Seventeen years to change practice: will the 2025 ESC/EAS dyslipidaemia guidelines finally break the Sisyphean cycle?

The 2025 Focused Update of the ESC/EAS Guidelines for the Management of Dyslipidemias modernizes guidelines on risk assessment, lipid-lowering treatments, and lipoprotein(a) management, and it incorporates modifications based on new data. The adopted SCORE2 and SCORE2-OP algorithms, which take into consideration both fatal and non-fatal events and extend risk prediction up to age 89, are crucial because they update cardiovascular risk assessment and rectify past underestimation of risk for women and younger persons. The extension of the pharmacological arsenal of lipid-lowering therapies with bempedoic acid, evinacumab, inclisiran, icosapent ethyl (and not mixtures with of eicosapentaenoic acid and docosahexaenoic acid) have enriched the arsenal of LDL-cholesterol and triglyceride-lowering drugs. In the case of acute coronary syndromes there is a move away from a sequential strategy to promoting quick LDL-cholesterol lowering to ensure early LDL-C goal attainment. Therefore, the guidelines recommend immediate initiation of high-intensity statin with ezetimibe for most patients with acute coronary syndrome or the immediate intensification of the therapy in those who are already on lipid-lowering drugs at the acute event. The update is in line with the EAS's requests for systematic lipoprotein(a) testing and risk management by recommending universal lipoprotein(a) assessment at least once in adulthood and highlighting its significance in risk classification. This update also has weaknesses, including missed opportunities to promote a more courageous approach for combination therapies, limitations in the diabetes risk classification, and discrepancies across ESC guideline papers which hopefully will be overcome in the next full update. Since real-world clinical adoption is far slower than evidence creation, implementation lags remain a Sisyphean obstacle, highlighting the ongoing need for standardized, practical guidelines in conjunction with initiatives to speed up normal practice change.