Reviewing Non-Statin Options: Choosing the Best Treatment Plan

The patient is a 58-year-old man with a history of coronary artery disease including a history of myocardial infarction (MI) treated with a percutaneous coronary intervention to the proximal left anterior descending artery (LAD) 3 years ago and then a recurrent MI 9 months ago resulting in another LAD stent placement. Additionally, he has a history of hypertension, dyslipidemia (high triglycerides, low HDL-C), obesity, pre-diabetes, prior 30 pack years of smoking (now quit), obstructive sleep apnea, and a family history of premature CAD.  He is referred to the lipid clinic for management of his dyslipidemia in the context of statin intolerance. He has tried several statins (atorvastatin, rosuvastatin, and pravastatin) and reported unacceptable muscle side effects each time even at the lowest approved dose.  He works as a flight attendant, travels frequently, and is regularly in a foreign country for 3-4 weeks at a time. His heart rate is 65 bpm and his blood pressure is 122/76 mmHg. His most recent lipid panel shows a TC 129, TG 150, LDL-C 63, and HDL-C 36 mg/dL. His lipoprotein (a) level is 64 nmol/L. His current medications include aspirin 81 mg, clopidogrel 75 mg, metoprolol succinate 50 mg, losartan 100 mg, amlodipine 5 mg, and ezetimibe 10 mg daily. The patient reports good compliance with taking his daily oral medications. He has heard recently about the newer agents available for additional lipid-lowering, and would like to lower his risk of a future heart attack.

Using the most recent 2022 ACC Expert Consensus Decision-Making Pathway on the Role of Non-Statin Therapies, he would be recommended to achieve a 50% reduction in his LDL-C and which of the following LDL-C thresholds?

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