Mr. Smith is a 32 year-old Caucasian male, who had a non-ST segment elevation myocardial infarction (NSTEMI) 3 months ago. He was not taking any medications prior to hospital admission. His LDL-C was measured within 24 hours of the NSTEMI, and it was 194 mg/dL. Secondary causes of very high LDL-C were ruled out. At the time of hospital discharge, he was given prescriptions for evidence-based therapies, including atorvastatin 80 mg PO daily.
Mr. Smith returned to clinic today. His LDL-C is 103 mg/dL. He states adherence with optimal lifestyle modifications and pharmacotherapy.
According to the 2016 ACC Expert Consensus Decision Pathway (ECDP) on non-statin therapies, which ONE of the following recommendations for non-statin therapy could be considered for this patient?
The correct answer is: C. Continue current atorvastatin regimen. Add ezetimibe 10 mg PO daily or a PCSK9 inhibitor to the patient's current medication regimen.
The patient has clinical atherosclerotic cardiovascular disease (ASCVD) and a baseline LDL-C > 190 mg/dL. Although the patient states adherence to high intensity statin therapy and lifestyle modifications, he did not achieve the anticipated >50% LDL-C reduction from baseline.
The 2016 ACC ECDP uses thresholds to guide the decision making for adding non-statin medications. For this patient, the threshold for considering the addition of a non-statin is when the patient does not achieve >50% LDL-C reduction from baseline, or if the LDL-C is not <70 mg/dL. This patient had 46% LDL-C reduction, and his current LDL-C is 103 mg/dL. The clinician and patient should consider discussing potential ASCVD benefit from additional LDL-C lowering, risk of adverse effects, potential drug-drug interactions, and patient preferences before a nonstatin is prescribed. Using the 2016 ACC ECDP algorithm, ezetimibe or a PCSK9 inhibitor may be considered as add-on therapy to this patient's atorvastatin 80 mg to further reduce LDL-C.
In addition to treating the patient aggressively, it is important to do cascade screening to identify family members who may also have very high LDL-C.
Options A, B, and D are not the best options for this patient. The medication regimen in option A includes simvastatin 40 mg daily, a moderate-intensity statin therapy, and ezetimibe. The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults recommends the use of high-intensity statin therapy for patients with clinical ASCVD, and the 2016 ACC ECDP recommends the use of maximally tolerated statin before considering the addition of non-statin therapy. In option B, both atorvastatin 80 mg daily and rosuvastatin 40 mg daily are high-intensity statin regimens, which would provide approximately the same amount of LDL-C reduction. For option D, the clinician may use the 2016 ACC ECDP thresholds to guide the decision making for adding a non-statin. This patient did not achieve either threshold (i.e., >50% LDL-C reduction from baseline or LDL-C <70 mg/dL) specified in the 2016 ACC ECDP, so the clinician and patient could discuss the net clinical benefit of adding a non-statin and the patient preferences.
Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology task force on clinical expert consensus documents. J Am Coll Cardiol 2016;68:92-125.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014;63:2889-934.