Severe Hypercholesterolaemia — EECC MCQ

Correct answer: D — High-intensity statin regardless of calculated risk

LDL-C 5.3 mmol/L is markedly elevated and exceeds the adult LDL-C threshold used in UK familial hypercholesterolaemia assessment. In this setting, treatment should not be deferred pending a calculated 10-year cardiovascular risk score: familial/severe hypercholesterolaemia confers high lifetime ASCVD risk, and NICE recommends a high-intensity statin as initial lipid-lowering treatment for adults with FH, aiming for at least a 50% reduction in LDL-C from baseline. Lifestyle advice is important but is not a substitute for drug therapy. Ezetimibe monotherapy is reserved for statin contraindication or intolerance, and PCSK9 inhibitors are specialist add-on options for selected patients not adequately controlled on maximally tolerated statin plus ezetimibe, not initial monotherapy. Therefore the appropriate initial therapy is high-intensity statin treatment regardless of calculated risk.

Reference: NICE Clinical Guideline CG71: Familial hypercholesterolaemia: identification and management, last updated 2019. Recommendation 1.3.1.2: offer a high-intensity statin as initial treatment for all adults with FH and aim for at least a 50% LDL-C reduction. https://www.nice.org.uk/guidance/cg71/chapter/recommendations