BACKGROUND: We characterised the phenotypic consequence of genetic variation at the PCSK9 locus and compared findings with recent trials of pharmacological inhibitors of PCSK9. METHODS: Published and individual participant level data (300,000+ participants) were combined to construct a weighted PCSK9 gene-centric score (GS). Seventeen randomized placebo controlled PCSK9 inhibitor trials were included, providing data on 79,578 participants. Results were scaled to a one mmol/L lower LDL-C concentration. RESULTS: The PCSK9 GS (comprising 4 SNPs) associations with plasma lipid and apolipoprotein levels were consistent in direction with treatment effects. The GS odds ratio (OR) for myocardial infarction (MI) was 0.53 (95% CI 0.42; 0.68), compared to a PCSK9 inhibitor effect of 0.90 (95% CI 0.86; 0.93). For ischemic stroke ORs were 0.84 (95% CI 0.57; 1.22) for the GS, compared to 0.85 (95% CI 0.78; 0.93) in the drug trials. ORs with type 2 diabetes mellitus (T2DM) were 1.29 (95% CI 1.11; 1.50) for the GS, as compared to 1.00 (95% CI 0.96; 1.04) for incident T2DM in PCSK9 inhibitor trials. No genetic associations were observed for cancer, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, or Alzheimer's disease - outcomes for which large-scale trial data were unavailable. CONCLUSIONS: Genetic variation at the PCSK9 locus recapitulates the effects of therapeutic inhibition of PCSK9 on major blood lipid fractions and MI. While indicating an increased risk of T2DM, no other possible safety concerns were shown; although precision was moderate.

Ageing Epidemiology Research Unit School of Public Health Imperial College London UK

Boston University School of Medicine Boston MA USA

Bradford Institute for Health Research Bradford Royal Infirmary Bradford UK

Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital Copenhagen The Capital Region of Denmark Denmark

Center for Human Genetics Marshfield Clinic Research Institute Marshfield USA

Center for Lifespan Changes in Brain and Cognition Dept Psychology University of Oslo Oslo Norway

Centre for Cardiovascular Genetics Department of Medicine University College London London UK

Centre for Population Health Research Sansom Institute for Health Research University of South Australia Adelaide Australia

Centre for Population Health Sciences The Usher Institute University of Edinburgh Edinburgh UK

Chair of Epidemiology Ludwig Maximilians Universität München UNIKA T Augsburg Augsburg Germany

Charité Universitätsmedizin Berlin BCRT Berlin Institute of Health Center for Regenerative Therapies Berlin Germany

Charité Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt Universität zu Berlin and Berlin Institute of Health Lipid Clinic at the Interdisciplinary Metabolism Center Berlin Germany

Children's Hospital of Philadelphia Philadelphia USA

Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford Richard Doll Building Old Road Campus Roosevelt Drive Oxford OX3 7LF UK

CNRS UMR 8199 European Genomic Institute for Diabetes Institut Pasteur de Lille University of Lille 59000 Lille France

Cyprus International Institute for Environmental and Public Health Cyprus University of Technology Limassol Cyprus

Départment de Diabétologie Endocrinologie et Nutrition Assistance Publique Hôpitaux de Paris Hôpital Bicha Paris France

Department of Biomedical Informatics and Medical Education University of Washington Seattle Seattle WA USA

Department of Cardiology Division Heart and Lungs University Medical Center Utrecht Utrecht University Utrecht the Netherlands

Department of Cardiology University of Groningen University Medical Center Groningen Groningen The Netherlands

Department of Clinical Epidemiology Biostatistics And Bioinformatics Academic Medical Center Amsterdam Amsterdam the Netherlands

Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands

Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark

Department of Epidemiology and Biostatistics Imperial College London London UK

Department of Epidemiology and Population Studies Faculty of Health Sciences Jagiellonian University Medical College Kraków Poland

Department of Epidemiology and Public Health UCL Institute of Epidemiology and Health Care University College London London UK

Department of Epidemiology Erasmus University Medical Center Rotterdam the Netherlands

