Atherosclerotic Cardiovascular Disease.pptx

Atherosclerotic Cardiovascular Disease

1. Atherosclerotic cardiovascular disease

2. Contents 1 Atherosclerosis and cardiovascular diseases 2 Role of lipids and inflammation in atherosclerotic cardiovascular disease 3 Management of atherosclerotic cardiovascular disease 4 Guidelines and recommendations

3. Atherosclerosis and cardiovascular diseases 1

4. Atherosclerosis is a lipoprotein-driven disease characterised by plaque formation at specific sites of the arterial tree 1 Atherosclerosis: definition LDL, low-density lipoprotein 1. Bentzon JF, et al. Circ Res 2014;114:1852–66; 2. University Health News. Available at: https://universityhealthnews.com/daily/heart-health/recognize-atherosclerosis-symptoms-that-indicate-heart-disease/ ; 3. Jebari-Benslaiman S, et al. Int J Mol Sci 2022;23:3346. Normal artery 2 Artery narrowed by plaque 2 Atherosclerosis is caused by abnormal lipoprotein levels, in particular high LDL levels, usually in combination with other risk factors 1 Plaque formation is initiated by endothelium activation, followed by a cascade of events leading to vessel narrowing and activation of inflammatory pathways 3

5. Directly damages arterial endothelium Pathophysiology of atherosclerosis (1) Dyslipidaemia 1 (LDL↑, Lp(a)↑, TG↑, HDL↓) Other risk factors Family history, hypertension, obesity, diabetes, older age (>45 years in men, >55 years in women), male gender, smoking, physical inactivity, diet 2,3 LDL diffuses across damaged endothelium and accumulates in the intima layer of the artery wall LDL in the intima is oxidised into lipids that trigger chronic inflammation in the vessel wall Inflammation recruits monocytes into the vessel wall, which then differentiate into macrophages ↑ Systemic markers of inflammation HDL, high-density lipoprotein; LDL, low-density lipoprotein; Lp(a), lipoprotein(a); TG, triglyceride. 1. The Calgary Guide to Understanding Disease. Available at: https://calgaryguide.ucalgary.ca/atherosclerosis-pathogenesis/; 2. Rafieian-Kopaei M, et al. Int J Prev Med 2014;5:927–46; 3. Lusis AJ. Nature 2000;407:233–41. Worsens dyslipidaemia Continued on the next slide…..

6. Pathophysiology of atherosclerosis (2) Development of a lipid filled plaque (“ atheroma ”) in the artery wall (atherosclerosis) Macrophages phagocytose the oxidised LDL and become filled with fat (“foam cells”) Foam cells accumulate in the intima to form an enlarging “ lipid core ”. Fibrous connective tissue accumulates around the lipid core, forming a “fibrous cap” The atheroma can calcify and further enlarge, and can either stay stable or rupture Streaks of fatty acid can be seen between the endothelium and SMC of the artery * Cells detach, enter lipid core and further enlarge it Foam cells also release inflammatory mediators, which ↑ proliferation of SMC *Early indicator of developing atherosclerosis. LDL, low-density lipoprotein; SMC, smooth muscle cells. 1. The Calgary Guide to Understanding Disease. Available at: https://calgaryguide.ucalgary.ca/atherosclerosis-pathogenesis/; 2. Rafieian-Kopaei M, et al. Int J Prev Med 2014;5:927–46; 3. Lusis AJ. Nature 2000;407:233–41. Continued from previous slide

7. MI, myocardial infarction. Heart Research Institute UK. Available at: https://www.hriuk.org/health/learn/cardiovascular-disease/atherosclerosis. Complications of atherosclerotic disease Peripheral artery disease Decreased blood pressure or numbness/pain in limbs. Increased risk of stroke and MI Coronary artery disease Narrowing of arteries close to the heart. Increased risk of angina, MI or heart failure Carotid artery disease Narrowing of the major blood vessels supplying the head and neck. Increased risk of stroke or a transient ischaemic attack Chronic kidney disease Gradual loss of kidney function over time

8. Atherosclerosis: aetiology Factors with a strong genetic component Environmental factors Physical inactivity Smoking Diet ‡ Age >45 years † / Male gender +45 *LDL↑, Lp(a)↑, TG↑, HDL↓; † >55 years in women; ‡ High in saturated and trans-fatty acids. HDL, high-density lipoprotein; LDL, low-density lipoprotein; Lp(a), lipoprotein(a); TG, triglyceride. 1. Rafieian-Kopaei M, et al. Int J Prev Med 2014;5:927–46; 2. Lusis AJ. Nature 2000;407:233–41. Family history Hypertension/ Obesity Abnormal lipid or cholesterol levels* ! Diabetes

9. CVD: epidemiology *Median, age-standardised annual incidence estimate: 747.6 (IQR 558.2–971.9) per 100,000 inhabitants (824.5 [IQR 663.0–1050.2] in males, 668.3 [IQR 483.5–857.9] in females); † Median, age-standardised annual prevalence estimate: 6963 (IQR 5719–7509) per 100,000 inhabitants (7586 [IQR 5963–8143] in males, 6369 [IQR 5385–7139] in females). CVD, cardiovascular disease; ESC, European Society of Cardiology; IQR, interquartile range. Timmis A, et al. Eur Heart J 2022;43:716–99. Incidence* 12.7 million estimated new CVD cases Prevalence † 113 million people living with CVD 6.1 million 6.5 million 53 million 60 million Across the 57 ESC member countries in 2019:

10. CVD: disease burden Global deaths (millions) CVD, cardiovascular disease. 1. British Heart Foundation. Available at: https://bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-global-factsheet.pdf; 2. World Heart Federation. Available at: https://world-heart-federation.org/resource/cardiovascular-diseases-cvds-global-facts-figures/; 3. World Health Organisation. Available at: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds); 4. Frostegård J. BMC Med 2013;11:117. annual global deaths from CVD 2 >17 million of all global deaths in 2019 1 34% of CVD deaths occur in low- and middle-income countries 3 >75% dominant cause of CVD 4 Atherosclerosis CVD was the leading cause of death worldwide prior to the coronavirus pandemic 1

11. CVD: disease burden CVD, cardiovascular disease; M, million; YLD, years lived with disability. Roth GA, et al. J Am Coll Cardiol 2020;76:2982–3021. CVD cases, deaths and YLD continue to increase globally 1990 CVD total cases 523M 271M CVD deaths 18.6M 12.1M CVD YLD 34.4M 17.7M 2019

12. Heart disease/CVD: estimated deaths Worldwide there are >17 million deaths from heart disease/CVD (34% of total deaths) 1,2 C VD, cardiovascular disease. 1. World Heart Federation. Available at: https://world-heart-federation.org/resource/cardiovascular-diseases-cvds-global-facts-figures/; 2. British Heart Foundation. Available at: https://bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-global-factsheet.pdf. Asia & Australasia 11 million deaths (36%) North America 1.1 million deaths (33%) South America 1 million deaths (28%) Europe 4.1 million deaths (46%) Africa 1.7 million deaths (19%)

13. *Based on data for chronic, non-communicable diseases in low- and middle-income countries; † €106 billion in 2009, €210 billion in 2017. CV, cardiovascular; CVD, CV disease; DM, diabetes mellitus; EU, European Union. 1. World Health Organisation/World Economic Forum. Available at: https://ncdalliance.org/sites/default/files/resource_files/WHO%20From%20Burden%20to%20Best%20Buys.pdf ; 2. Gheorghe A, et al. BMC Public Health 2018;18:975; 3. Wilkins E, et al. European Heart Network 2017. Available at: https://www.bhf.org.uk/-/media/files/research/heart-statistics/european-cardiovascular-disease-statistics-2017.pdf . CVD: economic burden Lost economic output by disease type (2011–2025) 1 * $3.76 trillion Cumulative lost output due to CVD (2011–2025) 1 * $500 to $1500 Cost per episode for hypertension and generic CVD 2 >€100 billion Increase in CV costs in the EU between 2009 and 2017 3† Cancer 21% Respiratory diseases 21% CVD 51% DM 6%

14. Key messages Atherosclerosis is a lipoprotein-driven disease characterised by plaque formation at specific sites of the arterial tree 1 Atherosclerotic disease is associated with a number of complications, including coronary artery disease, carotid artery disease, peripheral artery disease and chronic kidney disease 2 Risk factors for atherosclerosis include abnormal lipid and cholesterol levels, family history, diabetes, hypertension, obesity, age, male gender, diet, smoking and physical inactivity 3,4 CVD was the leading cause of death worldwide prior to the coronavirus pandemic 5 with >17 million deaths annually 6 , accounting for 34% of all deaths in 2019 5 The cumulative lost output due to CVD was estimated to be $3.76 trillion between 2011 and 2025 8 CVD, cardiovascular disease. 1. Bentzon JF, et al. Circ Res 2014;114:1852–66; 2. Heart Research Institute UK. Available at: https://www.hriuk.org/health/learn/cardiovascular-disease/atherosclerosis; 3. Rafieian-Kopaei M, et al. Int J Prev Med 2014;5:927–46; 4. Lusis AJ. Nature 2000;407:233–41; 5 . British Heart Foundation. Available at: https://bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-global-factsheet.pdf ; 6. World Heart Federation. Available at: https://world-heart-federation.org/resource/cardiovascular-diseases-cvds-global-facts-figures ; 8. World Health Organisation/World Economic Forum. Available at: https://ncdalliance.org/sites/default/files/resource_files/WHO%20From%20Burden%20to%20Best%20Buys.pdf .

15. Section bibliography (1) Bentzon JF, Otsuka F, Virmani R, et al. Mechanisms of plaque formation and rupture. Circ Res 2014;114:1852–66 British Heart Foundation. Global heart & circulatory diseases factsheet. Available at: https://bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-global-factsheet.pdf Frostegård J. Immunity, atherosclerosis and cardiovascular disease. BMC Med 2013;11:117 Gheorghe A, Griffiths U, Murphy A, et al. The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review. BMC Public Health 2018;18:975 Heart Research Institute UK. Atherosclerosis: causes and risk factors. Available at: https://www.hriuk.org/health/learn/cardiovascular-disease/atherosclerosis Jebari-Benslaiman S, Galicia-García U, Larrea-Sebal A, et al. Pathophysiology of atherosclerosis. Int J Mol Sci 2022;23:3346 Lusis AJ. Atherosclerosis. Nature 2000;407:233–41 Rafieian-Kopaei M, Setorki M, Doudi M, et al. Atherosclerosis: process, indicators, risk factors and new hopes. Int J Prev Med 2014;5:927–46 Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol 2020;76:2982–3021 The Calgary Guide to Understanding Disease. Atherosclerosis: pathogenesis. Available at: https://calgaryguide.ucalgary.ca/atherosclerosis-pathogenesis/ Timmis A, Vardas P, Townsend N, et al. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J 2022;43:716–99

16. Section bibliography (2) University Health News. Heart health. Available at: https://universityhealthnews.com/daily/heart-health/recognize-atherosclerosis-symptoms-that-indicate-heart-disease/ Wilkins E, Wilson L, Wickramasinghe K, et al. European cardiovascular disease statistics 2017. European Heart Network, Brussels. Available at: https://www.bhf.org.uk/-/media/files/research/heart-statistics/european-cardiovascular-disease-statistics-2017.pdf World Health Organisation/World Economic Forum. From burden to “best buys": reducing the economic impact of non-communicable diseases in low- and middle-income countries. Geneva: World Economic Forum, 2011. Available at: https://ncdalliance.org/sites/default/files/resource_files/WHO%20From%20Burden%20to%20Best%20Buys.pdf World Health Organisation. CVD fact sheets. Available at: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) World Heart Federation. cardiovascular diseases global facts and figures. Available at: https://world-heart-federation.org/resource/cardiovascular-diseases-cvds-global-facts-figures/

17. Role of lipids and inflammation in atherosclerotic cardiovascular disease 2

18. Lipoproteins Lipoproteins are biochemical assemblies that transport cholesterol and triglycerides to cells in the body There are seven classes of lipoproteins based on size, lipid composition and apolipoproteins: CM, CM remnants, VLDL, IDL, LDL, HDL and Lp(a) Proatherogenic : CM, CM remnants, VLDL, IDL, LDL, and Lp(a) Antiatherogenic : HDL CM, chylomicron; HDL, high-density lipoprotein; IDL, intermediate-density lipoproteins; LDL; low-density lipoprotein; Lp(a), lipoprotein(a); VLDL, very low-density lipoprotein. Feingold KF. Introduction to Lipids and Lipoproteins. Endotext 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK305896/. Introduction to lipoproteins Density Diameter CM remnant LDL IDL VLDL CM ↑Atherogenic risk Lipoproteins Lp(a) Hydrophobic core of non-polar lipids (cholesterol esters, triglycerides) Hydrophilic membrane (phospholipids, free cholesterol, apolipoproteins) ↓Atherogenic risk HDL 3 HDL 2

19. HDL, high-density lipoprotein; HDL-C, HDL-cholesterol; IDL, intermediate-density lipoproteins; LDL, low-density lipoprotein; VLDL, very low-density lipoprotein. Su X, et al. Lipids Health Dis 2019;18:134. Atherogenic properties of different lipoproteins Most lipid Lowest density Most protein Highest density Phospholipid Triglyceride Cholesterol Chylomicron Delivery of dietary fatty acids Delivery of dietary and other fatty acids Delivery of dietary and other fatty acids Delivery of cholesterol Scavenging excess cholesterol from cells for delivery back to the liver VLDL IDL LDL HDL Atherogenic lipoprotein Non-HDL-C

20. CVD, cardiovascular disease; LDL, low-density lipoprotein. 1. Sakai K, et al. Geriatr Gerontol Int 2018;18:965–72; 2. Superko H, et al. Biomedicines 2022;10:829; 3. Chancharme L, et al. J Lipid Res 2002;43:453–62. Types of LDL particles Phospholipid Triglyceride Cholesterol Particle size and number determine risk LDL I Large buoyant LDL LDL II Intermediate density LDL LDL III Smaller dense LDL Smaller dense LDL is more atherogenic than large LDL due to 1 : Higher penetration of arterial wall Lower binding affinity for the LDL receptor Prolonged plasma half life Lower resistance to oxidative stress Abnormal distribution in lipoprotein size and density (lipoprotein heterogeneity) contributes to CVD risk 2 Similar LDL levels can be associated with markedly different degrees of CVD risk 3 ↑CVD risk

21. *Large, medium, small; † Normal, triglyceride-rich, cholesterol rich, poor. Apo(a), apoliprotein(a); ApoB, apoliprotein B; LDL, low-density lipoprotein; Lp(a), lipoprotein(a). 1. Dayspring T, et al. Res Rep Clin Cardiol 2010;2010:1–10; 2. Ivanova EA, et al. Oxid Med Cell Longev 2017; 2017:1273042. Family of LDL particles All LDL particles contain one molecule of apoB 1,2 Larger Medium Small Lp(a) apoB apoB apoB apoB apo(a) Phospholipid Free cholesterol Cholesterol esters ApoB Triglyceride LDLs 1 Density: 1.019–1.063 g/mL Macromolecular collection Core: mostly cholesteryl ester, some triglycerides Surface: free cholesterol and phospholipids Characterised by particle diameter* or core composition † ApoB Each LDL has a surface molecule of apoB Provides structure, solubility in plasma and as a ligand for cellular LDL receptors Lp(a) 2 LDL-sized particle in which apoB is covalently linked to the unique glycoprotein, apo(a) Major risk factor for atherosclerosis and calcific aortic stenosis

22. Lipid phenotype: ↑LDL-C *Occurs in 79% of cases; † Autosomal dominant inherited disease. APOB, apolipoprotein B; APOE, apolipoprotein E; ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; CV, cardiovascular; CVD, CV disease; DNA, deoxyribonucleic acid; ESC/EAS, European Society of Cardiology/European Atherosclerosis Society; LDL-C, low-density lipoprotein-cholesterol; LDLR, LDL receptor; PCSK9, proprotein convertase subtilisin/kexin type 9; STAP1, signal transducing adaptor family member 1; SREBP2, sterol regulatory element-binding protein 2. 1. Stein R, et al. Curr Cardiol Rep 2019;21:68. 2. Mach F, et al. Eur Heart J 2020;41:111–88. Lipid disorders Dyslipidaemia, defined as abnormal lipid levels in the blood, is one of the main risk factors for the development of CVD Mutations: LDLR*, APOB, PCSK9, APOE, SREBP2, STAP1 Frequency: 1:250 Diagnosis 1 : Family history Clinical history (premature CAD, premature cerebral/peripheral vascular disease) Physical examination ↑LDL-C DNA analysis ESC/EAS guidelines emphasise the importance of reducing LDL-C levels to prevent ASCVD: the greater the absolute LDL-C reduction, the greater the CV risk reduction 2 Dyslipidaemia can be caused by lifestyle factors but to a large extent is determined by genetic factors Familial hypercholesterolaemia 1†

23. ASCVD can be reduced through reductions in LDL-C LDL-C reductions will result in parallel reductions in non-HDL-C and apoB LDL-C lowering has been shown to reduce the risk of atherothrombotic events such as MI, stroke, revascularisation or CV death ASCVD, atherosclerotic cardiovascular disease; apoB, apoliprotein B; CV, cardiovascular; CVD, CV disease; HDL-C, high-density lipoprotein-cholesterol ; LDL, low-density lipoprotein; LDL-C, LDL-cholesterol; Lp(a), lipoprotein(a); MI, myocardial infarction. Ray KK, et al. Global Heart 2022;17:75. Lipoproteins and ASCVD Atherosclerosis results from the retention of apoB-containing lipoproteins (mostly LDL) in the vessel wall LDL-C is not only causal but a cumulative risk factor for ASCVD Elevations in Lp(a) are an independent causal risk factor of ASCVD ↓ LDL-C Lp(a) LDL

24. ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; CHD, coronary heart disease; CLI, critical limb ischaemia; eNOS, endothelial nitric oxide synthase; LDL, low-density lipoprotein; LDL-C, LDL-cholesterol; MI, myocardial infarction. 1. Grundy SM, et al. J Am Coll Cardiol 1999;34:1348–59; 2. Davinon J, et al. Circulation 2004;109(23 Suppl 1):III27–32; 3. Glass CK, et al. Cell 2001;104:503–16; 4. Libby P. Nature 2002;420:868–74 . LDL-C: involved at every stage of atherosclerotic plaque formation     Endothelial dysfunction Fatty acid streaks Plaque Vulnerable plaque Rupture Thrombus Obstructive ASCVD Acute event Cardiac vessels - MI Brain vessels - stroke Peripheral vessels - CLI Procoagulant pathways may dominate, leading to occlusive blood clot 4 Lesion enlarges, arterial lumen narrows, blood flow hampered 4 Coagulation and platelet recruitment on exposure to tissue factor 3 High concentration of lipid-filled macrophages, thin fibrous cap, necrotic core 3 Foam cell necrosis 3 Increasing foam cell formation 3 LDL and macrophages within the vessel wall form foam cells 3 LDL-C reduces eNOS activity 2 LDL-C: primary risk factor in CHD and causative for development of CAD 1

25. ASCVD events remain high despite significant LDL-C reduction with cholesterol-lowering treatments, suggesting residual risk factors significantly contribute to the evolution and progression of ASCVD 1,2   ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a). 1. Dhindsa DS, et al. Front Cardiovasc Med 2020;7:88; 2. Aday AW, et al. Front Cardiovasc Med 2019;6:16. Residual CV risk Improved detection and management of residual CV risk factors will optimise prevention of ASCVD events 1,2 Hypertension Cholesterol Lp(a) Diabetes Tr i glycerides Smoking Obesity Inflammation Thrombosis

26. ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; GLP-1RA, glucagon-like peptide 1 receptor agonists; hsCRP, high-sensitivity C-reactive protein; IL, interleukin; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a); RNA, ribonucleic acid; SGLT2i, sodium-glucose cotransporter 2 inhibitors; TG, triglyceride; TGRL, TG-rich lipoproteins. Dhindsa DS, et al. Front Cardiovasc Med 2020;7:88. Residual CV risk Residual CV risk factors can be broadly categorised into lipid, inflammatory, prothrombotic and metabolic Residual lipid risk Observational and genetic epidemiology demonstrates a close relationship between Lp(a) with ASCVD and calcific aortic stenosis Novel RNA-targeting strategies are currently being investigated in a large CV outcomes trial TG and TGRL have also been identified as important contributors to residual risk Residual inflammatory risk Systemic inflammation has a well-established relationship with the development of atherosclerosis and subsequent ASCVD events Inflammation markers such as hsCRP and IL-1β and IL-6 are associated with an increased risk of CV events, independent of cholesterol and other conventional risk factors Residual prothrombotic risk Despite appropriate antiplatelet use, the risk of atherothrombosis and subsequent CV events remain Adding low-dose anticoagulation to antiplatelet therapy may be beneficial, but is associated with an increased risk of major bleeding Residual metabolic risk The antidiabetic drugs SGLT2i and GLP-1RA have demonstrated improvements in CV outcomes SGLT2i benefits include reductions in heart failure hospitalisations and a significant slowing of decline in renal function GLP-1RA have been shown to improve atherosclerotic outcomes but do not appear to significantly impact on heart failure outcomes

