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2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias
Open accessAbstract
1. Preamble 4361 2. Introduction 4363 3. Estimation of total cardiovascular risk and implications for dyslipidaemia management 4363 4. New low-density lipoprotein cholesterol-lowering therapies 4367 5. Combination of lipid-lowering therapies during index hospitalization for acute coronary syndromes 4369 6. Lipoprotein(a) 4370 7. Hypertriglyceridaemia 4371 8. Primary prevention in people with human immunodeficiency virus infection 4372 9. Patients with cancer at high or very high chemotherapy-related cardiovascular toxicity risk 4373 10. Dietary supplements 4373 11. Evidence tables 4374 12. Data availability statement 4374 13. Author information 4374 14. Appendix 4374 15. References 4375 Recommendation Table 1 — Recommendations for cardiovascular risk estimation in persons without known cardiovascular disease (see also Supplementary data online, Evidence Table 1) 4367 Recommendation Table 2 — Recommendations for pharmacological low-density lipoprotein cholesterol lowering (see also Supplementary data online, Evidence Table 2) 4369 Recommendation Table 3 — Recommendations for lipid-lowering therapy in patients with acute coronary syndromes (see also Supplementary data online, Evidence Table 3) 4370 Recommendation Table 4 — Recommendations for measurement of lipoprotein(a) (see also Supplementary data online, Evidence Table 4) 4370 Recommendation Table 5 — Recommendations for drug treatment of patients with hypertriglyceridaemia (see also Supplementary data online, Evidence Table 5) 4372 Recommendation Table 6 — Recommendations for statin therapy in primary prevention for people with human immunodeficiency virus infection (see also Supplementary data online, Evidence Table 6) 4373 Recommendation Table 7 — Recommendations for statin therapy in patients receiving cancer therapy (see also Supplementary data online, Evidence Table 7) 4373 Recommendation Table 8 — Recommendations for dietary supplements (see also Supplementary data online, Evidence Table 8) 4374 Table 1 Classes of recommendations 4362 Table 2 Levels of evidence 4362 Table 3 Cardiovascular risk categories 4364 Table 4 Intervention strategies as a function of total cardiovascular risk and untreated low-density lipoprotein cholesterol levels 4365 Figure 1 Treatment goals for low-density lipoprotein cholesterol across categories of total cardiovascular risk 4366 Figure 2 Average reduction in low-density lipoprotein cholesterol levels with different pharmacological therapies with proven cardiovascular benefits 4368 Figure 3 Association between Lp(a) levels and lifetime risk of major cardiovascular events 4371 Acute coronary syndromes Alanine aminotransferase Apolipoprotein B Apolipoprotein C-III Antiretroviral therapy Atherosclerotic cardiovascular disease Aspartate aminotransferase Aortic valve stenosis Coronary artery calcium Confidence interval Computed tomography Cardiovascular Cardiovascular disease Docosahexaenoic acid European Atherosclerosis Society European Medicines Agency Eicosapentaenoic acid European Society of Cardiology Familial chylomicronaemia syndrome US Food and Drug Administration Familial hypercholesterolaemia High-density lipoprotein cholesterol Human immunodeficiency virus Hazard ratio Low-density lipoprotein cholesterol Lipoprotein(a) Left ventricular ejection fraction Monoclonal antibody Major adverse cardiovascular event(s) Myocardial infarction Percutaneous coronary intervention Proprotein convertase subtilisin/kexin type 9 Peroxisome proliferator-activated receptor n-3 polyunsaturated fatty acid People with HIV Systematic Coronary Risk Evaluation 2 Systematic Coronary Risk Evaluation 2-Older Persons Total cholesterol Type 1 diabetes mellitus Type 2 diabetes mellitus Upper limit of normal Guidelines evaluate and summarize available evidence with the aim of assisting health professionals in proposing the best diagnostic or therapeutic approach for an individual patient with a given condition. The European Society of Cardiology (ESC) Guidelines are intended for use by health professionals but do not override their individual responsibility to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with the patient or the patient's caregiver where appropriate and/or necessary aiming at shared care decisions. It is also the health professional's responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription and to respect the ethical rules of their profession. The ESC Guidelines represent the official position of the ESC on a given topic. Guideline topics are selected for updating after annual expert review of new evidence conducted by the ESC Clinical Practice Guidelines (CPG) Committee. ESC Policies and Procedures for formulating and issuing the ESC Guidelines can be found on the ESC website (https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines). Interim
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“Importantly, the guidelines highlight that variability in LDL-C lowering is observed across all treatment options, likely reflecting differences in background LLT regimens [45].”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [45]
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“In line with this, they emphasize the importance of monitoring LDL-C response 4 to 6 weeks after initiation or intensification and making timely treatment adjustments to achieve recommended targets [45].”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [45]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The recent ESC/EAS 2025 Focused Update Guideline [9] emphasizes that elevated TG and TRLs contribute independently to cardiovascular risk, even in patients achieving LDL-C targets.”
