- Initial Focus: High-potency statin therapy is foundational unless contraindicated.
- Combination Therapy: Ezetimibe is the next step if LDL-C targets are not met with statins alone.
- PCSK9 Inhibitors: Added in cases where LDL-C remains above the goal despite statin and ezetimibe therapy.
- Goal: Achieve LDL-C levels <1.4 mmol/L (55 mg/dL) to reduce cardiovascular risk.
1. Assess Prior Treatment
• No prior treatment, low-dose, or low-intensity lipid-lowering therapy:
• Start high-potency, high-dose statin therapy (Class I recommendation).
• Immediate combination with ezetimibe can be considered if LDL-C > 3.5 mmol/L, possibly initiated during hospitalization (Class IIb recommendation).
• On highest tolerated dose statin:
• If LDL-C < 1.4 mmol/L (55 mg/dL): No change.
• If LDL-C ≥ 1.4 mmol/L (55 mg/dL): Add ezetimibe (Class I recommendation).
• On highest tolerated dose statin and ezetimibe:
• If LDL-C < 1.4 mmol/L (55 mg/dL): No change.
• If LDL-C ≥ 1.4 mmol/L (55 mg/dL): Add PCSK9 inhibitor (Class I recommendation).
2. Reassessment After 4–6 Weeks
• LDL-C levels are reassessed to evaluate the response:
• If LDL-C < 1.4 mmol/L (55 mg/dL): No change to the therapy.
• If LDL-C ≥ 1.4 mmol/L (55 mg/dL):
• Add ezetimibe (if not already added earlier).
• Add a PCSK9 inhibitor (if statin + ezetimibe combination is insufficient).