New Guidelines Signal a Shift in LDL Cholesterol Management

MADRID, Spain — In a significant move, the European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) have revamped their guidelines for managing dyslipidemia. While the fundamental treatment targets remain intact, new recommendations urge healthcare providers to ramp up interventions for specific high-risk patients.

During acute coronary syndrome (ACS) hospitalizations, experts now advocate for an intensified approach to lipid-lowering therapies. For patients already on treatment, immediate adjustments are essential (class I, level of evidence C). For those yet to start, the introduction of a high-intensity statin combined with ezetimibe is encouraged in individuals unlikely to achieve LDL goals with statins alone (class IIa, level of evidence C).

Time is of the Essence: Early Intervention Matters!

Dr. Konstantinos Koskinas from the University of Bern emphasizes that reducing LDL cholesterol swiftly is key to improving patient outcomes. "The earlier we get LDL to the recommended levels, the better it is for the patient," he stated at the ESC Congress 2025.

Same Targets, New Strategies

The updated guidelines maintain the same LDL cholesterol targets as previous years but introduce newer therapies. Notably, bempedoic acid (Nexletol) and evinacumab (Evkeeza) receive special mention as effective options for patients who cannot tolerate statins. Dr. Ulf Landmesser from the Deutsches Herzzentrum Charité points out the compelling evidence for bempedoic acid, making it a favored choice (class I, level of evidence B).

Risk Redefinition: The Emergence of Extreme Risk Categories

New classifications of patient risk, including an emerging "extreme risk" category, mark a robust expansion in how doctors assess treatment needs. This category encompasses patients with atherosclerotic cardiovascular disease (ASCVD) who experience recurrent vascular events despite maximum statin therapy. Here, the guidelines recommend striving for LDL cholesterol levels below 40 mg/dL.

Targeting High-Risk Groups for Effective Prevention

The guidelines also clarify when to initiate drug therapy for primary prevention. Specifically, patients at very high risk with LDL levels above 70 mg/dL, those at high risk above 100 mg/dL, and others in various risk brackets are urged to consider pharmaceutical interventions.

Personalized Risk Assessment Tools Improve Outcomes

In a bid to refine clinical decisions, the guidelines advocate for the use of the SCORE2 and SCORE2-Older Persons calculators, which help predict the 10-year risk of cardiovascular incidents in seemingly healthy individuals up to age 89.

Specialized Recommendations for Unique Cases

For patients with hypertriglyceridemia, the new guidance recommends the use of high-dose icosapent ethyl in combination with statins for those at high or very high cardiovascular risk (class IIa, level of evidence B). Moreover, statins are now broadly recommended for individuals ages 40 and over with HIV, regardless of their initial cardiovascular health.

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