From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [9]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The recent 2025 ESC/EAS Focused Update confirms this guidance, emphasizing the persistent role of statins as the cornerstone therapy for cardiovascular risk reduction in the presence of elevated TG, not only by targeting LDL-C but also by modulating TRLs and reducing the atherogenic potential of the lipid profile [9].”
From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [9]
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In the citing paper
“The recommendations position bempedoic acid alongside other established LLTs with demonstrated cardiovascular-risk reduction such as statins, ezetimibe, and PCSK9i.”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [45]
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In the citing paper
“Guidelines also recommend that the choice of treatment should not only be made based on the magnitude of additional LDL-C lowering needed, but also patient preference, treatment availability, and cost [45].”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [45]
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In the citing paper
“The 2025 ESC/EAS guidelines for the management of dyslipidemia provide new recommendations for bempedoic acid in both patients unable to take statins and as an adjunct to maximally tolerated statin therapy, with or without ezetimibe, including use in high- and very high-risk patients [45].”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [45]
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“the 2025 ESC/EAS Focused Update [9] emphasizes that consistent cardiovascular benefit has not been demonstrated in the overall population, and fibrate therapy should therefore be reserved for carefully selected patients with persistent hypertriglyceridaemia or features of atherogenic dyslipidemia despite optimal LDL-C lowering”
From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [9]
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“Overall, the joint guideline recognizes TG/TRL-mediated risk as a modifiable component of residual cardiovascular risk, addressed pragmatically through non–HDL-C/apoB targets and selective TG-lowering therapies integrated with intensive LDL-C reduction, with non-fasting testing as the default approach.”
From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [9]
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Mach, F., Baigent, C., Catapano, A. L., Koskinas, K. C., Casula, M., Badimon, L., Chapman, M. J., De Backer, G. G., Delgado, V., Ference, B. A., et al. (2020) · European Heart Journal · doi:10.1093/eurheartj/ehz455 · Cited by 8,961
Self-citationCholesterol Treatment Trialists' (CTT) Collaboration (2010) · The Lancet · doi:10.1016/s0140-6736(10)61350-5 · Cited by 6,550
2021 ESC Guidelines on cardiovascular disease prevention in clinical practice
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Self-citation2023 ESC Guidelines for the management of acute coronary syndromes
Byrne, R. A., Rossello, X., Coughlan, J. J., Barbato, E., Berry, C., Chieffo, A., Claeys, M. J., Dan, G.-A., Dweck, M. R., Galbraith, M., et al. (2023) · European Heart Journal · doi:10.1093/eurheartj/ehad191 · Cited by 5,333
