Management of Mixed Hyperlipidemia with Atherosclerotic Disease

Patient Assessment and Criteria Evaluation

A 67-year-old female patient with mixed hyperlipidemia and mild coronary artery disease has demonstrated significant LDL-C reduction on Leqvio therapy, with levels decreasing from a high cholesterol level to a low cholesterol level, meeting the Aetna CPB continuation criterion A for achieving LDL-C reduction 1
The patient is taking a high dose of a statin medication, meeting the Aetna CPB continuation criterion B for concomitant statin therapy 1
The American College of Cardiology recommends inclisiran as an adjunct to diet and maximally tolerated statin therapy for adults with clinical atherosclerotic cardiovascular disease who require additional lowering of LDL-C 2

The European Society of Cardiology recommends a target LDL-C level of less than 55 mg/dL and a ≥50% reduction from baseline, which this patient has achieved with Leqvio therapy 3
The use of Leqvio is supported for patients with atherosclerotic disease, including those with nonobstructive atherosclerotic heart disease, as documented in this patient's case 2, 3

The treatment algorithm for mixed hyperlipidemia with atherosclerotic disease involves starting with maximally tolerated statin therapy, and if LDL-C targets are not achieved, adding non-statin therapy such as Leqvio, as recommended by the American College of Cardiology and the European Heart Journal 2, 3
Continued therapy is indicated if the patient demonstrates an adequate response and tolerates treatment well, with regular monitoring of LDL-C levels to ensure sustained response to therapy 1

Aggressive risk factor modification, including continued lipid management, remains indicated for patients with mild coronary artery disease, as supported by the European Heart Journal 3
The American College of Cardiology expert consensus supports the use of Leqvio in patients with atherosclerotic cardiovascular disease when additional LDL-C lowering is needed, although it is considered off-label for this indication 2

The American College of Cardiology recommends intensive lipid-lowering therapy for patients with established atherosclerotic cardiovascular disease, such as coronary artery disease, who are at very high risk, and the patient's current LDL-C level of 33 mg/dL is well below the recommended target of <55 mg/dL for patients with established ASCVD, indicating excellent treatment response 4, 5
The patient is maintained on maximally tolerated statin therapy, which is classified as moderate-intensity statin therapy according to ACC/AHA guidelines, and the combination of inclisiran with statin therapy follows the recommended approach for patients with established ASCVD requiring additional LDL-C lowering 4, 5

Each 1% reduction in LDL-C provides approximately 1% reduction in ASCVD risk, and the patient has achieved a significant LDL-C reduction, which is associated with reduced cardiovascular risk 4

Guidelines explicitly recommend against de-escalating treatment when low LDL-C levels are achieved and therapy is well-tolerated, and discontinuation of inclisiran would likely result in rebound increases in LDL-C levels, potentially increasing cardiovascular risk 5