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ASCVD — ABIM Board MCQ

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ModerateBlood CholesterolASCVDABIM Board

A 58-year-old man had a myocardial infarction 6 years ago and has had no subsequent ASCVD events. He has no diabetes mellitus, hypertension, chronic kidney disease, heart failure, familial hypercholesterolemia, current tobacco use, or history of additional coronary revascularization. He is adherent to atorvastatin 80 mg daily and has no adverse effects. His LDL-C is 92 mg/dL. Which intervention is the most appropriate next step in lipid-lowering therapy?

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Correct answer: B — Add ezetimibe

This patient has clinical ASCVD but lacks features placing him at very high risk; his LDL-C goal is therefore below 70 mg/dL. Because LDL-C remains 92 mg/dL despite adherence to a maximally tolerated high-intensity statin, ezetimibe is the most appropriate next therapy. It provides additional LDL-C lowering and has demonstrated cardiovascular outcome benefit when added to statin therapy. The lipid panel should subsequently be reassessed, with further intensification considered if the goal is not achieved. Niacin does not improve cardiovascular outcomes when added to statins. Colesevelam can lower LDL-C but has less outcome evidence and poorer tolerability than ezetimibe. Reducing statin intensity would increase LDL-C, and continuing current therapy alone leaves LDL-C above the recommended secondary-prevention goal.

Reference: American College of Cardiology. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering, section on clinical ASCVD not at very high risk. 2022. https://pubmed.ncbi.nlm.nih.gov/36031461/