BACKGROUND AND OBJECTIVE: Evolocumab can reduce low-density lipoprotein cholesterol (LDL-C) levels and improve cardiovascular (CV) outcomes. While its benefits are well established in broader populations, its potential impact on patients with ST-segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI) remains underexplored, particularly in real-world settings. This study aimed to evaluate its efficacy and safety in this specific patient group on the basis of real-world clinical experience. METHODS: A total of 384 patients with STEMI who underwent emergency PCI at Hebei General Hospital between 1 July 2021 and 23 September 2022 were enrolled in this retrospective, single-center study. Of these, 85 patients received evolocumab (140 mg every 2 weeks) plus standard of care (SOC), while 299 received SOC alone. Patients were monitored for CV events and lipid levels during follow-up. Propensity score matching (PSM) and inverse probability treatment weighting (IPTW) were used to balance covariates. RESULTS: The experimental group had a lower cumulative incidence of the primary composite endpoint over 18 months in the unadjusted analysis (hazard ratio [HR] = 0.353
95% confidence interval [CI] 0.180-0.693
P = 0.002), as well as after adjustment for PSM (HR = 0.341
95% CI 0.165-0.706
P = 0.004) and IPTW (HR = 0.461
95% CI 0.241-0.881
P = 0.019). The 18-month cumulative incidence was 10 (12%) for evolocumab + SOC and 95 (32%) for SOC. LDL-C levels in the evolocumab + SOC group showed significant reductions across different cohorts, compared with the SOC group. No significant differences in adverse events were observed between the two groups. CONCLUSIONS: Evolocumab plus SOC significantly reduced postoperative CV events and LDL-C levels in patients with STEMI after emergency PCI.