Secondary stroke prevention-lipids — ABIM Board MCQ
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Correct answer: B — Add ezetimibe to reduce LDL-C to a target <70 mg/dL
For secondary stroke prevention in patients with TIA or ischemic stroke, current ACC/AHA and stroke society guidelines recommend achieving LDL-C <70 mg/dL. This patient's LDL-C of 88 mg/dL despite high-intensity statin therapy is above target. When LDL-C remains ≥70 mg/dL on maximally tolerated statin, ezetimibe addition is guideline-supported (Class IIa) and has evidence from clinical trials (SPARCL, TST, and recent network meta-analyses) showing reduction in recurrent stroke risk. Ezetimibe provides ~20% additional LDL-C reduction when combined with a statin. Switching to lower-intensity statin (C) worsens control. An LDL target <100 (A) is outdated for secondary prevention. Niacin (D) lacks evidence for stroke prevention and is not recommended for LDL reduction in this context. Continuing statin monotherapy without escalation (A) misses an opportunity for risk reduction. Discontinuing statin (E) is contraindicated.
Reference: 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol (https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/11/09/14/28/2018-guideline-on-management-of-blood-cholesterol); Park HK, et al. Switching to rosuvastatin plus ezetimibe in statin-treated stroke patients with LDL-C above 70 mg/dL. J Stroke. 2025 May;27(2):275–278