p.22 抽出テキスト

............................................................................................ treatment, although this consensus opinion has not been fully tested. For all these reasons, the European Task Force retains a goal approach to lipid management and treatment goals are tailored to the total CV risk level. There is also evidence suggesting that lowering of LDL-C beyond the goals that were set in the previous EAS/ESC Guidelines is associated with fewer ASCVD events.34,116,117

Therefore, it seems appropriate to reduce LDL-C to as low a level as possible, at least in patients at very high CV risk, and for this reason a minimum 50% reduction is suggested for LDL reduction, together with reaching the tailored goal. The lipid goals are part of a comprehensive CV risk reduction strategy and are summarized in Table 7. The rationales for the nonlipid targets are given in the 2016 ESC Joint Prevention Guidelines.10 The targeted approach to lipid management is primarily aimed at reducing atherosclerotic risk by substantially lowering LDL-C to levels that have been achieved in recent large-scale trials of PCSK-9 inhibitors. Therefore, for patients at very high CV risk, whether in secondary prevention or (rarely) in primary prevention, LDL-C reduction of >_50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) are recommended. For patients with ASCVD who experience a second vascular event within 2 years (not necessarily of the same type as the first event) while taking maximally tolerated statin-based therapy, an LDL-C goal <1.0 mmol/L (<40 mg/dL) may be considered.119,120 For people at high CV risk, an LDL-C reduction of >_50% from baseline and an LDL-C goal <1.8 mmol/L (<70 mg/dL) are recommended. In patients at moderate CV risk, an LDL-C goal <2.6 mmol/L (<100 mg/dL) should be considered, while for low-risk individuals a goal of <3.0 mmol/L (<116 mg/dL) may be considered (see Recommendations for treatment goals for low-density lipoprotein cholesterol below and Supplementary Table 2). Secondary goals have also been defined by inference for non- HDL-C and for ApoB; they receive a moderate grading, as they have not been extensively studied in RCTs. The specific goal for non- HDL-C should be 0.8 mmol/L (30 mg/dL) higher than the corresponding LDL-C goal; the adjustment of lipid-lowering therapy in accordance with these secondary goals may be considered in patients at very high CV risk after achievement of an LDL-C goal, although the clinical advantages of this approach with respect to outcomes remain to be addressed. When secondary targets are used the recommendations are: (i) non-HDL-C <2.2 mmol/L (<85 mg/dL), <2.6 mmol/L (<100 mg/dL), and <3.4 mmol/L (<130 mg/dL) in people at very high, high, and moderate CV risk, respectively;121123 and (ii) ApoB <65 mg/dL, <80 mg/dL, and <100 mg/dL in very-high, high, and moderate total CV risk, respectively.121,123,124

To date, no specific goals for HDL-C or TG levels have been determined in clinical trials, although increases in HDL-C predict atherosclerosis regression, and low HDL-C is associated with excess events and mortality in coronary artery disease (CAD) patients, even at low LDL levels. Clinicians should use clinical judgment when considering further treatment intensification in patients at high or very high total CV risk.

7 Lifestyle modifications to

improve the plasma lipid profile

The pivotal role of nutrition in the prevention of ASCVD has been extensively reviewed.125129 Dietary factors influence the development of CVD either directly or through their action on traditional risk factors, such as plasma lipids, BP, or glucose levels.

Recommendations for treatment goals for low-density lipoprotein cholesterol

Recommendations Classa Levelb In secondary prevention for patients at very-high risk,c an LDL-C reduction of >_50% from baselined and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) are recommended.3335,119,120 I A In primary prevention for individuals at very-high risk but without FH,c an LDL-C reduction of >_50% from baselined and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) are recommended.3436 I C In primary prevention for individuals with FH at very-high risk, an LDL-C reduction of >_50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) should be considered. IIa C For patients with ASCVD who experience a second vascular event within 2 years (not necessarily of the same type as the first event) while taking maximally tolerated statin-based therapy, an LDL-C goal of <1.0 mmol/L (<40 mg/dL) may be considered.119,120 IIb B In patients at high risk,c an LDL-C reduction of >_50% from baselined and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) are recommended.34,35 I A In individuals at moderate risk,c an LDL-C goal of <2.6 mmol/L (<100 mg/dL) should be considered.34 IIa A In individuals at low risk,c an LDL-C goal <3.0 mmol/L (<116 mg/dL) may be considered.36 IIb A

ASCVD = atherosclerotic cardiovascular disease; FH = familial hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol. aClass of recommendation. bLevel of evidence. cFor definitions see Table 4. dThe term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication. In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026