Question special
Lead Moderator

The short answer is very high risk (CVD "plus"- FH, diabetes, see below) with LDL-C >= 100-130 mg/dl (3.4 mmol/L) and high risk (CVD or FH) with LDL-C >=130 mg/dl.
A has been mentioned in previous posts, PCSK9 monoclonal antibodies are expensive, and payers have been reluctant to approve them, with onerous pre-approval processes.NNTs of 21-25 over 5 years may approach cost-effectiveness thresholds with significant discounting. We described this quantitative approach using NNT for guiding consideration of nonstatin therapy (Robinson JACC 2016). The potential for benefit depends on the absolute CVD risk of the patient and the level of LDL-C (Table).
other patients that are very high risk (>=30% 10-year ASCVD risk) on moderate-high intensity statins include those with clinical CVD "PLUS" (CVD and familial hypercholesterolemia (FH), diabetes, recent acute coronary syndromes, chronic kidney disease, multiple poorly controlled risk factors, polyvascular disease, men >=65 years). The very high risk and high risk groups in our paper generally support those identified in the 2016ACC nonstatin pathway.