The TIMI (Thrombolysis in Myocardial Infarction) Risk Score for Secondary Prevention (TRS 2 P) is an integer-based risk stratification tool for patients with ASCVD. TRS 2 P includes 9 readily avail- able clinical high-risk features and was initially developed in a population of patients with MI within 2 weeks to 1 year of randomization to a thrombin receptor agonistS4.1-44 and further vali- dated in IMPROVE-IT.S4.1-14 A higher number of these high-risk features was associated with a higher risk of recurrent ASCVD events. In post- ACS patients with 3 high-risk features, addition of ezetimibe was associated with substantial risk reduction (19% RRR; 6.3% ARR; number needed to treat, 16); those with 2 high-risk features had some benefit, whereas those with 0 or 1 addi- tional features had no benefit.S4.1-14 Therefore, it is reasonable to initiate ezetimibe in patients with ASCVD who are on maximally tolerated statin therapy and judged to be at very high risk. For the present guideline, a definition of very high risk is amalgamated from TRS 2 P and the recruitment criteria of 2 trials with PCSK9 inhibitors (Table 4). 6. The cost-effectiveness of using PCSK9 inhibi- tors for the secondary prevention of ASCVD has been evaluated in 7 published simulation mod- els, as detailed in Section 7 (and Online Data Supplements 44 and 45). The reported incremen- tal cost-effectiveness ratios range from $141700 to $450000 per added (QALY), with all but 1 model reporting low value (>$150000 per QALY added). All models agree that the value provided by PCSK9 inhibitors would be signifi- cantly improved by price reductions of 70% to 85% from the mid-2018 US list price of roughly $14000 a year. 7. 