A 65-year-old woman with stable angina and a QRISK3 score of 25% has been unable to tolerate multiple statins due to severe myalgia. She has been taking Ezetimibe 10 mg daily for 3 months, but her LDL remains high at 4.2 mmol/L. What is the most appropriate next step?

• A. Niacin
• B. Bempedoic acid 180 mg once daily
• C. Fibrate therapy
• D. PCSK9 inhibitors

Answer: (B)

When statin intolerance limits LDL lowering, the next step is to add a non-statin agent that can be taken orally and further reduce LDL. Bempedoic acid inhibits ATP citrate lyase in the liver, which decreases hepatic cholesterol synthesis and increases LDL receptor activity, lowering LDL cholesterol without targeting muscle tissue. This makes it especially suitable for someone who cannot tolerate statins and is already on ezetimibe but still has high LDL. It typically provides an additional meaningful reduction in LDL when added to ezetimibe, helping reach risk-based targets in high-risk patients. Niacin and fibrates have less favorable lipid-lowering profiles for LDL and more side effects; PCSK9 inhibitors are potent but are injections and costlier, usually considered after exhausting oral non-statin options. So adding bempedoic acid is the most appropriate next step.