ACC updates decision pathway on nonstatin drugs in ASCVD

Experts considered evidence from the FOURIER trial and the SPIRE-1 and SPIRE-2 trials, as well as evidence on addition of ezetimibe to statin therapy after acute coronary syndrome.


The American College of Cardiology issued an update last week to its expert consensus decision pathway for use of nonstatin drugs to lower LDL cholesterol levels in clinical atherosclerotic cardiovascular disease (ASCVD).

In revising the pathway, which was first published in 2016, experts considered evidence from recently published sources, including the FOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) trial and the SPIRE-1 and SPIRE-2 (Studies of PCSK9 Inhibition and the Reduction of Vascular Events) trials. Evidence on addition of ezetimibe to statin therapy after acute coronary syndrome was also considered.

The changes to the 2016 pathway include the following:

  • For adults who have clinical ASCVD, are taking a statin for secondary prevention, and have a baseline LDL cholesterol level of 70 to 189 mg/dL, the threshold for considering a net risk-reduction benefit remains a reduction in LDL cholesterol level of at least 50%. However, an LDL cholesterol level less than 70 mg/dL and a non-HDL cholesterol level less than 100 mg/dL may be considered as thresholds for those with clinical ASCVD and an LDL cholesterol level of 70 to 189 mg/dL at baseline.
  • For adults who have clinical ASCVD with comorbidities, are taking a statin for secondary prevention, and have a baseline LDL cholesterol level of 70 to 189 mg/dL, addition of ezetimibe or a PCSK9 inhibitor is reasonable. Ezetimibe may be preferred because it is less expensive or because a patient needs less than 25% additional LDL cholesterol lowering, among other factors. A PCSK9 inhibitor may be preferred if more than 25% additional LDL cholesterol lowering is required. Patient preferences should be considered in all cases. Patients in this group may be considered at higher risk if they are 65 years of age or older, currently smoke cigarettes, have previous myocardial infarction or nonhemorrhagic stroke, or have symptomatic peripheral artery disease with previous myocardial infarction or stroke, among other factors.

The clinical decision pathway was published online Sept. 5 by the Journal of the American College of Cardiology.