45
4.2.4.3. Severe Hypercholesterolemia With LDL-C ≥190 mg/dL
(4.9 mmol/L)*
COR LOE
Recommendations
1 B-NR
1. In adults with severe hypercholesterolemia with an
LDL-C ≥190 mg/dL (4.9 mmol/L)*, secondary causes of
dyslipidemia should be excluded and addressed to reduce
LDL-C (Table 16).
1 B-R
2. In adults with severe hypercholesterolemia with an LDL-C
≥190 mg/dL (4.9 mmol/L)*, treatment with maximally
tolerated statin therapy is recommended to lower LDL-C and
reduce ASCVD risk.
Severe Hypercholesterolemia in Primary Prevention
(Without HeFH, Subclinical Atherosclerosis, and Additional ASCVD Risk Factors)
1 B-NR
3. In adults with severe hypercholesterolemia with an LDL-C
≥190 mg/dL (4.9 mmol/L)* and without clinical ASCVD
†
,
additional ASCVD risk factors, HeFH, or subclinical
atherosclerosis who are on maximally tolerated statin therapy,
the addition of ezetimibe, a PCSK9 mAb, and/or bempedoic
acid is recommended to achieve a goal of LDL-C
<100 mg/dL (2.6 mmol/L) and a non–HDL-C goal of
<130 mg/dL (3.4 mmol/L) and to reduce ASCVD risk.
Severe Hypercholesterolemia With HeFH,
Subclinical Atherosclerosis, or With Additional Risk Factors
1 B-R
4. In adults with severe hypercholesterolemia with an LDL-C
≥190 mg/dL (4.9 mmol/L)* without clinical ASCVD
†
but
with clinical or genetic confirmation of HeFH, additional
ASCVD risk factors, or documented coronary calcification,
who are on maximally tolerated statin therapy, the addition
of ezetimibe, a PCSK9 mAb, and/or bempedoic acid to
achieve a goal of LDL-C <70 mg/dL (1.8 mmol/L) and
non–HDL-C <100 mg/dL (2.6 mmol/L) is recommended
to lower LDL-C and reduce ASCVD risk.
Severe Hypercholesterolemia With Clinical ASCVD
1
B-R
5. In adults with severe hypercholesterolemia with an LDL-C
≥190 mg/dL (4.9 mmol/L)* and clinical ASCVD who are on
maximally tolerated statin therapy, the addition of ezetimibe,
a PCSK9 mAb, and/or bempedoic acid is recommended
to achieve a goal of LDL-C <55 mg/dL (1.4 mmol/L) and
non–HDL-C <85 mg/dL (2.2 mmol/L) to lower LDL-C
and reduce ASCVD risk.
