 0.51
Peal CK-MB, median (25th, 75th) (IU/L) – 443 (93, 667) 355 (112, 521) 0.65
Creatinine, mg/dL 0.78
0.18 0.93
0.33 0.82
0.25 0.27
eGFR, mL/min/1.73 m2 75.6
16.5 69.9
23.9 72.0
18.6 0.77
HbA1C, % 6.3
0.6 6.2
0.7 6.1
0.6 0.69
Lipid markers
Total cholesterol, mg/dL 168.6
33.2 183.5
43.0 197.8
47.6 0.35
TG, mg/dL 156.5
97.4 121.7
151.0 131.8
76.2 0.80
LDL-C, mg/dL 114.4
27.7 126.8
33.6 135.4
22.8 0.38
HDL-C, mg/dL 49.3
13.8 48.3
13.8 46.8
11.8 0.77
Apolipoprotein AI, mg/dL 29.6
5.8 27.5
7.4 27.3
6.8 0.95
Apolipoprotein B, mg/dL 91.3
18.3 89.4
23.4 103.8
26.5 0.17
Medications on admission
Aspirin, n (%) 16 (100) 4 (24) 5 (26) 0.85
Clopidogrel, n (%) 16 (100) 2 (12) 2 (11) 0.91
ACE inhibitors or ARBs, n (%) 5 (31) 5 (29) 3 (16) 0.33
Beta-blockers, n (%) 6 (38) 3 (18) 4 (21) 0.80
Calcium channel blockers, n (%) 10 (63) 8 (47) 9 (47) 0.99
Statins, n (%) 16 (100) 2 (12) 3 (16) 0.73
Insulin, n (%) 0 (0) 0 (0) 0 (0) 1.00
PCSK9 values
Matured PCSK9, ng/mL 241.4
50.6 291.3
71.4 236.4
57.3 0.88
Furin-cleaved PCSK9, ng/mL 29.0
9.2 28.6
11.8 22.4
5.8 0.60
Lp(a), mg/dL 26.9
28.5 18.7
22.0 19.2
16.5 0.94

Data for continuous normally distributed variables are expressed as mean
SD. Continuous logarithmic variables are expressed as median (interquartile range).
ACE, angiotensin-converting enzyme; ALT, alanine transaminase; AST, aspartate transaminase; ARB, angiotensin II receptor blocker; BP, blood pressure; CABG, coronary
artery bypass grafting; CK-MB, creatine kinase-myocardial isoform; CPK, creatine phosphokinase; eGFR, estimated glomerular filtration rate; HDL-C, high-density
lipoprotein cholesterol; HbA1c, hemoglobin A1c; IHD, ischemic heart disease; LAD, left anterior descending artery; LCX, left circumflex artery; LDL-C, low-density
lipoprotein cholesterol; LMT, left main coronary artery; Lp(a), lipoprotein(a); MI, myocardial infarction; PCI, percutaneous coronary intervention; PCSK9, proprotein
convertase subtilisin/kexin type 9; RCA, right coronary artery; SAP, stable angina pectoris; STEMI, ST-segment elevation myocardial infarction; TG, triglycerides.

plasma PCSK9 levels transiently increase in acute MI in a rat model
[6]. Retrospective angiographic studies in humans have shown that
PCSK9 levels are upregulated during acute MI without statins
[7]. Our findings were compatible with these previous observa-
tions, and to the best of our knowledge, ours is the first study to
thoroughly assess the plasma kinetics of mature and furin-cleaved
PCSK9 separately in the specific setting of acute MI [2,21,22].
Mature PCSK9, not furin-cleaved PCSK9, has the ability to degrade
LDL-R [23], and each measurement of PCSK9 subtypes is
meaningful for investigating the role of PCSK9 in MI pathogenesis
 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401
Fig. 2. Changes in plasma levels of (A) mature PCSK9 and (B) furin-cleaved PCSK9.
Data are mean
SD. *p < 0.05, yp < 0.01, zp < 0.005, and §p < 0.001 vs. Day 0.