27. Apo(a), apolipoprotein(a); ApoB, apolipoprotein B; KIV, kringle IV; KV, kringle V; LDL, low-density lipoprotein; Lp(a), lipoprotein(a) 1. Reyes-Soffer G, et al. Arterioscler Thromb Vasc Biol 2022;42:e48-e60; 2. Coassin S, et al. Atherosclerosis 2022;349:17–35. Lp(a) structure, properties, regulation, and relation to disease 1 Lp(a) is produced in the liver and has two main components: An LDL-like particle comprising a central lipid core (primarily cholesteryl esters) surrounded by phospholipids, free cholesterol and apoB A single apo(a) molecule, which is bound to apoB via a single disulfide bond Apo(a) has a high carbohydrate content (~28%) and contains repeated kringle structures (KIV and KV), comparable with those in plasminogen There are 10 different KIV subtypes: One copy each of KIV 1 and KIV 3–10 Multiple copies of KIV 2 What is Lp(a) Apo(a) Lp(a) concentration (high variability) Genetics Ethnicity/Race Medical conditions Environment Regulation 1 LDL-like particle Lp(a) structure & property 1 ApoB Disease/condition Atherosclerosis Thrombosis Aortic valve calcification

28. *Oxidation of phospholipids produces biologically active OxPL species, which accumulate in atherosclerotic plaques and stimulate chronic inflammation and lipid deposition. Apo(a), apolipoprotein(a); ApoB, apolipoprotein B; KIV, kringle IV; KV, kringle V; LDL, low-density lipoprotein; Lp(a), lipoprotein(a); oxPL, oxidised phospholipid. Scipione CA, et al. Crit Rev Clin Lab Sci 2018;55:33–54. Structure of Lp(a) ApoB-containing lipoprotein Apo(a) Sources of mass heterogeneity in Lp(a) Potential heterogeneity of LDL-like component Lipid composition Preferential carrier of oxPL* Heterogeneity of the apo(a) component Apo(a) is extremely heterogeneous in size KIV 2 copy number can vary from <3 to >30 identical copies Large differences in extent of glycosylation between apo(a) molecules Lp(a) contains 10 KIV domains that differ in sequence

29. Apo(a), apolipoprotein(a); ApoB, apolipoprotein B; K, kringle; KIV, kringle IV; KV, kringle V; Lp(a), lipoprotein(a). 1. Tsimikas S, et al. J Am Coll Cardiol 2017;69:692–711; 2. Scipione CA, et al. Crit Rev Clin Lab Sci 2018;55:33–54; 3. Coassin S, et al. Atherosclerosis 2022;349:17–35. Lp(a) structure: apo(a) isoforms Variability in KIV 2 copy number accounts for the heterogeneity in isoform size 2 Apo(a) is composed of 1 copy of KIV 1 , multiple copies of KIV 2 and 1 copy each of KIV 3–10 1,2 KIV 2 copy number is determined by the size of the LPA allele, which encodes apo(a) 1,2 The median isoform size is inversely proportional to Lp(a) levels; the expression of a low number of KIV 2 repeats (<23) is characterised by small isoforms and markedly higher Lp(a) levels 3 Apo(a) ApoB-containing lipoprotein Plasminogen Lp(a) 1 4 KIV 2 24 KIV 2 8 KIV 2 40 KIV 2 OxPL OxPL OxPL OxPL KI KII KIII KIV KV Protease domain

30. CI, confidence interval; CVD, cardiovascular disease; Lp(a), lipoprotein(a); MI, myocardial infarction. Arsenault BJ, et al. Atherosclerosis 2022;349:7–16. Data show adjusted hazard ratios (95% CI) for selected outcomes, comparing participants in the top percentile of the Lp(a) distribution to those with lower Lp(a) levels Association between high Lp(a) levels and CVD/mortality Heart failure 1.57 (1.32–1.87) 1.79 (1.18–2.73) Ischaemic stroke 1.60 (1.24–2.05) Peripheral arterial disease 1.60 (1.30–2.00) Cardiovascular mortality 1.50 (1.28–1.76) All-cause mortality 1.20 (1.10–1.30) MI 1.85 (1.50–2.26) 2.47 (1.54–3.96) Calcific aortic valve stenosis 2.00 (1.20–3.40) 2.90 (1.80–4.90) 91–99th percentile >99th percentile 90–95th percentile >95th percentile

31. Apo(a), apolipoprotein(a); GFR, glomerular filtration rate; Lp(a), lipoprotein(a). 1. Cegla J, et al. Atherosclerosis 2019;291:62–70; 2. Schmidt K, et al. J Lipid Res 2016;57:1339–59; 3. Wilson PWF, et al. J Clin Lipidol 2019;13:374–92. Lp(a) levels are predominantly genetically determined Lp(a) concentrations are predominantly under genetic control 1,2 Some non-genetic factors may influence Lp(a) levels 1 Lifestyle changes have no significant impact on Lp(a) levels 3 Lp(a) concentration is 70% to >90% under genetic control The major locus controlling Lp(a) concentration is the LPA gene located on the reverse strand of chromosome 6q27 The LPA gene encodes the apo(a) component of Lp(a) Chronic kidney disease: ↑Lp(a) with ↓GFR and severe proteinuria (nephrotic syndrome) Liver disease: ↓Lp(a) Hyperthyroidism: ↑Lp(a) Postmenopausal women: ↑Lp(a) Low fat diet Physical exercise

32. Lp(a): independent, genetically determined risk factor for CVD Lp(a): independent, genetically determined risk factor for CVD 1.5 billion people (20% of global population) estimated to have elevated Lp(a) levels* in 2022 *>100–125 nmol/L. CVD, cardiovascular disease; Lp(a), lipoprotein(a); M, million; pop, population. Tsimikas S, et al. J Am Coll Cardiol 2022;80:934–46. ~20%, 75M North America 373,000,000 4.7% of world pop. ~15%, 99M 20%, 148M 30%, 418M 25%, 495M 10%, 270M 20%, 8.7M Isoform size/ distribution Estimates of Lp(a) >100–125 nmol/L (%, millions) Migration Track Migration Track Latin America/Caribbean 663,000,000 8.6% of world pop. Africa 1,394,000,000 16.7% of world pop. Europe 748,000,000 9.8% of world pop. Oceania 43,600,000 0.54% of world pop. South Asia 1,978,000,000 24.9% of world pop. Rest of Asia 2,701,000,000 34.8% of world pop. LPA gene with different isoforms migrates out of Africa The prevalence of elevated Lp(a) levels* varies by geographic location, due to: Variable migration patterns of people with different-sized isoforms Subsequent LPA gene remodelling

33. CI, confidence interval; CVD, cardiovascular disease; Lp(a), lipoprotein(a). Tsimikas S. J Am Coll Cardiol 2017;69:692–711 . Lp(a): independent, causal, genetic risk factor for CVD Meta-analysis: Lp(a) risk for CVD is curvilinear Mendelian randomisation: Lp(a) risk for CVD is linear Genome-wide association: Lp(a) risk for CVD is linear 1.8 0.8 Risk ratio (95% CI) Usual Lp(a), geometric mean, mg/dL 3 12 48 192 1.0 1.2 1.4 6 24 96 1.6 0.9 Adjustment for age and sex only Non-fatal Ml and coronary death Lp(a) (mg/dL) Hazard ratio (95% CI) 1 4 5–29 30–76 77–117 >117 <5 2 0.8 Multivariable adjusted P<0.001 8.0 0.0 Odds ratio for coronary disease Geometric mean Lp(a), mg/dL 75 125 1.0 25 50 100 4.0 2.0 0 variant alleles 1 variant allele 2 variant alleles

34. CCR7, C-C motif chemokine receptor; EC, endothelial cell; IL, interleukin; Lp(a), lipoprotein(a); SRA, scavenger receptor class A; TNF, tumour necrosis factor. Dzobo KE, et al. Atherosclerosis 2020;349:101–9. Lp(a) contributes to atherosclerosis via arterial wall inflammation

35. 2022 EAS Consensus Statement 1 2021 AHA Scientific Statement 2 2019 HEART UK Consensus Statement on Lp(a) 3 2019 NLA Scientific Statement 4 AHA, American Heart Association; CV, cardiovascular; EAS, European Atherosclerosis Society; Lp(a), lipoprotein(a); NLA, National Lipid Association; UK, United Kingdom. 1. Kronenberg F, et al. Eur Heart J 2022;43:3925–46; 2. Reyes-Soffer G, et al. Arterioscler Thromb Vasc Biol 2022;42:e48-e60; 3. Cegla J, et al. Atherosclerosis 2019;291:62–70; 4. Wilson DP, et al. J Clin Lipidol 2019;13:374–92; 5. Roche Diagnostics, 2022. Available at: https://diagnostics.roche.com/gb/en/products/params/tina-quant-lipoprotein-a-gen-2.html. Consensus on nmol/L as a preferred unit of measurement for Lp(a) Lp(a) measured in molar units (nmol/L) is preferable to mass (mg/dL) 1–4 High risk Low risk ! 20 mg/dL 1 mg/dL Low risk High risk 30 nmol/L 85 nmol/L Lp(a) measured in mass (mg/dL) 5 Lp(a) measured in mass does not account for size heterogeneity of Lp(a) particles Mass assays tend to underestimate small Lp(a) isoforms and overestimate large Lp(a) isoforms, potentially resulting in misclassification For example, the patient on the right is incorrectly categorised as lower risk than the patient on the left due to decreased Lp(a) when measured in mg/dL Lp(a) measured in molar units (nmol/L) 5 Lp(a) values reported in nmol/L are not influenced by isoform size and therefore provide a more specific and clinically useful indicator of CV risk

36. ECM, extracellular matrix; Inf-γ, interferon gamma; LDL, low density lipoprotein; MMPs, matrix metalloproteinases; MPO, myeloperoxidase; oxLDL, oxidized LDL; SMC, smooth muscle cells; Th, T-helper; TLR, toll like receptor; Treg, regulatory T cell 1. Raggi P, et al. Atherosclerosis 2018;276:98e108; 2. Gisterå A, et al. Nat Rev Nephrol 2017:13:368–380. Role of inflammation in the pathogenesis of atherosclerosis Both innate and adaptive immunity contributes to atherogenesis Innate immune system Several innate immune cells have important roles in atherosclerosis development Macrophages are the main innate immune effector cell type in the plaque Adaptive immune system T cells that respond to autoantigenic components of LDL particles orchestrate plaque development Th1 cells promote atherosclerosis Tregs are protective Th17 cells promote plaque stability Media Adventitia Vasa vasorum Thrombus Th2 Th1 Lymphocyte Monocyte LDL Lumen Adhesion Molecules Foam cell Macrophage oxLDL Endothelium TLR Calcium Inf-γ Cytokines SMC MMPs Collagenases MPO

