LDL-C lowering therapies

What is new?

Bempedoic acid

Combination therapy

Combination LDL-C lowering

As a general concept the Task Force recommends to add non-statin therapies with proven cardiovascular benefit such as ezetimibe, a PCSK9 mAb, or bempedoic acid, taken alone or in combination, to lower LDL-C if the LDL-C goals are not achieved with the maximum tolerated dose of a statin; the choice should be based on the magnitude of additional LDL-C lowering needed, patient reference, treatment availability, and cost.

Recommendations

Recommendations	Class^a	Level^b
Non-statin therapies with proven cardiovascular benefit^c, taken alone or in combination, are recommended for patients who are unable to take statin therapy to lower LDL-C levels and reduce the risk of CV events. The choice should be based on the magnitude of additional LDL-C lowering needed.^4,53,54	I	A
Bempedoic acid is recommended in patients who are unable to take statin therapy to achieve the LDL-C goal.⁴	I	B
The addition of bempedoic acid to the maximally tolerated dose of statin with or without ezetimibe should be considered in patients at high or very high risk in order to achieve the LDL-C goal.^42,55	IIa	C
Evinacumab should be considered in patients with homozygous familial hypercholesterolaemia aged 5 years or older who are not at LDL-C goal despite receiving maximum doses of lipid-lowering therapy to lower LDL-C levels.^5,50,51	IIa	B

This table complements the table of recommendations for pharmacological low-density lipoprotein cholesterol lowering in the 2019 ESC/EAS Guidelines and does not replace it.
CV, cardiovascular; LDL-C, low-density lipoprotein cholesterol; PCSK9, proprotein convertase
subtilisin/kexin type 9.
^a Class of recommendation.
^b Level of evidence.
^c Ezetimibe, PCSK9 monoclonal antibodies, bempedoic acid.