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Total CV risk assessment

See Table 4

Baseline LDL-C levels

Lifestyle advice / Lifestyle intervention Define treatment goal

See Table 7

LDL-C goal reached?

LDL-C goal reached?

Follow-up Annually, or more frequently

if indicated Add ezetimibe

Follow-up Annually, or more frequently

if indicated Add PCSK9 inhibitor

High potency statin at highest recommended / tolerable dose to reach the goal Indication for drug therapy?

See Table 5

In selected low- and moderate-risk patients

Risk modifiers imaging (subclinical atherosclerosis)

Risk Reclassification?

• Secondary prevention (very-high-risk) • Primary prevention: patients with FH and another major risk factor (very-high risk)

Consider adding PCSK9 inhibitor • Primary prevention: patients at very-high risk but without FH (see Table 4)

Y N

Y N

Y N

Treatment goal

for LDL-C

Low

& ≥50% reduction from baseline

Moderate High Very high CV Risk

• SCORE <1%

•  SCORE ≥1% and <5% •  Young patients (T1DM <35 years; T2DM <50 years) with DM duration <10 years without other risk factors

• SCORE ≥5% and <10% • Markedly elevated single risk factors, in particular TC >8 mmol/L (310 mg/dL) or LDL-C >4.9 mmol/L (190 mg/dL) or BP ≥180/110 mmHg • FH without other major risk factors • Moderate CKD (eGFR 30–59 mL/min) • DM w/o target organ damage, with DM duration ≥10 years or other additional risk factor

• ASCVD (clinical/imaging) • SCORE ≥10% • FH with ASCVD or with another major risk factor • Severe CKD (eGFR <30 mL/min) • DM & target organ damage: ≥3 major risk factors; or early onset of T1DM of long duration (>20 years)

3.0 mmol/L (116 mg/dL)

2.6 mmol/L (100 mg/dL)

1.8 mmol/L (70 mg/dL)

1.4 mmol/L (55 mg/dL) Low Moderate High Very High

A

B

Figure 4 (A) Treatment algorithm for pharmacological low-density lipoprotein cholesterol lowering. (B) Treatment goals for low-density lipoprotein cholesterol across categories of total cardiovascular disease risk. ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; FH = familial hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol; PCSK9 = proprotein convertase subtilisin/kexin type 9; SCORE = Systematic Coronary Risk Estimation; T1DM = type 1 DM; T2DM = type 2 DM; TC = total cholesterol. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026