37. *hsCRP assay measures very low levels of CRP vs conventional CRP testing (0.5–10 mg/L vs 10–1000 mg/L, respectively). Chr, chromosome; CRP, C-reactive protein; CVD, cardiovascular disease; EMP, endothelial microparticle; EPC, endothelial progenitor cells; hsCRP, highly sensitive CRP; ICAM-1, intercellular adhesion molecule-1; IL, interleukin; Lp-PLA 2 , lipoprotein-associated phospholipase A 2 ; MMP, matrix metalloproteinase; MPO, myeloperoxidase; NGAL, neutrophil gelatinase-associated lipocalin; PDE4D, phosphodiesterase 4D; ROS, reactive oxygen species; sd-LDL, small dense low-density lipoprotein-cholesterol; VCAM, vascular cell adhesion molecule. 1. Hong L-Z, et al. J Inflamm Res 2021;14:379–92; 2. Jin X, et al. Front Cardiovasc Med 2022;8:804214. Inflammatory biomarkers in CVD Humoral innate immunity Innate/adaptive immunity Endothelial dysfunction Genetics MMP-9 CRP/ hsCRP* MPO 1 Lp-PLA 2 1 MMP-9 1 ICAM-1/ VCAM 1 IL-6 1 NGAL 1 Inflammatory biomarkers for prediction of CVD EMPs/ EPCs 1 CRP/ hsCRP* ROS 1 CRP/ hsCRP* Chr9p21 1 PDE4D 1 sd-LDL 2 Dyslipidaemia marker

38. IL-1β and NLRP3 are hypothesised to drive inflammatory responses in CAD CAD, coronary artery disease; CRP, C-reactive protein; CV, cardiovascular; hsCRP, highly sensitive CRP; IL, interleukin; iNOS, inducible nitric oxide synthase; NLRP3, NOD-like receptor protein 3; NLRP3i, NLRP3 inhibitor; PAI-1, plasminogen activator inhibitor-1; SREBP2, sterol regulatory binding protein 2. 1. Ridker PM. Circ Res 2016;118:145–56; 2. Ridker PM, et al. N Engl J Med 2017;377:1119–31. IL-1β is associated with acute and chronic inflammation, with atherosclerotic lesions shown to contain IL-1β 1 Inflammatory signals stimulate NLRP3, ultimately leading to cytokine production, non-resolving inflammation and tissue damage 1 IL-1β blockade demonstrated significant reductions in recurrent CV events, independent of lipid-lowering 2 IL-1β blockade markedly reduces plasma levels of IL-6, hsCRP and fibrinogen 1 NLRP3i Canakinumab Anakinra Colchicine Tocilizumab Low-dose methotrexate IL-1 β iNOS, Endothelin-1 Chemokines, Cytokines Adhesion molecules Macrophage activation Smooth muscle proliferation Vascular inflammation Endothelial dysfunction Atherosclerosis IL-6 Active IL-1 β Pro-IL-1 β Cholesterol crystals Neutrophil extracellular traps Atheroprone flow Hypoxia NLRP3 Inflammasome Caspace-1 PAI-1 Fibrinogen CRP Liver Vascular risk HsCRP (mg/L) High Intermediate Low >3 1–3 <1 Macrophage

39. Time (years) PROVE-IT 1 Time (years) Recurrent vascular events (%) P<0.001 Event rate (100 patients/year) IMPROVE-IT 2 4.6 3.1 3.2 2.4 38.9 CV, cardiovascular; hs-CRP, high sensitivity C-reactive protein; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein-cholesterol; RR, relative risk. 1. Ridker PM, et al. N Engl J Med 2005;352:20–8; 2. Bohula EA, et al. Circulation 2015;132:1224–33. hsCRP predicts CV risk in secondary prevention 0.100 0.050 0.5 1.5 2.5 0.025 0.075 2.0 1.0 0.4 0.2 1 4 6 0.1 0.3 5 3 Recurrent vascular events (%) 33.7 33.4 28.0 2 RR (% at 7 years) P<0.001 Neither target Only LDL-C <1.8 mmol/L Only hs-CRP <2 mg/L Both targets Neither target Only LDL-C <1.8 mmol/L Only hs-CRP <2 mg/L Both targets

40. Key messages The following lipoproteins are proatherogenic: CM, CM remnants, VLDL, IDL, LDL and Lp(a) 1 HDL is antiatherogenic 1 Small dense LDL particles are more atherogenic than large buoyant LDL 2 Dyslipidaemia is one of the main risk factors for the development of CVD 3 LDL-C is both a causal and a cumulative risk factor for ASCVD 4 Residual risk factors significantly contribute to the evolution and progression of ASCVD 5   Lp(a) is an independent, causal, genetically determined risk factor for CVD 6 Lp(a) should be measured in molar units (nmol/L) rather than mass (mg/dL) 7 Inflammation plays a crucial role in the pathogenesis of atherosclerosis 8,9 ASCVD, atherosclerotic cardiovascular disease; CM, chylomicron; CVD, cardiovascular disease; HDL, high-density lipoprotein; IDL, intermediate-density lipoproteins; LDL, low-density lipoprotein; LDL-C; LDL- cholesterol; Lp(a), lipoprotein(a); VLDL, very low-density lipoprotein. 1. Feingold KF. Endotext 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK305896/ ; 2. Sakai K, et al. Geriatr Gerontol Int 2018;18:965–72; 3. Stein R, et al. Curr Cardiol Rep 2019;21:68; 4. Ray KK, et al. Global Heart 2022;17:75; 5. Dhindsa DS, et al. Front Cardiovasc Med 2020;7:88; 6. Arsenault BJ, et al. Atherosclerosis 2022;349:7–16; 7. Kronenberg F, et al. Eur Heart J 2022;43:3925–46; 8. Raggi P, et al. Atherosclerosis 2018;276:98e108; 9. Gisterå A, et al. Nat Rev Nephrol 2017;13:368–80.

41. Section bibliography (1) Aday AW, Ridker PM. Targeting Residual Inflammatory Risk: A Shifting Paradigm for Atherosclerotic Disease. Front Cardiovasc Med 2019;6:16 Arsenault BJ, Kamstrup PR. Lipoprotein(a) and cardiovascular and valvular diseases: A genetic epidemiological perspective. Atherosclerosis 2022;349:7–16 Balling M, et al. A third of nonfasting plasma cholesterol is in remnant lipoproteins: Lipoprotein subclass profiling in 9293 individuals. Atherosclerosis 2019;286:97–104 Besseling J, Capelleveen JV, Kastelein JJP, et al. LDL cholesterol goals in high-risk patients: how low do we go and how do we get there? Drugs 2013;73(4):293–301 Bhatt DL, Eagle KA, Ohman EM, et al. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA 2010;304:1350–7 Bohula EA, Giugliano RP, Cannon CP, et al. Achievement of dual low-density lipoprotein cholesterol and high-sensitivity C-reactive protein targets more frequent with the addition of ezetimibe to simvastatin and associated with better outcomes in IMPROVE-IT. Circulation 2015;132:1224–33 Burnett JR, Hooper AJ, Hegele RA. Remnant cholesterol and atherosclerotic cardiovascular disease risk. J Am Coll Cardiol 2020;76(23):2736–9 Cegla J, Neely RDG, France M, et al. HEART UK consensus statement on Lipoprotein(a): A call to action. Atherosclerosis 2019;291:62-70 Chait A, Ginsberg HN, Vaisar T et al. Remnants of the Triglyceride-Rich Lipoproteins, Diabetes, and Cardiovascular Disease. Diabetes 2020 Apr;69(4):508–16 Chancharme L, Thérond P, Nigon F, Zarev S, Mallet A, Bruckert E, Chapman MJ. LDL particle subclasses in hypercholesterolemia. Molecular determinants of reduced lipid hydroperoxide stability. J Lipid Res 2002;43:453–62

42. Section bibliography (2) Coassin S, Kronenberg F. Lipoprotein(a) beyond the kringle IV repeat polymorphism: The complexity of genetic variation in the LPA gene. Atherosclerosis 2022;349:17–35 Davinon J, Ganz P. Role of endothelial dysfunction in atherosclerosis. Circulation 2004;109(23 Suppl 1):III27–32 Dayspring T, Dall T, Abuhajir M. Moving beyond LDL-C: incorporating lipoprotein particle numbers and geometric parameters to improve clinical outcomes. Res Rep Clin Cardiol 2010;2010:1–10 Dekker JM, Girman C, Rhodes T, et al. Metabolic syndrome and 10-year cardiovascular disease risk in the Hoorn Study. Circulation 2005;112:666–73 Dhindsa DS, Sandesara PB, Shapiro MD, Wong ND. The Evolving Understanding and Approach to Residual Cardiovascular Risk Management. Front Cardiovasc Med 2020;7:88 Dzobo KE, Kraaijenhof JM, Stroes ESG, et al. Lipoprotein(a): An underestimated inflammatory mastermind. Atherosclerosis 2020;349:101–9 German CA, Shapiro MD. Assessing Atherosclerotic Cardiovascular Disease Risk with Advanced Lipid Testing: State of the Science. Eur Cardiol 2020;15:e56. Glass CK, Witztum JL. Atherosclerosis. the road ahead. Cell 2001;104(4):503–16 Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Eng J Med 2004;351:1296–1305 Grundy SM, Pasternak R, Greenland P, et al. AHA/ACC scientific statement: Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. J Am Coll Cardio;1999;34:1348–59

43. Section bibliography (3) Hong L-Z, Xue Q, Shao H. Inflammatory Markers Related to Innate and Adaptive Immunity in Atherosclerosis: Implications for Disease Prediction and Prospective Therapeutics. J Inflamm Res 2021;14:379–92. Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J. 2022;43:3925-3946.  Langrand WK, Visser CA, Hermens WT, et al. C-reactive protein as a cardiovascular risk factor: more than an epiphenomenon? Circulation 1999;100:96–102 Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111–88 Raggi P, Genest J, Giles JT, Rayner KJ, Dwivedi G, Beanlands RS, Gupta M. Role of inflammation in the pathogenesis of atherosclerosis and therapeutic interventions. Atherosclerosis 2018;276:98e108 Reyes-Soffer G, Ginsberg HN, Berglund L,et al. Lipoprotein(a): A Genetically Determined, Causal, and Prevalent Risk Factor for Atherosclerotic Cardiovascular Disease: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2022;42:e48-e60 Ridker PM, Cannon CP, Morrow D, et al. C-reactive protein levels and outcomes after statin therapy. N Engl J Med 2005;352:20–8 Roche Diagnostics. Tina-quant® Lipoprotein (a). 2022. Available at: https://diagnostics.roche.com/gb/en/products/params/tina-quant-lipoprotein-a-gen-2.html

