Secondary prevention of Dyslipidemia

Secondary Prevention

• Clinical ASCVD
• Secondary prevention refers to patients with clinical atherosclerotic cardiovascular disease (ASCVD). High-intensity statin therapy is recommended for all patients with atherosclerotic cardiovascular disease, including acute coronary syndromes, myocardial infarction, stable or unstable angina, or with a history of coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease including aortic aneurysm, all of atherosclerotic origin.

acute coronary syndrome (ACS) ¨ History of myocardial infarction (MI) ¨ Stable or unstable angina ¨ coronary or other arterial revascularization ¨ Stroke ¨ Transient ischemic attack (TIA) ¨ Peripheral artery disease (PAD) including aortic aneurysm

Who Should Receive Secondary Prevention?

All patients with clinically significant atherosclerotic cardiovascular disease (ASCVD)

• History of myocardial infarction (STMEI or NSTEMI)
• History of angina (stable or unstable angina)
• History of prior revascularization
• History of stroke or transient ischemic attack
• Symptomatic peripheral vascular disease

Guidelines for Secondary Prevention

Recommendation

• Very high risk includes:
  • Multiple ASCVD events or
  • One major ASCVD event and multiple high-risk conditions

Clinical ASCVD

• ASCVD not at very high-risk*

  • Age ≤75 y
    • High-intensity statin
      (Goal: ↓ LDL-C ≥50%)
      (Class I)
      • If high-intensity statin not tolerated, use moderate-intensity statin
        (Class I)
  • Age >75 y
    • Initiation of moderate- or high-intensity statin is reasonable
      (Class IIa)

• Very high-risk* ASCVD

  • High-intensity or maximal statin
    (Class I)
    • If on maximal statin therapy and LDL-C ≥70 mg/dL (≥1.8 mmol/L), adding ezetimibe may be reasonable
      (Class IIa)
    • If PCSK9-I is considered, add ezetimibe to maximal statin before adding PCSK9-I
      (Class I)
    • Dashed arrow indicates RCT-supported efficacy, but is less cost effective.
    • If on clinically judged maximal LDL-C lowering therapy and LDL-C ≥70 mg/dL (≥1.8 mmol/L), or non-HDL-C ≥100 mg/dL (≥2.6 mmol/L), adding PCSK9-I is reasonable
      (Class IIa)

Very High Risk

Includes:

• Multiple ASCVD events or
• One major ASCVD event and multiple high-risk conditions