The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) have developed the Guidelines for the Management of Dyslipidemias- 2016. there has been special contribution of the European Assocciation for Cardiovascular Prevention & Rehabilitation (EACPR) in this endeavour. The guidelines were published in the European Heart Journal. The key Recommendations are as follows
- Cholesterol lowering therapy with statins is not recommended in patients with heartfailure ín the absence of other indications for their use.
- Patients with stage 3 -5 CKD have to be considered at high or very high CV risk.
- The use of statins or statin/ezetimibe combination is indicated in patients with non-dialysis-dependent CKD.
- ln patients with dialysis-dependent CKD and free of atherosclerotic CVD, statins should not be initiated.
- PAD is a very high-risk condition and lipid-lowering therapy (mostly statins) is recommended in these patients.
- Statin therapy to reach established treatment goals ís recommended ín patíents at high or very high CV risk for primary prevention of stroke.
- Lipid-lowering therapy is recommended in patients with other manifestations of CVD for primary prevention of stroke.
- lntensive statin therapy is recommended in patients with a hístory of non-cardioembolic ischaemic stroke or TIA for secondary prevention of stroke.
Treatment target and goals are:
- No exposure to tobacco in any form
- Healthy diet low in saturated fat with a focus on whole grain products, vegetables, fruit and fish
- Physical activity 2.5- 5 hr moderately vigorous physical activity/ week or 30- 60 min most daysbody weight
- BMI 20- 25 kg/ m2
- Blood Pressure< 140/ 90 mmhg
- lipid targets As mentioned below
- Diabetes HbA1C < 7%
Risk Evaluation :
High and very high- risk individuals can be detected on the basis of documented CVD, DM, moderate to severe renal disease, very high levels of individual risk factors, familial hypercholesterolemia or a high SCORE risk and are a high priority for intensive advice with regard to all risk factors(IC).
|Very High-Risk||Persons with any of the following
|Moderate risk||SCORE is >1% and < 5% for 10 year risk of fatal CVD.|
|Low risk||SCORE <1% for 10 year risk of fatal CVD.|
- In patients at high CV risk, an LDL-C goal of < 2.6 mmol/L(100mg/dl), or a reduction of at least 50% if the baseline LDL-C is between 2.6 and 5.2 mmol/L(100-200mg/dL) is recommended.
- In subjects at low or moderate risk an LDL-C goal of <3.0mmol/L(<115mg/dL) should be considered.
- Prescribe statin up to the highest recommended dose or highest tolerable dose to reach the goal.
- In the case of statin intolerance, ezetimibe or bile acid sequestrants, or these combined, should be considered.
- If the goal is not reached, statin combination with a cholesterol absorption inhibitor should be considered.
- If the goal is not reached, statin combination with a bile acid sequestrant may be considered.
- In patients at very high risk, with persistent high LDL-C despite treatment with maximal tolerated statin dose, in combination with ezetimibe or in patients with statin intolerance, a PCSK9 inhibitor may be considered.
- Statin treatment may be considered as the first drug of choice for reducing CVD risk in high- risk individuals with hypertriglyceridemia.
- In high- risk patients with TG> 2.3mmol/L(200 mg/dL) despite statin treatment, fenofibrate ay be considered in combination with statins.
- Treatment should be considered to aim at reaching an LDL- C <2.6 mmol/L(100mg/dL) or in the presence of CVD <1.8 mmol/L(70 mg/dL). If targets cannot be reached, maximal reduction of LDL- C should be considered using appropriate drug combinations.
- Treatment with a PCSK9 antibody should be considered in FH patients with CVD or with other factors putting them very high- risk for CHD, such as other CV risk factors, family history, high Lp(a) or statin intolerance.
- In children, testing is recommended from age 5 years, or earlier if homozygous FH is suspected.
- Children with FH should be educated to adopt a proper diet and treated with statin from 8-10years of age. Targets for treatment should be LDL- c <3.5 mmol/l(135mg/ dL) at >10 years of age(IIaC)
- Lipid lowering drug should not be given when pregnancy is planned, during pregnancy or during the breast feeding period. However, bile acid sequestrants(which are not absorbed) maty be considered.
- Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients.
- Lipids should be re-evaluated 4- 6 weeks after ACS to determine whether target levels of LDL- C <1.8 mmol/L(<70mg/dL) or a reduction of at least 50% if baseline is between 1.8mmol/l and 3.5 mmol/L(70 and 135 mg/dL) have been reached and whether there are any safety issues. The therapy dose should then be adapted accordingly.
- In patients who are intolerant of statins or those with significant dyslipidemia and high residual risk despite a maximally tolerated statin dose, alternative or additional therapy may be considered: ezetimibe for whose where high LDL- C is the principal abnormality; or; fibrates for those where hypertriglyceridemia and/ or low HDL- C is the principal abnormality.
- For more details click on the link: https://doi.org/10.1093/eurheartj/ehw272