Although current guidelines are an honest attempt in reflecting complex medical evidence from clinical trials, they may not be very practical or user-friendly to general practitioners.
A simplified but reasonable approach to lipid management for secondary ASCVD prevention would be:
Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.
Secondary ASCVD Prevention
Younger ≤75 + NOT very-high risk
In patients ≤75 with clinical ASCVD, high-intensity statin therapy should be initiated or continued with the aim of achieving ≥50% reduction in LDLc levels
In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, at least moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30-49% reduction in LDLc levels
Younger ≤75 + VERY-high risk
In patients with clinical ASCVD who are on maximally tolerated statin therapy + at very high risk and have an LDLc level of ≥70 mg/dL, it is reasonable to add ezetimibe therapy
In patients with clinical ASCVD + at very high risk and considered for PCSK9 inhibitor therapy, maximally tolerated LDLc lowering therapy should include maximally tolerated statin + ezetimibe therapy.
In patients with clinical ASCVD + at very high risk and who are on maximally tolerated oral LDL-C lowering therapy with ≥LDLc 70 or a nonHDLc level of ≥100, it is reasonable to add a PCSK9 inhibitor following a clinician–patient discussion about the net benefit, safety, and cost.
In patients >75 with clinical ASCVD, it is reasonable to initiate moderate-high intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences
In patients >75 who are tolerating high-intensity statin therapy, it is reasonable to continue high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences.
In patients with clinical ASCVD who are receiving maximally tolerated statin therapy and whose LDL-C level remains ≥70 mg/dL, it may be reasonable to add ezetimibe
In patients with heart failure (HF) with reduced EF attributable to ischemic heart disease who have a reasonable life expectancy (3-5 years) and are not already on a statin because of ASCVD, clinicians may consider initiation of moderate-intensity statin therapy to reduce the occurrence of ASCVD events.
Clinical ASCVD definition:
Acute coronary syndrome (ACS)
Myocardial infarction (MI)
Stable or unstable angina
Other arterial revascularizations
Transient ischemic attack (TIA)
Peripheral artery disease (PAD)
PAD from an aortic aneurysm
PAD of any atherosclerotic origin
VERY HIGH RISK of future ASCVD events:
Multiple major ASCVD events, or
One major ASCVD event + multiple high-risk conditions.
Major ASCVD events and HIGH-RISK conditions:
History of claudication with ABI <0.85
ACS within the past 12 months
History of MI
History of ischemic STROKE
History of CABG or PCI
History of CHF
CKD with eGFR 15-59
LDLc ≥100 + maximally tolerated statin + ezetimibe