PCSK9, proprotein convertase subtilisin/kexin type 9; SAP, stable angina pectoris;
SD, standard deviation.
and other acute-phase responses. Because PCSK9–LDL-R binding in
the liver is the major mechanism underlying PCSK9 clearance [24],
blockage of this pathway by evolocumab might induce an increase
in circulating mature PCSK9 combined with antibodies. That is, the
possibility exists that most of mature PCSK9-evolocumab com-
plexes might flow out of the liver into blood vessels rather than
being taken up by the liver. If we could measure plasma levels of
these complexes, it would contribute to better understanding of
clinical significance of measuring mature PCSK9 levels after
administration of PCSK9 inhibitors. Interestingly, the kinetics of
furin-cleaved PCSK9 are in contrast to those of mature PCSK9 after
the administration of anti-PCSK9 antibodies. Although the
mechanism underlying a decrease in the circulating levels of
Fig. 3. Changes in plasma levels of LDL-C. Data are mean
SD. *p < 0.05 vs. Day
3. LDL-C, low-density lipoprotein-cholesterol; SAP, stable angina pectoris; SD,
standard deviation.
399
furin-cleaved PCSK9 remains unclear, PCSK9 antibodies seem to
promote the clearance of furin-cleaved PCSK9 into the liver with a
resultant decrease in its circulating levels. For the upregulation of
cholesterol synthesis due to an increase in LDL-R activity after
acute MI, a transient decrease in plasma LDL-C levels has been
reported [18,19]. A gradual decrease in plasma LDL-C levels in
patients without anti-PCSK9 antibody treatment and then a
transient increase might be explained by the increase in plasma
levels of mature PCSK9 in acute MI. A transient upregulation of
sterol regulatory element-binding protein-2 (SREBP-2) has been
reported in the acute phase of MI [6], and an explanation for the
mechanism underlying the plasma kinetics of LDL-C can be
partially provided by the activation of SREBP-2 pathway, resulting
in a decrease of plasma LDL-C levels by LDL-R activation and a
transient increase of them by PCSK9 induction in the liver.
Lp(a) is an independent risk of future cardiovascular disease [8–
10]. Studies have reported that plasma Lp(a) levels increase in MI
patients in whom apo(a) is synthesized actively in the liver
[25,26]. Villard et al. reported that Lp(a) secretion from the liver
increases in a mature PCSK9 ex vivo model using primary human
hepatocytes and dermal fibroblasts isolated from familial hyper-
cholesterolemia and nonfamilial hypercholesterolemia patients
[27]. Romagnuolo et al. demonstrated that PCSK9 decreases Lp(a)
uptake into the liver in human dermal fibroblasts expressing LDL-R
[28]. Therefore, the increase in plasma Lp(a) levels might be due to
progressive synthesis and increased secretion of apo(a) and
decreased Lp(a) uptake in the liver by mature PCSK9 during acute
MI. The mechanisms underlying the decrease in plasma Lp(a)
levels by anti-PCSK9 antibody with evolocumab in MI remain
unclear. Villard et al. demonstrated that the anti-PCSK9 antibody
inhibits Lp(a) production from the liver [27]. Studies have reported
a physical association between mature PCSK9 and Lp(a) [12] and
anti-PCSK9 antibody might cause alteration of Lp(a)–mature
PCSK9 binding and active clearance of Lp(a) into the liver. Further
studies are required in order to determine the mechanism
underlying Lp(a) clearance associated with PCSK9 and its antibody.
Although several therapies, such as an antisense oligonucleo-
tide-targeting hepatic apo(a) messenger RNA, are currently being
developed clinically for patients with elevated Lp(a) [29], an
effective and safe Lp(a)-lowering therapy has not yet been
established. Anti-PCSK9 antibody decreases plasma Lp(a) levels
[11,30] and this treatment could also be potentially used for MI
patients, especially in acute MI. Elevation of plasma Lp(a) levels is
known to be associated with a higher risk of coronary artery
disease (CAD) and this association is the most prominent causal
[31]. However, to date, it is not clear whether a large reduction in
plasma Lp(a) levels could achieve a clinically meaningful reduction
of CAD. Selective Lp(a)-lowering therapy could prove in clinical
trials the causality of elevated Lp(a) developing atherosclerotic
lesions. In addition, it would be significant to know whether
plasma Lp(a) elevation during acute MI was potentially the
biological determinant of plaque instability in non-infarct-related
coronary arteries as well as culprit lesions.
Limitations
This study had several limitations. First, we did not directly
evaluate the PCSK9–Lp(a) interaction. It is still unclear whether
decreased plasma Lp(a) levels are due to a direct or an indirect
effect of anti-PCSK9 antibody. Second, we did not observe long-
term clinical effects of a single dose of anti-PCSK9 antibody in
acute MI. It would be interesting to know whether the inhibition of
increased acute-phase-related substances, such as Lp(a), could
have an effect on the progress control of atherosclerotic lesions in
infarct-related or non-infarct-related vessels. Third, we did not
400 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401
Fig. 4. Changes in plasma levels of (A) Lp(a) and (B) comparison of iAUCs for Lp(a). Data are mean
SD. *p < 0.05; yp < 0.01; zp < 0.005: and §p < 0.001 vs. Day 0.
iAUC, incremental area under the curve; Lp(a), lipoprotein(a); SAP, stable angina pectoris; SD, standard deviation.
consider PCSK9 polymorphisms, which have the potential to
influence plasma PCSK9 levels [32].
