2019 Dyslipidemia Guideline Esc

2019 ESC/EAS Guidelines for the management
of dyslipidaemias: lipid modification to reduce

cardiovascular risk
Risk stratification for atherosclerotic cardiovascular disease

Brian A Ference, MD, MPhil, MSc, FACC, FESC
On behalf of:
Task Force Members:

François Mach (ESC Chairperson) (Switzerland), Colin Baigent (ESC Chaiperson) (United Kingdom), Alberico L. Catapano ( EAS
Chairperson) (Italy), Konstantinos C. Koskinas (Switzerland), Manuela Casula1 (Italy), Lina Badimon (Spain), M. John Chapman1
(France), Guy G. De Backer (Belgium), Victoria Delgado (Netherlands), Brian A. Ference (United Kingdom), Ian M. Graham
(Ireland), Alison Halliday (United Kingdom), Ulf Landmesser (Germany), Borislava Mihaylova (United Kingdom), Terje R.
Pedersen (Norway), Gabriele Riccardi1 (Italy), Dimitrios J. Richter (Greece), Marc S. Sabatine (United States of America), Marja-
Riitta Taskinen1 (Finland), Lale Tokgozoglu1 (Turkey), Olov Wiklund1 (Sweden).
2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce
www.escardio.org/guidelines cardiovascular risk (European Heart Journal 2019 -doi: 10.1093/eurheartj/ehz455) 1
www.escardio.org/guidelines cardiovascular risk (European Heart Journal 2019 -doi: 10.1093/eurheartj/ehz455) 2
Foundations of new Guidelines
These Guidelines recognize that low density lipoproteins and other apoB-containing
lipoproteins cause ASCVD
These Guidelines therefore make recommendations to reduce the risk of ASCVD by lowering
LDL and other apoB-containing lipoproteins
These Guidelines recognize that the benefit of lipid lowering therapies is determined by both
the absolute reduction in LDL and other apoB-containing lipoproteins and the corresponding
absolute reduction in ASCVD risk
These Guidelines therefore recommend titrating lipid lowering therapy intensity based on
both baseline lipid levels and baseline risk of ASCVD
These Guidelines prioritize identifying people at High and Very-High 10-year risk of
©ESC
experiencing a cardiovascular event because they are most likely to derive the greatest short-
term clinical benefit from aggressive lipid lowering therapy
www.escardio.org/guidelines cardiovascular risk (European Heart Journal 2019 -doi: 10.1093/eurheartj/ehz455)
Intensity of lipid lowering treatment
Treatment Average LDL-C reduction
Moderate intensity statin ≈ 30%
High intensity statin
≈ 50%
High intensity statin plus ezetimibe
≈ 65%
PCSK9 inhibitor ≈ 60%
PCSK9 inhibitor plus moderate intensity statin ≈ 75% Using baseline LDL-C and
PCSK9 inhibitor plus high intensity statin
plus ezetimibe
≈ 85%
risk of ASCVD to estimate
% reduction LDL-C Baseline LDL-C
expected clinical benefit
of low-density lipoprotein
lowering therapies
Absolute reduction LDL-C
Relative risk reduction Baseline risk

LDL-C = low-density lipoprotein cholesterol;
PCSK9 = proprotein convertase subtilisin/kexin type 9.
Absolute risk reduction
©ESC
≈ 50%
≈ 65%
plus ezetimibe
≈ 85%
lowering therapies

©ESC
≈ 50%
≈ 65%
plus ezetimibe
≈ 85%
lowering therapies

©ESC
Recommendations for cardiovascular disease risk
estimation
Risk stratification proceeds in 3 stages Class Level
Clinical Evaluation: It is recommended that high- and very-high-risk individuals are
identified on the basis of documented CVD, DM, moderate-to-severe renal disease, very
I C
high levels of individual risk factors, FH, or a high SCORE risk. It is recommended that such
patients are considered as a priority for advice and management of all risk factors.
SCORE 10-year risk estimate: Total risk estimation using a risk estimation system such as
SCORE is recommended for asymptomatic adults >40 years of age without evidence of I C
CVD, DM, CKD, familial hypercholesterolaemia, or LDL-C >4.9 mmol/L (>190 mg/dL).
Assessment of Risk Modifiers: In selected individuals at low to moderate risk, other

factors, including increased apolipoprotein B (apoB), lipoprotein(a) (Lp(a)), or C-reactive
! C
protein (CRP); family history of premature ASCVD; or the presence of atherosclerotic
plaque on imaging may improve risk stratification and inform treatment decisions.
©ESC
Cardiovascular risk categories: clinical assessment
Very-high-risk People with any of the following:

Documented ASCVD, either clinical or unequivocal on imaging.
Documented ASCVD includes previous ACS (MI or unstable angina), stable angina,
coronary revascularisation (PCI, CABG and other arterial revascularization procedures),
stroke and TIA, and peripheral arterial disease. Unequivocally documented ASCVD on
imaging includes those findings that are known to be predictive of clinical events, such as
significant plaque on coronary angiography or CT scan (multivessel coronary disease with
two major epicardial arteries having >50% stenosis) or on carotid ultrasound.
DM with target organ damage, ≥3 major risk factors or early onset of
T1DM of long duration (>20 years).
Severe CKD (eGFR <30 mL/min/1.73 m2).
FH with ASCVD or with another major risk factor.
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A calculated SCORE ≥10% for 10-year risk of fatal CVD.
Cardiovascular risk categories: clinical assessment
High-risk People with:

Markedly elevated single risk factors, in particular TC >8 mmol/L (>310
mg/dL), LDL-C >4.9 mmol/L (>190 mg/dL), or BP ≥180/110mmHg.
Patients with FH without other major risk factors.
Patients with DM without target organ damage*, with DM duration ≥10 years
or another additional risk factors.
Moderate CKD (eGFR 30–59 mL/min/1.73 m2).
Calculated SCORE ≥5% and <10% for 10-year risk of fatal CVD.
Moderate-risk Young patients (T1DM <35 years; T2DM <50 years) with DM duration <10 years, without
other risk factors. Calculated SCORE ≥1% and <5% for 10-year risk of fatal CVD.
©ESC
Low-risk None of above features . Calculated SCORE <1% for 10-year risk of fatal CVD.
*Target organ damage is defined as microalbuminuria, retinopathy or neuropathy
SCORE Cardiovascular Risk Chart
10-year risk of fatal CVD
High-risk regions of Europe
WOMEN MEN
Non-smoker Smoker Age Non-smoker Smoker
180 12 13 14 15 17 19 20 21 24 26 30 33 33 36 40 45
160 10 11 12 13 14 15 16 18 20 22 25 28 27 31 34 39
70
140 8 9 10 10 12 13 14 15 16 18 21 24 23 26 29 33
SCORE chart for European

120 7 7 8 9 10 10 11 12 13 15 17 20 19 22 25 28
Systolic blood pressure (mmHg)
180 7 8 8 9 11 12 13 15 15 17 20 23 23 26 30 34
populations at high
160 5 6 6 7 9 9 10 11 12 14 16 18 18 21 24 27
65
140 4 4 5 5 7 7 8 9 9 11 12 14 14 16 19 22
cardiovascular disease risk

