5
4. Patient Management Groups
4.1. Secondary ASCVD Prevention
COR LOE
Recommendations
I A 1. In patients who are 75 years of age or younger with clinical
ASCVD,* high-intensity statin therapy should be initiated
or continued with the aim of achieving a 50% or greater
reduction in LDL-C levels.
I A 2. In patients with clinical ASCVD in whom high-intensity
statin therapy is contraindicated or who experience statin-
associated side effects, moderate-intensity statin therapy
should be initiated or continued with the aim of achieving a
30% to 49% reduction in LDL-C levels.
I B-NR 3. In patients with clinical ASCVD who are judged to be very
high risk and considered for PCSK9 inhibitor therapy,
maximally tolerated LDL-C lowering therapy should include
maximally tolerated statin therapy and ezetimibe.
IIa
A
SR
4. In patients with clinical ASCVD who are judged to be
very high risk and who are on maximally tolerated LDL-C
lowering therapy with LDL-C 70 mg/dL (≥1.8 mmol/L) or
higher or a non–HDL-C level of 100 mg/dL (≥2.6 mmol/L)
or higher, it is reasonable to add a PCSK9 inhibitor following
a clinician-patient discussion about the net benefit, safety,
and cost.
IIa B-R 5. In patients with clinical ASCVD who are on maximally
tolerated statin therapy and are judged to be at very high risk
and have an LDL-C level of 70 mg/dL (≥1.8 mmol/L) or
higher, it is reasonable to add ezetimibe therapy.
Value Statement:
Low Value (LOE:
B-NR)
6. At mid-2018 list prices, PCSK9 inhibitors have a low cost
value (>$150,000 per QALY) compared to good cost value
(<$50,000 per QALY) (Figure 3 provides a full discussion
of the dynamic interaction of different prices and clinical
benefit).
IIa B-R 7. In patients older than 75 years of age with clinical ASCVD,
it is reasonable to initiate moderate- or high-intensity statin
therapy after evaluation of the potential for ASCVD risk
reduction, adverse effects, and drug-drug interactions, as well
as patient frailty and patient preferences.
IIa C-LD 8. In patients older than 75 years of age who are tolerating
high-intensity statin therapy, it is reasonable to continue
high-intensity statin therapy after evaluation of the potential
for ASCVD risk reduction, adverse effects, and drug-drug
interactions, as well as patient frailty and patient preferences.