Conclusions
Plasma levels of both mature and furin-cleaved circulating
PCSK9 are transiently upregulated in acute MI. The PCSK9 inhibitor
causes persistent, significant augmentation of plasma levels of
mature PCSK9 with a simultaneous decrease in plasma levels of
furin-cleaved PCSK9. Increased plasma Lp(a) levels are inhibited by
the PCSK9 inhibitor in acute MI. Therefore, PCSK9 and Lp(a) are
related in MI patients, and the anti-PCSK9 antibody might be one
potential therapy for MI patients.
Funding
This study received no grant from any funding agency in the
public, commercial, or not-for-profit sectors.
Conflict of interest
No conflicts of interest are declared.
Acknowledgments
The authors gratefully acknowledge clinical laboratory tech-
nologist Ms Ando, for their technical assistance with blood
sampling. We would also like to thank Enago (www.enago.jp)
for English language editing.
References
[1] Lambert G, Sjouke B, Choque B, Kastelein JJ, Hovingh GK. The PCSK9 decade. J
Lipid Res 2012;53:2515–24.
[2] Kataoka Y, Harada-Shiba M, Nakao K, Nakashima T, Kawakami S, Fujino M, et al.
Mature proprotein convertase subtilisin/kexin type 9, coronary atheroma
burden, and vessel remodeling in heterozygous familial hypercholesterolemia.
J Clin Lipidol 2017;11:413–21.
[3] Kawashiri M-A, Tada H, Nomura A, Yamagishi M. Mendelian randomization: its
impact on cardiovascular disease. J Cardiol 2018;72:307–13.
[4] Yano H, Horinaka S, Ishimitsu T. Effect of evolocumab therapy on coronary
fibrous cup thickness assessed by optimal coherence tomography in patients
with acute coronary syndrome. J Cardiol 2019;75:289–95.
[5] Denis M, Marcinkiewicz J, Zaid A, Gauthier D, Poirier S, Lazure C, et al. Gene
inactivation of proprotein convertase subtilisin/kexin type 9 reduces athero-
sclerosis in mice. Circulation 2012;125:894–901.
[6] Zhang Y, Liu J, Li S, Xu RX, Sun J, Tang Y, et al. Proprotein convertase subtilisin/
kexin type 9 expression is transiently up-regulated in the acute period of
myocardial infarction in rat. BMC Cardiovasc Disord 2014;14:192.
[7] Almontashiri NAM, Vilmundarson RO, Ghasemzadeh N, Dandona S, Roberts R,
Quyyumi AA, et al. Plasma PCSK9 levels are elevated with acute myocardial
infarction in two independent retrospective angiographic studies. PLoS ONE
2014;9:e106294.
[8] Tsimikas S, Hall JL. Lipoprotein(a) as a potential causal genetic risk factor of
cardiovascular disease: a rationale for increased efforts to understand its
pathophysiology and develop targeted therapies. J Am Coll Cardiol
2012;60:716–21.
[9] Tsimikas S. A test in context. Lipoprotein(a) diagnosis, prognosis, controver-
sies, and emerging therapies. J Am Coll Cardiol 2017;69:692–711.
[10] O’Donghue ML, Fazio S, Giugliano RP, Stroes ESG, Kanevsky E, Gouni-Berthold I,
et al. Lpoprotein(a), PCSK9 inhibition, and cardiovascular risk. Circulation
2019;139:1483–92.
[11] Raal FJ, Giugliano RP, Sabatine MS, Koren MJ, Langslet G, Bays H, et al. Reduc-
tion in lipoprotein(a) with PCSK9 monoclonal antibody evolocumab (AMG
145): a pooled analysis of more than 1,300 patients in 4 phase II trials. J Am Coll
Cardiol 2014;63:1278–88.
[12] Tavori H, Christian D, Minnier J, Plubell D, Shapiro MD, Yeang C, et al. PCSK9
association with lipoprotein(a). Circ Res 2016;119:29–35.
[13] Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al.
Management of acute myocardial infarction in patients presenting with per-
sistent ST-segment elevation. Eur Heart J 2008;29:2909–45.
