Thus, the Work Group decided upon a Strong for recommendation. Recommendation 12. For secondary prevention in higher risk patients who are willing to intensify treatment, we suggest offering high-dose statins for reducing non-fatal cardiovascular events after discussion of the risk of high-dose statins and an exploration of the patient s values and preferences. (Weak for | Reviewed, New-replaced) Discussion It is understood that the baseline risk for new CVD events is higher in patients treated for secondary prevention than patients treated for primary prevention. However, evidence suggests there are subgroups of patients with established CVD with features or risk factors that further increase their risk for future events. These subgroups include patients with (1) MI or ACS in past 12 months; (2) recurrent ACS, MI, or CVA; or (3) established CVD and with additional risk factors (e.g., currently smoking, DM, PAD, or CABG/PCI). These patients are more likely to benefit from intensified treatment (e.g., maximum dose statins, the addition of ezetimibe to statins, and then the addition of PCSK9 inhibitor to statins plus ezetimibe) to reduce their CV risk. Although there are no prospective studies comparing these higher risk groups to lower risk groups for secondary prevention, subgroup and post hoc analyses demonstrate a greater risk for CVD events in these patients who may benefit from more aggressive treatment.[75,76] The meta-analysis by de Vries et al. (2014) compared the incidence of major CV and cerebrovascular events between standard-dose statins and placebo (n=4,351) and standard-dose statins with intensive- dose statins (n=4,805) for secondary prevention in patients with DM.[77] There was a statistically significant reduction in major CV and cerebrovascular events in favor of the more intensive statin dose group versus standard dose (RR: 0.91, 95% CI: 0.84 0.98). Another meta-analysis, Koskinas et al. 