Department of Epidemiology University of Groningen University Medical Center Groningen Groningen Netherlands

Department of Genetics University of Groningen University Medical Center Groningen Groningen The Netherlands

Department of Genomics of Common Disease Imperial College London W12 0NN London United Kingdom

Department of Hematology Erasmus MC Cancer Institute 3075 EA Rotterdam the Netherlands

Department of Internal Medicine A University Medicine Greifswald Greifswald Germany

Department of Internal Medicine B University Medicine Greifswald Greifswald Germany

Department of Internal Medicine University Hospital of Cologne Cologne Germany

Department of Medical Sciences Molecular Epidemiology and Science for Life Laboratory Uppsala University Uppsala Sweden

Department of Medical Sciences Molecular Epidemiology Uppsala University Uppsala Sweden

Department of Medical Sciences University of Turin Turin Italy

Department of Medicine Department of Pharmacology Department of Biomedical Informatics Vanderbilt University School of Medicine Nashville TN USA

Department of Medicine Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA 94305 USA

Department of Medicine Imperial College London London UK

Department of Medicine Internal Medicine Lausanne University Hospital Lausanne Switzerland

Department of Neurology Inselspital University Hospital Bern University of Bern Bern Switzerland

Department of Neurology Medical University Innsbruck Innsbruck Austria

Department of Neurosurgery Bethel Clinic Kantensiek 11 33617 Bielefeld Germany

Department of Non Communicable Disease Epidemiology London School of Hygiene and Tropical Medicine London UK

Department of Nutrition and Gerontology German Institute of Human Nutrition Potsdam Rehbruecke 14558 Nuthetal Germany

Department of Respiratory Medicine Academic Medical Centre University of Amsterdam Amsterdam the Netherlands

Department of Surgery Nicosia Medical School University of Nicosia Nicosia Cyprus

Department of vascular medicine Academic Medical Center Amsterdam Amsterdam the Netherlands

Department of Vascular Surgery Imperial College London United Kingdom

Department Primary Care and Population Health University College London London UK

Deutsches Krebsforschungszentrum Heidelberg Germany

Div Molecular Genetic Epidemiology German Cancer Research Center Im Neuenheimer Feld 580 69120 Heidelberg Germany

Division of Genetics and Epidemiology The Institute of Cancer Research London UK

Division of Hematology Oncology Department of Pediatrics Dan L Duncan Cancer Center Baylor College of Medicine Houston Texas 77030 USA

Division of Pharmacoepidemiology and Clinical Pharmacology Utrecht Institute of Pharmaceutical Sciences Faculty of Science Utrecht University Utrecht The Netherlands

Durrer Center for Cardiovascular Research Netherlands Heart Institute Utrecht The Netherlands

DZHK partner site Greifswald Greifswald Germany

E CA Economics GmbH Berlin Germany

Geisinger Danville USA

Genetic and Molecular Epidemiology Group Lübeck Interdisciplinary Platform for Genome Analytics Institutes of Neurogenetics and Cardiogenetics University of Lübeck Lübeck Germany

Geriatrics Research Group Charité Universitätsmedizin Berlin 13347 Berlin Germany

Harvard Medical School Center for Cardiovascular Disease Prevention Brigham and Women's Hospital Boston USA

Health Data Research UK and Institute of Health Informatics University College London London United Kingdom

Health Data Research UK University College London 222 Euston Road London NW1 2DA UK

Hematology and Transfusion Medicine Department of Laboratory Medicine BMC B13 SE 221 84 Lund Sweden

Hematology Clinic Skåne University Hospital Skåne Sweden

Hunter New England Local Health District Newcastle NSW Australia

INSERM U 1138 Centre de Recherche des Cordeliers Paris France

Institute for Community Medicine University Medicine Greifswald Greifswald Germany

Institute for Social and Economic Research University of Essex Essex UK

Institute of Cardiovascular and Medical Sciences University of Glasgow Glasgow G12 8TA UK

