2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias

1. Preamble 3 2. Introduction 5 3. Estimation of total cardiovascular risk and implications for dyslipidaemia management 5 4. New low-density lipoprotein cholesterol-lowering therapies 9 5. Combination of lipid-lowering therapies during index hospitalization for acute coronary syndromes 11 6. Lipoprotein(a) 12 7. Hypertriglyceridaemia 13 8. Primary prevention in people with human immunodeficiency virus infection 14 9. Patients with cancer at high or very high chemotherapy-related cardiovascular toxicity risk 15 10. Dietary supplements 15 11. Evidence tables 16 12. Data availability statement 16 13. Author information 16 14. Appendix 16 15. References 17 Recommendation Table 1 — Recommendations for cardiovascular risk estimation in persons without known cardiovascular disease (see also Supplementary data online, Evidence Table 1) 9 Recommendation Table 2 — Recommendations for pharmacological low-density lipoprotein cholesterol lowering (see also Supplementary data online, Evidence Table 2) 11 Recommendation Table 3 — Recommendations for lipid-lowering therapy in patients with acute coronary syndromes (see also Supplementary data online, Evidence Table 3) 12 Recommendation Table 4 — Recommendations for measurement of lipoprotein(a) (see also Supplementary data online, Evidence Table 4) 12 Recommendation Table 5 — Recommendations for drug treatment of patients with hypertriglyceridaemia (see also Supplementary data online, Evidence Table 5) 14 Recommendation Table 6 — Recommendations for statin therapy in primary prevention for people with human immunodeficiency virus infection (see also Supplementary data online, Evidence Table 6) 15 Recommendation Table 7 — Recommendations for statin therapy in patients receiving cancer therapy (see also Supplementary data online, Evidence Table 7) 15 Recommendation Table 8 — Recommendations for dietary supplements (see also Supplementary data online, Evidence Table 8) 16 Table 1 Classes of recommendations 4 Table 2 Levels of evidence 4 Table 3 Cardiovascular risk categories 6 Table 4 Intervention strategies as a function of total cardiovascular risk and untreated low-density lipoprotein cholesterol levels 7 Figure 1 Treatment goals for low-density lipoprotein cholesterol across categories of total cardiovascular risk 8 Figure 2 Average reduction in low-density lipoprotein cholesterol levels with different pharmacological therapies with proven cardiovascular benefits 10 Figure 3 Association between Lp(a) levels and lifetime risk of major cardiovascular events 13 Acute coronary syndromes Alanine aminotransferase Apolipoprotein B Apolipoprotein C-III Antiretroviral therapy Atherosclerotic cardiovascular disease Aspartate aminotransferase Aortic valve stenosis Coronary artery calcium Confidence interval Computed tomography Cardiovascular Cardiovascular disease Docosahexaenoic acid European Atherosclerosis Society European Medicines Agency Eicosapentaenoic acid European Society of Cardiology Familial chylomicronaemia syndrome US Food and Drug Administration Familial hypercholesterolaemia High-density lipoprotein cholesterol Human immunodeficiency virus Hazard ratio Low-density lipoprotein cholesterol Lipoprotein(a) Left ventricular ejection fraction Monoclonal antibody Major adverse cardiovascular event(s) Myocardial infarction Percutaneous coronary intervention Proprotein convertase subtilisin/kexin type 9 Peroxisome proliferator-activated receptor n-3 polyunsaturated fatty acid People with HIV Systematic Coronary Risk Evaluation 2 Systematic Coronary Risk Evaluation 2-Older Persons Total cholesterol Type 1 diabetes mellitus Type 2 diabetes mellitus Upper limit of normal Guidelines evaluate and summarize available evidence with the aim of assisting health professionals in proposing the best diagnostic or therapeutic approach for an individual patient with a given condition. The European Society of Cardiology (ESC) Guidelines are intended for use by health professionals but do not override their individual responsibility to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with the patient or the patient's caregiver where appropriate and/or necessary aiming at shared care decisions. It is also the health professional's responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription and to respect the ethical rules of their profession. The ESC Guidelines represent the official position of the ESC on a given topic. Guideline topics are selected for updating after annual expert review of new evidence conducted by the ESC Clinical Practice Guidelines (CPG) Committee. ESC Policies and Procedures for formulating and issuing the ESC Guidelines can be found on the ESC website (https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines). Interim Focused Updates are created when the publication of new evidence could influence clinical practice before the next full update of a Guideline is published. This Focused Update provides new and revised recommendations