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Table 3 New recommendations, and new and revised concepts

New recommendations Cardiovascular imaging for assessment of ASCVD risk Assessment of arterial (carotid and/or femoral) plaque burden on arterial ultrasonography should be considered as a risk modifier in individuals at low or moderate risk. Cardiovascular imaging for assessment of ASCVD risk CAC score assessment with CT may be considered as a risk modifier in the CV risk assessment of asymptomatic individuals at low or moderate risk. Lipid analyses for CVD risk estimation 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. Drug treatments of patients with hypertriglyceridaemia In high-risk (or above) patients with TG between 1.5 and 5.6 mmol/L (135 - 499 mg/dL) despite statin treatment, n-3 PUFAs (icosapent ethyl 2  2g/day) should be considered in combination with statins. Treatment of patients with heterozygous FH 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. Treatment of dyslipidaemias in older people Treatment with statins is recommended for primary prevention, according to the level of risk, in older people aged <_75. Treatment of dyslipidaemias in older people Initiation of statin treatment for primary prevention in older people aged >75 may be considered, if at high risk or above. Treatment of dyslipidaemias in DM In patients with T2DM at very-high risk, an LDL-C reduction of >_50% from baseline and an LDL-C goal of <1.4 mmol/L (<55mg/dL) is recommended. In patients with T2DM at high risk, an LDL-C reduction of >_50% from baseline and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) is recommended. Statins are recommended in patients with T1DM who are at high or very-high risk. Treatment of dyslipidaemias in DM Intensification of statin therapy should be considered before the introduction of combination therapy. If the goal is not reached, statin combination with ezetimibe should be considered. Treatment of dyslipidaemias in DM Statin therapy is not recommended in pre-menopausal patients with DM who are considering pregnancy or not using adequate contraception. Lipid-lowering therapy in patients with ACS For patients who present with an ACS, and whose LDL-C levels are not at goal despite already taking a maximally tolerated statin dose and ezetimibe, adding a PCSK9 inhibitor early after the event (if possible, during hospitalization for the ACS event) should be considered. Changes in recommendations Upgrades

2016 2019

Lipid analyses for CVD risk estimation Lipid analyses for CVD risk estimation ApoB should be considered as an alternative risk marker whenever available, especially in individuals with high TG. ApoB analysis is recommended for risk assessment, particularly in

people with high TG, DM, obesity or metabolic syndrome, or very low LDL-C. 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, DM, obesity, or very low LDL-C.

Pharmacological LDL-C lowering Pharmacological LDL-C lowering If the LDL goal is not reached, statin combination with a cholesterol absorption inhibitor should be considered. If the goals are not achieved with the maximum tolerated dose of statin,

combination with ezetimibe is recommended.

Pharmacological LDL-C lowering Pharmacological LDL-C lowering In patients at very-high risk, with persistent high LDL-C despite treatment with maximal tolerated statin dose, in combination with ezetimibe or in patients with statin intolerance, a PCSK9 inhibitor may be considered. For secondary prevention, patients at very-high risk not achieving their goal on a maximum tolerated dose of statin and ezetimibe, a combination

with a PCSK9 inhibitor is recommended. For very-high-risk FH patients (that is, with ASCVD or with another major risk factor) who do not achieve their goals on a maximum tolerated dose of statin and ezetimibe, a combination with a PCSK9 inhibitor is recommended.

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