Impact of revised 2025 ESC/EAS guidelines for the management of dyslipidaemias in the community

Introduction In 2025, ESC/EAS issued an update of the 2019 guidelines for the management of dyslipidemias (also updating 2021 ESC guidelines on cardiovascular disease (CVD) prevention), strengthening the role of fixed LDL-cholesterol thresholds and expanding criteria for initiating lipid-lowering therapy (LLT). We evaluated the population-level impact of these changes in the general population compared to 2019/2021 guidelines. Purpose To establish eligibility for lipid-lowering therapy under 2025 ESC/EAS dyslipidemia guidelines compared to 2019/2021 ones, and to assess baseline characteristics and incident atherosclerotic CVD (ASCVD) events according to eligibility. Methods We used data from a prospective cohort. People free of ASCVD at baseline were classified into risk categories using SCORE2/SCORE2-OP with age-specific thresholds (2021) and fixed thresholds (2025) of risk. Eligibility for LLT was then determined according to each guideline. Result Among 5,010 participants without ASCVD at baseline, the proportion eligible for LLT increased from 35.2% under the 2019/2021 guidelines to 72.9% under 2025 ones. Out of 321 incidents ASCVD events, the proportion that occurred in people eligible for LLT rose from 68.2% (2019/2021) to 88.5% (2025). Sex-specific analyses showed that 45.3% and 83.5% of incident ASCVD events occurred in females eligible for LLT under the 2019/2021 and 2025 guidelines, respectively. In males, corresponding numbers were 81.4% (2019/2021) and 91.2% (2025). Conclusion 2025 guidelines better identify people eligible for LLT that will develop an ASCVD. However, almost 3 out of 4 people aged 40-75 years would be eligible to receive a LLT, largely questioning the precision of the eligibility criteria, and the population and economic impacts of those guidelines.