What other considerations for hyperlipidemia management would you have for a patient with multiple prior PCIs whose LDL remains above goal on high intensity statin, ezetimibe, and evolocumab, assuming the patient is compliant with medications?

There are a few options, most of which depend on insurance coverage and patient preferences. But first, would do a chart biopsy to assess the efficacy of each of the therapies to better understand the reason for persistent LDL elevation. Perhaps they have a dysfunctional LDL receptor, so upregulation with PCSK9 inh doesn't clear the LDL so well.

One option is to add bempedoic acid. It results in ~20% LDL reduction and lowers CV events in the CLEAR outcomes trial. It is also likely to be covered by insurance.

Another consideration is ANGPTL3 monoclonal antibodies (evinacumab) which can lower LDL by an additional 50%. It's another injection and insurance coverage could be challenging.

Finally, another option is to go after the inflammatory pat...

Challenging and agree that compliance is something I would be concerned about. If compliance not the reason patient not at goal, colchicine would be a cheap option to lower risk via an orthogonal pathway of inflammation, particularly if the patient had an elevated hsCRP. Bempedoic acid would be my next option as the most affordable although the benefit modest so best if patient near goal. If LDL still significantly above target, agree that ANGPTL3 inhibitor the only additional agent that would get patient to goal but almost impossible to gain insurance coverage.

1. Don't assume and make sure the patient has had TSH.
2. Dietary consultation and in-depth analysis.
3. Emphasize risk factor modification, exercise, weight loss, and consideration of GLP1, if indicated.
4. Review of medications that could be affecting the lipid profile.