What’s new in the 2025 ESC/EAS Guideline Update for Dyslipidaemia Management

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The 2025 Focused Update¹ of the 2019 European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) Guidelines² for the management of dyslipidaemias reviewed the latest evidence and provided new recommendations based on compelling and practice-changing evidence.

Here is a summary of key updates.

Estimating cardiovascular risk

The new guideline provides updated definitions for extreme, very high, high, moderate, and low cardiovascular (CV) risk, using the SCORE2/SCORE2-OP instead of the previous SCORE algorithm from the 2019 ESC/EAS Guidelines.²

The SCORE2/SCORE2-OP tools incorporate non-HDL cholesterol, providing a more precise lifetime risk assessment up to age 89. These risk scores guide the treatment goal for each risk group.
Clinical conditions/demographics (e.g., family history, obesity, and HIV) and selected biomarkers (e.g., elevated Lipoprotein (a) [Lp(a)] or high-sensitivity C-reactive protein) are considered risk modifiers that may support reclassifying an individual to a higher risk category.
For clinicians, this means better identification of patients who appear to be at moderate risk on paper but are actually at high risk and require earlier intervention.

Recommendation framework
Class of recommendation	Level of evidence
I: Recommended or indicated IIa: Should be considered IIb: May be considered III: Not recommended	A: Data derived from multiple randomized clinical trials or meta-analyses B: Data derived from a single randomized clinical trial or large non-randomized studies C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries

Recommendations for new LDL-C lowering therapies (see Recommendation Table 2):

Recommendations incorporate data from the bempedoic acid clinical development program including CLEAR Outcomes in which bempedoic acid reduced CV events in statin-intolerant patients at high risk of CV events compared to placebo.
Evinacumab data has been incorporated into the guidelines specifically for patients with homozygous familial hypercholesterolemia

Class I, Level A	Class I, Level B	Class IIa, Level C	Class IIa, Level B
Non-statin therapies (including bempedoic acid)	Bempedoic acid	Bempedoic acid combination	Evinacumab
Alone or in combination, for patients unable to take statin therapy to lower LDL-C levels and reduce the risk of CV events. The choice should be based on the magnitude of additional LDL-C lowering needed.	For patients unable to take statin therapy to achieve the LDL-C goal.	The addition of bempedoic acid to the maximally tolerated dose of statin with or without ezetimibe for patients at high or very high risk in order to achieve the LDL-C goal.	For patients with homozygous familial hypercholesterolaemia, aged 5 years or older, who are not at LDL-C goal despite receiving maximum doses of lipid-lowering therapy to lower LDL-C levels.

Recommended combination therapies in acute coronary syndromes

The 2025 update recommends starting statins immediately for every patient with acute coronary syndrome (ACS) and combination treatment with one or more classes of non-statin therapy with proven CV benefit as needed, whether or not the patient was already on therapy before the event.
The 2025 update proposes a ‘strike early and strong’ approach for patients with or without pre-existing lipid-lowering therapy at the time of the ACS event (see Recommendation Table 3):

Class I, Level C	Class IIa, Level B
Intense lipid-lowering therapy	High-intensity statin plus ezetimibe
Intensification of lipid-lowering therapy during the index ACS hospitalization for patients on any lipid-lowering therapy before admission to further lower LDL-C levels.	Initiating combination therapy with high-intensity statin plus ezetimibe during index hospitalization for ACS for patients who were treatment-naïve and are not expected to achieve the LDL-C goal with statin therapy alone.

Recommendations for measurement of lipoprotein(a)

Lp(a) measurement should be considered at least once in every adult’s lifetime, with focused screening for those with familial hypercholesterolaemia, premature ASCVD, family history, or in moderate risk.
Lp(a) levels may increase after menopause, and a second measurement is reasonable, particularly if the pre-menopausal levels were borderline.
Class IIa, level B recommendation: Lp(a) levels above 50 mg/dL (105 nmol/L) should be considered in all adults as a CV risk-enhancing factor, with higher Lp(a) levels associated with a greater increase in risk.

Recommendations for hypertriglyceridaemia

Class IIa, Level B	Class IIa, Level B
High-dose icosapent ethyl plus statin	Volanesorsen
For high-risk or very high-risk patients with elevated triglyceride levels (fasting level 135–499 mg/dL or 1.52–5.63 mmol/L) to reduce the risk of cardiovascular events	For patients with severe hypertriglyceridaemia (>750 mg/dL or >8.5 mmol/L) due to familial chylomicronaemia syndrome to lower triglyceride levels and reduce the risk of pancreatitis.

Primary prevention recommendations for people with HIV

Pitavastatin validated for primary CV risk prevention in REPRIEVE trial.
Class I, level B recommendation: Statin therapy for people in primary prevention aged ≥40 years with HIV, irrespective of estimated CV risk and LDL-C levels; the choice of statin should be based on potential drug interactions.

Recommendations for patients with cancer at high cardiotoxicity risk

Anthracycline-based chemotherapy is associated with the development of heart failure in up to 20% of patients within 5 years.
STOP-CA study showed that atorvastatin helped preserve left ventricular function in lymphoma patients receiving anthracyclines.
Class IIa, level B recommendation for statins in adult patients at high or very high risk of developing chemotherapy-related CV toxicity to reduce the risk of anthracycline-induced cardiac dysfunction.

Recommendations for dietary supplements

No supplements or phytosterols recommended for CV risk reduction due to absence of compelling evidence in clinical trials.
Monacolins from red yeast rice are now restricted by European Commission regulation.
Class III, level B recommendation: Dietary supplements or vitamins without documented safety and significant LDL-C-lowering efficacy are not recommended to lower the risk of ASCVD.
Patients may think they’re “doing something healthy” with supplements; this guideline gives clinicians the evidence to reframe that conversation.

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Abbreviation

ACS, Acute coronary syndrome; ASCVD, Atherosclerotic cardiovascular disease; CV, Cardiovascular; HDL, High-density lipoprotein; HIV, Human immunodeficiency virus; LDL-C, Low-density lipoprotein cholesterol; Lp(a), Lipoprotein(a); MACE, Major adverse cardiovascular events.

References

François Mach, Konstantinos CK Koskinas, Jeanine E Roeters van Lennep, Lale Tokgözoğlu, Lina Badimon, Colin Baigent, Marianne Benn, Christoph J Binder, Alberico L Catapano, Guy G De Backer, Victoria Delgado, Natalia Fabin, Brian A Ference, Ian M Graham, Ulf Landmesser, Ulrich Laufs, Borislava Mihaylova, Børge Grønne Nordestgaard, Dimitrios J Richter, Marc S Sabatine, ESC/EAS Scientific Document Group , 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias: Developed by the task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS), European Heart Journal, 2025;, ehaf190, https://doi.org/10.1093/eurheartj/ehaf190
François Mach, Colin Baigent, Alberico L Catapano, Konstantinos C Koskinas, Manuela Casula, Lina Badimon, M John Chapman, Guy G De Backer, Victoria Delgado, Brian A Ference, Ian M Graham, Alison Halliday, Ulf Landmesser, Borislava Mihaylova, Terje R Pedersen, Gabriele Riccardi, Dimitrios J Richter, Marc S Sabatine, Marja-Riitta Taskinen, Lale Tokgozoglu, Olov Wiklund, ESC Scientific Document Group , 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS), European Heart Journal, Volume 41, Issue 1, 1 January 2020, Pages 111–188, https://doi.org/10.1093/eurheartj/ehz455