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............................................................................................................................................................................. 4.6.1.2 Low-density lipoprotein cholesterol measurement LDL-C can be measured directly, but in most studies and many laboratories, LDL-C is calculated using the Friedewald formula:

• In mmol/L: LDL-C = total cholesterol  HDL-C  (0.45  triglycerides) • In mg/dL: LDL-C = total cholesterol  HDL-C  (0.2  triglycerides)

The calculation is only valid when the concentration of triglycerides is <4.5 mmol/L (400 mg/dL), and not precise when LDL-C is very low [<1.3 mmol/L (50 mg/dL)]. In patients with low LDL-C levels and/or hypertriglyceridaemia (<_800 mg/dL), alternative formulae are available511,512 or LDL-C can be measured directly.

4.6.1.3 Non-high-density lipoprotein cholesterol The non-HDL-C value is calculated by subtracting HDL-C from total cholesterol. Non-HDL-C, unlike LDL-C, does not require the triglyceride concentration to be <4.5 mmol/L (400 mg/dL). It also has an advantage in that it is accurate in a non-fasting setting, and may be more accurate in patients with DM. There is evidence for a role of non-HDL-C as a treatment target as it captures the information regarding all apolipoprotein-B-containing lipoproteins.513 We suggest it as a reasonable alternative treatment goal for all patients, particularly for those with hypertriglyceridaemia or DM. How non-HDL-C levels correspond to commonly used LDL-C goals is shown in Table 10.

4.6.1.4 Apolipoprotein B Apolipoprotein B provides a direct estimate of the total concentration of atherogenic lipid particles, particularly in patients with elevated triglycerides. However, on average, the information conferred by apolipoprotein B is similar to that of calculated LDL-C.514 How apolipoprotein B levels correspond to commonly used LDL-C goals is shown in Table 10.

4.6.2 Defining lipid goals 4.6.2.1 Low-density lipoprotein cholesterol goals

LDL-C goals are summarized in the recommendations below. As not all drugs are tolerated or available/affordable, treatment should focus on achieving LDL-C levels as close as possible to the given goals. Treatment should be a shared decision-making process between physicians and the patient. As explained earlier in these guidelines (section 3.2.3.1), we propose a stepwise approach to treatment goals, also for LDL-C (Figures 68). This approach may seem novel but, in reality, resembles clinical practice, where treatment intensification is considered based on anticipated benefit, side-effects, and—importantly—patient preferences. The ultimate lipid goals are the same as in the 2019 ESC/EAS dyslipidaemia Guidelines.3 Evidence from glucose-lowering treatment studies indicates that stepwise treatment does not compromise goal attainment, and is associated with fewer side-effects and higher patient satisfaction.66,67 In specific cases (at very high risk), the physician may opt to merge both steps and proceed directly to the low LDL-C target level of STEP 2. In apparently healthy people, lifetime treatment benefit of LDL-C reduction may play a role in shared decision-making, together with risk modifiers, comorbidities, patient preference, and frailty. Figure 12 may support decision-making, as it shows the estimated lifetime benefits in years-free-of-CVD in relation to the total CVD risk profile, calibrated in low-to-moderate CVD risk countries.

After STEP 1, treatment intensification with STEP 2 must be considered in all patients. Given that lower is better, we encourage liberal intensification of treatment, particularly if submaximal doses of (lowcost) generic statins are used and side-effects are not apparent. The treatment goal of LDL-C <1.4 mmol/L (55 mg/dL) in STEP 2, in patients with established ASCVD or without ASCVD but at very high risk, is lower than the lowest LDL-C goal of 1.8 mmol/L (70 mg/ dL) in the 2016 ESC prevention Guidelines.2 This low goal was established based on data from recent Mendelian randomization studies,80 meta-analyses from the Cholesterol Treatment Trialists’ Collaboration,21 RCTs such as IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial),515 and—more recently—proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor clinical outcome studies.516518 The class and level of evidence supporting this LDL-C target of <1.4 mmol/L (55 mg/dL) for patients with ASCVD is identical to that in the recent ESC/EAS dyslipidaemia guidelines.3 For primary prevention in very-high-risk patients, however, the class of recommendation is lower (Class I in the dyslipidaemia guidelines, Class IIa in the current guidelines), because the Task Force was less unanimous with regards to this low LDL-C target in the primary prevention context. For patients with ASCVD who experience a second vascular event within 2 years (not necessarily of the same type as the first) while taking maximum tolerated statin-based therapy, an even lower LDL-C goal of <1.0 mmol/L (40 mg/dL) may be considered. Importantly, there are no differences in the RR reductions between men and women and between younger and older patients (at least up to age 75 years), or between those with and without DM.3

4.6.2.2 Triglyceride-rich lipoproteins and their remnants There are no treatment goals for triglycerides, but <1.7 mmol/L (150 mg/dL) is considered to indicate lower risk, whereas higher levels indicate a need to look for other risk factors.

4.6.2.3 High-density lipoprotein cholesterol To date, no specific goals for HDL-C levels have been determined in clinical trials, although low HDL-C is associated with (residual) risk in ASCVD patients. PA and other lifestyle factors, rather than drug treatment, remain important means of increasing HDL-C levels.

Recommendation on low-density lipoprotein cholesterol goalsa Recommendation Classb Levelc A stepwise treatment-intensification approach is recommended for apparently healthy people at high or very high CVD risk, as well as patients with established ASCVD and/or DM with consideration of CVD risk, treatment benefit, risk modifiers, comorbidities, and patient preferences. I C

ASCVD = atherosclerotic cardiovascular disease; DM = diabetes mellitus. aRecommendation from section 3.2. bClass of recommendation. cLevel of evidence. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026