Choice of Lipid-lowering Drugs for Patients with Clinical ASCVD* COR LOE New, Revised, or Unchanged In patients who are 75 years of age or younger with clinical ASCVD, high- intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels. I A Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate- intensity statin therapy should be initiated or continued with the aim of achieving a 30% to 49% reduction in LDL-C levels. I A Recommendation unchanged from 2018 Cholesterol Guidelines. In patients at increased ASCVD risk with chronic, stable liver disease (including nonalcoholic fatty liver disease) when appropriately indicated, it is reasonable to use statins after obtaining baseline measurements and determining a schedule of monitoring and safety checks. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD, who are judged to be very high-risk and considered for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy, maximally tolerated LDL-C lowering therapy should include maximally tolerated statin therapy and ezetimibe. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD who are judged to be very high risk and who are on maximally tolerated LDL-C lowering therapy with LDL-C 70 mg/dL or higher ( 1.8 mmol/L) or a non HDL-C level of 100 mg/dL or higher ( 2.6 mmol/L), it is reasonable to add a PCSK9 inhibitor following a clinician patient discussion about the net benefit, safety, and cost. IIa A Recommendation unchanged from 2018 Cholesterol Guidelines. At mid-2018 list prices, PCSK9 inhibitors have a low cost value (>$150000 per quality-adjusted life-year) compared to good cost value (<$50000 per quality- adjusted life-year). 