The Impact of Pcsk-9 Inhibition on PET CFR in Patients at High CV Risk

Intervention Group: Inclusion Criteria: * Age: ≥ 50 (men) or ≥ 55 (women) * Low-density lipoprotein cholesterol (LDL-C) ≥ 70 mg/dL * Stable coronary artery disease (without plan to undergo revascularization before randomization) defined as one or more of the following: 1. Abnormal nuclear perfusion imaging 1. At least moderate ischemia involving \>10% of the LV myocardium or 2. Global coronary flow reserve (CFR) \<1.8 or 3. Stress myocardial blood flow (MBF) \<1.8 2. Abnormal coronary angiography (invasive coronary angiography or coronary computed tomography) 1. ≥ 50% stenosis in ≥ 2 coronary vessels or 2. Diffuse atherosclerosis in a 3-vessel distribution 3. Elevated coronary calcium score 1. CAC \>100 + \>1 ASCVD risk factor 2. CAC \>300 * If the patient is on a statin they must be on a stable dose for at least 3 months prior to enrollment. Exclusion Criteria: * History of myocardial infarction or stroke * CABG \< 3 months prior to screening * Homozygous familial hypercholesterolemia * History of cardiac transplantation * LV ejection fraction \< 40% or New York Heart Failure Association (NYHA) class III-IV for angina and/or dyspnea. * History of infiltrative or hypertrophic cardiomyopathy * Severe valvular disease * Uncontrolled or recurrent ventricular tachycardia * Fasting triglycerides \> 500 mg/dL * GFR ˂ 30 mL/min/1.73 m² * Current use of a PCSK-9 inhibitor * Currently pregnant or breastfeeding * Contraindication to receive vasodilator agent * Latex allergy Parallel Control Group: Patients will be invited to participate in the parallel control group if they meet study criteria, but 1) have a latex allergy and cannot use the Evolocumab autoinjector 2) LDL-C is just below the enrollment criteria (LDL 60-69), or 3) meet study criteria but prefer to not take an injectable medication at this time.