Response

We thank Dr Aubrey-Bassler for his comment¹ pertaining to the PEER simplified lipid guideline 2023 update.² Both the 2023 and 2015 PEER simplified lipid guidelines do not recommend repeat lipid testing for primary or secondary prevention patients, or treating to a target low-density lipoprotein level after initiation of statins.^2,3

In our guideline we state, “In secondary prevention, if additional cardiovascular risk reduction is desired beyond maximized statin therapy, we recommend a discussion of ezetimibe or PCSK9 [proprotein convertase subtilisin-kexin type 9] inhibitors.”² The evidence for ezetimibe and PCSK9 inhibitors for patients with nonfamilial hypercholesteremia is almost exclusively for when they are added to statins in patients with previous cardiovascular disease (CVD).

Statins provide a 25% to 35% relative risk reduction in major adverse cardiovascular events (from low to high potency) and about a 10% relative risk reduction in mortality. Ezetimibe and PCSK9 inhibitors provide an additional 7% and 15% relative risk reduction in major adverse cardiovascular events, respectively, and no clear benefits on mortality.⁴ We believe the conversation regarding the consideration of these medicines should focus on the potential benefits and harms (including costs and convenience) rather than lipid levels.

For clinicians interested in more explicit patient characteristics for which to consider adding ezetimibe or a PCSK9 inhibitor without specific reference to lipid levels, one could follow the 2020 Veterans Affairs guideline recommendations.⁵ These characteristics included the following:

• recent (<1 year after event) or recurrent CVD; and

• known CVD and additional risk factors (eg, smoking, diabetes, chronic kidney disease).

We trust this clarifies our recommendation.

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