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..................................................................................... 20% of patients there may be discordance between measured LDL-C and ApoB levels.85,109

Considering the potential inaccuracy of LDL-C in dyslipidaemia, among patients with DM or high TG levels, and in patients with very low LDL-C levels, measurement of both ApoB and non-HDL-C is recommended as part of routine lipid analysis for risk evaluation in patients with elevated plasma TGs. Because ApoB provides an accurate estimate of the total concentration of atherogenic particles under all circumstances, it is the preferred measurement to further refine the estimate of ASCVD risk that is modifiable by lipid-lowering therapy. Lp(a) has a similar structure to plasminogen and binds to the plasminogen receptor, leading to increased thrombosis (pro-thrombotic factor). Measurement of Lp(a) should be considered at least once in each person’s lifetime, if available, to identify people who have inherited an extremely elevated level of Lp(a) >_180 mg/dL (>_430 nmol/L) and therefore have a very high lifetime risk of ASCVD that is approximately equivalent to the risk associated with HeFH. In addition, this strategy can identify people with less-extreme Lp(a) elevations who may be at a higher risk of ASCVD, which is not reflected by the SCORE system, or by other lipid or lipoprotein measurements. Measurement of Lp(a) has been shown to provide clinically significant improved risk reclassification under certain conditions, and therefore should be considered in patients who have an estimated 10-year risk of ASCVD that is close to the threshold between high and moderate risk.110112 Recommendations for measuring lipids and lipoproteins to estimate the risk of ASCVD are summarized below. 6 Treatment targets and goals

In previous EAS/ESC Guidelines for the management of dyslipidaemias1,113 and other major guidelines on the treatment of blood cholesterol to reduce atherosclerotic CV risk in adults,40,114 the importance of LDL-C lowering to prevent ASCVD is strongly emphasized. The European Task Force felt that limiting the current knowledge on CV prevention only to results from RCTs reduces the exploitation of the potential that is available for the prevention of ASCVD. It is the concordance of the conclusions from many different approaches (from basic science, clinical observations, genetics, epidemiology, RCTs, etc.) that contributes to the understanding of the causes of ASCVD and to the potential of prevention. The Task Force is aware of the limitations of some of the sources of evidence and accepts that RCTs have not examined different LDL-C goals systematically, but felt that it was appropriate to look at the totality of the evidence. Particular consideration was given to results from metaanalyses confirming the dose-dependent reduction in ASCVD with LDL-C-lowering agents; the greater the absolute LDL-C reduction, the greater the CV risk reduction.35,36,50,115 The benefits related to LDL-C reduction are not specific for statin therapy.33 No level of LDL-C below which benefit ceases or harm occurs has been defined. There is considerable individual variability in the LDL-C response to dietary and drug treatments,31 which is traditionally taken to support a tailored approach to management. Total CV risk reduction should be individualized, and this can be more specific if goals are defined. The use of goals can also aid patientdoctor communication. It is judged that a goal approach may facilitate adherence to

Recommendations for lipid analyses for cardiovascular disease risk estimation

Recommendations Classa Levelb

TC is to be used for the estimation of total CV risk by means of the SCORE system. I C HDL-C analysis is recommended to further refine risk estimation using the online SCORE system. I C LDL-C analysis is recommended as the primary lipid analysis method for screening, diagnosis, and management. I C TG analysis is recommended as part of the routine lipid analysis process. I C Non-HDL-C evaluation is recommended for risk assessment, particularly in people with high TG levels, DM, obesity, or very low LDL-C levels. I C ApoB analysis is recommended for risk assessment, particularly in people with high TG levels, DM, obesity, metabolic syndrome, or very low LDL-C levels. It can be used as an alternative to LDL-C, if available, as the primary measurement for screening, diagnosis, and management, and may be preferred over non-HDL-C in people with high TG levels, DM, obesity, or very low LDL-C levels. I C Lp(a) measurement should be considered at least once in each adult person’s lifetime to identify those with very high inherited Lp(a) levels >180 mg/dL (>430 nmol/L) who may have a lifetime risk of ASCVD equivalent to the risk associated with heterozygous familial hypercholesterolaemia. IIa C Lp(a) should be considered in selected patients with a family history of premature CVD, and for reclassification in people who are borderline between moderate and high-risk. IIa C

Apo = apolipoprotein; ASCVD = atherosclerotic cardiovascular disease; CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; Lp(a) = lipoprotein(a); SCORE = Systematic Coronary Risk Estimation; TC = total cholesterol; TG = triglyceride. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026