Summary : This flowchart summarizes patient management groups for cholesterol and cardiovascular risk, outlining key factors to consider and optional interventions for different patient populations. flowchart: # Nodes : • "PATIENT MANAGEMENT GROUPS" (black rectangle, top center) • "Secondary prevention" (green rounded rectangle, below left) • "Primary prevention" (green rounded rectangle, below right) • "Adults with clinical ASCVD" (green rounded rectangle, under Secondary prevention) • "Adults with primary severe hypercholesterolemia (LDL-C ≥190 mg/dL [≥4.9 mmol/L])" (green rounded rectangle, center, under both prevention types) • "Adults with diabetes" (green rounded rectangle, under Primary prevention) • "Adults without diabetes" (green rounded rectangle, under Primary prevention) • "FACTORS TO CONSIDER:" (purple rectangle, below all patient groups) • "OPTIONAL INTERVENTIONS TO CONSIDER IN APPROPRIATE PATIENT GROUPS:" (orange rectangle, bottom) # Connectors : • Downward arrows from "PATIENT MANAGEMENT GROUPS" to "Secondary prevention" and "Primary prevention". • Downward arrow from "Secondary prevention" to "Adults with clinical ASCVD". • Downward arrows from "Primary prevention" to "Adults with diabetes" and "Adults without diabetes". • "Adults with primary severe hypercholesterolemia" is connected to both prevention types. • All four patient group nodes point downward to "FACTORS TO CONSIDER". • "FACTORS TO CONSIDER" points downward to "OPTIONAL INTERVENTIONS TO CONSIDER IN APPROPRIATE PATIENT GROUPS". # Layout : • Hierarchical, top-down arrangement. • Two main branches (Secondary and Primary prevention) with subgroups. • Central node for severe hypercholesterolemia connects both branches. • Factors and interventions listed in large rectangles below patient groups. # Factors to Consider : • Adherence to lifestyle modifications and evidence-based, guideline-recommended statin therapy. • Patient on guideline-recommended statin therapy. • Risk-enhancing factors. • Control of other risk factors. • Clinician-patient decision about potential benefits, harms, and preferences regarding nonstatin therapies. • Percentage LDL-C reduction and absolute LDL-C or non-HDL-C level achieved. • Monitoring response to lifestyle modifications, adherence, and therapy. • Cost of therapy. • Statin-associated side effects. • Persistent hypertriglyceridemia. # Optional Interventions : • Referral to lipid specialist and registered dietitian/registered dietitian nutritionist. • Ezetimibe. • Bile acid sequestrants. • PCSK9 mAbs (alirocumab and evolocumab). • Bempedoic acid. • Inclisiran. • LDL apheresis (for familial hypercholesterolemia). • Lomitapide (only in HoFH). • Evincamab (only in HoFH). # Analysis : • The flowchart organizes patient management by prevention type and risk group, emphasizing a stepwise approach: first considering lifestyle and statin therapy, then evaluating additional risk factors and patient preferences, and finally listing optional interventions for those not achieving targets or with specific needs. • The central placement of severe hypercholesterolemia highlights its importance across both prevention categories. • The chart provides a comprehensive overview for clinicians to tailor therapy based on individual patient characteristics and response.

Summary : This figure presents the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) guidelines for LDL-C (low-density lipoprotein cholesterol) treatment goals, stratified by cardiovascular (CV) risk categories. It visually links risk categories to specific LDL-C targets and provides criteria for classifying patients into low, moderate, high, very high, and extreme CV risk groups. flowchart: # Risk Categories and LDL-C Treatment Goals : • Low risk: SCORE2/SCORE2-OP <2%; LDL-C goal <3.0 mmol/L (<116 mg/dL), Class IIb. • Moderate risk: SCORE2/SCORE2-OP ≥2% and <10%; LDL-C goal <2.6 mmol/L (<100 mg/dL), Class IIa. • High risk: SCORE2/SCORE2-OP ≥10% and <20%, markedly elevated single risk factors, FH without other major risk factors, moderate CKD, DM without target organ damage but with long duration or other risk factors; LDL-C goal <1.8 mmol/L (<70 mg/dL) & ≥50% reduction from baseline, Class I. • Very high risk: ASCVD, SCORE2/SCORE2-OP ≥20%, FH with ASCVD or other major risk factor, severe CKD, DM with target organ damage or ≥3 major risk factors or early onset T1DM of long duration; LDL-C goal <1.4 mmol/L (<55 mg/dL), Class Ia (Class IIa for FH in primary prevention at very high risk). • Extreme risk: Patients with ASCVD who experience recurrent vascular events while on maximally tolerated statin-based therapy, patients with polyvascular disease; LDL-C goal <1.0 mmol/L (<40 mg/dL), Class