What is changing in the guidelines of the European Society of Cardiology for Dyslipidemia in 2020?

D. Richter, MD, FESC, FAHA

Director of the Cardiology Clinic of the Euroclinic of Athens Former Chairman and current Board Member of the Hellenic Society of Lipidology, Atherosclerosis and Vascular Disease
The latest guidelines for the treatment of dyslipidemia were announced at the Congress of the European Society of Cardiology in Paris. These guidelines directly affect the daily clinical practice and are adopted both by the cardiology companies of all European countries, as well as by scientific companies of other medical specialties.
Cholesterol is known to be obtained from food, but it is also produced by the body in a ratio of about 1 to 2. Increased intake of saturated fatty acids, found mainly in animal fats, such as red meat and fatty cheeses, and Obesity is often the cause of hypercholesterolemia. Unfortunately, the importance of high cholesterol is particularly high in the younger age groups (30-60 years) and gradually declines to give the first place, as a risk factor, in hypertension and coronary heart disease. Especially in our country, for the last 20 years, coronary heart disease is consistently the first cause of death, with a constant difference from the second, which is neoplasms. In 2001 we had 19,500 deaths from coronary heart disease in Greece.

There are several types of dyslipidemia, the most common being elevated total cholesterol and LDL, which is the main target of medication. The incidence of the “metabolic syndrome” type, ie abdominal obesity, is constantly increasing, with low (<40 mg / dl for men and <50 mg / dl for women) “good” HDL-cholesterol and high (> 150 mg / dl) triglycerides. There are also isolated forms, with only HDL cholesterol being abnormal or only triglycerides being particularly elevated.

Reference values ​​for LDL are determined by the patient and his / her risk factors. According to the latest guidelines, in patients at moderate risk the target is reduced to 100 mg / dl instead of 115 mg / dl, while in high risk patients the target is reduced to 70 mg / dl instead of 100 mg / dl. At very high risk patients, whether they already have coronary heart disease or are in primary prevention, the LDL target is reduced from 70 mg / dl to 55 mg / dl. In patients who have suffered two acute episodes within two years (eg two heart attacks or one heart attack and one stroke) the target is reduced to <40 mg / dl.

Of course, scientific data from recent years have shown that there is no lower safety margin for low LDL, but the benefit of reducing cardiovascular events increases as LDL falls lower. Analysis of several studies showed that each time LDL decreased by 10%, the incidence of coronary heart disease decreased by 22% in 2 to 5 years and by 25% after 5 years.

Although the main goal of hypolipidemic treatment is always LDL with all other indicators being secondary, we have a significant change in its goals. Lipoprotein a [Lp (a)] is recommended to be measured in the entire population once in a lifetime. Although its levels are inherited, elevated levels increase cardiovascular risk. The risk rises from Lp (a) levels of 30 mg / dl. Although we do not have a drug specifically for it, we can reduce the overall risk of these patients by further reducing LDL.

Also, if a patient’s triglycerides exceed 150 mg / dl they are high and if they exceed 200 mg / dl he is a candidate for drug treatment, depending on his overall risk. Statins are the drug of choice for their reduction.

As in America, the amount of calcium in axial coronary angiography is introduced as an indicator of atherosclerosis, except for the carpus or carotid arteries of the lower extremities. When plaque is found in the triplex or a significant amount of calcium in the axial, the patient changes risk category and is ranked higher.

The use of ezetimibe has been greatly enhanced at the pharmaceutical level. Thus it is increasingly recommended in combination with high power statin in large doses. At the same time there has been a major upgrade in the recommendation for PCSK9 in out-of-target patients, something that after recent successful studies these drugs were entitled to. Of course with regard to medication, the intervention must last at least two years to bring clinical benefit. This means that an occasional diet or use of medication, which will improve cholesterol levels, is not enough if it does not last. This duration is usually for life, or at least for many decades. We must keep in mind that only the permanent and systematic treatment of dyslipidemia brings significant results (which are often impressive) in reducing heart attacks and other forms of coronary heart disease.

Limits are constantly falling and many are complaining about whether this is normal and right. The scientific reality that is evolving through large randomized trials documents that the benefit of reducing a risk factor ends, and as far as LDL is concerned, it has not yet reached a lower point. “The lower the better” is systematically confirmed in each new study.

But to succeed in such a subversive endeavor, which has changed established views of recent decades, requires the support of two valuable allies. Initially, the Biopathologists – Microbiologists, through the reference values ​​and the separation of these values ​​according to the patient’s history, create the first feeling of security or not of the patient as to whether he should seek further therapeutic advice. Then the pharmacists, who usually have significantly more time with the patient than the clinician and contribute to the confirmation or doubt of the prescribed medication, also play an important role in his future compliance.

No project will really succeed without synergy and alliance between the various parties.