Physicians' Academy for Cardiovascular Education

New dyslipidaemia guidelines issued by ESC/EAS

News - Oct. 25, 2016

European Heart Journal’s edition of October 14 is largely dedicated to the new 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. The ESC Task Force Members reviewed currently available evidence and have formulated updated recommendations to guide cardiovascular prevention in clinical practice, focussing on plasma lipid levels.
 
The document discusses the concept and different approaches of risk assessment. Various lipids and apolipoproteins may be analysed to assess risk, and it is summarised what their levels can tell about the risk of an individual.
 
Concerning treatment targets, the ESC/EAS 2016 Guidelines acknowledge that the AHA/ACC guidelines focused on a hard source of evidence coming from results in RCTs, resulting in a recommendation for the use of high-dose statins in all high-risk people regardless of baseline LDL-c level. This has, however, not been studied in an RCT. The European Task Force felt that, despite of limitations of some sources, the conclusions from many different types of studies contribute to the understanding of the causes of CVD and to the potential of prevention. The Task Force therefore retained a goal approach to lipid management and treatment goals are defined, tailored to the total CV risk level. Evidence suggests that lowering LDL-C beyond the goals that were set in the previous ESC/EAS guidelines is associated with fewer CVD events. “Therefore, it seems appropriate to reduce LDL-C as low as possible, at least in patients at very high CV risk.”
 
Lifestyle modifications that can improve the plasma lipid profile are outlined, and of course a large section is dedicated to optimal treatment of dyslipidaemias. The different classes of lipid-lowering agents are described: mechanisms of action and efficacy and safety results are summarised. After that, management of specific clinical settings and syndromes are considered in detail.
 
Statins received a 1A recommendation, reflecting general agreement on its benefit and effectiveness, while the combination of statins plus ezetimibe a class IIb recommendation, indicating that its usefulness is less well established by evidence or opinion.  
Despite recent publications reporting large LDL-c reductions achieved with PCSK9 antibodies on top of statins, or in patients with statin intolerance, or in those on lipid apheresis, without increasing the risk of diabetes, PCSK9 inhibitors are considered with caution.
 
By lack of evidence from trials, consensus-based recommendations are formulated on what tests should be carried out to monitor lipids and possible toxicity in patients on lipid-lowering treatment. Measuring LDL-c is the minimum approach, but better management decisions will likely be taken when a full lipid profile is performed, including HDL-c and triglycerides. Non-HDL-c and apoB are useful as a secondary treatment target.
Safety blood tests may included ALT and CK at baseline. During treatment, CK may be checked more often in patients at high risk for myopathy, but routine control of ALT is not recommended, unless indicated based on clinical observation. HbA1c may be checked regularly in patients on statin therapy, who are at high risk of developing diabetes.
 
The guidelines stimulate a lifetime approach of improving lifestyle habits and reducing risk factors, both in patients with established risk or at risk of CVD and in healthy people of all ages. Suggestions are given on how to stimulate achievement and adherence to healthy lifestyle and adherence to medication and the document end with a list of to do and not to do messages.
 
Alberico Catapano and Ian Graham, as members of the Guideline Task Force, have formulated 10 commandments based on the new guidelines, which can be found here.
 

Sources

2016 ESC/EAS Guidelines for the Management of Dyslipidaemias
Catapano AL, Graham AL, De Backer G, et al., Eur Heart J 2016 37: 2999-3058

‘Ten Commandments’ from the 2016 ESC/EAS Guidelines for the management of dyslipidaemias
Eur Heart J 2016 37: 2966
 
Lipoprotein(a): another emergent target for PCSK9 inhibitors?
Eur Heart J 2016 37: 2966-2967
 
Dyslipidaemias: new mechanistic insights and the 2016 ESC Guidelines
Thomas F. Lüscher Eur Heart J 2016 37: 2963-2965
 

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