The Sixth Joint Task Force of the European Society of Cardiology (ESC) and Other Societies on Cardiovascular Disease Prevention in Clinical Practice has now published guidelines for prevention and management of cardiovascular risk factors in Europe.¹ Importantly, these comprehensive guidelines have reaffirmed LDL‑C as the number one priority for lipid control. According to Professor Alberico L. Catapano (University of Milan, Italy), European Atherosclerosis Society (EAS) President and representative of the Society in the Writing Group for these guidelines: ‘The causality of elevated LDL-C in atherosclerotic cardiovascular disease is proven. Therefore, clinicians should focus on lowering LDL-C levels in their patients, to reduce the risk of early heart attacks and strokes.’

While LDL-C goals remain unchanged across the spectrum of cardiovascular risk, the Sixth Joint Task Force has refined the alternative goal of at least 50% reduction from baseline LDL-C levels for high risk (baseline LDL-c between 2.6 and 5.1 mmol/L (100 and 200 mg/dL)) and very high risk patients (between 1.8 and 3.5 mmol/L (70 and 135 mg/dL)) (see Table below).
Consistent with the 2011 Joint ESC/EAS guidelines,² non-HDL-C is recommended as a reasonable and practical alternative to LDL-C as it does not require fasting for measurement.
Statins are the first choice for treating elevated LDL-C. In patients at high or very high risk of a heart attack or stroke, who require further LDL-C lowering to reach goal, ezetimibe is the treatment of choice for combination with a statin, supported by evidence from randomized controlled trials.³  With respect to new therapies, the guidelines recognize that there is consistent support from clinical trials for up to 60% lowering of LDL-C with the new proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. However, the results of ongoing outcomes studies are needed before any definitive recommendations on their use can be made.

The Sixth Joint Task Force has updated previous recommendations for HDL-C, triglycerides, and lipoprotein(a), but also recognizes the gaps in evidence.

• Consistent with the Joint Guidelines for Dyslipidaemia,² the Task Force recognizes that high fasting triglycerides (>1.7 mmol/L or >~150 mg/dL) and low HDL-C (<1.0 mmol/L or 40 mg/dL in men and <1.2 mmol/L or <45 mg/dL in women) are independent markers of increased cardiovascular risk. However, currently the evidence does not support targets for either measure. 
• New to the Sixth Joint Task Force guidelines is the recommendation that clinicians may consider measuring lipoprotein(a) in patients at moderate risk to help in risk evaluation, or in those with a family history of early heart disease. This is supported by evidence that high lipoprotein(a) levels have been shown to have a causal role in cardiovascular disease.⁴ However, the guidelines do not give any goal as there are no randomized studies with treatments that are specific for lowering lipoprotein(a).  

The guidelines emphasize lifestyle as the first fundamental step for preventing and managing cardiovascular disease and discourage consumption of sugar-sweetened soft drinks. Recommendations for lifestyle intervention now extend to people at very low risk (SCORE <1%), with LDL-C levels <2.6 mmol/L or 100 mg/dL. 

The guidelines suggest that functional foods containing plant sterols or stanols, often referred to as phytosterols, which lower LDL-C levels by about 10% at an intake of 2 g/day, and other food supplements with a lipid-lowering effect may be considered, but emphasize that so far there is no evidence that these reduce the risk of heart attacks and strokes.

Table. Recommendations for lipid control: LDL-C and non-HDL-C

Risk category	LDL-C goal	Non-HDL-C goal
Very high risk	<1.8 mmol/L (<70 mg/dL) OR ≥50% reduction if baseline is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL)	<2.6 mmol/L (<100 mg/dL)
High risk	<2.6 mmol/l (100 mg/dL) OR ≥50% reduction if baseline is between 2.6 and 5.1 mmol/l (100 and 200 mg/dL)	<3.3 mmol/L (<130 mg/dL)
Other patients on LDL-C lowering treatment	<3.0 mmol/L (<115 mg/dL)	<3.8 mmol/L (<145 mg/dL)

 Press release 84^th European Atherosclerosis Society Congress, Innsbruck, Austria, May 29, 2016 
Click here for mere information about the guidelines.

References

1. European Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal. doi: 10.1093/eurheartj/ehw106 http://eurheartj.oxfordjournals.org/lookup/doi/10.1093/eurheartj/ehw106
2. Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D. ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 2011;32:1769-818. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21712404
3. Cannon CP, Blazing MA, Giugliano RP, McCagg A, White JA, Theroux P, Darius H, Lewis BS, 5032 Ophuis TO, Jukema JW, De Ferrari GM, Ruzyllo W, De Lucca P, Im K, Bohula EA, Reist C, Wiviott SD, 5033 Tershakovec AM, Musliner TA, Braunwald E, Califf RM, Investigators I-I. Ezetimibe Added to Statin 5034 Therapy after Acute Coronary Syndromes. N Engl J Med 2015;372:2387-97.
4. Nordestgaard BG, Chapman MJ, Ray K, Boren J, Andreotti F, Watts GF, Ginsberg H, Amarenco 5081 P, Catapano A, Descamps OS, Fisher E, Kovanen PT, Kuivenhoven JA, Lesnik P, Masana L, Reiner Z, 5082 Taskinen MR, Tokgozoglu L, Tybjaerg-Hansen A, European Atherosclerosis Society Consensus P. Lipoprotein(a) as a cardiovascular risk factor: current status. Eur Heart J 2010;31:2844-53.