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Symptomatic carotid artery stenosis — ABIM Board MCQ

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HardNeurologySymptomatic carotid artery stenosisABIM Board

A 66-year-old man with an atherosclerotic ischemic stroke takes atorvastatin 80 mg daily with confirmed adherence. LDL cholesterol is 86 mg/dL, triglycerides are 140 mg/dL, and liver tests are normal. What is the best next lipid-lowering step?

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Correct answer: A — Add ezetimibe to the current atorvastatin regimen

The best answer is “Add ezetimibe to the current atorvastatin regimen”. Secondary prevention after atherosclerotic stroke targets LDL below 70 mg/dL. Ezetimibe is the appropriate next addition when maximally tolerated high-intensity statin therapy is insufficient; a PCSK9 inhibitor can be considered if the target remains unmet in very-high-risk disease. Niacin and fibrates are not substitutes for this LDL-lowering sequence.

Reference: 2021 AHA/ASA Guideline for Prevention of Stroke After Stroke or TIA: https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack