According to the last ESC Guidelines of CVD prevention, they put a class I recommendation to use PCSK9 inhibitors for patients with FH in general who are classified as very high risk (that is with ASCVD or with another major risk factor) and failed to reach the LDL goal on a maximally tolerated dose of statin & ezetimibe. So according to this evidence if a patient with heterzygous FH who would mostly have a lower LDL level than homozygous FH, we are going to start high intensity statin with ezetimibe and reassess lipid profile after 1 month, and if failed to reach the goal we can plan to start PCSK9 inhibitors especially if very high risk.
