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The new ESC Guidelines dyslipidaemia: the lower the better

Prof. Colin Baigent
ESC 2019
LDL-C levels should be lowered as much as possible to prevent cardiovascular disease, particularly in patients with high and very high risk, according to the 2019 ESC/EAS Guidelines for the management of dyslipidaemia. LDL-C goals have thus been lowered compared with the 2016 Guidelines.

Prof. Colin Baigent (chairperson of the guidelines task force) made it very clear that data take centre stage in the new ESC Guidelines on dyslipidaemia, alongside the categorisation of patients. “Refining the definition of risk was the first step we took, by distinguishing between very high-risk (>10% over 10 years) and high-risk (5-10% risk over 10 years) patients. The emphasis was on a large relative reduction in low-density lipoprotein cholesterol (LDL-C) to achieve a large absolute reduction where possible and to reduce the risk” [1].
“Lower is better in all available trials when it comes to LDL-C,” Prof. Baigent said. “There is now evidence that lowering LDL-C to at least 1.4 mmol/L (55 mg/dL) is safe and effective.” This translates into new recommended treatment goals, replacing the 2016 recommendations. For very high-risk patients, a reduction of at least a 50% in LDL-C and a <1.4 mmol/L (55 mg/dL) target is currently recommended. For high risk patients, a 50% reduction is also recommended, but their LDL-C target is slightly higher: <1.8 mmol/L (70 mg/dL). For moderate-risk patients, the target LDL-C is <2.6 mmol/L (100 mg/dL). The only category to remain the same in terms of treatment goals are the low-risk patients. Their target LDL-C is set at <3.0 mmol/dL (115 mg/dL).

Prof. Baigent explained that the key recommendations for LDL-C lowering focus on consistency. “In each case –whether this is secondary or primary prevention or in patients with (very high-risk) familial hypercholesterolemia– a minimum 50% reduction and LDL-C <1.4 mmol/dL is needed. Very high-risk patients with atherosclerotic cardiovascular disease who have already had a vascular event, may even go lower. An LDL-C goal of <1.0 mmol/L may be considered in this population.”

The 2019 ESC/EAS Guidelines for the management of dyslipidaemias have been published in the European Heart Journal 2019 and on the ESC website.

1. Baigent C, et al. 2019 ESC/EAS Guidelines on Dyslipidaemias. FP Number 1054. ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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