Table XVII.
Summary of recommendations on the principles of lipid-lowering therapy
| Recommendation | Class | Level |
|---|---|---|
| High-intensity statin therapy with the highest tolerated dose is recommended in order to achieve the targets defined for a specific level of risk. | I | A |
| If goals have not been achieved with the maximum tolerated statin dose, combination with ezetimibe is recommended. | I | B |
| In post-ACS patients with (1) extreme cardiovascular risk, (2) familial hypercholesterolaemia, or (3) baseline LDL-C concentration (with or without treatment) that prevents achievement of the treatment goal with statin therapy, initiation of combination therapy with ezetimibe may be considered. | IIb | C |
| In very high-risk patients in primary prevention but without FH, combination with a PCSK9 inhibitor may be considered if the LDL-C goal has not been achieved with the maximum tolerated dose of a statin and ezetimibe. | IIb | C |
| In secondary prevention, combination with a PCSK9 inhibitor is recommended in very high-risk patients in whom the target has not been achieved with the maximum tolerated dose of a statin and ezetimibe. | I | A |
| Combination with a PCSK9 inhibitor is recommended in very high-risk patients with FH (i.e., with ASCVD or another major risk factor) in whom the target has not been achieved with the maximum tolerated dose of a statin and ezetimibe. | I | B |
| If a statin-based regimen is not tolerated at any dose (even after rechallenge), the use of ezetimibe should be considered. | IIa | C |
| In statin-intolerant patients who require discontinuation of lipid-lowering therapy, immediate initiation of ezetimibe may be considered. | IIb | C |
| In high-risk patients with partial statin intolerance requiring statin dose reduction, immediate addition of ezetimibe to a tolerated dose of a statin may be considered. | IIb | C |
| If a statin-based regimen is not tolerated at any dose (even after rechallenge), addition of a PCSK9 inhibitor to ezetimibe should be considered. | IIa | B |
| In patients requiring statin/ezetimibe combination therapy, a fixed dose formulation (polypill) should be considered. | IIa | C |