120 3 3 4 4 5 5 6 7 7 8 10 11 11 13 15 17
180 4 4 5 5 7 8 9 10 10 11 13 15 16 19 22 25
160 3 3 3 4 5 6 6 7 7 8 10 11 12 14 16 19
60
140 2 2 2 3 4 4 4 5 5 6 7 8 9 10 12 14
120 1 1 2 2 3 3 3 3 4 4 5 6 6 7 9 10
180 2 2 3 3 5 5 6 7 6 7 9 10 11 13 16 18
160 1 2 2 2 3 3 4 4 4 5 6 7 8 9 11 13
55
140 1 1 1 1 2 2 2 3 3 3 4 5 5 6 7 9
120 1 1 1 1 1 1 2 2 2 2 3 3 4 4 5 6
180 1 1 2 2 3 3 4 4 4 5 6 7 8 9 11 13
160 1 1 1 1 2 2 2 3 2 3 3 4 5 6 7 9
50
140 0 0 1 1 1 1 1 2 2 2 2 3 3 4 5 6
120 0 0 0 0 1 1 1 1 1 1 1 2 2 2 3 4
180 0 0 1 1 1 1 2 2 2 2 2 3 4 4 5 7
160 0 0 0 0 1 1 1 1
40
1 1 1 2 2 2 3 4 <3% 3-4% 5-9% ≥10%
140 0 0 0 0 0 0 0 1 0 1 1 1 1 1 2 2
120 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
©ESC
Total cholesterol (mmol/L)
Cardiovascular risk categories: risk SCORE
Very-high-risk Calculated SCORE ≥10% for 10-year risk of fatal CVD.
High-risk Calculated SCORE ≥5% and <10% for 10-year risk of fatal CVD.
Moderate-risk Calculated SCORE ≥1% and <5% for 10-year risk of fatal CVD.
Low-risk Calculated SCORE <1% for 10-year risk of fatal CVD.
• SCORE can be used to estimate risk in patients who do not have clinical
ASCVD or other any clinical features that define a risk category
• Or to place a person into a higher risk category due to combination of
lipid levels and other risk factors
©ESC
Risk estimation charts for different countries
The low-risk charts should be considered for use in Austria, Belgium, Cyprus, Denmark, Finland,
France, Germany, Greece, Iceland, Ireland, Italy, Israel, Luxembourg, Netherlands, Norway,
Malta, Portugal, Slovenia, Spain, Sweden, Switzerland and United Kingdom.
The high-risk charts should be considered for use in Albania, Algeria, Armenia, Bosnia and
Herzegovina, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lebanon, Libya, Lithuania,
Montenegro, Morocco, Poland, Romania, Serbia, Slovakia, Tunisia and Turkey.
Some countries have a CVD mortality rate more than 350/100 000, and the high-risk chart may
underestimate risk. These are Azerbaijan, Belarus, Bulgaria, Egypt, Georgia, Kazakhstan,
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Kyrgyzstan, North Macedonia, Republic of Moldova, Russian Federation, Syria, Tajikistan,
Turkmenistan, Ukraine and Uzbekistan.
SCORE chart for European populations at low
cardiovascular disease risk (3)
Low-risk regions of Europe
WOMEN MEN

180 2 3 3 3 4 5 5 6 5 6 7 8 8 10 11 13
160 2 2 2 2 3 3 4 4 4 4 5 5 6 7 8 9
60
140 1 1 1 2 2 2 3 3 3 3 3 4 4 5 6 7
120 1 1 1 1 2 2 2 2 2 2 2 3 3 4 4 5
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
<3% 3-4% 5-9% ≥10%
©ESC
SCORE chart for European populations at high
cardiovascular disease risk (3)

High-risk regions of Europe
WOMEN MEN

180 4 4 5 5 7 8 9 10 10 11 13 15 16 19 22 25
160 3 3 3 4 5 6 6 7 7 8 10 11 12 14 16 19
60
140 2 2 2 3 4 4 4 5 5 6 7 8 9 10 12 14
120 1 1 2 2 3 3 3 3 4 4 5 6 6 7 9 10
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
<3% 3-4% 5-9% ≥10%
©ESC
Non-smoker Age Smoker
Without HDL: 4.4 180 7 7 8 8 9 14 14 15 16 17 Without HDL: 5.7
160 5 5 6 6 7 10 11 12 12 13
HDL 0.8: 8.1 65 HDL 0.8: 10.2
140 4 4 4 5 5 8 8 9 9 10
HDL 1.0: 6.7 120 3 3 3 4 4 6 6 7 7 8 HDL 1.0: 8.5
HDL 1.4:
HDL 1.8:
4.5
3.0
180
160
3
2
3
3
4
3
4
3
4
3
6
5
7
5
7
5
8
6
8
6
HDL 1.4:
HDL 1.8: 4.0
5.9
Risk function with high-
density lipoprotein
60
140 2 2 2 2 2 4 4 4 4 5
HDL 0.8: 8.0
180
160
2
1
2
1
2
2
2
2
2
2
4
3
4
3
4
3
4
3
5
4
HDL 0.8: 8.5 cholesterol for women
HDL 1.0: 6.5 140 1 1 1 1 1
55
2 2 2 2 3 HDL 1.0: 7.0
in populations at high
HDL 1.4: 4.4 120 1 1 1 1 1 2 2 2 2 2 HDL 1.4: 4.7

