Bempedoic Acid Lowers Low-Density Lipoprotein Cholesterol and Attenuates Atherosclerosis in Low-Density Lipoprotein Receptor–Deficient (LDLR+/− and LDLR−/−) Yucatan Miniature Pigs

<i><b>Objective</b></i>—Bempedoic acid (BemA; ETC-1002) is a novel drug that targets hepatic ATP-citrate lyase to reduce cholesterol biosynthesis. In phase 2 studies, BemA lowers elevated low-density lipoprotein cholesterol (LDL-C) in hypercholesterolemic patients. In the present study, we tested the ability of BemA to decrease plasma cholesterol and LDL-C and attenuate atherosclerosis in a large animal model of familial hypercholesterolemia.<br/> <i><b>Approach and Results</b></i>—Gene targeting has been used to generate Yucatan miniature pigs heterozygous (<i>LDLR^+/−</i>) or homozygous (<i>LDLR^−/−</i>) for LDL receptor deficiency (ExeGen). <i>LDLR^+/−</i> and <i>LDLR^−/−</i></sup></i> pigs were fed a high-fat, cholesterol-containing diet (34% kcal fat; 0.2% cholesterol) and orally administered placebo or BemA for 160 days. In <i>LDLR^+/−</i> pigs, compared with placebo, BemA decreased plasma cholesterol and LDL-C up to 40% and 61%, respectively. In <i>LDLR^−/−</i> pigs, in which plasma cholesterol and LDL-C were 5-fold higher than in <i>LDLR^+/−</i> pigs, BemA decreased plasma cholesterol and LDL-C up to 27% and 29%, respectively. Plasma levels of triglycerides and high-density lipoprotein cholesterol, fasting glucose and insulin, and liver lipids were unaffected by treatment in either genotype. In the aorta of <i>LDLR^+/−</i> pigs, BemA robustly attenuated en face raised lesion area (−58%) and left anterior descending coronary artery cross-sectional lesion area (−40%). In <i>LDLR^−/−</i> pigs, in which lesions were substantially more advanced, BemA decreased aortic lesion area (−47%) and left anterior descending coronary artery lesion area (−48%).<br/> <i><b>Conclusions</b></i>—In a large animal model of <i>LDLR</i> deficiency and atherosclerosis, long-term treatment with BemA reduces LDL-C and attenuates the development of aortic and coronary atherosclerosis in both <i>LDLR^+/−</i> and <i>LDLR^−/−</i> miniature pigs.