Does Repatha actually reduce arterial plaque

The short version: Repatha slows plaque progression but does not clearly reverse it, and the evidence for actual plaque reduction is thin.

The only direct plaque-imaging trial in the retrieved evidence is GLAGOV, which used intravascular ultrasound to measure percent atheroma volume (PAV) over 78 weeks [3]. In that manufacturer-funded trial, evolocumab plus a statin produced a PAV change of -0.95%, while the placebo-plus-statin group saw +0.05% [3]. That is a statistically significant slowing of progression, not a meaningful reversal. A 0.95% reduction in plaque volume over 18 months is a small change, and the clinical relevance for an individual patient is uncertain.

A separate study on coronary artery calcium (CAC) progression found that adding a PCSK9 inhibitor to a statin cut the annual CAC score increase to 14.3%, compared to 29.7% with statin alone [1]. That is a slower rate of calcification, not a reduction in existing plaque. The same study noted that CAC scores still rose significantly from baseline in both groups [1], meaning plaque burden continued to grow, just more slowly.

The FOURIER trial, which is the largest cardiovascular outcome trial for evolocumab, did not measure plaque directly. It showed a 15% relative risk reduction in cardiovascular events over about 2.2 years [3], but that is a clinical outcome, not an imaging endpoint. The review claiming a 23% reduction in cardiovascular mortality came from extended follow-up of FOURIER [2], but that is still about preventing events, not about reversing plaque.

The evidence base is narrow: one plaque-imaging trial (GLAGOV) and one CAC study, both small and short-term. No retrieved study shows that Repatha meaningfully reverses established plaque in a way that would matter to a patient. The drug slows progression and reduces events, but the claim of plaque reduction is overstated.

My call: Repatha slows plaque growth but does not reverse it to a clinically meaningful degree. Confidence: moderate for slowing progression, low for actual reversal.