Choice of initial therapy for LDL-C lowering for secondary prevention of ASCVD

This algorithm is a guide to management of LDL-C in patients with known ASCVD without recent acute coronary syndrome and without familial hypercholesterolemia. Refer to UpToDate content on LDL-C lowering after an acute coronary syndrome or with familial hypercholesterolemia. ASCVD includes atherosclerotic coronary artery disease (>50% stenosis, angina, or MI), cerebrovascular disease (stroke or transient ischemic attack), peripheral vascular disease, and disease of the aorta.

ALT: alanine aminotransferase; AST: aspartate aminotransferase; ASCVD: atherosclerotic cardiovascular disease; CK: creatine kinase; FDA: US Food and Drug Administration; HDL-C: high-density lipoprotein cholesterol; LDL-C: low-density lipoprotein cholesterol; MI: myocardial infarction; PCSK9: proprotein convertase subtilisin/kexin type 9; TC: total cholesterol; TG: triglyceride; TSH: thyroid-stimulating hormone.

* Refer to UpToDate content on statin doses, intensities, and intolerance. The maximum tolerated statin intensity should be used. High-intensity statin therapy consists of rosuvastatin 20 to 40 mg orally once daily or atorvastatin 40 to 80 mg once daily.

¶ Options are either to first start the statin to assess statin tolerability and then add ezetimibe OR to start both agents at the same time. The ezetimibe dose is 10 mg orally daily.

Δ Statin intolerance is identified when there are unacceptable statin-associated side effects (eg, myalgias) with at least 2 statin therapies, including one attempt at the lowest FDA-approved daily dose and a trial of an alternative dosing regimen.

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Choice of initial therapy for LDL-C lowering for secondary prevention of ASCVD