IIb. # Node Details : • Each risk category is represented by a colored box: yellow (low), orange (moderate), red (high), dark red (very high), black (extreme). • Each box contains criteria for risk classification and corresponding LDL-C treatment goal. • LDL-C goals are listed in a vertical column on the left, color-coded to match risk categories. # Connectors and Layout : • Arrows connect risk categories to their respective LDL-C goals. • The flow is diagonal from top left (low risk) to bottom right (extreme risk), indicating increasing CV risk and stricter LDL-C targets. • Additional notes clarify special cases (e.g., young patients, FH, CKD, DM). # Design Encodings : • Color coding: yellow (low), orange (moderate), red (high), dark red (very high), black (extreme). • Boxed text for risk criteria and LDL-C goals. • Dotted and solid arrows indicate progression and relationships. • ESC and EAS logos at the bottom right. # Analysis : • The figure visually emphasizes the stepwise intensification of LDL-C targets as CV risk increases. • The most stringent LDL-C goals (<1.0 mmol/L) are reserved for patients at extreme risk, such as those with recurrent ASCVD events or polyvascular disease. • The diagram provides a clear decision-making pathway for clinicians to match patient risk profiles with appropriate LDL-C treatment goals, highlighting the importance of risk stratification in lipid management. • The color gradient reinforces the urgency and clinical priority associated with higher risk categories.

Summary : This flowchart outlines the stepwise management of adults with clinical ASCVD (atherosclerotic cardiovascular disease) at very high risk who are on statin therapy for secondary prevention, focusing on achieving LDL-C and non-HDL-C targets and escalation to nonstatin agents if goals are not met. flowchart: # Nodes : • Start (rounded rectangle): "Adults with clinical ASCVD at very high risk* on statin therapy for secondary prevention" • Decision (diamond): "≥50% LDL-C reduction and LDL-C <55 mg/dL (or non-HDL-C <85 mg/dL) on maximally-tolerated statin therapy‡" • If NO (rectangle): 1. "Evaluate and optimize lifestyle modifications, adherence to guideline-recommended statin therapy, risk factor control, and SASEs" 2. "Increase to high-intensity statin therapy, if not already taking†" • Decision (diamond): "≥50% LDL-C reduction and LDL-C <55 mg/dL (or non-HDL-C <85 mg/dL) on maximally-tolerated statin therapy‡" • If NO (rectangle): "Consider the following as the initial nonstatin agent and addition of other agents as needed to achieve desired reduction of LDL-C‡‡" • Branch 1 (rectangle): "Consider ezetimibe and/or PCSK9 mAb" • Branch 2 (rectangle): "May consider bempedoic acid or inclisiran§§" • Decision (diamond, both branches): "≥50% LDL-C reduction and LDL-C <55 mg/dL (or non-HDL-C <85 mg/dL) on maximally-tolerated statin therapy‡" • If NO (rectangle): 1. "Referral to lipid specialist" 2. "Referral to RD/RDN" • If YES (rectangle): "Monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia,** refer to the 2021 ACC ECDP on Management of Hypertriglyceridemia††" • Decision for no additional medication (gray rectangle) # Connectors : • Arrows flow top-down, with YES/NO branches at each decision diamond. • YES branches lead to monitoring or end nodes. • NO branches lead to further evaluation, escalation, or referral. • After nonstatin agent consideration, two parallel branches (ezetimibe/PCSK9 mAb and bempedoic acid/inclisiran) both lead to the same decision diamond. • All YES outcomes eventually merge into the monitoring node. • NO outcomes from the final decision diamonds lead to referral nodes. # Layout : • Vertical flow, starting from the top. • Decision diamonds split into YES (right) and NO (left or downward) branches. • Parallel branches for nonstatin agent options. • Final nodes merge into a single monitoring node. • Color coding: blue for statin therapy steps, orange for nonstatin agent options, gray for decision of no additional medication, purple for initial evaluation, and light blue for monitoring. # Analysis : • The flowchart provides a clear, stepwise escalation pathway for lipid management in very high-risk ASCVD patients on statin therapy. • It emphasizes repeated assessment of LDL-C/non-HDL-C targets, optimization of statin therapy, and addition of nonstatin agents if goals are not met. • Referral to specialists is recommended if targets remain unmet after all pharmacologic options. • The process is cyclical, with ongoing monitoring and adjustment based on response. • The chart visually prioritizes statin optimization before considering nonstatin agents, and highlights the importance of lifestyle and adherence throughout.