Nationwide implementation of PCSK9--targeted therapies after myocardial infarction and ischemic stroke: structural barriers and disparities in a universal healthcare system
P Sedova, P Kala, P Ostadal, J Jarkovsky, S Littnerova, R Mikulik, A Tomek, A Tichopad, V K Somers, R D Brown, M VrablikAbstract
Background
Proprotein convertase subtilisin/kexin 9 (PCSK9)–targeted therapies substantially reduce LDL cholesterol and recurrent major cardiovascular events in very high-risk patients following myocardial infarction (MI) or ischemic stroke, yet real-world implementation remains critically insufficient despite robust trial evidence and Class I ESC guideline recommendations.
Purpose
To evaluate 24-month initiation rates of PCSK9-targeted therapies [monoclonal antibodies (mAbs) and inclisiran] following MI and ischemic stroke across the entire Czech national population, and to quantify disparities by age, sex, region, and therapeutic class (mAbs vs. inclisiran).
Methods
A nationwide population-based cohort study was conducted using the National Registry of Reimbursed Health Services, encompassing complete reimbursement data from all statutory health insurers. All adults hospitalized with incident MI (ICD-10 I21–I22) or ischemic stroke (I63) between 2018 and 2024 were included. Therapy initiation within 24 months was the primary endpoint. Multivariable logistic regression identified independent predictors, including sex, age group (<65, 65–74, ≥75 years), and region.
Results
Among 81,366 patients with incident MI, only 780 (1.0%) initiated PCSK9-targeted therapy within 24 months. Uptake increased from 0.2% (2018) to 2.0% (2023) yet remained markedly low. A pronounced age gradient was observed: 1.5% (<65 years), 0.9% (65–74 years), and 0.3% (≥75 years); patients ≥75 years had an adjusted OR of ~0.47 for treatment initiation. Substantial regional heterogeneity was observed; sex differences were modest. Initiation rates after ischemic stroke were uniformly lower than after MI across all calendar years (<1%), with pronounced age-related disparities. Notably, inclisiran surpassed monoclonal antibodies in recent initiations, potentially reflecting system-level prescribing constraints at lipid centers.
Conclusions
In this comprehensive national analysis, fewer than 2% of post-MI patients and fewer than 1% of post-stroke patients initiated PCSK9-targeted therapy within 24 months. Age- and region-based inequities persist within a universal coverage system. Restrictive reimbursement criteria, mandatory specialist referral requirements, and limited cross-disciplinary pathways represent actionable structural barriers. Systemic reforms targeting prescribing pathways, reimbursement thresholds, and accountability frameworks are required to close the implementation gap in secondary cardiovascular prevention.Initiation of PCSK9 After MIInitiation of PCSK9 After Ischemic Stroke