As a result of recent evidence regarding proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors and ezetimibe in some patients, the ACC had released the 2017 Focused Update of the 2016 ACC Expert Consensus "Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk," which was published Sept. 5 in the Journal of the American College of Cardiology.

The 2016 document provided guidance regarding the incorporation of non-statin therapies into treatment strategies to lower low-density lipoprotein (LDL)–cholesterol for patients who may need additional therapies beyond statins. The goal of that document was to provide practical guidance for clinicians and patients in situations not covered by the 2013 ACC/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults until the next round of guidelines has the opportunity to formally review the recent scientific evidence for atherosclerotic cardiovascular disease risk reduction.

Since the publication of the 2016 expect consensus decision pathway, additional evidence and perspectives have emerged from randomized clinical trials and other sources, particularly considering the longer-term efficacy and safety of PCSK9 inhibitors in secondary prevention of atherosclerotic cardiovascular disease (ASCVD), as well as evidence on the types of patients most likely to benefit from the use of ezetimibe in addition to statin therapy after acute coronary syndrome. Due to these findings, the writing committee, chaired by Donald M. Lloyd-Jones, MD, FACC, has provided the focused update to help guide clinicians more clearly on decision making regarding the use of ezetimibe and PCSK9 inhibitors in these patients.

In the focused update, revised recommendations are provided for patients with clinical ASCVD with or without comorbidities on statin therapy for secondary prevention, indicating more clearly when ezetimibe or a PCSK9 inhibitor may be considered. The writing committee judged that the new data did not warrant changes to the decision pathways and algorithms regarding the use of ezetimibe or PCSK9 inhibitors in primary prevention patients LDL-C <190 mg/dl with or without diabetes or patients without ASCVD and LDL-C <190 mg/dl not due to secondary causes. Also provided in the focused update is new information on diagnostic categories of heterozygous and homozygous familial hypercholesterolemia, based on clinical criteria with and without genetic testing.