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Peripheral Artery Disease — ABIM Board MCQ

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ModerateLipid ManagementPeripheral Artery DiseaseABIM Board

A 65-year-old man has type 2 diabetes mellitus and symptomatic lower-extremity peripheral artery disease, for which he previously underwent revascularization. He is adherent to atorvastatin 80 mg daily, his maximally tolerated statin dose. His LDL cholesterol has decreased from 168 mg/dL to 72 mg/dL. Which of the following is the most appropriate lipid-management strategy?

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Correct answer: E — Add nonstatin LDL-lowering therapy and target an LDL-C below 55 mg/dL

Symptomatic PAD is clinical ASCVD, and this patient has additional high-risk features, including diabetes and prior peripheral revascularization. He therefore warrants very-high-risk secondary prevention, with a contemporary LDL-C goal below 55 mg/dL. Despite an appropriate greater-than-50% LDL-C reduction on high-intensity statin therapy, his LDL-C remains 72 mg/dL, so nonstatin therapy should be added. Options include ezetimibe, a PCSK9 monoclonal antibody, or other evidence-based therapy selected according to the reduction needed and patient factors. Continuing statin monotherapy with a goal of either 100 or 70 mg/dL undertreats his residual risk. Statin intensity should not be reduced in the absence of intolerance. Niacin has not demonstrated incremental ASCVD benefit when added to effective statin therapy, and HDL-C is not a pharmacologic treatment target.

Reference: Blumenthal RS, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia, secondary-prevention LDL-C goals, 2026. https://professional.heart.org/en/science-news/2026-guideline-on-the-management-of-dyslipidemia/top-things-to-know