Self-citationEzetimibe Added to Statin Therapy after Acute Coronary Syndromes
Cannon, C. P., Blazing, M. A., Giugliano, R. P., McCagg, A., White, J. A., Theroux, P., Darius, H., Lewis, B. S., Ophuis, T. O., Jukema, J. W., et al. (2015) · New England Journal of Medicine · doi:10.1056/nejmoa1410489 · Cited by 4,487
Ference, B. A., Ginsberg, H. N., Graham, I., Ray, K. K., Packard, C. J., Bruckert, E., Hegele, R. A., Krauss, R. M., Raal, F. J., Schunkert, H., et al. (2017) · European Heart Journal · doi:10.1093/eurheartj/ehx144 · Cited by 3,962
Self-citation2024 ESC Guidelines for the management of chronic coronary syndromes
Vrints, C. J., Andreotti, F., Koskinas, K. C., Rosselló, X., Adamo, M., Ainslie, J., BANNING, A. P., Budaj, A., Buechel, R. R., Chiariello, G. A., et al. (2024) · European Heart Journal · doi:10.1093/eurheartj/ehae177 · Cited by 3,521
Self-citationLyon, A. R., López‐Fernández, T., Couch, L. S., Asteggiano, R., Aznar, M. C., Bergler-Klein, J. K., Boriani, G., Cardinale, D. M., Córdoba, R., Cosyns, B., et al. (2022) · European Heart Journal · doi:10.1093/eurheartj/ehac244 · Cited by 3,457
Self-citationCardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia
Bhatt, D. L., Steg, P. G., Miller, M., Brinton, E. A., Jacobson, T. A., Ketchum, S. B., Doyle, R. T., Juliano, R. A., Jiao, L., Granowitz, C., et al. (2019) · New England Journal of Medicine · doi:10.1056/nejmoa1812792 · Cited by 3,317
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Metadata
- Authors
- Mach, F., Koskinas, K. C., Roeters van Lennep, J. E., Tokgözoğlu, L., Badimon, L., Baigent, C., Benn, M., Binder, C. J., Catapano, A. L., De Backer, G. G., Delgado, V., Fabin, N., Ference, B. A., Graham, I. M., Landmesser, U., Laufs, U., Mihaylova, B., Nordestgaard, B. G., Richter, D. J., Sabatine, M. S., ESC/EAS Scientific Document Group, Mueller, C. E., Drexel, H., Abreu, A., Adamo, M., Aktaa, S., Asselbergs, F. W., Baldini, A., Boriani, G., Brida, M., Brodmann, M., Cenko, E., Dagres, N., Dopheide, J., Ebenbichler, C., Gandjbakhch, E., Gorog, D. A., Gouni-Berthold, I., Guasti, L., Heidecker, B., Ibanez, B., James, S., Juni, P., Kałużna-Oleksy, M., Krychtiuk, K. A., Lip, G. Y. H., Lorusso, R., Mahfoud, F., Metra, M., Moelgaard, I., Morais, J., Neubeck, L., Nissen, S. E., Osto, E., Parhofer, K. G., De Isla, L. P., Pesce, M., Petrulioniene, Z., Prescott, E., Rietzschel, E., Rocca, B., Rodriguez Palomares, J. F., Rossello, X., Sannino, A., Semb, A. G., Siller-Matula, J. M., Socrates, T., Tanner, F. C., Wojta, J., Zambon, A., Zeppenfeld, K., Laredj, N., Hayrapetyan, H., Speidl, W. S., Samadov, F., van de Borne, P., Kusljugic, Z., Postadzhiyan, A., Heracleous, H., Ostadal, P., Henriksen, F. L., Mohamed, M. S., Viigimaa, M., Juonala, M., Boccara, F., Chukhrukidze, A., Weingärtner, O., Marketou, M., Kiss, R. G., Sigurdsson, A. F., Maher, V., Henkin, Y., Nodari, S., Bekbossynova, M., Ibrahimi, P., Mirrakhimov, E., Jegere, S., Arnaout, S., Bheleel, O., Plisiene, J., Visser, L., Abela, M., Ivanov, V., Boskovic, A., Mbarek, N., Leening, M. J. G., Bosevski, M., Vesterbekkmo, E. K., Kubica, J., Ferreira, J., Pop, D., Stefanelli, U. M., Giga, V., Pella, D., Fras, Z., Fernandez-Olmo, R., Nilsson, L., Sudano, I., Marjeh, M. Y. B., Triki, F., Degertekin, M. M., Mitchenko, O., Banerjee, A., & Shek, A.
