COMMENTARY

Highlights of the Updated European Dyslipidemia Guidelines

Guy G. De Backer, MD, PhD

Disclosures

October 05, 2016

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My name is Guy De Backer from Ghent University in Belgium. I would like to make a few points about the new European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) Guidelines on the Management of Dyslipidaemias[1] that have been released for the first time at the ESC Congress in Rome.

These guidelines are from a joint taskforce with experts from both the EAS and the ESC. A first important point is that we are recommending that clinicians adapt the intensity of preventive actions in accordance with the total cardiovascular risk of the patient. That means that we have to define "total cardiovascular risk" one way or another, so we have now four categories of total risk.

The first category is what we are calling "very high risk," which, in the updated guidelines, is much more precise and defined than ever before. These are the patients with established cardiovascular disease or with unequivocal lesions on imaging (echo or angiography). These very-high-risk patients are those with diabetes and, in addition to diabetes, target organ damage (such as proteinuria) or another cardiovascular risk factor.

The very-high-risk category also includes patients with severe chronic kidney disease (CKD) and persons with a calculated Systemic Coronary Risk Estimation (SCORE) of 10% of more. That is an estimation of total risk based on sex, age, smoking, blood pressure, and cholesterol. We are recommending the SCORE model in Europe. (There are other models available.) When the SCORE is 10% or higher, that means a 10% chance of dying in the next 10 years from cardiovascular disease. We consider these people to be "very high risk."

Then we have the "high-risk" group. These are patients with severely elevated risk factors, such as familial dyslipidemias, severe hypertension, diabetes with no target organ damage or other major risk factors, moderate CKD, or a SCORE between 5% and 10%. Patients with a SCORE between 1% and 5% are considered at "moderate risk," and this is the large majority of the asymptomatic, apparently healthy population in our communities. Those at low risk are people with a SCORE <1%. It is important to have these risk categories because, as a function of that risk category, our treatment targets will be very different.

Once again we have the treatment targets, which is what we are trying to reach in terms of management. The low-density lipoprotein cholesterol (LDL-C) level is still the primary target in these guidelines. Once we have defined the risk category of the patient, then that will influence the treatment goals. The treatment goals for LDL-C are a little bit different from what they were 5 years ago. I want to go through them very quickly.

In the patients at very high risk, we are aiming for an LDL-C level of <1.8 mmol/L (70 mg/dL) or a reduction of at least 50% if the patient starts from a baseline LDL-C level of 1.8-3.5 mmol/L (70-135 mg/dL). That is a little bit different. Now, our targets are expressed both as absolute values (for example, trying to reach a level of <70 mg/dL) or as a percent reduction from baseline (eg, trying to reach at least 50% reduction).

In patients at high risk, the targets are a little bit different; they are less strict. The LDL-C goal is now <2.6 mmol/L (<100 mg/dL) or a reduction of at least 50% if the patient starts with an LDL-C level of 2.6-5.2 mmol/L (100-200 mg/dL). In our entire population at low or moderate risk, we would like to have an LDL-C goal of <3 mmol/L (<115 mg/dL).

This raises the question: How will we reach these goals? There are several recommendations on that. There is a full chapter on what we are calling "lifestyle changes to reduce risk" related to dyslipidemia. We are thinking particularly of changes in dietary habits.

If we do not reach our goals with diet alone, we are recommending the prescription of a statin as the first step. In the few cases where there is true statin intolerance, then the second step would be to use either ezetimibe or a bile acid sequestrant. If, with a statin at the highest tolerable dose, we do not reach the goal, then we have to think of combinations. This is a little bit different from previous guidelines. Nowadays, we know that by combining ezetimibe and a statin, we can achieve a better result in terms of cardiovascular disease prevention.

In patients at very high risk, with persistent high LDL-C levels despite treatment with the maximal tolerated statin dose, even in combination with ezetimibe, or in patients who really are completely statin intolerant, then this new family of drugs, the PCSK9 [proprotein convertase subtilisin/kexin] type 9] inhibitors, may be considered. That is a class IIb recommendation. We are still waiting for the large trials with hard endpoints that are ongoing; we will probably have results by the end of next year.

Then there is a long list of all kinds of recommendations covering different clinical settings. The first topic in that chapter is dealing with familial dyslipidemias. We have indeed a big problem in most European countries with detection of familial hypercholesterolemia. Only about 5% of patients with that condition are identified, and we should be doing much better. Once identified, we have treatment modalities that can reduce the severely elevated LDL-C levels, and it has been clearly shown that by treating people with familial hypercholesterolemia, we can indeed reduce their risk by 40%-50%, which is enormous.

At the end of the recommendations you will find additional chapters. One that I would like to recommend to you very strongly contains all kinds of tips to aid in what we are calling "adherence to lifestyle" or "compliance with multiple drug therapy." We know from observational studies that 1 year after starting a statin, approximately 50% of our patients have stopped the treatment.[2,3] If you do not take a drug, you cannot have any advantage from it. We should invest much more in compliance with multiple drug therapy, and that can be done with these tips or aids to the patients and family, including improving the patient's attitude, motivation, health literacy, and things like that. There is quite a bit of information on these topics in these new guidelines.

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