2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias

What is new in the updated ESC/EAS Dyslipidaemia Guidelines?

Since the publication of the 2019 ESC/EAS Guidelines on the management of dyslipidaemias: lipid modification to reduce cardiovascular risk, several randomized controlled trials have been published.

Focused Update ≠ New Guidelines

This 2025 Focused Update addresses changes in recommendations for the treatment of dyslipidaemias based on new evidence published up until 31 March 2025. All major randomized controlled 12 clinical trials and meta-analyses published after the publication of the 2019 Guideline document were presented and discussed in detail before a consensus was reached about any possible classes of recommendations.

Previous recommendations that have not changed are still valid and not mentioned in this update.

To the full article in Atherosclerosis To the editorial in Atherosclerosis To the full article in European Heart Journal Download EAS Official Slide Set

Watch our webinars on Lp(a) and combination therapies!

Lipoprotein(a) – guideline updates and clinical case
Date: Monday, September 29
Time: 17:00-18:00 CET
Speakers: Prof Konstantinos Koskinas and Prof Lale Tokgözoğlu

View on-demand here

Combination therapies – guideline updates and clinical case
Date: Wednesday, October 22
Time: 17:00-18:00 CET
Speakers: Prof Jeanine Roeters van Lennep and Prof Ulrich Laufs

View on-demand here

Preamble

Classes of recommendations & Levels of evidence

	Definition	Wording to use
Class I	Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.	Is recommended or is indicated
Class II	Conflicting evidence and/or a divergence of opinion about the usefulness/ efficacy of the given treatment or procedure.
Class IIa	Weight of evidence/opinion is in favour of usefulness/efficacy.	Should be considered
Class IIb	Usefulness/efficacy is less well established by evidence/opinion.	May be considered
Class III	Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful.	Is not recommended

Level of evidence

Level of evidence A	Data derived from multiple randomized clinical trials or meta-analysis.
Level of evidence B	Data derived from a single randomized clinical trial or large non-randomized studies.
Level of evidence C	Consensus of opinion of the exprets and/or small studies, retrospective studies, registries.

Summary of the new recommendations

The taskforce have updated the recommendations for the following sections:

Recommendations for cardiovascular risk estimation in persons without known cardiovascular disease

Recommendations	Class^a	Level^b
SCORE2 is recommended in apparently healthy people <70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk.^2c	I	B
SCORE2-OP is recommended in apparently healthy people ≥70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk.^3c	I	B
Presence of subclinical coronary atherosclerosis by imaging or increased CAC score by CT should be considered as risk modifiers in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.^{24,27,28,36 d}	IIa	B
Risk modifiers should be considered in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification.^{17,27,37 f}	IIa	B
In primary prevention,^g pharmacological LDL-C-lowering therapy is recommended in persons: – at very high risk and LDL-C ≥1.8 mmol/L (70 mg/dL), or – at high risk and LDL-C ≥2.6 mmol/L (100 mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.^1,13,38,39	I	A
In primary prevention,^g pharmacological LDL-C-lowering therapy should be considered in persons: – at very high risk and LDL-C ≥1.4 (55 mg/dL) but <1.8 mmol/L (70 mg/dL), or – at high risk and LDL-C ≥1.8 (70 mg/dL) but <2.6 mmol/L (100 mg/dL), or – at moderate risk and LDL-C ≥2.6 (100 mg/dL) but <4.9 mmol/L (190 mg/dL), or – at low risk and LDL-C ≥3.0 (116 mg/dL) but <4.9 mmol/L (190 mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.^1,13,38,39	IIa	A

ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery calcium; CKD, chronic kidney disease; CT, computed tomography; CVD, cardiovascular disease; DM, diabetes mellitus; LDL-C, low-density lipoprotein cholesterol; SCORE2, Systematic Coronary Risk Estimation 2; SCORE2-OP, Systematic Coronary Risk Estimation 2 for Older Patients.
^a Class of recommendation.
^b Level of evidence.
^c Revised recommendation replacing the respective recommendation based on SCORE in the 2019 ESC/EAS Guidelines.
^d Revised recommendation replacing the recommendation on CAC score for CV risk assessment in the 2019 ESC/EAS Guidelines.
^e Listed in Box 1 in the Guidelines.
^f New recommendation.
^g Persons without known clinical atherosclerotic cardiovascular diseas

Learn more about SCORE2 & SCORE2-OP>

Recommendations for statin therapy in primary prevention

Recommendations	Class^a	Level^b
In primary prevention, pharmacological LDL-C-lowering therapy is recommended in persons: – at very high risk and LDL-C ≥1.8 mml/L (70 mg/dL), or – at high risk and LDL-C ≥2.6 mmol/L (100mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.	I	A
IIn primary prevention, pharmacological LDL-C-lowering therapy should be considered in persons: – at very high risk and LDL-C ≥1.4 mmol/L (55mg/dL) but <1.8 mmol/L (70 mg/dL), or – at high risk and LDL-C ≥1.8 mmol/L (70 mg/dL) but 2.6 mmol/L (100mg/dL), or – at moderate risk and LDL-C ≥2.6 mmol/L (100mg/dL) but <4.9 mmol/L (190 mg/dL), or – at low risk and LDL-C ≥ 3.0 mmol/L (116 mg/dL) but <4.9 mmol/L (190 mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk.	IIa	A

