The Role of Bempedoic Acid For Patients at Elevated ASCVD Risk Who Need Further LDL-C Level Lowering

A 54-year-old woman with a medical history of hypertension (HTN), type 2 diabetes mellitus (DM), and previous pre-eclampsia presents as a new patient for a routine health maintenance examination.

She has a family history of premature coronary artery disease. Her father had a myocardial infarction at 48 years of age and underwent three-vessel coronary artery bypass grafting at 54 years of age. She works as a computer programmer, spending most of her day sitting at her computer. She has been smoking one-half pack of cigarettes daily for the previous 15 years. She has been told of "high cholesterol" at previous visits and has been recommended for statin therapy. She was initially started on atorvastatin but could not tolerate any dose because of muscle aches. She has been able to tolerate rosuvastatin 5 mg daily; however, repeated attempts to uptitrate her dose have been unsuccessful. She is adamant that she will not take an injectable medication for her cholesterol levels.

Her current medications include telmisartan 40 mg daily, metformin 1000 mg daily, empagliflozin 10 mg daily, rosuvastatin 5 mg daily, and ezetimibe 10 mg daily. On examination, her height is 157.5 cm, weight is 77 kg, body mass index is 31.1 kg/m2, and blood pressure is 126/72 mm Hg. The remainder of her physical examination findings are unremarkable. She is of self-reported Black race.

Laboratory evaluation includes a metabolic panel with significant findings of blood urea nitrogen level 20 mg/dL, creatinine (Cr) level 1.3 mg/dL, aspartate aminotransferase level 24 U/L, alanine aminotransferase level 29 U/L, and fasting glucose level 137 mg/dL. Urine albumin-to-Cr ratio is found to be 100 mcg/mg, hemoglobin A1c concentration is 7%, thyroid-stimulating hormone level is within the reference range, and uric acid level is 5.3 mg/dL. A fasting lipid profile reveals total cholesterol level 164 mg/dL, low-density lipoprotein cholesterol (LDL-C) level 88 mg/dL, high-density lipoprotein cholesterol (HDL-C) level 43 mg/dL, and triglyceride (TG) level 138 mg/dL. A coronary artery calcium (CAC) score obtained before her visit was found to be 347 Agatston units (AU).

In addition to aggressive lifestyle modification including dietary intervention and smoking cessation, shared decision making leads to adding bempedoic acid into her treatment regimen to further reduce her risk of an atherosclerotic cardiovascular disease (ASCVD) event.

Which one of the following best describes the mechanism of action of bempedoic acid?

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