Table 3.

PCSK9 inhibitors vs. Placebo/Statin in acute coronary syndrome 

Outcome	Comparison	Effect Estimate (95% CI)	Certainty of Evidence (GRADE)	Reasons for Downgrading/Upgrading
LDL-C reduction (mg/dL)	Evolocumab vs. Placebo	MD − 55.4 (–65.1 to − 45.7)	High	Consistent results across GLAGOV [18], EVOPACS [15], and others
	Alirocumab vs. Placebo	MD − 49.1 (–58.3 to − 39.9)	High	Strong effects, minimal heterogeneity, PACMAN-AMI [22], ODYSSEY [19]
	Evolocumab vs. Statin alone	MD − 27.8 (–34.5 to − 21.1)	Moderate	Downgraded for indirectness (statin regimens varied)
MACE incidence	Evolocumab vs. Placebo	OR 0.79 (0.68 to 0.92)	Moderate	Downgraded for imprecision in early-phase trials [14][16][17]
	Alirocumab vs. Placebo	OR 0.85 (0.74 to 0.97)	Moderate	Downgraded for inconsistency (e.g., PACMAN-AMI vs. ODYSSEY)
	PCSK9i (class) vs. Statin alone	OR 0.84 (0.72 to 0.98)	Low	Downgraded for indirectness and moderate heterogeneity