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................................................................. triglycerides are >10 mmol/L (900 mg/dL), they must be reduced not only by drugs, but also by restriction of alcohol, treatment of DM, withdrawal of oestrogen therapy, etc. In patients with severe primary hypertriglyceridaemia, referral to a specialist must be considered. An evidence-based approach to the use of lipid-lowering nutraceuticals could improve the quality of the treatment, including therapy adherence, and achievement of the LDL-C goal in clinical practice. However, it has to be clearly stressed that there are still no outcome studies proving that nutraceuticals can prevent CVD morbidity or mortality.532 4.6.4 Important groups 4.6.4.1 Women The proportional reductions per mmol/L reduction in LDL-C in major vascular events, major coronary events, coronary revascularization, and stroke are similar in women and men. In addition, the relative effects of non-statin drugs that lower LDL-C (ezetimibe and PCSK9 inhibitors, on top of high-intensity statin therapy) are also similar in both women and men.3 4.6.4.2 Older patients (70 years) Compared to the 2019 ESC/EAS dyslipidaemia guidelines,3 we provide a single cut-off for identifying ‘older persons’ as those >_70 years of age, as opposed to 75 years, for reasons of consistency with other parts of the current guidelines. As a result, class and level of evidence have been modified in some age groups, in particular the category of patients between 70 and 75 years. Although a single age cut-off is now used, it is important to stress that all such age cut-offs are relatively arbitrary, and biological age influences this threshold in clinical practice. For example, a very fit 75-year-old person may qualify for a treatment normally reserved for those <70 and, conversely, a very frail 65-year-old person should sometimes be considered ‘older’. General recommendations for lipid-lowering treatment in older patients are summarized below. Recent evidence has strengthened the role of LDL-C as an ASCVD risk factor in older patients.537 Evidence from trials indicates that statins and other lipid-lowering drugs produce significant reductions in major vascular events irrespective of age.538,539 However, there is less direct evidence of statin benefit in those without evidence of ASCVD. Under the age of 70 years, statins are recommended for primary prevention depending on the level of risk. Above that age, initiation of statin treatment for primary prevention may be considered when at (very) high risk, but we explicitly recommend also taking other arguments into account, such as risk modifiers, frailty, estimated life-time benefit, comorbidities, and patient preferences (see section 3.2.3.3 and Figure 12). In case of renal function impairment or risk for drug interactions, the statin dose should be up-titrated carefully. In terms of LDL-C targets, there is insufficient evidence to support targets for primary prevention in older patients. Although the conventional LDL-C target of <2.6 mmol/L (100 mg/dL) may seem reasonable, the results of ongoing primary prevention trials in older patients must be awaited [STAREE (STAtin Therapy for Reducing Events in the Elderly) trial; clinicatrials. gov registration: NCT02099123]. Frailty, polypharmacy, and muscle symptoms remain relevant factors to consider in older patients. 4.6.4.3 Diabetes mellitus Lowering of LDL-C in patients with DM is consistently associated with lower CVD risk. Similar to prevention in apparently healthy individuals, we propose a stepwise approach to lipid control, dependent on risk, estimated lifetime benefit, comorbidities, and patient preferences (Figure 8). PCSK9 inhibitors can also be used in patients with DM not reaching their LDL-C targets with statins and/ or ezetimibe. Recommendations for the treatment of dyslipidaemias in older people (70 years). Recommendations Classa Levelb Treatment with statins is recommended for older people with ASCVD in the same way as for younger patients.538,539 I A Initiation of statin treatment for primary prevention in older people aged >_70 may be considered, if at high risk or above.538,539 IIb B It is recommended that the statin is started at a low dose if there is significant renal impairment and/or the potential for drug interactions. I C ASCVD = atherosclerotic cardiovascular disease. aClass of recommendation. bLevel of evidence. Adapted from 3 ............................................................................................................ Recommendations for drug treatments of patients with hypertriglyceridaemia. Recommendations Classa Levelb Statin treatment is recommended as the first drug of choice for reducing CVD risk in high-risk individuals with hypertriglyceridaemia [triglycerides >2.3 mmol/L (200 mg/dL)].533 I A In patients taking statins who are at LDL-C goal with triglycerides >2.3 mmol/L (200 mg/dL), fenofibrate or bezafibrate may be considered.534536 IIb B In high-risk (or above) patients with triglycerides >1.5 mmol/L (135 mg/dL) despite statin treatment and lifestyle measures, n-3 PUFAs (icosapent ethyl 2 2 g/day) may be considered in combination with a statin.84 IIb B CVD = cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; PUFA = polyunsaturated fatty acid. aClass of recommendation. bLevel of evidence. Adapted from 3 Recommendations for the treatment of dyslipidaemias in diabetes mellitus. Recommendations Classa Levelb In patients with type 2 DM at very high risk (e.g. with established ASCVD and/or severe TODc), intensive lipid-lowering therapy, ultimatelyd aiming at >_50% LDL-C reduction and an LDL-C of <1.4 mmol/L (55 mg/dL) is recommended.21,22,522,540,541 I A Continued ESC 2021 ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026