Dyslipidemia Clinical Practice Guidelines (2019)

In August 2019, the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) released updates to their 2016 guidelines for the management of dyslipidemia.^[1,2] Among the changes are new and more aggressive proposed goals for low-density lipoprotein cholesterol (LDL-C) levels, revised cardiovascular (CV) risk stratification, particularly for patients at high to very high risk, as well as new patient management recommendations.^[1,2]

New LDL Targets Across CV Risk Categories

For very-high-risk patients (10-year risk of CV death ≥10%): Use an LDL-C reduction of at least 50% from baseline and an LDL-C goal of below 1.4 mmol/L (<55 mg/dL).

For very high-risk patients who experience a second vascular event within 2 years (not necessarily of the same type as the first event) while taking maximally tolerated statin therapy: An LDL-C goal of below 1.0 mmol/L (<40 mg/dL) may be considered.

For patients at high risk (10-year risk for CV death of 5% to <10%): Use an LDL-C reduction of at least 50% from baseline and an LDL-C goal of below 1.8 mmol/L (<70 mg/dL).

For individuals at moderate risk (10-year risk for CV death of 1% to <5%): Consider an LDL-C goal of below 2.6 mmol/L (<100 mg/dL).

For individuals at low risk (10-year risk for CV death <1%): Consider an LDL-C goal of below 3.0 mmol/L (<116 mg/dL).

New Recommendations

Cardiovascular imaging for assessment of ASCVD risk (should be considered)

Consider assessment of carotid and/or femoral arterial plaque burden on arterial ultrasonography as a risk modifier in individuals at low or moderate risk.

Consider coronary artery calcium (CAC) score assessment with computed tomography (CT) as a risk modifier in the CV risk assessment of asymptomatic individuals at low or moderate risk.

Lipid analyses for CVD risk estimation (should be considered)

Consider measurement of lipoprotein(a) (Lp(a)) at least once in each adult’s lifetime to identify those with very high inherited Lp(a) levels above 180 mg/dL (>430 nmol/L) who may have a lifetime risk of atherosclerotic CV disease (ASCVD) that is equivalent to the risk associated with heterozygous familial hypercholesterolemia (FH).

Pharmacotherapy of patients with hypertriglyceridemia (should be considered)

In high-risk (or above) patients with triglyceride (TG) levels between 1.5 and 5.6 mmol/L (135-499 mg/dL) despite statin treatment, consider the combination of n-3 polyunsaturated fatty acids (PUFAs) (icosapent ethyl 2 × 2g/day) with statins.

Treatment of patients with heterozygous FH (should be considered)

For primary prevention in individuals with FH at very-high risk, consider an LDL-C reduction of over 50% from baseline and an LDL-C goal below 1.4 mmol/L (<55 mg/dL).

Dyslipidemia therapy in older patients

For primary prevention in older people aged up to 75 years, statin therapy is recommended based on the level of risk.

For primary prevention in older people older than 75 years, initiation of statin treatment may be considered if they are at high risk or above.

Dyslipidemia therapy in the setting of diabetes mellitus

For patients with type 2 diabetes mellitus (T2DM) at very-high risk, an LDL-C reduction of at least 50% from baseline and an LDL-C goal of below 1.4 mmol/L (<55mg/dL) is recommended.

For those with T2DM at high risk, an LDL-C reduction of at least 50% from baseline and an LDL-C goal of below 1.8 mmol/L (<70 mg/dL) is recommended.

For individuals with T1DM who are at high or very-high risk, statins are recommended.

Consider intensification of statin therapy before introducing combination therapy. If the goal is not reached, consider a statin combined with ezetimibe. (Each should be considered.)

Statin therapy is not recommended in premenopausal diabetic patients who are considering pregnancy or who are not using adequate contraception.

Lipid-lowering therapy in patients with ACS (should be considered)

For patients who present with an acute coronary syndrome (ACS), and whose LDL-C levels are not at goal despite already taking a maximally tolerated statin dose and ezetimibe, consider adding a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor early after the event (if possible, during hospitalization for the ACS event).

For more information, please go to Primary and Secondary Prevention of Coronary Artery Disease, Familial Hypercholesterolemia, Hypertriglyceridemia, and LDL Cholesterol Genetics.

For more Clinical Practice Guidelines, please go to Guidelines.

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