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Prevention has experienced enormous progress over the last decades with the development of effective antihypertensive drugs and then aspirin and statins1 as outlined in the most recent ESC Guidelines.2 More recently, new drugs improving outcome such as the proprotein convertase subtilisin/kexin type 9 or PCSK9 inhibitors3–5 for high risk patients with markedly elevated LDL cholesterol (LDL-C) levels and the sodium/glucose transport inhibitors for diabetes have been introduced. Thus, the Consensus Statement entitled ‘European Society of Cardiology/European Atherosclerosis Society Task Force consensus statement on proprotein convertase subtilisin/kexin type 9 inhibitors: practical guidance for use in patients at very high cardiovascular risk’6 is a timely document. Indeed, monoclonal antibodies targeting PCSK9, a member of the serine protease family which regulates hepatic LDL receptors, are highly efficacious in lowering LDL-C. These treatments were recently approved in many European countries, albeit with some restrictions due to the high costs. The patient groups prioritized for treatment are those with established atherosclerotic cardiovascular disease (either clinical or unequivocal on imaging), including patients with rapidly progressive disease, diabetes with target organ damage or with a major risk factor, patients with familial hypercholesterolaemia without atherosclerotic cardiovascular disease, but with substantially elevated LDL-C levels, as well those with verified statin intolerance. Clinical algorithms focus on suggested pre-treatment requirements with statin and ezetimibe therapy, and LDL-C thresholds before consideration of PCSK9 inhibition. These recommendations aim to identify very high-risk patients who are likely to approach the LDL-C goal as a consequence of at least 50% lowering of LDL-C levels and thus likely to derive a relevant reduction in absolute cardiovascular risk, while also taking account of financial restraints in healthcare budgets. The Consensus Statement is put into perspective in an Editorial by Marc S. Sabatine from the Brigham and Women’s Hospital in Boston, MA, USA.7
