The ‘10 commandments’ for the 2025 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias

Abstract

The 2025 Focused Update1 refines the 2019 Guidelines for the management of dyslipidaemia with new evidence published after 2019. All new recommendations included in this Focused Update are additive to the recommendations of the 2019 ESC/EAS Guidelines,2 and all changed recommendations substitute those of the 2019 document.1,2 These are the ‘10 commandments’ summarizing the key messages. Adopt SCORE2 or SCORE2-OP, instead of the previously recommended SCORE,2 to estimate the 10-year risk of fatal or non-fatal cardiovascular (CV) events in apparently healthy people of <70 or ≥70 years of age, respectively. Consider using risk modifiers to enhance risk stratification. In moderate-risk individuals or those who are around treatment threshold, consider demographical or clinical conditions which are associated with increased CV risk, biomarkers such as hs-CRP >2 mg/L and lipoprotein(a) [Lp(a)] >50 mg/dL (>105 nmol/L), or imaging-based variables (subclinical atherosclerosis or increased coronary calcium score) to reclassify CV risk. Use non-statin therapies with proven cardiovascular benefit (ezetimibe, bempedoic acid, or PCSK9 monoclonal antibodies) in patients who are unable to take statin therapy to reduce low-density lipoprotein cholesterol (LDL-C) levels and CV risk. The choices of therapies should be based on the magnitude of LDL-C lowering needed to reach the treatment goal. Consider using evinacumab in patients with homozygous familial hypercholesterolemia who are not at LDL-C goal despite receiving maximum doses of lipid-lowering therapy. Intensify lipid-lowering therapy during the index hospitalization in patients who present with an acute coronary syndrome (ACS) and were on any lipid-lowering therapy before admission. In patients with ACS who were treatment-naïve before admission, combining high-intensity statin with ezetimibe during hospitalization should be considered if the LDL-C goal is unlikely to be met with statin alone. The association between high plasma levels of Lp(a) and atherosclerotic CVD is continuous. Measure Lp(a) at least once in every adult's lifetime, and consider levels >50 mg/dL (>105 nmol/L) as CV risk-enhancing factor. Consider adding high-dose icosapent ethyl (2 × 2 g/day) to statin therapy in high-risk or very-high-risk patients with moderately elevated triglycerides (1.52–5.63 mmol/L or 135–499 mg/dL). Prescribe statin therapy to all people with human immunodeficiency virus (HIV) aged ≥40 years in primary prevention, irrespective of estimated cardiovascular risk and LDL-C levels. The choice of statin should be based on potential drug interactions. Consider treating patients at high/very high risk of chemotherapy-induced cardiotoxicity with statins to reduce the risk of anthracycline-induced cardiac dysfunction. It is not recommended to use dietary supplements or vitamins without documented safety and significant LDL-C-lowering efficacy for the aim of reducing CV risk. All authors declare no disclosure of interest for this contribution.

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