44. Section bibliography (4) Sabatine MS, Giugliano RP, Keech AC, Honarpour N, Wiviott SD, Murphy SA, Kuder JF, Wang H, Liu T, Wasserman SM, Sever PS, Pedersen TR, FOURIER Steering Committee and Investigators. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med 2017;376:1713–22 Sakai K, et al. Geriatr Gerontol Int 2018;18:965–72 Scipione CA, Koschinsky ML, Boffa MB. Lipoprotein(a) in clinical practice: New perspectives from basic and translational science. Crit Rev Clin Lab Sci 2018;55(1):33-54. Stein R, Ferrari F, Scolari F. Genetics, Dyslipidemia, and Cardiovascular Disease: New Insights. Curr Cardiol Rep 2019;21: 68 Su X, Kong Y, Peng D. Evidence for changing lipid management strategy to focus on non-high density lipoprotein cholesterol. Lipids Health Dis 2019;18:134 Superko H, Garrett B. Small Dense LDL: Scientific Background, Clinical Relevance, and Recent Evidence Still a Risk Even with ‘Normal’ LDL-C Levels. Biomedicines 2022;10:829 Tsimikas S. A Test in Context: Lipoprotein(a): Diagnosis, Prognosis, Controversies, and Emerging Therapies. J Am Coll Cardiol 2017;69:692-711 Tsimikas S, Fazio S, Ferdinand KC, et al. NHLBI Working Group Recommendations to Reduce Lipoprotein(a)-Mediated Risk of Cardiovascular Disease and Aortic Stenosis. J Am Coll Cardiol 2018;71:177–92 Wilson PWF, Jacobson TA, Martin SS, et al. Lipid measurements in the management of cardiovascular diseases: Practical recommendations a scientific statement from the national lipid association writing group. J Clin Lipidol 2021;15:629–48 World Heart Federation. Cardiovascular disease risk factors: https://world-heart-federation.org

45. Management of atherosclerotic cardiovascular disease 3

46. *>175 mg/dL, >2 mmol/L; † <100 mg/dL for ASCVD or high risk patientts; ‡ LDL-C can be estimated from total cholesterol, HDL- C and triglyceride measurements; ¥ <70 mg/dL for ASCVD or high risk patients. ASCVD, atherosclerotic CVD; CVD, cardiovascular disease; HDL-C, high density lipoprotein cholesterol ; LDL-C, low density lipoprotein cholesterol. Wilson PWF, et al. J Clin Lipidol 2021;15:629–48; Darras P, et al. CMAJ 2018;190:E1317–8. Routine lipid measurements in CVD Fasting vs non-fasting measurements Non-fasting lipids acceptable for initial screening 1 If ↑triglycerides*, a fasting lipid measurement is recommended 1 Non-HDL-C measured reliably in fasting or non-fasting state 1 HDL-C levels have been shown not to vary between fasting and non-fasting states 2 Routine lipid tests Target values Total cholesterol <200 mg/dL HDL-C >40 mg/dL for men >50 mg/dL for women Non-HDL-C <130 mg/dL † LDL-C ‡ <100 mg/dLs ¥ Triglycerides <150 mg/dL fasting <175 mg/dL non-fasting LDL-C ≥190 mg/dL is recommended to be reported as severe hypercholesterolemia Non-HDL-C ≥220 mg/dL is recommended to be reported as possible inherited hyperlipidaemia Triglyceride ≥500 mg/dL is recommended to be reported as severe hypertriglyceridemia

47. ApoB, apolipoprotein B; CVD, cardiovascular disease; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; LDL-C, low density lipoprotein cholesterol; Lp(a), lipoprotein(a) German CA, et al. Eur Cardiol 2020;15:e56. Advanced lipid measurements in CVD Advanced lipid tests may help guide therapeutic decisions in certain patients, but data are limited for patients already on lipid lowering therapy with low LDL-C levels ApoB Lp(a) Represents levels of atherogenic particles in the plasma ESC/EAS suggest measuring Lp(a) at least once to identify people with high lifetime risk of CVD Risk-enhancing factor: ≥125 nmol/l Target levels: Very high risk: <1.2 μmol/l High risk: <1.6 μmol/l Moderate risk: <1.9 μmol/l ApoB Represents levels of atherogenic particles in the plasma

48. ACC/AHC, American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; ATP, adult treatment panel; BP, blood pressure; LDL, low-density lipoprotein 1. Arnett et al. Circulation 2019; 140: e596-e646. Primary prevention of ASCVD First-line cholesterol -lowering with a statin: Obesity Asymptomatic adults aged 40–75 years High BP Diabetes Blood cholesterol Alcohol and smoking Clinical ASCVD LDL ≥190 mg/dL 40–75 years with diabetes and LDL 70–189 mg/dL without clinical ASCVD 40–75 years with LDL 70–189 mg/dL and a 10 year ASCVD risk of ≥7.5% Lifestyle optimisation Assess 10-year risk of ASCVD 1 ACC/AHA cholesterol guidelines 1 All patients Patients at higher CV risk

49. Cholesterol-lowering treatment for the prevention of ASCVD Anti-inflammatory pleiotropic effects ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; LDL-C, low-density lipoprotein-cholesterol 1. Arnett et al. Circulation 2019; 140: e596-e646; 2. Pinal-Fernandez et al. Med Clin 2018; 150: 398-402; 3. Oesterle et al. Circ Res 2017; 120: 229-43 Statin treatment reduces the risk of primary and secondary CV events 1,2 There are 7 approved statins 2 Lovastatin ( Altoprev, Mevacor) Simvastatin (Zocor, Simvador) Pravastatin (Pravachol) Fluvastatin (Lescol) Atorvastatin (Lipitor) Rosuvastatin (Crestor) Pitavastatin (Livalo, Zypitamag) Inhibits hepatic sterol biosynthesis in the liver 2 Upregulates LDL-C receptors Increases the clearance of LDL-C Anti-inflammatory effects 3 Inhibits cytokines and adhesion molecules Reduces serum cholesterol Slow, stop, or reverse the build-up of fatty deposits in blood vessels Aggressive lowering of LDL cholesterol levels

50. Significant risk reduction with statin therapy Non-fatal MI (38%) CVD mortality (20%) All-cause mortality (11%) Non-fatal stroke (17%) Unstable angina (25%) Composite major CV events (26%) CV, cardiovascular; CVD, cardiovascular disease; MI, myocardial infarction Yebyo et al. Am Heart J 2019; 210: 18-28. Meta-analysis of randomised trials including 94,283 people receiving statin treatment Lovastatin Simvastatin Pravastatin Fluvastatin Atorvastatin Rosuvastatin Pitavastatin Significant risk increase with statin therapy Renal dysfunction (12%) Hepatic dysfunction (16%) Myopathy (8%) Random-effect pairwise meta-analysis of data published in English up to 1 January 2018 Safety Effectiveness

51. Long-term adherence to statin therapy is poor, even among patients in the secondary prevention setting 1,2 ACS, acute coronary syndrome; CHD, coronary heart disease; CV, cardiovascular; PAD, pulmonary artery disease 1. Lin et al. J Managed Care & Specialty Pharmacy 2016; 22: 685-98. 2. Alonso et al. J Atheroscler Thromb 2019; 26: 207-15 Real-world statin use in patients at high-risk of CV events Observational study of 541,221 patients in the US receiving statin treatment over a median follow-up of 16.6 months 1 The proportion of days covered with statin treatment was about 55% Truven MarketScan Commercial and Medicare databases from Jan 2007 to June 2013 Patients: diabetes (61.1%), ACS event (15.8%), recent non-ACS CV event (9.9%), PAD (4.7%), CHD (4.4%), history of ischaemic stroke (4.1%) Median time to statin discontinuation was about 15 months Patient categorisation Proportion of days covered (%) 80 ACS event n=72,355 40 90 100 70 60 50 30 20 10 Non-ACS event n=45,413 CHD n=20,243 Ischaemic stroke n=19,094 PAD n=21,519 Diabetes n=285,083 66.4 61.5 56.2 61.1 58.0 55.5 Months following start of statin therapy Percentage of days covered (%) 80 40 90 100 70 60 50 30 20 10 60 57 54 51 48 45 42 39 36 33 30 27 24 21 18 15 12 9 6 3 High-intensity statin Moderate- to low-intensity statin Median time to discontinuation (high-intensity statin) Median time to discontinuation (moderate- to low-intensity statin) P<0.001

52. CoA, coenzyme A; ATP, citrate lysate; HDL-C, high-density lipoprotein-cholesterol; HMG-CR, HMG-CoA reductase; LDL-C, low-density lipoprotein-cholesterol; mRNA, messenger RNA; NPC1L1, Niemann-Pick C1-like; PCSK, proprotein convertase subtilisin/kexin; PPAR, peroxisome proliferator-activated receptor Bardolia C, et al. Front Cardiovasc Med 2021;8. Cholesterol-lowering, non-statin treatments in atherosclerotic cardiovascular disease PCSK9 inhibitors Human monoclonal antibodies Binds PCSK9 and prevents binding with LDL receptors, increasing receptor recycling, and permitting the uptake of circulating LDL-C Inclisiran Cholesterol-lowering, double-stranded, small interfering ribonucleic acid (siRNA) Inhibits PCSK9 production by cleaving PCSK9 mRNA Lowers LDL-C levels by preventing the interaction of PCSK9 with LDL receptors Decrease triglycerides and increase HDL-C Ezetimibe Inhibits the absorption of cholesterol via a sterol transporter in the small intestine, reducing the delivery of cholesterol into the mesenteric veins Bempedoic acid Prevents de-novo cholesterol synthesis in the liver by inhibiting ATP citrate, an enzyme in the cholesterol biosynthesis pathway Fibrates PPAR-alpha agonists Decrease triglycerides and increase HDL-C

