7
Figure 1. Secondary Prevention in Patients With Clinical
ASCVD
Clinical ASCVD
High-intensity statin
(Goal: ↓ LDL-C ≥50%)
(Class I)
Dashed arrow indicates RCT-supported efficacy but is less cost effective.
Clinical ASCVD consists of acute coronary syndrome (ACS), those with history of myocardial
infarction (MI), stable or unstable angina or coronary other arterial revascularization, stroke,
transient ischemic attack (TIA), or peripheral artery disease (PAD) including aortic aneurysm,
all of atherosclerotic origin.
Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event
and multiple high-risk conditions (Table 2).
Healthy Lifestyle
ASCVD not at very
high-risk*
Very high-risk*
ASCVD
Age ≤75 y Age >75 y
If high-
intensity statin
not tolerated,
use moderate-
intensity statin
(Class I)
If on maximal
statin therapy and
LDL-C ≥70 mg/
dL (≥1.8 mmol/L),
adding ezetimibe
may be reasonable
(Class IIb)
Initiation of
moderate- or high-
intensity statin is
reasonable
(Class IIa)
Continuation of
high-intensity
statin is
reasonable
(Class IIa)
High-intensity or
maximal statin
(Class I)
If on maximal statin
and LDL-C ≥70
(≥1.8 mmol/L),
adding ezetimibe is
reasonable
(Class IIa)
If PCSK9-I is
considered, add
ezetimibe to
maximal statin
before adding
PCSK9-I
(Class I)
If on clinically judged
maximal LDL-C
lowering therapy and
LDL-C ≥100 mg/dL
(≥2.6 mmol/L), adding
PCSK9-I is reasonable
(Class IIa)
