A 60-year-old female patient presents to the clinic for follow up. She has a history of hypertension, hyperlipidemia, and prior angina. Past work-up revealed the presence of coronary artery disease (CAD) diagnosed by CT coronary angiography, which showed a calcium score of 213 and CAD-RADS 3 disease (stenosis 50-69%) in the proximal left circumflex. She is being treated with medical therapy for her stable CAD and is currently free of symptoms. She also has a family history of premature CAD in her father. Her current medications include aspirin 81mg, pravastatin 20mg, ezetimibe 10mg, and amlodipine 2.5mg daily. Her lipid panel on current treatment shows total cholesterol 181 mg/dL, LDL-C 103 mg/dL, HDL-C 61 mg/dL, and triglycerides 85 mg/dL. Lp(a) is <8.4 nmol/L and high-sensitivity CRP (hsCRP) is 0.8 mg/L. She is a marathon runner and was previously unable to tolerate atorvastatin, rosuvastatin, or a higher dose of pravastatin due to muscle pain after running.
What is the next best step in her lipid management?
Show Answer
The correct answer is: B. Add bempedoic acid 180mg daily
The patient has clinical ASCVD but is not at very high risk based on the ACC Expert Consensus Decision Pathway.1 Therefore, her lipid lowering therapy should be intensified to target an LDL-C < 70 mg/dL (thus, answer D is incorrect), and preference should be given to therapies with demonstrated cardiovascular outcomes benefits (answer A is incorrect). Bempedoic acid can be expected to result in a ~22% reduction in LDL-C in patients not taking statins, and has been shown to confer a significant reduction in major adverse cardiovascular events in patients with statin intolerance who remained above a baseline LDL-C in the CLEAR OUTCOMES trial.2 When added to statin therapy, bempedoic acid has been shown to result in an additional 15-17.8% reduction in LDL-C.3-5 It is therefore possible that adding bempedoic acid would achieve an LDL-C at or close to goal in this patient. A PCSK9 inhibitor would also be a reasonable next step, which could be expected to result in about a ~60% reduction in LDL-C as well as a reduction in major adverse cardiovascular events in patients with stable CAD.6 Colchicine would not be expected to lower LDL-C (answer C is incorrect). However, colchicine has been shown to reduce major adverse cardiovascular events in patients with chronic coronary disease, particularly in those with residual inflammatory risk.7 Once her LDL-C is < 70 mg/dL, colchicine might be a reasonable next step, especially if she had an elevated hsCRP; however, bempedoic acid also results in a reduction in hsCRP(2).
This patient case quiz is part of an ACC course titled Bempedoic Acid: New Evidence Transforming the LDL-C Treatment Landscape. Educational grant support is provided by Esperion. To visit the Online Course page for the Bempedoic Acid: New Evidence Transforming the LDL-C Treatment Landscape Grant, click here.
References
Lloyd-Jones Donald M., Morris Pamela B., et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk. J Am Coll Cardiol 2022;80(14):1366–418.
Nissen SE., Lincoff AM., Brennan D., et al. Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients. N Engl J Med 2023;388(15):1353–64.
Paruchuri K, Finneran P, Marston NA, et al. Out- comes of a smartphone-based application with live health-coaching post-percutaneous coronary intervention. EBioMedicine. 2021;72:103593.
Ray KK, Bays HE, Catapano AL, et al. Safety and efficacy of bempedoic acid to reduce LDL cholesterol. N Engl J Med. 2019;380:1022–1032.
Goldberg AC, Leiter LA, Stroes ESG, et al. Effect of bempedoic acid vs placebo added to maximally tolerated statins on low-density lipoprotein cholesterol in patients with high risk for cardiovascular disease: the CLEAR wisdom randomized clinical trial. JAMA. 2019;322:1780–1788.
O'Donoghue ML., Giugliano RP., Wiviott SD., et al. Long-Term Evolocumab in Patients With Established Atherosclerotic Cardiovascular Disease. Circulation 2022;146(15):1109–19.
Nidorf SM., Fiolet ATL., Mosterd A., et al. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med 2020;383(19):1838–47.
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