53. AcCoA, acetyl-CoA; ANGPLT, angiopoietin-like protein; Apo(a), apoliprotein(a); APOC3, Apolipoprotein C3; ASO, antisense oligonucleotide; ATP, adenosine triphosphate; IDL, intermediate-density lipoproteins; LDL, low-density lipoprotein; Lp(a), Lipoprotein(a); LPL, lipoprotein lipase; MoAb, monoclonal antibody; PCSK, proprotein convertase subtilisin/kexin; siRNA, small interfering RNA; TG, triglyceride; VLDL, very low-density lipoprotein Tokgozoglu L, et al. Eur Heart J 2022;43:3198–3208. Targets for new and emerging lipid-lowering therapies Cholesterol, TG AcCoA Citrate B-100 ATP Citrate Lyase B-100 Bempedoic acid PCSK9 Inclisiran B-100 Evolocumab Alirocumab Apo(a) Pelacarsen Olpasirin Lp(a) LDL B-100 IDL VLDL Volanesorsen Evinacumab Volanesorsen PCSK9 APOC3 ANGPLT3 Chylo remnant Chylomicron Evolocumab * B-48 TG Cholesterol ASO siRNA MoAb * Reduces synthesis of apo(a) in the liver LPL

54. *Therapies shown to decrease cardiovascular events. ASO, antisense oligonucleotide; IPE, icosapent ethyl; LDL-C, low-density lipoprotein cholesterol; Lp(a), Lipoprotein(a); MoAb, monoclonal antibody; non-HDL, non-high-density lipoprotein; siRNA, small interfering RNA Tokgozoglu L, et al. Eur Heart J 2022;43:3198–3208. Evolution of lipid lowering therapies Monthly Bimonthly Weekly Monthly Bianually Daily Annual? For life? Volanesorsen Vupanorsen Pelacarsen Inclisiran Olpasiran Alirocumab* Evolocumab* Evinocumab* Ezetimibe* Icosapent ethyl* Bempedoic acid Fibrate Statins* Oral combination MoAb ASO siRNA Vaccination Gene editing + LDL-C Main target Non-HDL (including remnants) Secondary target Lp(a) New target

55. Pelacarsen ASO targeting apo(a) mRNA; once monthly subcutaneous injection Phase 2 dosing study showed a 65–80% reduction in Lp(a) levels without significant side effects Phase 3 HORIZON study* will assess the effect of pelacarsen on CV endpoints in patients at increased CVD-risk and Lp(a) levels of >70 mg/dL (completion 2025) *NCT04023552 Apo(a), apolipoprotein(a); ASO, antisense oligonucleotide; CV, cardiovascular; Lp(a), lipoprotein(a); mRNA, messenger RNA Tromp TR, et al. Expert Opin Investig Drugs 2020;29:483–93. Emerging Lp(a)-lowering ASO-based therapies After entering the nucleus, the ASO binds to the complementary sequence of the targeted mRNA The resulting mRNA antisense duplex is recognised by RNase H, which cleaves the mRNA, preventing protein translation ASO-based therapies ASO Cytoplasm Nucleus mRNA Antisense duplex DNA mRNA Rnase H

56. *Placebo-adjusted reductions in Lp(a) of 70.5% (10-mg dose), 97.4% (75-mg dose), 101.1% (225-mg dose) given every 12 weeks, and 100.5% (225-mg dose) given every 24 weeks (p<0.001 for all). Apo(a), apolipoprotein(a); ASCVD, atherosclerotic cardiovascular disease; Lp(a), lipoprotein(a); RISC, RNA-induced silencing complex; siRNA, short-interfering RNA 1. O'Donoghue ML, et al. N Engl J Med 2022;387:1855–64; 2. Nissen SE, et al. JAMA 2022;327:1679–87; 3. Tromp TR, et al. Expert Opin Investig Drugs 2020;29:483–93. Emerging Lp(a)-lowering siRNA-based therapies After siRNA enters the cell, it is recognised by RISC, which removes the sense strand The resulting complex binds to the complementary mRNA sequence and degrades it, preventing protein translation siRNA-based therapies 3 Olpasiran 1 siRNA targeting hepatic production of apo(a) Longer acting: 12–24 week dosing Phase 2 study showed significant Lp(a) reductions (70.5–101.1%*) in patients with established ASCVD SLN360 2 siRNA targeting hepatic production of apo(a) Longer acting: effects persisted 150 days after single dose Phase 1 study completed siRNA molecule Cytoplasm Nucleus Antisense strand DNA mRNA RISC complex Sense strand

57. Key messages Advanced lipid tests, including apoB and Lp(a), may provide further insights into CV risk 1 The most important way to prevent ASCVD is to promote a healthy lifestyle throughout life 2 Adults who are 40 to 75 years of age and are being evaluated for CVD prevention should undergo 10-year ASCVD risk estimation 2 Statin treatment reduces the risk of primary and secondary cardiovascular events 2,3 Long-term adherence to statin therapy is poor, 4,5 in part owing to muscle pain, costs and perceived lack of efficacy 6 Non-statin treatments for CVD include PCSK9 inhibitors, inclisiran, ezetimibe, bempedoic acid and fibrates 7,8 Pelacarsen 9 , Olpasiran 10 and SLN360 11 are emerging Lp(a)-lowering therapies ASCVD, atherosclerotic CVD; ATP, adenosine triphosphate; CVD, cardiovascular disease; HDL-C, high-density lipoprotein-cholesterol; HMG-CR, hydroxymethylglutaryl coenzyme A reductase; LDL, low-density lipoprotein; LDL-C, LDL-cholesterol; Lp(a), lipoprotein(a); PCSK, proprotein convertase subtilisin/kexin; PPAR, peroxisome proliferator-activated receptor; siRNA, small interfering RNA. 1. Wilson PWF, et al. J Clin Lipidol 2021;15:629–48; 2. Arnett et al. Circulation 2019; 140: e596-e646; 3. Pinal-Fernandez et al. Med Clin 2018; 150: 398-402; 4. Lin et al. J Managed Care & Specialty Pharmacy 2016; 22: 685-98. 5. Alonso et al. J Atheroscler Thromb 2019; 26: 207-15; 6. Wei et al. J Clin Lipid 2013;7:472-83; 7. Bardolia C, et al. Front Cardiovasc Med 2021;8; 8. Tokgozoglu L, et al. Eur Heart J 2022;43:3198–3208; 9. Tromp TR, et al. Expert Opin Investig Drugs 2020;29:483–93; 10. O'Donoghue ML, et al. N Engl J Med 2022;387:1855–64; 11. Nissen SE, et al. JAMA 2022;327:1679–87.

58. Section bibliography (1) Aday AW, Ridker PM. Targeting residual inflammatory risk: a shifting paradigm for atherosclerotic disease. Front Cardiovasc Med 2019;6:16 Arsenault BJ, Kamstrup PR. Lipoprotein(a) and cardiovascular and valvular diseases: a genetic epidemiological perspective. Atherosclerosis 2022;349:7–16 Bohula EA, Giugliano RP, Cannon CP, et al. Achievement of dual low-density lipoprotein cholesterol and high-sensitivity C-reactive protein targets more frequent with the addition of ezetimibe to simvastatin and associated with better outcomes in IMPROVE-IT. Circulation 2015;132:1224–33 Cegla J, Neely RDG, France M, et al. HEART UK consensus statement on Lipoprotein(a): a call to action. Atherosclerosis 2019;291:62–70 Chancharme L, Thérond P, Nigon F, et al. LDL particle subclasses in hypercholesterolemia. Molecular determinants of reduced lipid hydroperoxide stability. J Lipid Res 2002;43:453–62 Coassin S, Kronenberg F. Lipoprotein(a) beyond the kringle IV repeat polymorphism: the complexity of genetic variation in the LPA gene. Atherosclerosis 2022;349:17–35 Davinon J, Ganz P. Role of endothelial dysfunction in atherosclerosis. Circulation 2004;109(23 Suppl 1):III27–32 Dayspring T, Dall T, Abuhajir M. Moving beyond LDL-C: incorporating lipoprotein particle numbers and geometric parameters to improve clinical outcomes. Res Rep Clin Cardiol 2010;2010:1–10 Dhindsa DS, Sandesara PB, Shapiro MD, Wong ND. The evolving understanding and approach to residual cardiovascular risk management. Front Cardiovasc Med 2020;7:88 Dzobo KE, Kraaijenhof JM, Stroes ESG, et al. Lipoprotein(a): an underestimated inflammatory mastermind. Atherosclerosis 2020;349:101–9

59. Section bibliography (2) Feingold KF. Introduction to Lipids and Lipoproteins. Endotext 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK305896/ Gisterå A, Hansson GK. The immunology of atherosclerosis. Nat Rev Nephrol 2017;13:368–80 Glass CK, Witztum JL. Atherosclerosis. the road ahead. Cell 2001;104:503–16 Grundy SM, Pasternak R, Greenland P, et al. AHA/ACC scientific statement: assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 1999;34:1348–59 Hong L-Z, Xue Q, Shao H. Inflammatory markers related to innate and adaptive immunity in atherosclerosis: implications for disease prediction and prospective therapeutics. J Inflamm Res 2021;14:379–92 Ivanova EA, Myasoedova VA, Melnichenko AA, et al. Small dense low-density lipoprotein as biomarker for atherosclerotic diseases. Oxid Med Cell Longev 2017; 2017:1273042 Jin X, Yang S, Lu J, Wu M. Small, dense low-density lipoprotein-cholesterol and atherosclerosis: relationship and therapeutic strategies. Front Cardiovasc Med 2022;8:804214 Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J. 2022;43:3925-3946 Libby P. Inflammation in atherosclerosis. Nature 2002;420:868–74 Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111–88

60. Section bibliography (3) Raggi P, Genest J, Giles JT, et al. Role of inflammation in the pathogenesis of atherosclerosis and therapeutic interventions. Atherosclerosis 2018;276:98e108 Ray KK, Ference BA, Séverin T,et al. World Heart Federation Cholesterol Roadmap 2022. Global Heart 2022;17:75 Reyes-Soffer G, Ginsberg HN, Berglund L, et al. Lipoprotein(a): a genetically determined, causal, and prevalent risk factor for atherosclerotic cardiovascular disease: a scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol 2022;42:e48–e60 Ridker PM. From C-reactive protein to interleukin-6 to interleukin-1: moving upstream to identify novel targets for atheroprotection. Circ Res 2016;118:145–56 Ridker PM, Everett BM, Thuren T, et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med 2017;377:1119–31 Ridker PM, Cannon CP, Morrow D, et al. C-reactive protein levels and outcomes after statin therapy. N Engl J Med 2005;352:20–8 Roche Diagnostics. Tina-quant® Lipoprotein (a). 2022. Available at: https://diagnostics.roche.com/gb/en/products/params/tina-quant-lipoprotein-a-gen-2.html Sakai K, Koba S, Nakamura Y, et al. Small dense low-density lipoprotein cholesterol is a promising biomarker for secondary prevention in older men with stable coronary artery disease. Geriatr Gerontol Int 2018;18:965–72 Schmidt K, Noureen A, Kronenberg F, Utermann G. Structure, function, and genetics of lipoprotein (a). J Lipid Res 2016;57:1339–59 Scipione CA, Koschinsky ML, Boffa MB. Lipoprotein(a) in clinical practice: new perspectives from basic and translational science. Crit Rev Clin Lab Sci 2018;55:33–54

