Atherosclerotic Cardiovascular Disease (ASCVD)

Use a high-intensity or maximally tolerated statin, adding nonstatin therapy when needed. Assess both the percentage reduction and the level reached.

The 2026 ACC/AHA multisociety dyslipidemia guideline sets lipid goals for established clinical ASCVD based on whether the patient meets very-high-risk criteria. Use these goals to assess response to maximally tolerated statin therapy and the need for additional lipid lowering.

Patients with multiple major ASCVD events, or one major event plus multiple high-risk conditions.

Major ASCVD events include:

• ACS within the past 12 months
• Prior MI, excluding the recent ACS already counted
• Ischemic stroke
• Symptomatic PAD

High-risk conditions include:

• Age >65 years
• Prior coronary bypass surgery or percutaneous coronary intervention (PCI) outside the major ASCVD event already counted
• Current smoking
• Diabetes
• Hypertension
• History of congestive heart failure
• LDL-C >100 mg/dL despite maximally tolerated statin therapy plus ezetimibe

Example: a patient with a prior MI, diabetes, and hypertension qualifies as very high risk. Coronary revascularization alone is a high-risk condition, rather than a major event in this classification.

In established ASCVD, add therapy when maximally tolerated statin treatment doesn’t achieve the patient’s lipid goals, generally LDL-C <70 mg/dL, or <55 mg/dL for very-high-risk patients. Confirm adherence and assess the additional reduction needed.

• Very-high-risk ASCVD: Add ezetimibe and/or a PCSK9 monoclonal antibody (evolocumab or alirocumab) to reach goal. Bempedoic acid is another guideline-supported option when additional lowering is needed.
• ASCVD not at very high risk: Ezetimibe, a PCSK9 monoclonal antibody, or bempedoic acid are reasonable options. Choose based on the reduction needed, patient preference, tolerability, and access.

There’s no requirement to try every agent in order. Some patients need combination therapy to reach goal.

For very-high-risk patients, inclisiran is a reasonable option when evolocumab or alirocumab can’t be tolerated or obtained, or when patients strongly prefer less frequent dosing. It lowers LDL-C, though cardiovascular outcomes trials are still ongoing.

• Evaluate reported statin symptoms, interactions, and other possible causes; adjust treatment rather than leaving LDL-C unaddressed.
• Repeat a lipid panel 4–12 weeks after starting or adjusting therapy, then every 6–12 months.
• Assign responsibility among the medical team/support staff for repeat testing and treatment follow-up.

• Low-dose aspirin (75–100 mg daily, typically 81 mg in the U.S.) is recommended for chronic coronary disease when there’s no indication for oral anticoagulation.
• After ACS, aspirin plus a P2Y12 inhibitor (e.g., clopidogrel, prasugrel, or ticagrelor) for at least 12 months is the default for patients without high bleeding risk. Agent selection depends on the clinical setting and contraindications.
• Bleeding risk, PCI history, and concurrent anticoagulation can change the regimen and duration. Document the indication and planned duration at transitions of care.

• Treat angina alongside cardiovascular risk. Consider revascularization when symptoms persist despite medical therapy, or when coronary anatomy indicates a potential survival benefit from intervention.
• Revascularization doesn’t replace preventive care. Refer eligible patients to cardiac rehab.

If a beta-blocker was started after MI, it’s reasonable to reassess its use beyond one year when there’s no history of—or current—left ventricular ejection fraction (LVEF) ≤50%, angina, arrhythmia, or uncontrolled hypertension. In coronary disease without prior MI or LVEF ≤50%, beta-blockers don’t reduce major cardiovascular events in the absence of another indication. These recommendations support reviewing the indication, rather than automatically stopping treatment.