Focused update of the guidelines for the management of dyslipidaemias

“This focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias introduces several new recommendations for cardiovascular risk estimation,” said Dr Konstantinos Koskinas (Bern University Hospital, Switzerland) at the start of the presentation [1].

In individuals without known cardiovascular disease:

SCORE2/SCORE2-OP is recommended in apparently healthy people <70 years/ ≥70 years of age without established  atherosclerotic cardiovascular disease (ASCVD), diabetes mellitus (DM), chronic kidney disease (CKD), genetic/rare lipid or blood pressure (BP) disorders to estimate 10-year fatal and non-fatal CVD risk (class 1/level B)

“The SCORE2 replaced SCORE in this context,” clarified Dr Koskinas.

Next to this, 2 new 2a/B recommendations were added:

• Presence of subclinical coronary atherosclerosis by imaging or increased coronary artery calcium (CAC) score by CT should be considered as risk modifiers in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.
• Risk modifiers should be considered in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.

The authors added a table of risk modifiers to complement risk estimation from the SCORE2 and SCORE2-OP algorithms, including family history, high-risk ethnicity, social deprivation, physical inactivity, and major psychiatric disorders.

Dr Koskinas mentioned that SCORE2 or SCORE2-OP replaced the SCORE/SCORE-OP cut-offs previously used to define risk categories. In addition, for the ‘very high risk’ category, a markedly elevated CAC score on CT was added to the imaging modalities to identify ASCVD.

“The treatment goals are unchanged from the 2019 guidelines,” according to Dr Koskinas. “We did add a treatment goal for the extreme risk category (<1.0 mmol/L; <40 mg/dL), which is consistent with the 2019 guidelines.” Additionally, the team provided clear recommendations for when to initiate LDL-cholesterol-lowering therapy in the various risk groups.

Subsequently, Prof. Francois Mach (University of Geneva, Switzerland) discussed the recommendation with regard to new drug treatments [1].

• Non-statin therapies with proven cardiovascular benefit, taken alone or in combination, are recommended for patients who are unable to take statin therapy, to lower LDL-cholesterol levels and reduce cardiovascular risk. The choice should be based on the magnitude of the additional LDL-cholesterol lowering needed (1/A).
• Bempedoic acid is recommended in patients who are unable to take statin therapy to achieve the LDL-cholesterol goal (1/B).
• The addition of bempedoic acid to the maximally tolerated dose of statin with or without ezetimibe should be considered in patients at high or very high risk to achieve the LDL-cholesterol goal (2a/C).
• Evinacumab should be considered in patients with homozygous familial hypercholesterolaemia aged 5 years or older who are not at LDL-cholesterol goal despite receiving maximum doses of lipid-lowering therapy to lower LDL-cholesterol levels (2a/B).

Prof. Mach also mentioned 2 new recommendations for patients hospitalised for acute coronary syndrome (ACS):

• Intensification of lipid-lowering therapy during the index ACS hospitalisation is recommended for patients who were on any lipid-lowering treatment before admission to further lower LDL-cholesterol levels (1/C).
• Initiating combination therapy with high-intensity statin plus ezetimibe during index hospitalisation for ACS should be considered in patients who were treatment-naïve and are not expected to achieve the LDL-cholesterol goal with statin therapy alone (2a/B).

The last new recommendation that Prof. Mach shared was that Lp(a) levels above 50 mg/dL (105 nmol/L) should be considered in all adults as a CV risk-enhancing factor, with higher Lp(a) levels associated with a greater increase in risk (2a/B).

Dr Jeanine Roeters van Lennep (Erasmus Medical Centre, the Netherlands) said that one 2a/B recommendation with respect to hypertriglyceridaemia had been revised [1]:

• High-dose icosapent ethyl (2 x 2 g/day) should be considered in combination with a statin in high-risk or very high-risk patients with elevated triglyceride levels (fasting triglycerides 135-499 mg/dL or 1.52-5.63 mmol/L) to reduce the cardiovascular risk.

A new 2a/B recommendation is that volanesorsen (300mg/week) should be considered in patients with severe hypertriglyceridaemia (>750 mg/dL; 8.5 mmol/L) due to familial chylomicronaemia syndrome, to lower triglyceride levels and reduce the risk of pancreatitis.

The last three recommendations introduced in this update are:

• Statin therapy is recommended for people in primary prevention aged ≥ 40 years with HIV, irrespective of estimated cardiovascular risk and LDL-cholesterol levels, to reduce the risk of cardiovascular events; the choice of statin should be based on potential drug interactions (1/B).
• Statins should be considered in adult patients at high or very high risk of developing chemotherapy-related cardiovascular toxicity to reduce the risk of anthracycline-induced cardiac dysfunction (2a/B)
• Dietary supplements or vitamins without documented safety and significant LDL-cholesterol-lowering efficacy are not recommended for ASCVD prevention (3/B).

1. Koskinas K, March F, van Lennep JR et al. 2025 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias. ESC Congress 2025, 29 August – 1 September, Madrid, Spain.

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Posted on 7 November 20257 November 2025