Table 3.
Comparison of LDL-C lowering strategies in CAD and CVD patients as recommended by the American and European Guidelines.
| American Guidelines | European Guidelines | |
|---|---|---|
| CHD patients | ||
| Risk stratification | Patients with multiple major ASCVD events * OR multiple high-risk conditions § must be considered at very-high risk | All patients with CAD must be considered at very-high risk |
| Treatment strategies | Initiate with high intensity or maximal statin therapy to lower LDL-C levels by ≥50% (Class I, Levels A) | Initiate with high-dose, high intensity statin therapy (Class I, Level A) |
| If on maximal stain therapy LDL-C > 70 mg/dL add ezetimibe (Class IIa); If iPCSK9 is considered, add ezetimibe to maximal statin therapy before adding iPCSK9 (Class I, Levels B) | Revaluation after 4–6 weeks to determine whether a reduction of >50% from baseline and LDL-C goal < 55 mg/dL have been reached (Class I, Level A) (LDL-C goal < 40 mg/dL may be considered in patients with recurrent events (Class IIb, Level B)) |
|
| If on clinically judged maximal LDL-C lowering therapy and LDL-C > 70 mg/dL adding iPCSK9 is reasonable (Class IIa, Level A) | If not consider adding ezetimibe and eventually iPCSK9 (Class I, Levels B) | |
| CeVD patients | ||
| Risk stratification | Patients with multiple ASCVD events OR multiple high-risk conditions must be considered at very-high risk | All patients with ischemic stroke or TIA (particularly if recurrent) must be considered at very-high risk |
| Treatment strategies | Initiate with high intensity or maximal statin therapy to lower LDL-C levels by ≥50% (Class I, Levels A) | Initiate with high dose statin therapy (Class I, Level A) |
| If on maximal stain therapy LDL-C > 70 mg/dL add ezetimibe (Class IIa); If iPCSK9 is considered, add ezetimibe to maximal statin therapy before adding iPCSK9 (Class I, Levels B) | Revaluation safter 4–6 weeks to determine whether a reduction of >50% from baseline and LDL-C goal < 55 mg/dL have been reached (LDL-C goal < 40 mg/dL in patients with recurrent events (Class I, Level A) | |
| If on clinically judged maximal LDL-C lowering therapy and LDL-C > 70 mg/dL adding iPCSK9 is reasonable (Class IIa, Level A) | If not consider adding ezetimibe and eventually iPCSK9 (Class I, Levels B) |
* Multiple ASCVD events include MI, stroke and PAD; § Multiple high-risk conditions include: age > 65 years, HeFH, DM, HTN, CKD, smoking, LDL-C > 100 despite lipid lowering therapy, CHF. CAD, coronary artery disease; CeVD, cerebrovascular disease; ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; iPCSK9, inhibitors of PCSK9, MI, myocardial infarction; PAD, peripheral artery disease; HeFH, heterozygous familial hypercholesterolemia; DM, diabetes mellitus; HTN, hypertension; CKD, chronic kidney disease; CHF, congestive heart failure.