2016 ESC/EAS Guidelines for the Management of Dyslipidaemias

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

General Guidelines:

• 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:

1. No exposure to tobacco in any form


2. Healthy diet low in saturated fat with a focus on whole grain products, vegetables, fruit and fish


3. Physical activity 2.5- 5 hr moderately vigorous physical activity/ week or 30- 60 min most daysbody weight


4. BMI 20- 25 kg/ m2


5. Blood Pressure< 140/ 90 mmhg


6. lipid targets As mentioned below


7. 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 Documented cardiovascular dísease (CVD), DM with target organ damge such as proteinuria or with a major rísk factor such as smokíng, hypertension or dyslipidaemia. Severe ckd (GFR <30 ml/min/1.73 m2). A calculated score >10 %
High-risk	Persons with: Markedly elevated single risk factors, in particular cholesterol > 8mmol/L (>310 mg/dL) or B.P > 180/110 mm Hg Most other people with DM (some young people with Type I DM maybe at low or moderate risk) Moderate CKD (GFR 30-59 mL/min/1.73m2) Calculated SCORE >5% and <10% for 10 year risk of fatal CVD
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.

 

Major Recommendations:

1. 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.


2. In subjects at low or moderate risk an LDL-C goal of <3.0mmol/L(<115mg/dL) should be considered.


3. Prescribe statin up to the highest recommended dose or highest tolerable dose to reach the goal.


4. In the case of statin intolerance, ezetimibe or bile acid sequestrants, or these combined, should be considered.


5. If the goal is not reached, statin combination with a cholesterol absorption inhibitor should be considered.


6. If the goal is not reached, statin combination with a bile acid sequestrant may be considered.


7. 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.


8. Statin treatment may be considered as the first drug of choice for reducing CVD risk in high- risk individuals with hypertriglyceridemia.


9. In high- risk patients with TG> 2.3mmol/L(200 mg/dL) despite statin treatment, fenofibrate ay be considered in combination with statins.


10. 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.


11. 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.


12. In children, testing is recommended from age 5 years, or earlier if homozygous FH is suspected.


13. 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)


14. 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.


15. Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients.


16. 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.


17. 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.


18. For more details click on the link: https://doi.org/10.1093/eurheartj/ehw272