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Document Reviewers: Christian Mueller (ESC Review Coordinator) (Switzerland), Heinz Drexel (EAS Review Coordinator) (Austria), Victor Aboyans (France), Alberto Corsini1 (Italy), Wolfram Doehner (Germany), Michel Farnier (France), Bruna Gigante (Sweden), Meral Kayikcioglu1 (Turkey), Goran Krstacic (Croatia), Ekaterini Lambrinou (Cyprus), Basil S. Lewis (Israel), Josep Masip (Spain), Philippe Moulin1 (France), Steffen Petersen (United Kingdom), Anna Sonia Petronio (Italy), Massimo Francesco Piepoli (Italy), Xavier Pinto1 (Spain), Lorenz R€aber (Switzerland), Kausik K. Ray1 (United Kingdom), Zeljko Reiner1 (Croatia), Walter F. Riesen (Switzerland), Marco Roffi(Switzerland), Jean-Paul Schmid (Switzerland), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Erik Stroes1 (Netherlands), Isabella Sudano (Switzerland), Alexandros D. Tselepis1 (Greece), Margus Viigimaa1 (Estonia), Cecile Vindis (France), Alexander Vonbank (Austria), Michal Vrablik1 (Czech Republic), Mislav Vrsalovic (Croatia), Jose ́ Luis Zamorano Gomez (Spain), Jean-Philippe Collet (ESC CPG Supervisor) (France) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines

For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see https://academic.oup.com/eurheartj/article-lookup/doi/ 10.1093/eurheartj/ehz455#supplementary-data Online publish-ahead-of-print 31 August 2019

................................................................................................................................................................................................... Keywords Guidelines • dyslipidaemias • cholesterol • triglycerides • low-density lipoproteins • high-density lipoproteins • apolipoprotein B • lipoprotein(a) • lipoprotein remnants • total cardiovascular risk • treatment (lifestyle) • treatment (drugs) • treatment (adherence) • very low-density lipoproteins • familial hypercholesterolaemia

Table of contents

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 2.1 What is new in the 2019 Guidelines? . . . . . . . . . . . . . . . . . . . . . . . . 118 3 What is cardiovascular disease prevention? . . . . . . . . . . . . . . . . . . . . . . 118 3.1 Definition and rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 3.2 Development of the Joint Task Force Guidelines for the management of dyslipidaemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 4 Total cardiovascular risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 4.1 Total cardiovascular risk estimation . . . . . . . . . . . . . . . . . . . . . . . . . 118 4.1.1 Rationale for assessing total cardiovascular disease risk . . . 121 4.1.2 How to use the risk estimation charts . . . . . . . . . . . . . . . . . . . 124 4.2 Risk levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 4.2.1 Role of non-invasive cardiovascular imaging techniques in the assessment of total cardiovascular disease risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 4.2.2 Risk-based intervention strategies . . . . . . . . . . . . . . . . . . . . . . . 127 5 Lipids and lipoproteins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 5.1 Biological role of lipids and lipoproteins . . . . . . . . . . . . . . . . . . . . . . 127 5.2 Role of lipids and lipoproteins in the pathophysiology of atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 5.3 Evidence for the causal effects of lipids and lipoproteins on the risk of atherosclerotic cardiovascular disease . . . . . . . . . . . . . . . . 128

5.3.1 Low-density lipoprotein cholesterol and risk of atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 5.3.2 Triglyceride-rich lipoproteins and risk of atherosclerosis . 128 5.3.3 High-density lipoprotein cholesterol and risk of atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 5.3.4 Lipoprotein(a) and risk of atherosclerosis . . . . . . . . . . . . . . . 129 5.4 Laboratory measurement of lipids and lipoproteins . . . . . . . . . . 129 5.4.1 Lipoprotein measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 5.4.2 Lipid measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 5.4.3 Fasting or non-fasting? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 5.5 Recommendations for measuring lipids and lipoproteins to estimate risk of atherosclerotic cardiovascular disease . . . . . . . . . . . 130 6 Treatment targets and goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 7 Lifestyle modifications to improve the plasma lipid profile . . . . . . . . . 132 7.1 Influence of lifestyle on total cholesterol and low-density lipoprotein cholesterol levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 7.2 Influence of lifestyle on triglyceride levels . . . . . . . . . . . . . . . . . . . . 134 7.3 Influence of lifestyle on high-density lipoprotein cholesterol levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 7.4 Lifestyle recommendations to improve the plasma lipid profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

7.4.1 Body weight and physical activity . . . . . . . . . . . . . . . . . . . . . . . . 135 7.4.2 Dietary fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 7.4.3 Dietary carbohydrate and fibre . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.4.4 Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.4.5 Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.5 Dietary supplements and functional foods for the treatment of dyslipidaemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

7.5.1 Phytosterols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.5.2 Monacolin and red yeast rice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 7.5.3 Dietary fibre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 7.5.4 Soy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 7.5.5 Policosanol and berberine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 7.5.6 n-3 unsaturated fatty acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026