European Guidelines for Management of Dyslipidaemias
- Catapano AL, Graham I, De Backer G, et al.
- 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Eur Heart J 2016;Aug 27:[Epub ahead of print].
The following are key points to remember from the 2016 Guidelines for the Management of Dyslipidaemias, written by the Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS):
- It is cost-effective to implement lifestyle modification and/or medication for the prevention of cardiovascular disease (CVD). Factors influencing cost-effectiveness include baseline CV risk, cost of drug therapy and lifestyle programs, reimbursement for procedures, and the uptake of preventive strategies.
- Risk factor screening is recommended to include a lipid profile for men ≥40 years and women ≥50 years (or postmenopausal). Risk is often the interaction of multiple factors; thus, a risk estimation with tools such as the Systemic Coronary Risk Estimation (SCORE) can be used to estimate CVD risk and the need for preventive strategies.
- Patients considered very high risk include those with documented CVD or a calculated SCORE ≥10% for a 10-year risk of fatal CVD, diabetes mellitus (DM) with targeted organ damage (or a major risk factor such as smoking), and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) <30 ml/min/1.73 m2. High risk is defined as elevated risk factors such as cholesterol, presence of DM, moderate CKD (GFR 30-59 ml/min/1.73 m2), or a calculated SCORE of between 5 and <10%. Moderate risk is defined as a SCORE between 1% and <5%.
- Treatment targets should include no smoking; a diet low in saturated fats with a focus on whole grains, vegetables, and fruit; and moderate to vigorous activity for 2.5-5 hours per week or 30-60 minutes per day. Body mass index should be 20-25 kg/m2, with a waist circumference of <94 cm for men and <80 cm for women.
- Lipid targets include: for very high-risk patients, low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L (<70 mg/dl), or a reduction of ≥50% if the baseline is between 1.8 and 3.5 mmol/L (70 and 135 mg/dl). High-risk patient targets are LDL-C <2.6 mmol/L (<100 mg/dl), or a reduction of ≥50% if the baseline is between 2.6 and 5.2 mmol/L (100 and 200 mg/dl). For low- to moderate-risk patients, the LDL-C target is <3.0 mmol/L (<115 mg/dl).
- Non–high-density lipoprotein cholesterol (HDL-C) should be calculated, in particular among patients with high triglycerides. Secondary targets include non–HDL-C of <2.6 mmol/L (100 mg/dl) for very high-risk, <3.4 mmol/L (130 mg/dl) for high-risk, and <3.8 mmol/L (145 mg/dl) for moderate-risk patients.
- There is no recommended target for HDL. However, lower risk is associated with an HDL-C of >1.0 mmol/L (40 mg/dl) in men and >1.2 mmol/L (48 mg/dl) in women. There is no recommended target for triglycerides. However, <1.7 mmol/L (150 mg/dl) is associated with lower risk.
- Statin therapy is recommended as a first-line agent and should be the highest tolerated dose to reach goal.
- For patients at very high risk of CVD including those with heterozygous or homozygous familial hypercholesterolemia, treatment with PCSK9 therapy may be reasonable. Other potential candidates include those who are statin intolerant or on a maximally tolerated dose of first- and second-line therapy with persistent high levels of LDL-C.
- Among patients with heart disease before the age of 55 years for men and 60 years for women, patients with xanthomas, or with an LDL-C of >5 mmol/L (190 mg/dl) for adults or >4 mmol/L (150 mg/dl) for children, or among patients with a family member who has premature CVD, a diagnosis of familial hypercholesterolemia should be suspected. Family screening is recommended. Treatment of affected family members is recommended with intense-dose statin. Addition of ezetimibe should also be considered.
- Cholesterol-lowering therapy is not recommended for patients with heart failure in the absence of additional indications for use. Cholesterol-lowering medication is also not indicated for patients with aortic valvular stenosis in the absence of additional indications for use.
- Among patients with CKD, stage 3-5, the use of statins or a combination of statins with ezetimibe is indicated among those patients with nondialysis-dependent CKD. Statin therapy is not recommended among patients who are dialysis-dependent in the absence of additional indications for use.
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