61. Section bibliography (4) Stein R, Ferrari F, Scolari F. Genetics, dyslipidemia, and cardiovascular disease: new insights. Curr Cardiol Rep 2019;21:68 Su X, Kong Y, Peng D. Evidence for changing lipid management strategy to focus on non-high density lipoprotein cholesterol. Lipids Health Dis 2019;18:134 Superko H, Garrett B. Small dense LDL: scientific background, clinical relevance, and recent evidence still a risk even with ‘normal’ LDL-C levels. Biomedicines 2022;10:829 Tsimikas S. A test in context: lipoprotein(a): diagnosis, prognosis, controversies, and emerging therapies. J Am Coll Cardiol 2017;69:692–711 Tsimikas S, Marcovina SM. Ancestry, lipoprotein(a), and cardiovascular risk thresholds: JACC review topic of the week. J Am Coll Cardiol 2022;80:934–46 Wilson PWF, Jacobson TA, Jones PH, et al. Use of lipoprotein(a) in clinical practice: a biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2019;13:374–92

62. Prescribing Information and Summary of Product Characteristics (1) Ezetimibe 10 mg tablets. Summary of Product Characteristics. Aurobindo Pharma - Milpharm Ltd, Middlesex, UK. 2020 Fenofibrate 160 mg tablets. Summary of Product Characteristics. Genus Pharmaceuticals Limited, Huddersfield, UK. 2020 Inegy 10 mg/20 mg tablets. Summary of Product Characteristics. Organon Pharma UK Ltd, London, UK. 2022 Leqvio 284 mg solution for injection in prefilled syringe. Summary of Product Characteristics. Novartis Pharmaceuticals UK Ltd. 2022 Leqvio (inclisiran) injection for oral use. Prescribing Information. Novartis, New Jersey, USA. 2021 Nexletol (bempedoic acid) tablets for oral use. Prescribing Information. Esperion Therapeutics, Inc, USA. 2020 Nilemdo 180 mg film-coated tablets. Summary of Product Characteristics. Daiichi Sankyo Europe GmbH, Munich, Germany. Praluent 150 mg solution for injection in pre-filled pen. Summary of Product Characteristics. Sanofi, Berkshire, UK. 2022 Praluent (alirocumab) injection for oral use. Prescribing information. Sanofi-aventis U.S. LLC, NJ, USA. 2021

63. Prescribing Information and Summary of Product Characteristics (2) Repatha (evolocumab) injection for oral use. Prescribing Information. Amgen Inc. California, USA. 2015 Repatha SureClick. Summary of Product Characteristics. Amgen Ltd, Cambridge, UK. 2022 Tricor (fenofibrate) tablet for oral use. Prescribing Information. AbbVie Inc., North Chicago, USA. 2018 Vytorin (ezetimibe / simvastatin tablets). Prescribing Information. Merck/Schering-Plough Pharmaceuticals, PA, USA. 2004 Zetia (ezetimibe) tablets. Prescribing Information. Merck/Schering-Plough Pharmaceuticals, PA, USA. 2012

64. Guidelines and recommendations 4

65. ACC/AHA 2019 guideline recommendations ACC, American College of Cardiology; AHA, American Heart Association. Arnett DA, et al. Circulation 2019;140:e596–e646.

66. Recommendations for atherosclerotic cardiovascular prevention *Class I=strong, Class IIa=moderate, Class IIb=weak; † A=high quality from ≥1 RCT, B-R=moderate quality from ≥1 RCT, B-NR=moderate quality from ≥1 non-randomised study. ASCVD, atherosclerotic cardiovascular disease; NR, non-randomised; PCE, pooled cohort equations; RCT, randomised controlled trial. Arnett DA, et al. Circulation 2019;140:e596–e646. Recommendations for assessment of cardiovascular risk Class* Level † For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the PCE I B-NR For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years IIa B-NR In adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk (≥7.5% to <20% 10-year ASCVD risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions (e.g., statin therapy) IIa B-NR In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk) or selected adults at borderline risk (5% to <7.5% 10-year ASCVD risk), if risk-based decisions for preventive interventions (e.g., statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician–patient risk discussion IIa B-NR For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be considered IIb B-NR

67. Risk-enhancing factors for clinician-patient risk discussion ABI, ankle-brachial index; AIDS, acquired immunodeficiency syndrome; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein-cholesterol; HIV, human immunodeficiency virus; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a); RA, rheumatoid arthritis. Arnett DA, et al. Circulation 2019;140:e596–e646. *Optimally, 3 determinations Risk-enhancing factors Family history of premature ASCVD (males, age <55 years; females, age <65 years) Primary hypercholesterolaemia (LDL-C, 160–189 mg/dL [4.1–4.8 mmol/L]; non–HDL-C 190–219 mg/dL [4.9–5.6 mmol/L])* Metabolic syndrome (increased waist circumference [by ethnically appropriate cut-points], elevated triglycerides [>150 mg/dL, non-fasting], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in males; <50 mg/dL in females] are factors; a tally of 3 makes the diagnosis) Chronic kidney disease (eGFR 15–59 mL/min/1.73 m 2 with or without albuminuria; not treated with dialysis or kidney transplantation) Chronic inflammatory conditions, such as psoriasis, RA, lupus, or HIV/AIDS History of premature menopause (before age 40 years) and history of pregnancy-associated conditions that increase later ASCVD risk, such as preeclampsia High-risk race/ethnicity (e.g., South Asian ancestry) Lipids/biomarkers: associated with increased ASCVD risk Persistently elevated* primary hypertriglyceridaemia (≥175 mg/dL, non-fasting) If measured, elevated: hsCRP (≥2.0 mg/L), Lp(a) (≥125 nmol/L), apoB (≥130 mg/dL), ABI (<0.9)

68. ESC/EAS 2019 guidelines recommendations EAS, European Atherosclerosis Society; ESC, European Society of Cardiology. Mach F, et al. Eur Heart J 2020;41:111–88.

69. Recommendations for lipid analyses for CVD risk estimation (1) *Class I=recommended/indicated, Class IIa=should be considered, Class IIb=may be considered, Class III=is not recommended; † A=>1 RCT/meta-analyses, B=1 RCT or large non-randomised study, C=consensus papers, small studies, retrospective studies or registries. CV, cardiovascular; CVD, CV disease; DM, diabetes mellitus; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-cholesterol; RCT, randomised controlled trial; SCORE, Systematic Coronary Risk Estimation; TC, total cholesterol; TG, triglyceride. Mach F, et al. Eur Heart J 2020;41:111–88. Recommendations Class* Level † TC is to be used for the estimation of total CV risk by means of the SCORE system I C HDL-C analysis is recommended to further refine risk estimation using the online SCORE system I C LDL-C analysis is recommended as the primary lipid analysis method for screening, diagnosis and management I C TG analysis is recommended as part of the routine lipid analysis process I C Non-HDL-C evaluation is recommended for risk assessment, particularly in people with high TG levels, DM, obesity or very low LDL-C levels I C

70. Recommendations for lipid analyses for CVD risk estimation (2) *Class I=recommended/indicated, Class IIa=should be considered, Class IIb=may be considered, Class III=is not recommended; †A=>1 RCT/meta-analyses, B=1 RCT or large non-randomised study, C=consensus papers, small studies, retrospective studies or registries. ApoB, apolipoprotein B; CVD, cardiovascular disease; DM, diabetes mellitus; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a); RCT, randomised controlled trial; TG, triglyceride. Mach F, et al. Eur Heart J 2020;41:111–88. Recommendations Class* Level † ApoB analysis is recommended for risk assessment, particularly in people with high TG levels, DM, obesity, metabolic syndrome, or very low LDL-C levels. It can be used as an alternative to LDL-C, if available, as the primary measurement for screening, diagnosis, and management, and may be preferred over non-HDL-C in people with high TG levels, DM, obesity, or very low LDL-C levels I C Lp(a) measurement should be considered at least once in each adult person’s lifetime to identify those with very high inherited Lp(a) levels >180 mg/dL (>430 nmol/L) who may have a lifetime risk of ASCVD equivalent to the risk associated with heterozygous familial hypercholesterolaemia IIa C Lp(a) should be considered in selected patients with a family history of premature CVD, and for reclassification in people who are borderline between moderate- and high-risk IIa C

71. ESC 2021 guidelines recommendations ESC, European Society of Cardiology Visseren FLJ, et al. Eur Heart J 2021;42:3227–37.

72. ESC/EAS: ASCVD risk factor algorithm Documented ASCVD, diabetes, very high levels of individual risk factors or CKD? Total CV risk assessment (e.g. SCORE)* *Estimated 10-year cumulative risk of a first fatal atherosclerotic event; † Based on total CV risk (if calculated) + LDL-C level. ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; CV, cardiovascular; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-cholesterol; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; SCORE, Systematic Coronary Risk Estimation. Mach F, et al. Eur Heart J 2020;41:111–88. Low risk † Lifestyle advise Moderate risk † High risk † Lifestyle intervention, consider adding drug if uncontrolled Lifestyle intervention + concomitant drug intervention Very high risk † Lifestyle intervention + concomitant drug intervention Targets Low risk Moderate risk High risk Very high risk LDL-C↓ from baseline - - ≥50% ≥50% Target LDL-C <3.0 mmol/L <2.6 mmol/L <1.8 mmol/L <1.4 mmol/L Non-HDL-C - <3.4 mmol/L <2.6 mmol/L <2.2 mmol/L Treatment Average LDL-C↓ Moderate-intensity statin ~30% High-intensity statin ~50% High-intensity statin + ezetimibe ~65% PCSK9i ~60% PCSK9i + high-intensity statin ~75% PCSK9i + high-intensity statin + ezetimibe ~85% No Yes >40 years ≤40 years

73. CV, cardiovascular; EAS, European Atherosclerosis Society ; ESC, European Society of Cardiology; FH, familial hypercholesterolaemia; LDL-C, low-density lipoprotein-cholesterol; PCSK9i; proprotein convertase subtilisin/kexin type 9 inhibitor. Mach F, et al. Eur Heart J 2020;41:111–88. ESC/EAS: LDL-C lowering treatment algorithm Total CV risk assessment Baseline LDL-C levels Indication for drug therapy? Risk modifiers imaging (subclinical atherosclerosis) Risk reclassification? In selected low- and moderate-risk patients Define treatment goal High potency statin at highest recommended / tolerable dose to reach goal LDL-C goal reached? Lifestyle advice / Lifestyle intervention Follow up annually, or more frequently if indicated Add ezetimibe LDL-C goal reached? Follow up annually, or more frequently if indicated Add PCSK9 inhibitor Consider adding PCSK9 inhibitor Secondary prevention (very high risk) Primary prevention: patient with FH and another major risk factor Primary prevention: patient at very high risk but without FH

74. EAS 2022 consensus statement ESA, European Atherosclerosis Society. Kronenberg F, et al. Eur Heart J 2022;43:3925–46.

