Secondary Prevention Lipids — ABIM Board MCQ

Correct answer: B — Add ezetimibe to the maximally tolerated statin

The correct answer is B. Prior myocardial infarction establishes clinical ASCVD, and an LDL-C level of 92 mg/dL remains above contemporary secondary-prevention goals despite adherent, tolerated high-intensity statin therapy. Lipid lowering should therefore be intensified with an evidence-based nonstatin while the statin is continued. Among these choices, ezetimibe is the appropriate add-on. Current guidance permits individualized selection among ezetimibe, bempedoic acid, and PCSK9 monoclonal antibodies based on risk, required LDL-C reduction, and patient factors; it does not require rigid stepwise sequencing. Option E is incorrect because a PCSK9 inhibitor should not replace a tolerated statin. Reducing statin intensity would sacrifice proven benefit. Bile acid sequestrants are not the preferred escalation strategy, and niacin has not provided incremental cardiovascular benefit when added to effective statin therapy.

Reference: Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia; secondary-prevention goals and nonstatin therapy. Published March 13, 2026. https://www.acc.org/Latest-in-Cardiology/Journal-Scans/2026/03/13/15/20/ACC-AHA-Release-New-Clinical-Guideline-For-Managing-Dyslipidemia