3.3.4.0 Sec­ondary Pre­ven­tion (Pa­tients With ASCVD)

Be­cause risk is high in pa­tients with ASCVD, in­ten­sive ther­a­py is in­di­cated and has been shown to be of benefit in mul­ti­ple large ran­dom­ized car­dio­vas­cu­lar out­comes tri­als (86,90,92,93). High-‍in­ten­si­ty statin ther­a­py is rec­om­mend­ed for all pa­tients with di­a­betes and ASCVD. This rec­om­mendation is based on the Choles­terol Treat­ment Tria­lists’ Col­lab­o­ra­tion in­volv­ing 26 statin tri­als, of which 5 com­pared high-‍in­ten­si­ty ver­sus mod­er­ate-‍in­ten­si­ty statins. To­geth­er, they found re­duc­tions in non­fa­tal car­dio­vas­cu­lar events with more in­ten­sive ther­a­py, in pa­tients with and with­out di­a­betes (78,82,92).

Over the past few years, there have been mul­ti­ple large ran­dom­ized tri­als in­ves­ti­gat­ing the benefits of adding non­sta­tin agents to statin ther­a­py, in­clud­ing those that eval­u­ated fur­ther low­er­ing of LDL choles­terol with eze­tim­ibe (90,94) and pro­pro­tein con­ver­tase subtilisin/‍kexin type 9 (PCSK9) in­hibitors (93). Each trial found a significant benefit in the re­duc­tion of ASCVD events that was di­rectly re­lat­ed to the de­gree of fur­ther LDL choles­terol low­er­ing. These large tri­als in­cluded a significant num­ber of par­tic­i­pants with di­a­betes. For pa­tients with ASCVD who are on high-‍in­ten­si­ty (and max­i­mal­ly tol­er­at­ed) statin ther­a­py and have an LDL choles­terol ≥70 mg/dL, the ad­di­tion of non­sta­tin LDL-‍low­er­ing ther­a­py is rec­om­mend­ed fol­lowing a clin­ician-pa­tient dis­cussion about the net benefit, safe­ty, and cost (Table 10.2).