HDL 1.8: 2.9 180 1 1 1 1 1 1 2 2 2 2 HDL 1.8: 3.2 cardiovascular disease
Without HDL: 2.4
160
140
120
1
0
0
1
0
0
1
1
0
1
1
0
1
1
0
50
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
Without HDL: 4.5 risk
HDL 0.8: 4.6 HDL 0.8: 8.3
180 0 0 0 0 0 0 0 1 1 1
HDL 1.0: 3.8 HDL 1.0: 6.9
160 0 0 0 0 0 0 0 0 0 0
HDL 1.4: 2.5 40 HDL 1.4: 4.7
140 0 0 0 0 0 0 0 0 0 0
HDL 1.8: 1.7 120 0 0 0 0 0 0 0 0 0 0 HDL 1.8: 3.2
4 5 6 7 8 4 5 6 7 8
©ESC
Risk function with high-density lipoprotein (HDL) cholesterol for
women in populations at high cardiovascular disease risk
WOMEN
HDL 0.8: 8.0 160 2 3 3 3 3 5 5 5 6 6 HDL 0.8: 8.5
HDL 1.0: 6.5 60 HDL 1.0: 7.0
140 2 2 2 2 2 4 4 4 4 5
HDL 1.4: 4.4 HDL 1.4: 4.7
HDL 1.8: 2.9 120 1 1 2 2 2 3 3 3 3 4 HDL 1.8: 3.2
4 5 6 7 8 4 5 6 7 8
©ESC
Risk function with high-density lipoprotein (HDL) cholesterol
for men in populations at high cardiovascular disease risk (4)
MEN
HDL 0.8: 4.6 160 3 3 3 4 5 5 5 6 8 9 HDL 0.8: 6.6
HDL 1.0: 4.2 50 HDL 1.0: 5.9
140 2 2 2 3 4 3 4 5 5 7
HDL 1.4: 3.4 HDL 1.4: 4.6
HDL 1.8: 2.8 120 1 1 2 2 3 2 3 3 4 5 HDL 1.8: 3.6
4 5 6 7 8 4 5 6 7 8
©ESC
Qualifiers for risk estimating equations
The charts can assist in risk assessment and management but must be interpreted in light of
the clinician’s knowledge and experience and of the patient’s pre-test likelihood of CVD.
Risk will be overestimated in countries with a decreasing CVD mortality, and underestimated in
countries in which mortality is increasing. This is dealt with by recalibration
(www.heartscore.org).
Risk estimates are lower in women than in men. However, risk is only deferred in women; the
risk of a 60-year-old woman is similar to that of a 50-year-old man. Ultimately more women die
from CVD than men.
©ESC
Relative risks may be unexpectedly high in young persons, even if absolute risk levels are low.
The relative risk chart and the estimated risk age may be helpful in identifying and counselling
such persons.
Central Illustration Lower panel: Treatment
algorithm for pharmacological LDL-C lowering (1)
In selected low- and Total CV risk assessment

moderate-risk patients
Baseline LDL-C levels
Risk modifiers
Imaging (subclinical
atherosclerosis)
Risk reclassification? Indication for drug therapy?
Y N
©ESC
Factors modifying SCORE risks (1)
Family history of premature CVD (men: <55 years; women: <60 years).
Elevated biomarkers including apoB, Lp(a), CRP, TG; or atherosclerosis on non-invasive
imaging
Social deprivation – the origin of many of the causes of CVD.
Obesity and central obesity as measured by the body mass index and waist circumference,
respectively.
©ESC
Physical inactivity.
Psychosocial stress including vital exhaustion.
Chronic immune-mediated inflammatory disorder.
Factors modifying SCORE risks (2)
Major psychiatric disorders.

