What are the ECS (European Cardiology Society) 2025 guidelines for managing dyslipidemia?

ESC Guidelines for Dyslipidemia Management (2025)

The European Society of Cardiology (ESC) 2025 guidelines for dyslipidemia management recommend risk-stratified treatment targets with LDL-C goals of <55 mg/dL for very high-risk patients, <70 mg/dL for high-risk patients, <100 mg/dL for moderate-risk patients, and <116 mg/dL for low-risk patients. 1

Risk Stratification Categories

Risk stratification is essential for determining treatment goals and strategies:

1. Very High Risk:

   • Documented cardiovascular disease (invasive/non-invasive testing)
   • Previous myocardial infarction, ACS, coronary revascularization
   • Ischemic stroke or peripheral arterial disease
   • Type 2 diabetes or type 1 diabetes with target organ damage
   • Moderate to severe CKD (GFR <60 mL/min/1.73 m²)
   • SCORE ≥10% for 10-year risk of fatal CVD 2, 1

2. High Risk:

   • Markedly elevated single risk factors (familial dyslipidemia, severe hypertension)
   • SCORE ≥5% and <10% for 10-year risk of fatal CVD 2, 1

3. Moderate Risk:

   • SCORE ≥1% and <5% at 10 years
   • Risk modified by family history of premature CAD, abdominal obesity, physical activity, HDL-C, TG levels, hs-CRP, Lp(a), and other factors 2

4. Low Risk:

   • SCORE <1% 2, 1

Screening Recommendations

• Adult men ≥40 years of age
• Women ≥50 years of age or post-menopausal
• Earlier screening for individuals with:
  • Family history of premature CVD
  • Known atherosclerosis
  • Type 2 diabetes
  • Hypertension
  • Central obesity (waist circumference ≥94 cm for European men, ≥80 cm for women)
  • BMI ≥25 kg/m² 2, 1
• Special populations requiring screening:
  • Autoimmune inflammatory conditions (rheumatoid arthritis, SLE, psoriasis)
  • CKD patients
  • Patients with clinical manifestations of genetic dyslipidemia
  • Patients on antiretroviral therapy
  • Offspring of patients with severe dyslipidemia 2

Treatment Goals

Risk Category	LDL-C Target
Very High Risk	<55 mg/dL or reduction >50%
High Risk	<70 mg/dL or reduction >50%
Moderate Risk	<100 mg/dL
Low Risk	<116 mg/dL [1]

Treatment Approach

Lifestyle Modifications (First-line for all patients)

• Diet recommendations:

  • Reduce saturated fat intake
  • Eliminate trans fats
  • Increase fruits, vegetables, and whole grains
  • Consider foods enriched with phytosterols 1, 3
  • For LDL-C reduction: reduce cholesterol-raising fatty acids and dietary cholesterol, increase unsaturated fatty acids, plant proteins, and viscous fibers 3
  • For TG reduction: restrict alcohol, added sugars, and refined starches 3

• Physical activity: Regular aerobic exercise 4, 3

• Weight management: Achieve and maintain healthy weight 4, 3

• Smoking cessation 4

Pharmacological Therapy

1. Statins (First-line):

   • Inhibit HMG-CoA reductase
   • Reduce LDL-C by 28-63% 1
   • Should be considered in all MI patients regardless of LDL-C levels 2

2. Ezetimibe (Second-line):

   • Inhibits intestinal cholesterol absorption
   • Reduces LDL-C by 15-20% 1

3. PCSK9 Inhibitors:

   • For patients not reaching targets with maximum tolerated statin + ezetimibe 5

4. Fibrates:

   • Activate PPAR-α
   • Reduce triglycerides by 30-50%
   • Increase HDL-C by 5-15% 1
   • Indicated for TG ≥500 mg/dL 1

5. Omega-3 Fatty Acids:

   • Reduce triglycerides by 20-40%
   • Increase HDL-C by 15-35% 1

6. Novel Agents (for refractory cases):

   • ATP-citrate lyase inhibitors
   • Selective PPAR-α modulators
   • CETP inhibitors
   • Antisense oligonucleotides
   • ANGPTL3 inhibitors 5

Monitoring and Follow-up

• Assess lipid levels 4-12 weeks after initiating therapy or changing dose
• Once target levels achieved, monitor every 6-12 months 1
• For triglyceride management:
  • TG 150-499 mg/dL: lifestyle modification
  • TG ≥500 mg/dL: consider fibrates or nicotinic acid
  • TG >1000 mg/dL: urgent intervention to prevent pancreatitis (fasting, fibrates, omega-3) 1

Special Considerations

• Older patients: Clinical judgment is crucial; prioritize lifestyle measures before drug therapy 2
• Severe hypertriglyceridemia: Requires individualized approach to prevent pancreatitis 3
• Combined dyslipidemia: Implement strategies for both LDL-C and TG reduction 3
• Multidisciplinary approach: Consider referral to registered dietitian nutritionist for sustained dietary changes 3

The 2025 ESC guidelines emphasize the concept of lifetime exposure to elevated LDL-C levels and the importance of non-HDL-C, apolipoprotein B, and lipoprotein(a) in determining cardiovascular risk, with a trend toward earlier and more aggressive intervention in high-risk patients 6.