for the 2019 ESC/European Atherosclerosis Society (EAS) Guidelines for the management of dyslipidaemias. View the full 2019 ESC/EAS Guidelines here: https://doi.org/10.1093/eurheartj/ehz455. This Task Force was selected by the ESC and EAS to include professionals involved with the medical care of patients with this pathology as well as methodologists. Guidelines Task Forces perform a critical review and evaluation of the published literature on diagnostic and therapeutic approaches including assessment of the risk–benefit ratio. Recommendations are based on major randomized trials and relevant systematic reviews and meta-analyses, when available. Systematic literature searches are conducted in cases of controversy or uncertainty to ensure that all key studies were considered. For recommendations related to diagnosis and prognosis, additional types of evidence are included, such as diagnostic accuracy studies and studies focused on the development and validation of prognostic models. The strength of each recommendation and the of evidence are and to as in 1 and 2. and are also when available as the for recommendations and/or in Classes of recommendations Classes of recommendations Levels of evidence Levels of evidence Evidence tables key information relevant studies are to the of to of recommendations after and to in the Guidelines development The tables are published in their of the Focused Update and recommendation an of a Task Force on all recommendations is conducted to the of of Task Force on all recommendations is conducted after the of review and For each the Task Force ESC and all recommendations at to be be based on of The and of for all that be as or of of of are to the ESC of rules can be found on the ESC website and are in a published in a with the for the development of this ESC/EAS Focused Update was the ESC and EAS with of the The ESC and the of new Guidelines and Focused Updates and their to review by the ESC this ESC/EAS Focused Update of review on a review The review was conducted by including ESC and relevant ESC The Focused Update Task Force all review and was to to all as appropriate the Task Force and the ESC and the EAS the for publication in the European and in the Focused Update to as the condition of or by and use of be in this Focused Update a of evidence that can be appropriate for a given condition. decisions on use be by the health consideration to ethical rules the of the patient and health the publication of the 2019 ESC/EAS Guidelines for the management of to cardiovascular randomized trials that patient management of the next full dyslipidaemia This Focused Update in recommendations for the treatment of based on new evidence published major randomized clinical trials and published after the publication of the 2019 ESC/EAS Guidelines were and in before a was of recommendations (see Table 1) and levels of evidence (see Table 2) to be were for by all Task Force with of in topics were to on The Task Force and the new and Systematic Coronary Risk Evaluation 2 and Systematic Coronary Risk Evaluation 2-Older Persons for estimation of 10 an in Patients with Familial of Levels in Familial to Cardiovascular in HIV to Risk with in Cardiovascular Risk Patients with for or and in with Myocardial the Task Force also and therapy with statin and of lipid-lowering therapy during the index hospitalization for patients with acute coronary syndromes as well as new data on lipoprotein(a) as a risk that to new or or recommendations were selected for in Recommendation new recommendations in this Focused Update are to the recommendations of the 2019 ESC/EAS Guidelines for the management of and all recommendations of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. the Task Force to update recommendations for the of the 2019 ESC/EAS Guidelines for the management of Recommendations for risk with of the new and risk Recommendations on low-density lipoprotein cholesterol including new for treatment acid and for patients with Recommendations for lipid-lowering therapy during index hospitalization of Recommendations on Recommendations for drug treatment in patients with Recommendations for statin therapy in primary disease prevention for people with human immunodeficiency virus Recommendations for statin therapy for patients with cancer at high or very high chemotherapy-related toxicity Recommendations for dietary Atherosclerosis is by the of and the artery a of to the and of the the and the risk of an acute is not a risk for disease but is a of lowering levels be the for clinical the of that can the artery is by levels of represent the total of cholesterol by low-density The of a risk of an is to at risk to and of The clinical of lowering on the with risk lowering to the of risk on treatment as with with For an reduction in risk each lowering by 1 the risk of a with a risk of an acute to a but risk the risk of a with a risk to but risk This Focused Update to the in the 2019 ESC/EAS 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