Physicians' Academy for Cardiovascular Education

ESC/EAS guidelines for the management of dyslipidaemias

Literature - European Heart Journal (2011) 32, 1769–1818

First ESC/EAS guidelines for dyslipidemia

The guidelines represent a landmark for these two European Societies and substantially expand on information given in the Fourth Joint Task Force guidelines for cardiovascular disease prevention.

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2. Introduction guidelines

Cardiovascular disease (CVD) due to atherosclerosis of the arterial vessel wall and to thrombosis is the foremost cause of premature mortality and of disability-adjusted life years (DALYs) in Europe, and is also increasingly common in developing countries. In the European Union, the economic cost of CVD represents annually ∼€192 billion1 in direct and indirect healthcare costs.

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3. Total cardiovasular risk

CV risk in the context of these guidelines means the likelihood of a person developing an atherosclerotic CV event over a defined period of time.

Rationale for total cardiovasular disease risk:
All current guidelines on the prevention of CVD in clinical practice recommend the assessment of total CAD or CV risk because, in most people, atherosclerotic CVD is the product of a number of risk factors.

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4. Evaluation of laboratory lipid and apolipoprotein parameters

Risk factor screening, including the lipid profile, may be considered in adult men ≥40 years of age, and in women ≥50 years of age or post-menopausal, particularly in the presence of other risk factors. In addition, all subjects with evidence of atherosclerosis in any vascular bed or with type 2 diabetes, irrespective of age, are regarded as being at high risk;

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5. Treatment targets

Treatment targets of dyslipidaemia are primarily based on results from clinical trials. In nearly all lipid-lowering trials the LDL-C level has been used as an indicator of response to therapy. Therefore, LDL-C remains the primary target of therapy in most strategies of dyslipidaemia management.

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6. Lifestyle modifications to improve the plasma lipid profile

The role of nutrition in the prevention of CVD has been extensively reviewed. There is strong evidence showing that dietary factors may influence atherogenesis directly or through effects on traditional risk factors such as lipid levels, blood pressure, or glucose levels.

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7. Drugs for treatment of hypercholesterolaemia

Cholesterol levels are determined by multiple genetic factors as well as environmental factors, primarily dietary habits. Hypercholesterolaemia can also be secondary to other medical conditions. Secondary dyslipidaemia can have different causes; the possibility of secondary hypercholesterolaemia should be considered before initiating therapy.

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8. Drugs for treatment of hypertriglyceridaemia

Although the role of TG as a risk factor for CVD has been strongly debated, recent data strongly favour the role of TG-rich lipoproteins as a risk factor for CVD. Recent large prospective studies reported that non-fasting TG predict CHD risk more strongly than fasting TG. Whether the impact of high TG levels on CVD risk is explained by the burden of remnant particles, small dense LDL particles or associated low HDL remains unsettled.

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9. Drugs affecting high-density lipoprotein

Low levels of HDL-C constitute a strong, independent, and inverse predictor of the risk of premature development of atherosclerosis and CVD.Moreover, the decrease in CV risk relative to HDL-C levels is especially dramatic over the range of HDL-C from ∼0.65 to 1.17 mmol/L (25–45 mg/dL).

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10. Management of dyslipidaemias in different clinical settings

Plasma lipid levels are to a very large extent determined by genetic factors. In its more extreme forms this is manifested as familial hyperlipidaemia. A number of monogenic lipid disorders have been identified, and among those FH is most common and strongly related to CVD.

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11. Monitoring of lipids and enzymes in patients on lipid-lowering drug therapy

Evidence for what tests should be carried out to monitor lipids in patients on treatment is limited. Similar limited evidence applies to tests of possible toxicity such as ALT and CK. Recommendations stem from consensus rather than evidence-based guidelines.

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12. How to improve adherence to lifestyle changes and compliance with drug therapy

No smoking, healthy eating, and being physically active are the foundations of preventive cardiology. These lifestyles are most effectively achieved through formal programmes of preventive care; such programmes are also more appropriate for initiating and up-titrating drug therapies, achieving the treatment goals, and adherence over the long-term which in turn improves event-free survival.

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