Hyperlipidemia (Nonstatin Add-on) — ABIM Board MCQ

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ModerateCardiologyHyperlipidemia (Nonstatin Add-on)ABIM Board

A 51-year-old man with a 10-year ASCVD risk of 15% has an LDL-C of 128 mg/dL despite maximally tolerated statin therapy, with only 25% LDL reduction achieved. What is the next step in management?

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Correct answer: A — Add ezetimibe

This patient has inadequate LDL-C lowering (25% reduction) on maximally tolerated statin, which warrants intensification. According to the 2022 ACC Expert Consensus Decision Pathway on Nonstatin Therapies, ezetimibe is the initial nonstatin agent for patients with clinical ASCVD not at very high risk who have inadequate response to statin monotherapy. Ezetimibe reduces LDL-C by approximately 18% as monotherapy and improves combined statin–ezetimibe efficacy to 50–70% reduction. Niacin is reserved for hypertriglyceridemia and is not indicated here. Bile acid sequestrants provide only 15–27% reduction with no cardiovascular outcome data. Discontinuing statin for PCSK9 monotherapy violates guideline principles; statins remain foundational, and PCSK9 inhibitors are added to, not substituted for, statin therapy.

Reference: American College of Cardiology, 2022 ACC ECDP on Role of Nonstatin Therapies for LDL-C Lowering. https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2022/08/25/13/13/2022-ACC-ECDP-on-Nonstatin. Accessed July 2026.