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The prospective, multi-center observational study included 1695 patients with dyslipidemia. Eligible patients were adults with familial or non-familial hypercholesterolemia, mixed dyslipidemia, or other therapy-refractory lipid disorders in line with the G-BA reimbursement regulations. Treatment decisions, including PCSK9-mAb administration, were made at the discretion of the treating physician. At baseline, 804 (47.4%) patients received PCSK9-mAb therapy, and 891 (52.5%) did not. There were 42 (4.7%) new PCSK9-mAb receivers during the follow-up. Median propensity-score adjusted LDL-C levels in PCSK9-mAb non-receivers decreased over time from 106.0 to 68.4 mg\/dL. LDL-C in PCSK9-mAb receivers dropped from 112.5 mg\/dL at baseline to 58.0 mg\/dL at 3 years, consistently outperforming non-receivers. Target LDL-C goal attainment (&lt;\u200955mg\/dL) after 3 years was higher in the PCSK9-mAb group (43.2% vs. 34.5%). Persistence with PCSK9-mAb therapy over 3 years since treatment initiation was high (91.5%). Higher discontinuation rates of PCSK9-mAb were associated with baseline statin intolerance (HR\u2009=\u20092.3,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.012). The use of PCSK9-mAb was associated with numerically fewer cardiovascular events (9.3 versus 15.7 per 100 patient-years,\n                    <jats:italic>p<\/jats:italic>\n                    not significant) and lower hospitalization rates due to cardiovascular events compared to non-users (6.3 versus 12.4 per 100 patient years,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.001). This study underscores the real-world efficacy and safety of PCSK9-mAb therapy in achieving sustained LDL-C reduction. Identifier: Clinicaltrials.gov NCT03110432.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical Abstract<\/jats:bold>\n                  <\/jats:p>","DOI":"10.1007\/s00392-025-02719-z","type":"journal-article","created":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T18:26:10Z","timestamp":1754331970000},"page":"288-303","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Treatment persistence, lipid lowering, and 3-year clinical outcomes in patients at very high cardiovascular risk on PCSK9 monoclonal antibodies"],"prefix":"10.1007","volume":"115","author":[{"given":"Klaus G.","family":"Parhofer","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Pittrow","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas L.","family":"Birkenfeld","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Uwe","family":"Fraass","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernd","family":"Hohenstein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carsten","family":"Siegert","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jens","family":"Klotsche","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elisabeth","family":"Steinhagen-Thiessen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Dexl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Volker J. 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Prior to the commencement of this study, the research protocol received the ethical approval of the institutional review board at the Medical Faculty of the Technical University of Dresden, Germany, under reference number EK 4761120166.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"Written informed consent was obtained from all individual participants included in the study.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Klaus G. Parhofer has received research funding and honoraria for consultancy and\/or speaker\u2019s bureaus and\/or Data Monitoring Committee activity from Akcea, Amarin, Amgen, Boehringer-Ingelheim, Dr. Sch\u00e4r, Daiichi Sankyo, Ionis, MSD, Novartis, Pfizer, Regeneron, Sanofi, and Silence Therapeutics. Ulrich Laufs: Leipzig University has received research funding from Amgen, Daiichi Sankyo, Novartis. UL has received honoraria from Amarin, Amgen, Daiichi Sankyo, Novartis, Sanofi, Synlab. Andreas L. Birkenfeld: none reported. Uwe Fraass: full-time employee of Amgen GmbH, Germany. Bernd Hohenstein: none reported. Carsten Siegert: full-time employee of Amgen GmbH, Germany. Jens Klotsche: none reported. Elisabeth Steinhagen-Thiessen: none reported. David Pittrow: received consultancy fees from Amgen, Aspen, Biogen, Daiichi Sankyo, Sanofi-Genzyme, Sandoz\/Novartis, Viatris, MSD. Stefan Dexl: full-time employee of Amgen GmbH, Germany. Volker J.J. Schettler: received consultancy fees and\/or speaker\u2019s bureaus and\/or Data Monitoring Committee activity from Amgen GmbH, Daiichi Sankyo GmbH, Novartis GmbH, Sanofi-Aventis GmbH.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}