For many of our highest risk patients, especially those with premature disease, we should be asking: Are we satisfied with “better” or are we aiming for optimal?

In this PulsePoints case with Ambreen Mohamed, MD, FACC, a 49-year-old South Asian male came to us after a premature NSTEMI. He had diabetes, a strong family history of early heart disease, and a baseline LDL of 162 mg/dL.

We started high-intensity statin therapy and ezetimibe, alongside lifestyle changes, and his LDL came down to 82 mg/dL.

By older standards, this is a sufficient decrease, but by current secondary prevention standards and when aiming for optimal, it falls short.
Given high-risk status, our LDL goal was below 55 mg/dL. So, we added a PCSK9 inhibitor evolocumab. 12 weeks later, his LDL dropped to 28 mg/dL, with no side effects, causing the patient to feel empowered.

PCSK9 inhibitors are an optimal solution because they are a protein that binds LDL receptors in the liver and marks them for destruction, delivering 50 to 60% additional LDL reduction on top of statins.

High-intensity statin plus ezetimibe is not the ceiling in very high-risk patients. If LDL remains above goal, PCSK9 inhibitors are not extreme. They are evidence-based. The combination of aggressive lipid lowering and lifestyle intervention is powerful, especially in populations at high risk.

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