75. Lp(a) (nmol/L) Statement reinforces evidence for Lp(a) as a causal risk factor for cardiovascular outcomes ASCVD, atherosclerotic cardiovascular disease; CI, confidence interval; CVD, cardiovascular disease; EAS, European Atherosclerosis Society; HR, hazard ratio; Lp(a), lipoprotein(a). Kronenberg F, et al. Eur Heart J 2022;43:3925–46. Lp(a) should be measured at least once in adults Interpretation of Lp(a) concentration in the context of absolute global CVD risk Intensified risk factor management by lifestyle modification and medications Specific Lp(a)-lowering therapies in phase II/III trials Very low Lp(a) may associate with type 2 diabetes Not a risk factor for venous thrombosis New risk factor for aortic valve stenosis 2022 EAS Consensus on Lp(a) HR (95% CI) 4.0 3.0 2.5 2.0 1.5 1.0 Causal continuous association between Lp(a) and ASCVD 20 50 100 150 200 250 300 350 400 EAS

76. Measurement of non-HDL-C ApoB, apolipoprotein B; DM, diabetes mellitus; ESC, European Society of Cardiology; LDL-C, low-density lipoprotein-cholesterol; HDL-C, high-density lipoprotein-cholesterol. Visseren FLJ, et al. Eur Heart J 2021;42:3227–37. Corresponding non-HDL-C and apoB levels for commonly used LDL-C goals LDL-C Non-HDL-C ApoB 2.6 mmol/L (100 mg/dL) 3.4 mmol/L (131 mg/dL) 100 mg/dL 1.8 mmol/L (70 mg/dL) 2.6 mmol/L (100 mg/dL) 80 mg/dL 1.4 mmol/L (55 mg/dL) 2.2 mmol/L (85 mg/dL) 65 mg/dL Non-high-density lipoprotein-cholesterol The non-HDL-C value is calculated by subtracting HDL-C from total cholesterol Non-HDL-C, unlike LDL-C, does not require the triglyceride concentration to be <4.5 mmol/L (400 mg/dL) It also has an advantage in that it is accurate in a non-fasting setting, and may be more accurate in patients with DM There is evidence for a role of non-HDL-C as a treatment target as it captures the information regarding all apoB-containing lipoproteins ESC recommend non-HDL-C as an alternative treatment goal for all patients, particularly for those with hypertriglyceridaemia or DM

77. hsCRP is included as a risk predictor in US 1 and Canadian 2 guidelines ACC, American College of Cardiology; AHA, American Heart Association; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CAD, coronary artery disease; CV, cardiovascular; HIV, human immunodeficiency virus; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a); US, United States. 1. Arnett DA, et al. Circulation 2019;140:e596–e646; 2. Pearson GJ, et al. Can J Cardiol 2021;37:1129–50. Considered as part of CV risk assessment in primary prevention ASCVD Risk Enhancers: Family history of premature ASCVD Persistently elevated LDL-C ≥160 mg/dL (≥4.1 mmol/L) Chronic kidney disease Conditions specific to women (e.g., preeclampsia, premature menopause) Inflammatory diseases (especially rheumatoid arthritis, psoriasis, HIV) Ethnicity (e.g., South Asian ancestry) Lipid/Biomarkers: Persistently elevated triglycerides (≥175 mg/dL, [≥2.0 mmol/L]) In selected individuals if measured: hs-CRP ≥2.0 mg/L Lp(a) levels >50 mg/dL (125 nmol/L) apoB ≥130 mg/dL Ankle-brachial index <0.9 Considered as part of CV risk assessment in primary prevention in the ‘Intermediate-risk’ category Other risk modifiers: hsCRP ≥2.0 mg/L CAC >0 AU Family history of premature CAD Lp(a) ≥50 mg/dL (100 nmol/L)

78. Assessment of ASCVD risk remains the foundation of primary prevention of cardiovascular disease 1 LDL-C analysis is recommended as the primary lipid analysis for screening, diagnosis and management 2 Lp(a) levels should be assessed at least once in life 2 Evidence reinforced for Lp(a) as a causal risk factor for cardiovascular outcomes 3 Non-HDL-C is a reasonable alternative treatment goal for all patients, particularly for those with hypertriglyceridaemia or diabetes 4 hsCRP is included as a risk predictor in US 1 and Canadian 5 guidelines ASCVD, atherosclerotic cardiovascular disease; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein A; HDL-C, high-density lipoprotein-cholesterol; US, United States. 1. Arnett DA, et al. Circulation 2019;140:e596–e646; 2. Mach F, et al. Eur Heart J 2020;41:111–88; 3. Kronenberg F, et al. Eur Heart J 2022;43:3925–46; 4. Visseren FLJ, et al. Eur Heart J 2021;42:3227–37; 5. Pearson GJ, et al. Can J Cardiol 2021;37:1129–50. Key messages

79. Section bibliography Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the primary prevention of cardiovascular disease. Circulation 2019;140:e596–e646 Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J 2022;43:3925–46  Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111–88 Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian cardiovascular society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol 2021;37:1129–50 Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:3227–37

80. Executive summary (1) CVD was the leading cause of death worldwide prior to the coronavirus pandemic, accounting for 34% of all deaths in 2019 1 Atherosclerosis, the dominant cause of CVD 2 , results from retention of apoB-containing lipoproteins (mainly LDL) within the arterial wall 3 , usually in combination with other risk factors, including: Family history, diabetes, hypertension, obesity, age, male gender, diet, smoking and physical inactivity 4,5 Atherosclerotic disease is associated with a number of complications, including coronary artery disease, carotid artery disease, peripheral artery disease and chronic kidney disease 6 Proatherogenic (non-HDL-C lipoproteins) comprise CM, CM remnants, VLDL, IDL, LDL and Lp(a) 7 LDL-C is both a causative and cumulative risk factor for ASCVD 3,8 ASCVD can be reduced through reductions in LDL-C, resulting in parallel reductions in non-HDL-C and apoB 3 ApoB, apoliprotein B; ASCVD, atherosclerotic CVD; CM, chylomicron; CVD, cardiovascular disease; HDL, high-density lipoprotein; IDL, intermediate-density lipoproteins; LDL; low-density lipoprotein; LDL-C, LDL-cholesterol; Lp(a), lipoprotein(a); VLDL, very low-density lipoprotein; 1. British Heart Foundation. Available at: https://bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-global-factsheet.pdf; 2. Frostegård J. BMC Med 2013;11:117; 3. Ray KK, et al. Global Heart 2022;17:75; 4. Rafieian-Kopaei M, et al. Int J Prev Med 2014;5:927–46; 5. Lusis AJ. Nature 2000;407:233–41; 6. Heart Research Institute UK. Available at: https://www.hriuk.org/health/learn/cardiovascular-disease/atherosclerosis; 7. Dayspring T, et al. Res Rep Clin Cardiol 2010;2010:1–10; 8. Grundy SM, et al. J Am Coll Cardiol 1999;34:1348–59.

81. Executive summary (2) ASCVD events remain high despite significant LDL-C reduction, suggesting residual risk factors significantly contribute to the evolution and progression of ASCVD 1,2 Residual CV risk may include lipid, inflammatory, prothrombotic and metabolic factors 1 Lp(a), an LDL-like particle comprising an extra apo(a) protein, is an independent, genetically determined causal risk factor for ASCVD 3 In 2022, 1.5 billion people (20% of global population) were estimated to have elevated Lp(a) levels 3 Inflammation plays a crucial role in the pathogenesis of atherosclerosis 4,5 Both innate and adaptive immunity contributes to atherogenesis 4,5 IL-1β and NLRP3 are hypothesised to drive inflammatory responses in CAD 6 Apo(a), apoliprotein(a); ASCVD, atherosclerotic CV disease; CAD, coronary artery disease; CV, cardiovascular; IL, interleukin; LDL; low-density lipoprotein; LDL-C; LDL cholesterol; Lp(a), lipoprotein(a); NLRP3, NOD-like receptor protein 3 1. Dhindsa DS, et al. Front Cardiovasc Med 2020;7:88; 2. Aday AW, et al. Front Cardiovasc Med 2019;6:16; 3. Tsimikas S, et al. J Am Coll Cardiol 2022;80:934–46; 4. Raggi P, et al. Atherosclerosis 2018;276:98e108; 5. Gisterå A, et al. Nat Rev Nephrol 2017:13:368–380; 6. Ridker PM. Circ Res 2016;118:145–56.

82. Executive summary (3) Adults aged 40–75 years should undergo 10-year ASCVD risk estimation 1 LDL-C is recommended as the primary lipid analysis for screening, diagnosis and management 2 Lp(a) levels should be assessed at least once in life 2 Patients should receive guidance on lifestyle optimisation to minimise risk of future ASCVD events 1 Patients deemed at moderate or high CV risk may receive lifestyle intervention with concomitant drug intervention (e.g., statin therapy) 1 Statin treatment reduces the risk of primary and secondary cardiovascular events 2,3, although long-term adherence to statin therapy is poor, 1,3 Non-statin treatments for CVD include PCSK9 inhibitors, inclisiran, ezetimibe, bempedoic acid and fibrates 4,5 ASCVD, atherosclerotic CVD; CV, cardiovascular; CVD, CV disease; IL, interleukin; LDL-C; low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); PCSK, proprotein convertase subtilisin/kexin 1. Arnett et al. Circulation 2019; 140: e596-e646; 2. Mach F, et al. Eur Heart J 2020;41:111–88; 3. Pinal-Fernandez et al. Med Clin 2018; 150: 398-402; 4. Bardolia C, et al. Front Cardiovasc Med 2021;8; 5. Tokgozoglu L, et al. Eur Heart J 2022;43:3198–3208.