Secondary Prevention Lipids — ABIM Board MCQ

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ModerateCardiologySecondary Prevention LipidsABIM Board

A 58-year-old man with coronary artery disease and LDL cholesterol 96 mg/dL remains on maximally tolerated statin therapy. Which add-on agent is recommended first to achieve target LDL reduction?

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Correct answer: A — Ezetimibe

The correct answer is A (Ezetimibe). For secondary prevention of CAD with inadequate LDL response to maximally tolerated statin (LDL 96, target <70), current ACC/AHA guidelines recommend ezetimibe as the first-line add-on non-statin therapy. Ezetimibe provides 20–25% additional LDL reduction and has demonstrated cardiovascular outcomes benefit in the IMPROVE-IT trial. B (Niacin) and C (Fibrate) are secondary agents, typically reserved for triglyceride-dominant dyslipidemia or specific contexts. D (Bile acid sequestrant) is an older, less effective agent with tolerability issues. E (No add-on therapy) fails the therapeutic goal of target LDL <70 in secondary prevention.

Reference: American College of Cardiology & American Heart Association. 2026 Guideline on the Management of Dyslipidemia. https://www.acc.org/about-acc/press-releases/2026/03/13/18/01/accaha-issue-updated-guideline-for-managing-lipids-cholesterol and 2018 AHA/ACC Cholesterol Management Guideline, supported by evidence from the IMPROVE-IT trial (NEJM 2015) demonstrating cardiovascular benefit of ezetimibe combined with statin in post-ACS.