[14] American Diabetes Association. Standard of medical care in diabetes—2010.
Diabetes Care 2010;33:S11–61.
[15] European Society of Hypertension-European Society of Cardiology Guidelines
Committee. 2003 European Society of Hypertension-European Society of
Cardiology guidelines for the management of arterial hypertension. J Hyper-
tens 2003;21:1011–53.
[16] TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial:
phase 1 findings. N Engl J Med 1985;312:932–6.
[17] Balci B. The modification of serum lipids after acute coronary syndrome and
importance in clinical practice. Curr Cardiol Rev 2011;7:272–6.
[18] Rosenson RS. Myocardial injury: the acute phase response and lipoprotein
metabolism. J Am Coll Cardiol 1993;22:933–40.
[19] Pfohl M, Schreiber I, Liebich HM, Häring HU, Hoffmeister HM. Upregulation of
cholesterol synthesis after acute myocardial infarction—is cholesterol a posi-
tive acute reactant? Atherosclerosis 1999;142:389–93.
[20] Lagace TA, Curtis DE, Garuti R, McNutt MC, Park SW, Prather HB, et al. Secreted
PCSK9 decreases the number of LDL receptors in hepatocytes and in livers of
parabiotic mice. J Clin Invest 2006;116:2995–3005.
[21] Benjannet S, Rhainds D, Hamelin J, Nassoury N, Seidah NG. The proprotein
convertase (PC) PCSK9 is inactivated by furin and/or PC5/6A: functional
consequences of natural mutations and post-translational modifications. J
Biol Chem 2006;281:30561–72.
[22] Essalmani R, Susan-Resiga D, Chamberland A, Abifadel M, Creemers JW,
Boileau C, et al. In vivo evidence that furin from hepatocytes inactivates
PCSK9. J Biol Chem 2011;286:4257–63.
[23] Han B, Eacho PI, Knierman MD, Troutt JS, Konrad RJ, Yu X, et al. Isolation and
characterization of the circulating truncated form of PCSK9. J Lipid Res
2014;55:1505–14.
[24] Tavori H, Fan D, Blakemore JL, Yancey PG, Ding L, Linton MF, et al. Serum
proprotein convertase subtilisin/kexin type 9 and cell surface low-density
lipoprotein receptor: evidence for a reciprocal regulation. Circulation
2013;127:2403–13.
[25] Maeda S, Abe A, Seishima M, Makino K, Noma A, Kawade M. Transient changes
of serum lipoprotein(a) as an acute phase protein. Atherosclerosis
1989;78:145–50.
[26] Noma A, Abe A, Maeda S, Seishima M, Makino K, Yano Y, et al. Lp(a): an acute-
phase reactant? Chem Phys Lipids 1994;67–8:411–7.
 A. Nakamura et al. / Journal of Cardiology 76 (2020) 395–401
[27] Villard EF, Thedrez A, Blankenstein J, Croyal M, Tran TT, Poirier B, et al. PCSK9
modulates the secretion but not the cellular uptake of lipoprotein(a) ex vivo.
JACC Basic Transl Sci 2016;1:419–27.
[28] Romagnuolo R, Scipione CA, Boffa MB, Marcovina SM, Seidah NG, Koschinsky
ML. Lipoprotein(a) catabolism is regulated by proprotein convertase subtilisin/
kexin type 9 through the low density lipoprotein receptor. J Biol Chem
2015;290:11649–62.
[29] Tsimikas S, Viney NJ, Hughes SG, Singleton W, Graham MJ, Baker BF, et al.
Antisense therapy targeting apolipoprotein(a): a randomized, double-blind,
placebo-controlled phase 1 study. Lancet 2015;386:1472–83.
401
[30] Willeit P, Ridker PM, Nestel PJ, Simes J, Tonkin AM, Pedersen TR, et al. Baseline
and on-statin treatment lipoprotein(a) levels for prediction of cardiovascular
events: individual patient-data meta-analysis of statin outcome trials. Lancet
2018;392:1311–20.
[31] Erqou S, Kaptoge S, Perry PL, Angelantonio ED, Thompson A, White IR, et al.
Lipoprotein(a) concentration and the risk of coronary heart disease, stroke,
and nonvascular mortality. JAMA 2009;302:412–23.
[32] Ference BA, Robinson JG, Brook RD, Catapano AL, Chapman MJ, Neff DR, et al.
Variation in PCSK9 and HMGCR and risk of cardiovascular disease and diabe-
tes. N Engl J Med 2016;375:2144–53.