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Secondary prevention after MI — USMLE Step 3 MCQ

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HardInternal Medicine (Chronic Management)Secondary prevention after MIUSMLE Step 3

A 66-year-old man with prior myocardial infarction and symptomatic peripheral artery disease is adherent to atorvastatin 80 mg and ezetimibe 10 mg daily. LDL-C is 74 mg/dL. Which additional agent has both the magnitude of LDL-C reduction needed to reach the current goal below 55 mg/dL and completed cardiovascular-outcome evidence in this setting?

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Correct answer: E — Add the PCSK9 monoclonal antibody evolocumab

The best answer is “Add the PCSK9 monoclonal antibody evolocumab”. His LDL-C remains well above the current goal of less than 55 mg/dL despite maximal statin plus ezetimibe. A PCSK9 monoclonal antibody offers the magnitude of additional lowering and cardiovascular-outcome evidence needed in this very-high-risk setting. Very-high-risk polyvascular ASCVD has an LDL-C goal below 55 mg/dL; a PCSK9 monoclonal antibody provides the large additional LDL-C reduction needed when maximal statin plus ezetimibe remains inadequate.

Reference: ACC: Implications of the 2026 Dyslipidemia Guideline for Vascular Disease: https://www.acc.org/latest-in-cardiology/articles/2026/06/15/14/16/implications-of-the-2026-multisociety-dyslipidemia-guideline