Learn more about statin therapy in primary prevention >

Recommendations for pharmacological low-density lipoprotein cholesterol lowering

Recommendations	Class^a	Level^b
Non-statin therapies with proven cardiovascular benefit^c, taken alone or in combination, are recommended for patients who are unable to take statin therapy to lower LDL-C levels and reduce the risk of CV events. The choice should be based on the magnitude of additional LDL-C lowering needed.^4,53,54	I	A
Bempedoic acid is recommended in patients who are unable to take statin therapy to achieve the LDL-C goal.⁴	I	B
The addition of bempedoic acid to the maximally tolerated dose of statin with or without ezetimibe should be considered in patients at high or very high risk in order to achieve the LDL-C goal.^42,55	IIa	C
Evinacumab should be considered in patients with homozygous familial hypercholesterolaemia aged 5 years or older who are not at LDL-C goal despite receiving maximum doses of lipid-lowering therapy to lower LDL-C levels.^5,50,51	IIa	B

This table complements the table of recommendations for pharmacological low-density lipoprotein cholesterol lowering in the 2019 ESC/EAS Guidelines and does not replace it.
CV, cardiovascular; LDL-C, low-density lipoprotein cholesterol; PCSK9, proprotein convertase
subtilisin/kexin type 9.
^a Class of recommendation.
^b Level of evidence.
^c Ezetimibe, PCSK9 monoclonal antibodies, bempedoic acid.

Learn more about news for LDL-C lowering therapies >

Recommendations for lipid-lowering therapy in patients with acute coronary syndromes

Recommendations	Class^a	Level^b
Intensification of lipid-lowering therapy during the index ACS hospitalization is recommended for patients who were on any lipid-lowering therapy before admission in order to further lower LDL-C levels.	I	C
Initiating combination therapy with high-intensity statin plus ezetimibe during index hospitalization for ACS should be considered in patients who were treatment-naïve and are not expected to achieve the LDL-C goal with statin therapy alone.⁶⁶	IIa	B

This table complements the ESC 2019 ESC/EAS Guidelines table and does not replace it.
ACS, acute coronary syndromes; LDL-C, low-density lipoprotein cholesterol.
^a Class of recommendation.
^bLevel of evidence.

Learn more about news for lipid lowering therapy & ACS >

Recommendations on Lp(a)

Recommendations	Class^a	Level^b
Lp(a) levels above 50 mg/dL (≈105 nmol/L) should be considered in all adults as a CV risk-enhancing factor, with higher Lp(a) levels associated with a greater increase in risk.^37,100	IIa	B

CV, cardiovascular; Lp(a), lipoprotein(a).
^a Class of recommendation.
^bLevel of evidence.

Learn more about new recommendations for Lp(a) >

Recommendations for drug treatment in patients with hypertriglyceridaemia

Recommendations	Class^a	Level^b
High-dose icosapent ethyl (2 x 2 g/day) should be considered in combination with a statin in high-risk or very high-risk patients with elevated triglyceride levels (fasting triglyceride level 135–499 mg/dL or 1.52–5.63 mmol/L) to reduce the risk of cardiovascular events.^8,110	IIa	B
Volanesorsen (300 mg/week) should be considered in patients with severe hypertriglyceridaemia (>750 mg/dL, >8.5 mmol/L) due to familial hylomicronaemia syndrome, to lower triglyceride levels and reduce the risk of pancreatitis.^6,116	IIa	B

^a Class of recommendation.
^b Level of evidence.

Learn more about recommendations for hypertriglyceridaemia >

Recommendations for statin therapy in primary CV disease (CVD) prevention for persons with human immunodeficiency virus (HIV) infection

Recommendations	Class^a	Level^b
Statin therapy is recommended for people in primary prevention aged ≥40 years with HIV, irrespective of estimated cardiovascular risk and LDL-C levels, to reduce the risk of cardiovascular events; the choice of statin should be based on potential drug interactions.⁷	I	B

HIV, human immunodeficiency virus; LDL-C, low-density lipoprotein cholesterol.
^a Class of recommendation.
^b Level of evidence.

Learn more about news for HIV >

Recommendations for statin therapy for patients with cancer at high or very high chemotherapy-related cardiovascular toxicity ris

Recommendation	Class^a	Level^b
Statins should be considered in adult patients at high or very high risk of developing chemotherapy-related cardiovascular toxicity^cto reduce the risk of anthracycline-induced cardiac dysfunction.^9,131–133	IIa	B

^a Class of recommendation.
^bLevel of evidence.
^cBaseline cardiovascular toxicity risk stratification discussed in detail in the 2022 ESC Guidelines on
Cardio-oncology.¹³⁴

Learn more about news for patients with cancer >

Recommendations for dietary supplements

Recommendation	Class^a	Level^b
Dietary supplements or vitamins without documented safety and significant LDL-C-lowering efficacy are not recommended to lower the risk of ASCVD.^10,11	III	B

ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol.
^aClass of recommendation.
^bLevel of evidence.

Learn more about recommendations for dietary supplements >

Other

The physiological and biological basis of atherosclerotic cardiovascular disease.

The physiological and biological basis of atherosclerotic cardiovascular disease >