European Primary Care Cardiovascular Society

New ESC/EAS dyslipidaemia guidelines: “lower is better” for LDL-c

News - Sep. 4, 2019

Presented at ESC Congress 2019 in Paris, France

LDL-c levels should be lowered as much as possible to prevent cardiovascular disease, especially in high and very high risk patients. That is one of the main messages of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) Guidelines on dyslipidaemias, presented at the ESC congress in Paris, France. The guidelines are an update to the 2016 ESC/EAS Dyslipidemia guidelines. Since then, major clinical trials have demonstrated the efficacy of PCSK9 inhibiting therapy in lowering LDL-c levels beyond those attained on intensive statin treatment. This results in significant reduction in CV events in patients with established atherosclerotic CV disease and acute coronary syndrome (ACS). There is no lower limit of LDL-c that is known to be unsafe. The guidelines aim to ensure that the available drugs (statins, ezetimibe, PCSK9 inhibitors) are used as effectively as possible to lower levels in those most at risk.

Additionally, there has been further information from the IMPROVE-IT trial with ezetimibe, which demonstrated enhanced absolute CV benefit in very high-risk individuals with diabetes compared with those without, reflecting the higher absolute risk of this group.

Moreover, knowledge of the impact of genetic variants influencing LDL-C levels and lifelong risk for ischaemic heart disease has increased, driven largely by insights from Mendelian randomisation studies.

New recommendations in these guidelines, compared to the 2016 version, include:

In conclusion, these new ESC/EAS dyslipidaemia guidelines emphasise that lower LDL-c is better; the absolute LDL-c reduction drives the clinical benefit. Evidence from Mendelian randomisation studies has been critical in driving a ‘sea change’ to treat earlier, which ultimately may mean less intensive therapy in the longer-term. With the new LDL-c goals comes recognition of the importance of combination therapy in high and very high-risk patients, first with ezetimibe and then a PCSK9 inhibitor, to attain these levels. The fundamental next steps are appropriate implementation by clinicians in their practice, together with ensuring treatment adherence by patients.

- Our reporting is based on the information provided at the ESC congress -

The new ESC/EAS dyslipidaemia guidelines were simultaneously published in Eur Heart J Watch our video about the dyslipidemia guidelines

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