ESC/EAS 2019 Guidelines for the management of dyslipidaemias

2019 ESC/EAS Guidelines for the management of Dyslipidaemias: lipid modification to reduce cardiovascular risk

Recommendations	Classa	Levelb
CVD risk estimation
Total risk estimation using a risk estimation system such as SCORE is recommended for asymptomatic adults aged >40 years without evidence of CVD, DMCKD, FH, or LDL >4.9 mmol/L (>190 mg/dL).	I	C
High- and very-high-risk individuals may be identified on the basis of documented CVD, DM, moderate-to-severe renal disease, very high levels of individual risk factors, FH, or a high SCORE risk, and are a priority for advice and management of all risk factors.	I	C
Risk scores developed for the general population are not recommended for CV risk assessment in patients with DM or FH.	III	C
Lipid analyses for CVD risk estimation
TC is to be used for the estimation of total CV risk by means of the SCORE system.	I	C
HDL-C analysis is recommended to further refine risk estimation using the online SCORE system.	I	C
LDL-C analysis is recommended as the primary lipid analysis method for screening, diagnosis, and management.	I	C
TG analysis is recommended as a part of the routine lipid analysis approach.	I	C
Non-HDL-C evaluation is recommended for risk assessment, particularly in people with high TG levels, DM, obesity, or very low LDL-C levels.	I	C
ApoB analysis is recommended for risk assessment, particularly in people with high TG levels, DM, obesity, or MetS, or very low LDL-C levels. It can be used as an alternative to LDL-C, if available, as the primary measurement for screening, diagnosis, and management, and may be preferred over non-HDL-C in people with high TG levels, DM, obesity, or very low LDL-C levels.	I	C
Treatment goals for LDL-C
In secondary prevention for patients at very-high risk,anLDL-Creduction of>_50% from baseline and an LDL-C goal of <1.4 mmol/L(<55 mg/dL) are recommended.	I	A
In primary prevention for individuals at very-high risk, an LDL-C reduction of>_50% from baseline and an LDL-C goal of <1.4 mmol/L(<55 mg/dL) are recommended.	I	C
In patients at high risk, an LDL-C reduction of >_50% from baseline and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) are recommended.	I	A
Pharmacological LDL-C lowering
It is recommended that a high-intensity statin is prescribed up to the highest tolerated dose to reach the goals set for the specific level of risk.	I	A
If the goals are not achieved with the maximum tolerated dose of a statin, combination with ezetimibe is recommended.	I	B
For secondary prevention in patients at very-high risk not achieving their goal on a maximum tolerated dose of a statin and ezetimibe, a combination with a PCSK9 inhibitor is recommended.	I	A
For very-high-risk FH patients (that is, with ASCVD or with another major risk factor) who do not achieve their goal on a maximum tolerated dose of a statin and ezetimibe, a combination with a PCSK9 inhibitor is recommended.	I	C
Drug treatment of patients with HTG
Statin treatment is recommended as the first drug of choice for reducing CVD risk in high-risk individuals with HTG [TGs >2.3 mmol/L(>200mg/dL)].	I	B
Management of patients with HeFH
It is recommended that a diagnosis of FH is considered in patients with CHD aged<55 years for men and <60 years for women, in people with relatives with premature fatal or non-fatal CVD, in people with relatives having tendon xanthomas, in people with severely elevated LDL-C levels [in adults >5 mmol/L (>190 mg/dL), in children >4 mmol/L (>150 mg/dL)], and in first-degree relatives of FH patients.	I	C
It is recommended that FH is diagnosed using clinical criteria and confirmed, when possible, with DNA analysis.	I	C
Once the index case is diagnosed, family cascade screening is recommended.	I	C
It is recommended that FH patients with ASCVD or who have another major risk factor are treated as very-high-risk, and those with no prior ASCVD or other risk factors as high-risk.	I	C
For FH patients with ASCVD who are at very-high risk, treatment to achieve a ≥ 50% reduction from baseline and an LDL-C <1.4mmol/L (<55mg/dL)is recommended. If goals cannot be achieved, a drug combination is recommended.	I	C
Treatment with a PCSK9inhibitor is recommended in very-high risk FH patients if the treatment goal is not achieved on a maximal tolerated statin plus ezetimibe.	I	C
In children, testing for FH is recommended from the age of 5 years, or earlier if HoFH is suspected.	I	C
Treatment of Dyslipidaemias in older people
Treatment with statins is recommended for older people with ASCVD in the same way as for younger patients.	I	A
Treatment with statins is recommended for primary prevention, according to the level of risk, in older people aged ≤ 75 years.	I	A
It is recommended that the statin is started at a low dose if there is significant renal impairment and/or the potential for drug interactions, and then titrated upwards to achieve LDL-C treatment goals.	I	C
Treatment of Dyslipidaemias in DM
In patients with T2DM at very-high risk, an LDL-C reduction of ≥ 50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) is recommended.	I	A
In patients with T2DM at high risk, an LDL-C reduction of ≥ 50% from baseline and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) is recommended.	I	A
Statins are recommended in patients with T1DM who are at high or very-high risk.	I	A
Statin therapy is not recommended in pre-menopausal patients with or without DM who are considering pregnancy, or not using adequate contraception.	III	C
Management of patients with ACS
In all ACS patients without any contraindication or definite history of intolerance, it is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values.	I	A
If the LDL-C goal is not achieved after 4-6 weeks with the maximally tolerated statin dose, combination with ezetimibe is recommended.	I	B
If the LDL-C goal is not achieved after 4-6 weeks with the maximally tolerated statin dose, combination with ezetimibe is recommended.	I	B
Lipid-lowering therapy for prevention of ASCVD events in patients with prior ischaemic stroke
Patients with a history of ischaemic stroke or TIA are at very-high risk of ASCVD, particularly recurrent ischaemic stroke, so it is recommended that they receive intensive LDL-C-lowering therapy.	I	A
Treatment of dyslipidaemias in chronic HF or valvular heart diseases
Initiation of lipid-lowering therapy is not recommended in patients with HF in the absence of other indications for their use.	III	A
Initiation of lipid-lowering treatment is not recommended in patients with aortic valvular stenosis without CAD to slow progression of aortic valve stenosis in the absence of other indications for their use.	III	A
Lipid management in patients with moderate-to-severe (Kidney disease outcomes quality initiative stages 3-5) CKD
It is recommended that patients with stage 3-5 CKD are considered to be at high or very-high risk of ASCVD.	I	A
The use of statins or statin/ezetimibe-combination is recommended in patients with non-dialysis-dependent stage 3-5 CKD.	I	A
In patients with dialysis-dependent CKD who are free of ASCVD, commencement of statin therapy is not recommended	III	A
Lipid-lowering drugs in patients with PAD(including carotid artery disease)
In patients with PAD, lipid-lowering therapy—including a maximum tolerated dose of a statin, plus ezetimibe, or a combination with a PCSK9 inhibitor if needed—is recommended to reduce the risk of ASCVD events.	I	A
Lipid-lowering drugs in patients with CIID
The use of lipid-lowering drugs only on the basis of the presence of CIID is not recommended.	III	C
Lipid-lowering drugs in patients with SMI
It is recommended that SMIs are used as modifiers for estimating total ASCVD risk.	I	C
It is recommended that the same guidelines for the management of total ASCVD risk are used in patients with SMI as are used in patients without such disease.	I	C
It is recommended that in patients with SMI, intensified attention is paid to adherence to lifestyle changes and to compliance with drug treatment.	I	C