Treatment for human immunodeficiency virus (HIV) infection.
Atrial fibrillation.
Left ventricular hypertrophy.
Chronic kidney disease.
Obstructive sleep apnoea syndrome.
©ESC
Non-alcoholic fatty liver disease.
Risk-estimating equations :
potential under-estimate of risk in younger people
WOMEN MEN

180 0 0 0 0 1 1 1 1 1 1 1 1 2 2 3 3
160 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 2
40
140 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
120 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
<3% 3-4% 5-9% ≥10%
©ESC
Chart for estimating the relative risk
for 10-year cardiovascular mortality in young people
Non-smoker Smoker
180 3 3 4 5 6 6 7 8 10 12
160 2 3 3 4 4 4 5 6 7 8
140 1 2 2 2 3 3 3 4 5 6
120 1 1 1 2 2 2 2 3 3 4
4 5 6 7 8 4 5 6 7 8
©ESC
Low-risk regions of Europe (age interactions included)
WOMEN MEN
180 7 8 8 9 11 11 12 13 12 14 15 17 18 20 22 24
160 6 6 7 7 9 9 10 11 10 11 13 14 15 16 18 20
Illustration of the risk age concept

70
140 5 5 6 6 7 8 8 9 8 9 10 12 12 13 15 17
120 4 4 5 5 6 6 7 7 7 8 9 10 10 11 12 14
180 4 4 5 5 7 7 8 9 8 9 10 12 12 14 16 18
160 3 3 4 4 5 6 6 7 6 7 8 9 9 11 12 14
65
140 2 3 3 3 4 4 5 5 5 5 6 7 7 8 9 11
120 2 2 2 2 3 3 3 4 3 4 5 5 5 6 7 8
180 2 3 3 3 4 5 5 6 5 6 7 8 8 10 11 13
160 2 2 2 2 3 3 4 4 4 4 5 5 6 7 8 9
140 1 1 1 2 2 2 3 3
60
3 3 3 4 4 5 6 7 The risk of this 40 – year old
120 1 1 1 1 2 2 2 2 2 2 2 3 3 4 4 5 male smoker with risk factors is
180 1 1 2 2 3 3 3 4 3 4 4 5 6 7 8 9 the same (3-4%) as that of a 65
160 1 1 1 1 2 2 2 3 2 2 3 3 4 4 5 6
55 year – old man with ideal risk
140 1 1 1 1 1 1 1 2 1 2 2 2 3 3 3 4
120 0 0 0 1 1 1 1 1 1 1 1 2 2 2 2 3 factor levels– therefore his risk
180 1 1 1 1 2 2 2 3 2 2 3 3 4 5 5 6 age is 65 years.
160 0 0 1 1 1 1 1 2 1 1 2 2 2 3 3 4
50
140 0 0 0 0 1 1 1 1 1 1 1 1 1 2 2 3
120 0 0 0 0 0 0 0 1 0 1 1 1 1 1 1 2
180 0 0 0 0 1 1 1 1 1 1 1 1 2 2 3 3
160 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 2
40
140 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
120 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 <3% 3-4% 5-9% ≥10%
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
©ESC
Risk-estimating equations :
potential over-estimate of risk in older persons
WOMEN MEN

180 7 8 8 9 11 11 12 13 12 14 15 17 18 20 22 24
160 6 6 7 7 9 9 10 11 10 11 13 14 15 16 18 20
70
140 5 5 6 6 7 8 8 9 8 9 10 12 12 13 15 17
120 4 4 5 5 6 6 7 7 7 8 9 10 10 11 12 14
4 5 6 7 4 5 6 7 4 5 6 7 4 5 6 7
<3% 3-4% 5-9% ≥10%
©ESC
Recommendations for lipid analyses for
cardiovascular disease risk estimation (1)
Recommendations Class Level

TC is to be used for the estimation of total CV risk by means of the
I C
SCORE system.
HDL-C analysis is recommended to further refine risk estimation using
I C
the online SCORE system.
LDL-C analysis is recommended as the primary lipid analysis for
I C
screening, diagnosis and management.
©ESC
TG analysis is recommended as a part of the routine lipid analysis. I C

