Expanding the Role of PCSK9, SGLT2 Inhibitors in Cardiovascular Prevention: Deepak Bhatt, MD, MPH, MBA

The landscape of cardiovascular prevention is being rapidly reshaped by emerging data on PCSK9 and SGLT2 inhibitors, alongside evolving imaging technologies that refine risk assessment, Deepak Bhatt, MD, MPH, MBA, director of the Mount Sinai Fuster Heart Hospital and the Dr Valentin Fuster Professor of Cardiovascular Medicine at the Icahn School of Medicine at Mount Sinai, explained. Although these therapies have demonstrated substantial clinical benefit, questions remain about how best to deploy them across primary and secondary prevention populations and how to balance efficacy with cost and access.

PCSK9 inhibitors represent one of the clearest examples of translational success in cardiology, evolving from genetic discoveries to powerful low-density lipoprotein (LDL)-lowering therapies. Despite robust trial evidence supporting their use in high-risk patients, early clinical uptake was limited by high prices and restricted access. Recent cost reductions have broadened access and boosted utilization, creating a paradox in which lower per-patient prices have led to higher overall expenditures due to expanded use. Clinically, however, these agents are still underutilized, particularly in secondary prevention. Ongoing trials are expected to better define which patients—especially those with well-controlled LDL on statins—derive the greatest benefit and whether routine use should extend into primary prevention.

At the same time, traditional distinctions between primary and secondary prevention are being challenged. Asymptomatic individuals with significant plaque on CT coronary angiography, for example, may not fit neatly into either category. Parallel advances in imaging, including assessment of epicardial fat and coronary inflammation, may enable more nuanced risk stratification. Researchers are actively investigating whether measures such as epicardial adipose tissue, coronary artery calcification scoring, and artificial intelligence-enhanced CT angiography provide incremental prognostic value over standard risk scores and whether they should guide therapeutic decisions.

SGLT2 inhibitors have emerged as another transformative class, improving outcomes in heart failure with reduced and preserved ejection fraction, as well as in chronic kidney disease—irrespective of diabetes status. Despite strong evidence, many eligible patients remain untreated, in part due to cost barriers. The recent availability of generic options may help close this gap, enabling broader use of SGLT2 inhibitors as life-saving agents across a spectrum of cardiovascular and renal conditions.