Dr Carlos Brotons – Sardenya Primary Health Care Center, Barcelona, Spain

What do the 2016 ESC Guidelines on cardiovascular risk and elevated lipids say and what are the implications for primary care?

In 2016, updated versions of both the ESC Guidelines on CVD prevention and ESC/EAS Guidelines for the management of dyslipidaemia were published. Similar to previous years, it is recommended to assess CV risk using the SCORE risk tool, with adapted risk categories for high- and low-risk countries. After risk assessment, LDL-c level is the main focus of treatment of dyslipidaemia, and it is also used as a therapeutic target.
Some changes in these updated guidelines are seen with regard to which patients should be considered to be at high and very high risk. In certain situation, the guidelines have changed as compared to previous versions with respect to advising lower LDL-c goals in certain high-risk patients.
Concerning HDL-c levels; low levels can be an indicator of risk, but it is currently not a treatment target.
 
Statins remain the cornerstone of therapy of dyslipidaemias. Unfortunately, some patients do not tolerate statins, and it was discussed how patients may be re-challenged and/or given a different dosing scheme or a different statin. If statin therapy is not tolerated, or when maximally tolerated statin therapy does not sort adequate LDL-c lowering, other therapies may be needed. Bile acid sequestrants, fibrates or ezetimibe are non-statin lipid-lowering agents that may be used in primary care. In very high-risk patients, such as those with coronary artery disease or familial hypercholesterolaemia, the newly available PCSK9 antibodies may be used. Very recently, the first CV outcome trial with the PCSK9 inhibitor evolocumab was published, which showed a 15% reduction in the primary composite outcome (CV death, MI, stroke, hospitalisation for unstable angina or coronary revascularisation) and 20% in the harder secondary endpoint of CV death, MI or stroke.
Shared decision-making is important at all stages of management; also because patient preferences may change over time. In the elderly, more attention may need to be given to multimorbidity, and the benefit of treatment should be considered in light of possible adverse effects and life expectancy.