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Primary prevention statin — ABIM Board MCQ

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ModerateCardiovascularPrimary prevention statinABIM Board

A 55-year-old man has an LDL cholesterol level of 158 mg/dL and blood pressure of 138/82 mm Hg. He has no history of atherosclerotic cardiovascular disease, diabetes mellitus, chronic kidney disease, or HIV infection. His calculated 10-year PREVENT-ASCVD risk is 12%. Liver enzyme levels are normal, and he has no contraindication to statin therapy. Lifestyle counseling has been provided, and he is willing to begin medication. Which of the following is the most appropriate initial pharmacologic therapy?

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Correct answer: D — High-intensity statin therapy

The correct answer is D. A 10-year PREVENT-ASCVD risk of 12% is high risk (at least 10%). Current ACC/AHA guidance recommends high-intensity statin therapy for primary prevention in this category, aiming for at least a 50% LDL-C reduction and an LDL-C below 70 mg/dL. Statins remain first-line because they have established cardiovascular outcome benefits. Ezetimibe, bempedoic acid, and PCSK9 inhibitors are generally added when LDL-C remains above goal despite maximally tolerated statin therapy or when statins cannot be used; they are not preferred initial monotherapy here. Niacin is not recommended for routine ASCVD prevention because it has not demonstrated sufficient incremental cardiovascular benefit and causes adverse effects. Lifestyle measures should continue but are insufficient as the sole intervention at this risk level.

Reference: American Heart Association. Top Take-Home Messages for Clinicians: Using PREVENT-ASCVD Equations for Risk-Based Lipid Management, adapted from the 2026 ACC/AHA Guideline on the Management of Dyslipidemia, March 2026. https://professional.heart.org/en/-/media/PHD-Files-2/Science-News/t/Top-Take-Home-Messages-for-Clinicians-Using-PREVENT-ASCVD-Equations.pdf