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European guidelines on lipid control advocate “lower is better” for cholesterol levels

The European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) launched new guidelines for the management of dyslipidaemias at the ESC meeting 1–4 September 2019 with the guidelines concurrently published in the European Heart Journal. Professor Borislava Mihaylova, Chair in Health Economics at the Centre for Primary Care and Public Health at the Blizard Institute, is a member of the guidelines Taskforce.

27 September 2019

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Cardiovascular disease (CVD) is responsible for more than four million deaths in Europe each year. Clogged arteries, known as atherosclerotic CVD, are the main type of disease.

The new guidelines update recommendations on how to modify plasma lipid levels through lifestyle and medication to reduce the risk of atherosclerotic CVD. One of the main points is that low-density lipoprotein (LDL) cholesterol levels, also known as ‘bad cholesterol’, should be lowered as much as possible, especially in high and very high-risk patients. This includes patients with atherosclerotic CVD, diabetes with target organ damage, familial hypercholesterolaemia, and severe chronic kidney disease.

Professor Colin Baigent, Chairperson of the guidelines Taskforce and Director of the MRC Population Health Research Unit at the University of Oxford, said: “There is now overwhelming evidence from experimental, epidemiological, genetic studies, and randomised clinical trials that higher LDL cholesterol is a potent cause of heart attack and stroke. Lowering LDL cholesterol reduces risk irrespective of the baseline concentration.”

The Taskforce advocate a lifetime approach to managing LDL levels, meaning that people of all ages and risk levels should adopt and sustain a healthy lifestyle such as following a healthy diet, avoiding cigarette smoking and taking regular exercise.

The guidelines also aim to ensure that available drugs (statins, ezetimibe, PCSK9 inhibitors), shown to lower the level of LDL cholesterol in the blood and reduce risks of heart attacks and strokes, are used as effectively as possible in those most at risk. The guidelines recommend that patients should achieve at least a 50 per cent relative reduction in their LDL cholesterol, irrespective of starting level.

“This is to ensure that high- or very high-risk patients receive intensive LDL cholesterol lowering therapy irrespective of their baseline level,” said Professor Alberico L. Catapano, Chairperson of the guidelines Taskforce and Professor of Pharmacology at the Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy.

Professor Borislava Mihaylova, a member of the guidelines Taskforce and Professor of Health Economics at the Blizard Institute, Queen Mary University of London, said: “All statin regimens and ezetimibe are now generically available across Europe and most of the world. These treatments, at low generic prices, reduce cardiovascular disease risk cost-effectively across the spectrum of patients at increased risk, with patients at higher risk and patients achieving larger reductions in LDL cholesterol benefiting most. Recent price reductions of PCSK9 inhibitors have led to their increased use to treat residual risk in people at very-high risk; further price reductions will broaden their appeal in a wider spectrum of high risk patients.” 

The guidelines advise taking level of risk, baseline LDL cholesterol, health status and the risk of drug interactions into account when doctors are deciding whether statins and other medications are appropriate for their patients.

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