Bempedoic acid in a high-risk primary-prevention patient unable to take statins: a case-based approach

Low-density lipoprotein cholesterol (LDL-C) is a predominant risk factor for atherosclerotic cardiovascular disease (ASCVD) [1].The lower the LDL-C remains for a longer period of time, the better the ASCVD outcomes.Contrary to exaggerated claims, statins, the cornerstone of lipid-lowering therapy (LLT), cause symptomatic adverse events in roughly 1-2% of patients treated for 5 years [2].Beyond muscle outcomes and diabetes, only 4 of 66 undesirable effects listed in product labels are attributable to statins [3].Nonetheless, almost 1 in 10 patients is intolerant to statins [4], primarily due to statin-associated muscle symptoms (SAMS), which lead to severe pain in 43% of affected individuals [5].Given that 76% of statin-intolerant patients do not achieve the recommended LDL-C targets, well-tolerated non-statin LLTs are necessary to reduce LDL-C levels and ASCVD risk in this challenging population [6].Bempedoic acid was introduced as an add-on to ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors in patients at high ASCVD risk who are unable or unwilling to take statins [7].Here, we describe a practical approach to the utilization of bempedoic acid in the treatment of a high-risk primary-prevention patient unable to take statins.A 52-year-old female was referred to the outpatient lipid clinic due to suspected familial hypercholesterolemia and statin intolerance.The initial, fasting, off-treatment lipid profile showed total cholesterol of 370 mg/dl (≈9.6 mmol/l), non-high-density lipoprotein cholesterol of 293 mg/dl (≈7.6 mmol/l), calculated LDL-C of 268 mg/dl (≈6.9 mmol/l), high-density lipoprotein cholesterol of 77 mg/dl (≈2.0 mmol/l), and triglycerides (TG) of 126 mg/dl (≈1.4 mmol/l).The patient had a history of hypothyroidism, which was excluded as a cause of secondary hypercholesterolemia, given that the euthyroid state was restored with levothyroxine 25 μg.The patient was optimally treated for arterial hypertension with a single-pill combination of perindopril 2.5 mg and amlodipine 2.5 mg.Other modifiable ASCVD risk factors were not found, as the patient had normal glycated hemoglobin, normal kidney function, and no history of tobacco consumption.Carotid ultrasound revealed bilateral non-stenotic atherosclerotic plaques.Coronary computed tomography angiography demonstrated the coronary artery calcium score of zero.The patient presented no symptoms or signs of ASCVD, had no further medical history, was physically active, followed a healthy dietary pattern, displayed a body mass index of 22 kg/m 2 , high-sensitivity C-reactive protein (hs-CRP) of < 1 mg/l, and lipoprotein (a) [Lp(a)] of 9 mg/dl (≈19.4 nmol/l).