- Affiliations
- (Switzerland)
- (Netherlands)
- (Türkiye)
- (Spain)
- (United Kingdom)
- (Denmark)
- (Austria)
- (Italy)
- (Belgium)
- (Ireland)
- (Germany)
- (Greece)
- (United States of America)
- (Portugal)
- (Croatia)
- (France)
- (Sweden)
- (Poland)
- (Austria/Switzerland)
- (Italy/Saudi Arabia)
- (Lithuania)
- (Norway)
- Corresponding author
- Mach, François
- Koskinas, Konstantinos C
- ORCID
- Mach, François
- Koskinas, Konstantinos C
- Roeters van Lennep, Jeanine E
- Tokgözoğlu, Lale
- Badimon, Lina
- Baigent, Colin
- Benn, Marianne
- Binder, Christoph J
- Catapano, Alberico L
- De Backer, Guy G
- Delgado, Victoria
- Fabin, Natalia
- Graham, Ian M
- Landmesser, Ulf
- Laufs, Ulrich
- Mihaylova, Borislava
- Nordestgaard, Børge Grønne
- Richter, Dimitrios J
- Sabatine, Marc S
- Mueller, Christian Eugen
- Drexel, Heinz
- Abreu, Ana
- Adamo, Marianna
- Aktaa, Suleman
- Asselbergs, Folkert W
- Boriani, Giuseppe
- Brida, Margarita
- Brodmann, Marianne
- Cenko, Edina
- Dagres, Nikolaos
- Dopheide, Jörn
- Ebenbichler, Christoph
- Gandjbakhch, Estelle
- Gorog, Diana A
- Guasti, Luigina
- Heidecker, Bettina
- James, Stefan
- Krychtiuk, Konstantin A
- Lip, Gregory Y H
- Lorusso, Roberto
- Mahfoud, Felix
- Metra, Marco
- Neubeck, Lis
- Nissen, Steven E
- Osto, Elena
- Parhofer, Klaus G
- Pesce, Maurizio
- Prescott, Eva
- Rietzschel, Ernst
- Rocca, Bianca
- Sannino, Anna
- Semb, Anne Grete
- Siller-Matula, Jolanta M
- Socrates, Thenral
- Tanner, Felix C
- Wojta, Johann
- Zambon, Alberto
- Zeppenfeld, Katja
- Hayrapetyan, Hamlet
- Speidl, Walter Stefan
- Samadov, Fuad
- van de Borne, Philippe
- Postadzhiyan, Arman
- Henriksen, Finn Lund
- Juonala, Markus
- Boccara, Franck
- Chukhrukidze, Archil
- Weingärtner, Oliver
- Marketou, Maria
- Nodari, Savina
- Bekbossynova, Makhabbat
- Mirrakhimov, Erkin
- Bheleel, Osama
- Abela, Mark
- Ivanov, Victoria
- Leening, Maarten J G
- Bosevski, Marijan
- Vesterbekkmo, Elisabeth K
- Kubica, Jacek
- Ferreira, Jorge
- Pop, Dana
- Giga, Vojislav
- Pella, Daniel
- Sudano, Isabella
- Triki, Faten
- Mitchenko, Olena
- Banerjee, Amitava
- Shek, Aleksandr
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2025-08-29
- Volume
- 46
- Issue
- 42
- Pages
- 4359-4378
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W4413804012
- Cited by
- 688
- References
- 136
- Citations by year
- 2026: 601 · 2025: 87
- FWCI
- 649.14
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Heart Journal (publishedVersion)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion, other-oa)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion)
- Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion, other-oa)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- UCL Discovery (University College London) (submittedVersion)
- IrInSubria (University of Insubria) (submittedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
- Padua Research Archive (University of Padova) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- dyslipidemia, dyslipidemia management, cardiovascular risk prediction, LDL-C lowering therapy, acute coronary syndrome, lipoprotein(a), hypertriglyceridemia, HIV infection, cancer patients, statins, dietary supplements, treatment goals, cardiovascular risk reduction, cardiovascular mortality, cardiovascular hospitalization, cardiovascular disease prevention
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