ᵃClass of recommendation.

ᵇLevel of evidence.

Abbreviations

ACS = Acute Coronary Syndrome(s); Apo = Apolipoprotein; ASCVD = Atherosclerotic Cardiovascular Disease; CAD = Coronary Artery Disease; CHD = Coronary Heart Disease; CIID= Chronic Immune-Mediated Inflammatorydiseases;CKD=Chronickidneydisease;CV=Cardiovascular;CVD=Cardiovasculardisease;DM=Diabetesmellitus;FH=Familial Hypercholesterolaemia; HDL-C = High-Density Lipoprotein Cholesterol; HeFH = Heterozygous FH; HF = Heart Failure; HoFH = Homozygous FH; HTG = Hypertriglyceridaemia; LDL-C = Low-Density Lipoprotein Cholesterol; MetS = Metabolic Syndrome; PAD = Peripheral Arterial Disease; PCSK9 = Proprotein Convertase Subtilisin/Kexin type 9; SCORE = Systematic Coronary Risk Estimation; SMI = Severe Mental Illness; TC = Total Cholesterol; TG = Triglycerides; TIA = Transient Ischaemic Event; T1DM = Type 1 DM; T2DM= Type 2DM

ᵃClass of recommendation.

ᵇLevel of evidence.

References

Toujeo® European Summary of Product Characteristics. December 2015.
Titration algorithm for people with T2DM is based on EDITION studies 1,2 and 3. Insulin dose is to be increased not more than every 3-4 days (based on the preceding 3 measurements).
ADA Guidelines 2017.
Bergenstal RM et al. Diabetes care 2017. 40:554-560.
Adapted from Jeandidier N et al. Abstract at 50th Annual Meeting of the European Association for the Study of Diabetes 2014. Poster presentation, abstract 961.
Peyrot M et al. Diabetes Med 2012;29:682–689.