Secondary Prevention (Lipid Lowering) — ABIM Board MCQ

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ModerateCardiologySecondary Prevention (Lipid Lowering)ABIM Board

A 65-year-old with NSTEMI treated with percutaneous coronary intervention is on high-intensity statin therapy. At 8 weeks post-MI, lipid panel shows LDL-C 78 mg/dL. Which is the next step to achieve guideline-recommended LDL-C targets for secondary prevention?

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Correct answer: A — Add ezetimibe

The correct answer is A (Add ezetimibe). After NSTEMI, guidelines mandate an LDL-C target of <55 mg/dL for very-high-risk secondary prevention. This patient's LDL-C of 78 mg/dL on high-intensity statin is above goal, requiring addition of a nonstatin lipid-lowering agent. Ezetimibe is the preferred first-line oral nonstatin option, reducing LDL-C by ~20% additively with statins. Choice B is incorrect because downgrading statin intensity contradicts guideline recommendations. C (niacin) is not first-line for post-ACS despite modest LDL-lowering. D is harmful—stopping statin eliminates plaque stabilization and other cardioprotective effects critical post-MI. E (fenofibrate) targets elevated triglycerides, not LDL-C, and has no role in this scenario.

Reference: 2026 ACC/AHA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. https://newsroom.heart.org/news/accaha-issue-updated-guideline-for-managing-lipids-cholesterol (2026); OLA Study demonstrating ezetimibe efficacy in ACS. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12328763/ (2025).