Institute of Cardiovascular Science University College London 222 Euston Road London NW1 2DA UK

Institute of Genetic Epidemiology Department of Genetics and Pharmacology Medical University of Innsbruck 6020 Innsbruck Austria

Institute of Genetics and Molecular Medicine University of Edinburgh Edinburgh UK

Institute of Health and Wellbeing University of Glasgow Glasgow G12 8RZ Scotland UK

Institute of Health Informatics University College London 222 Euston Road London NW1 2DA UK

Institute of Human Genetics Lübeck Germany

Institute of Internal and Preventive Medicine Siberian Branch of the Russian Academy of Medical Sciences Novosibirsk Russian Federation

Institute of Nutritional Science University of Potsdam 14558 Nuthetal Germany

Interfaculty Institute of Genetics and Functional Genomics University Medicine Greifswald Greifswald Germany

Italian Institute for Genomic Medicine Turin Italy

Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht University Utrecht the Netherlands

Kaiser Permanente Washington Health Research Institute Seattle WA USA

l'institut du Thorax INSERM CNRS UNIV Nantes CHU Nantes Nantes France

Lithuanian University of Health Sciences Kaunas Lithuania

Lübeck Interdisciplinary Platform for Genome Analytics Institutes of Neurogenetics and Cardiogenetics University of Lübeck Lübeck Germany

Massachusetts Veterans Epidemiology and Research Information Center Veterans Affairs Boston Healthcare System Boston USA

Mayo Clinic Rochester USA

Medical Research Council Population Health Research Unit Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford Oxford UK

MRC Epidemiology Unit Institute of Metabolic Science University of Cambridge School of Clinical Medicine Cambridge Biomedical Campus Addenbrooke's Hospital Cambridge UK

Myeloma Institute for Research and Therapy University of Arkansas for Medical Sciences Little Rock USA

National Institute of Public Health Prague Czech Republic

Northern Institute for Cancer Research Newcastle University Newcastle upon Tyne UK

Novo Nordisk Foundation Center for Basic Metabolic Research Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark

Novosibirsk State Medical University Novosibirsk Russian Federation

Penn State State College USA

Population Health Research Institute Hamilton Ontario Canada

Population Health Research Institute St George's University of London London UK

Population Health Sciences University of Bristol Bristol UK

Population Policy and Practice UCL GOS Institute of Child Health London UK

Postgraduate Program in Epidemiology Federal University of Pelotas Pelotas Brazil

Public Health Program Hunter Medical Research Institute Newcastle NSW Australia

Robertson Centre for Biostatistics University of Glasgow Glasgow UK

Sorbonne Universités UPMC Université Paris 06 UMR S 1127 F 75013 Paris France

South Australian Health and Medical Research Institute Adelaide Australia

The Alan Turing Institute British Library 96 Euston Rd London NW1 2DB UK

The Barts Heart Centre St Bartholomew's Hospital London UK

The Department of Medical Research Bærum Hospital Vestre Viken Hospital Trust Gjettum Norway

The Institut du Cerveau et de la Moelle épinière ICM Paris France

The National Institute for Health Research University College London Hospitals Biomedical Research Centre University College London 222 Euston Road London NW1 2DA UK

UCL's BHF Research Accelerator Centre London UK

UFR de Médecine Université Paris Diderot Sorbonne Paris Cité Paris France

Unit of Cancer Epidemiology Città della Salute e della Scienza University Hospital and Center for Cancer Prevention Turin Italy

University Clinic Heidelberg Internal Medicine 5 and National Center for Tumor Diseases Heidelberg Germany

University College London Farr Institute of Health Informatics London UK

University of Colorado Denver Denver USA

University of Minnesota Minneapolis USA

University of Newcastle Newcastle NSW Australia

UPenn Philadelphia USA

UWash Seattle USA

Vanderbilt University Nashville USA

Wallenberg Center for Molecular Medicine Lund University Lund Sweden

Wellcome Trust Centre for Human Genetics University of Oxford Oxford England

WHI Seattle USA

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