Non-HDL-C evaluation is recommended for risk assessment, particularly
I C
in people with high TG, diabetes, obesity or very low LDL-C.
ApoB analysis is recommended for risk assessment, particularly in people
with high TG, diabetes, obesity or metabolic syndrome, or very low LDL-C.
It can be used as an alternative to LDL-C, if available, as the primary
I C
measurement for screening, diagnosis and management, and may be
©ESC
preferred over non-HDL-C in people with high TG, diabetes, obesity or
very low LDL-C.

Lp(a) measurement should be considered at least once in each adult
person’s lifetime to identify those with very high inherited Lp(a) levels
>180 mg/dL (>430 nmol/L) who may have a lifetime risk of ASCVD IIa C
equivalent to the risk associated with heterozygous familial
hypercholesterolaemia.
Lp(a) should be considered in selected patients with a family history of
©ESC
premature CVD, and for reclassification in people who are borderline IIa C
between moderate and high-risk.
Risk estimation: key messages (1)
In apparently healthy persons, CVD risk is most frequently the result of multiple, interacting risk
factors. This is the basis for total CV risk estimation and management.
Risk factor screening including the lipid profile should be considered in men >40 years old and
in women >50 years of age or post-menopausal.
Certain individuals declare themselves to be at high or very-high CVD risk without needing risk
©ESC
scoring and require immediate attention to all risk factors. This is true for patients with
documented CVD, diabetes, familial hypercholesterolaemia, chronic kidney disease, carotid or
femoral plaques, coronary artery calcium (CAC) score >100, or extreme Lp(a) elevation.
Risk estimation: key messages (2)
A risk estimation system such as SCORE can assist in making logical management decisions, and
may help to avoid both under- and over-treatment.
All risk estimation systems are relatively crude and require attention to qualifying statements.
Additional factors affecting risk can be accommodated in electronic risk estimation systems
such as HeartScore (www.heartscore.org).
The total risk approach allows flexibility – if optimal control cannot be achieved with one risk
factor, trying harder with the other factors can still reduce risk.
©ESC

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2019 Dyslipidemia Guideline Esc

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2019 ESC/EAS Guidelines for the management

of dyslipidaemias: lipid modification to reduce

Risk stratification for atherosclerotic cardiovascular disease

Task Force Members:

Relative risk reduction Baseline risk

Relative risk reduction Baseline risk

Relative risk reduction Baseline risk

Assessment of Risk Modifiers: In selected individuals at low to moderate risk, other

Very-high-risk People with any of the following:

High-risk People with:

*Target organ damage is defined as microalbuminuria, retinopathy or neuropathy

SCORE chart for European

cardiovascular disease risk

Very-high-risk Calculated SCORE ≥10% for 10-year risk of fatal CVD.

Low-risk Calculated SCORE <1% for 10-year risk of fatal CVD.

Non-smoker Smoker Age Non-smoker Smoker

Total cholesterol (mmol/L)

<3% 3-4% 5-9% ≥10%

SCORE Cardiovascular Risk Chart

Non-smoker Smoker Age Non-smoker Smoker

Total cholesterol (mmol/L)

<3% 3-4% 5-9% ≥10%

HDL 1.4: 4.4 120 1 1 1 1 1 2 2 2 2 2 HDL 1.4: 4.7

Total cholesterol (mmol/L)

Total cholesterol (mmol/L)

Total cholesterol (mmol/L)

In selected low- and Total CV risk assessment

Major psychiatric disorders.

Non-smoker Smoker Age Non-smoker Smoker

Total cholesterol (mmol/L)

<3% 3-4% 5-9% ≥10%

Systolic blood pressure (mmHg)

Total cholesterol (mmol/L)

Illustration of the risk age concept

Non-smoker Smoker Age Non-smoker Smoker

Total cholesterol (mmol/L)

<3% 3-4% 5-9% ≥10%

Recommendations Class Level

Recommendations Class Level

Recommendations Class Level

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