Dyslipidemia Management (ESC/EAS 2019)

Algorithm Steps

1. ▶

   Start

   Assess CV Risk

   SCORE2 or SCORE2-OP

   1. ◆

      Decision

      CV Risk Category

      Determines LDL target

      1. ●

         Action

         Very High Risk

         LDL <55 mg/dL + ≥50% reduction

         • ASCVD documented
         • DM + target organ damage
         • Severe CKD (eGFR <30)
         • SCORE2 ≥7.5% (≥50yo)
         1. ⚠

            Warning

            Recurrent Event <2y

            LDL <40 mg/dL

            1. ●

               Action

               Step 1: High-Intensity Statin

               First-line therapy

               • Atorvastatin 40-80mg
               • Rosuvastatin 20-40mg
               • Recheck in 4-6 weeks
               1. ●

                  Action

                  Step 2: Add Ezetimibe

                  If not at target

                  • Ezetimibe 10mg daily
                  • +15-20% LDL reduction
                  1. ●

                     Action

                     Step 3: Add PCSK9 Inhibitor

                     If still not at target

                     • Evolocumab or Alirocumab
                     • +50-60% LDL reduction
                     • Consider in-hospital initiation post-ACS
                     1. ✓

                        Outcome

                        Monitor & Maintain

                        Annual lipid panel, adherence check

               2. ⚠

                  Warning

                  Statin Intolerant

                  Alternative strategies

                  • Alternate statin/lower dose
                  • Bempedoic acid
                  • Inclisiran (siRNA)
                  • PCSK9i monotherapy
      2. ●

         Action

         High Risk

         LDL <70 mg/dL + ≥50% reduction

         • Single major RF markedly elevated
         • FH without ASCVD
         • DM ≥10y or with RF
         • SCORE2 2.5-7.5%
      3. ●

         Action

         Moderate Risk

         LDL <100 mg/dL

         • Young DM (<35yo T1, <50yo T2)
         • DM <10y without RF
         • SCORE2 1-2.5%
      4. ●

         Action

         Low Risk

         LDL <116 mg/dL

         • SCORE2 <1%