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Blood Cholesterol

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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.

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