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Hyper- and dyslipidemia contribute to cardiovascular morbidity and mortality in diabetic patients. Pharmacological therapy to lower LDL cholesterol has convincingly shown to reduce cardiovascular risk in diabetic patients. The present article represents the recommendations of the Austrian Diabetes Association for the use of lipid-lowering drugs in diabetic patients according to current scientific evidence., (© 2023. The Author(s).)

Background: An elevated low-density lipoproteincholesterol (LDL-C) level is one of the most important modifiable cardiovascular risk factors. Despite potent combination treatment, the LDL‑C target values are not achieved in many high-risk patients., Objective: Presentation of the rationale for lowering LDL‑C, the current status of lipid-lowering treatment and established and novel approaches to lower LDL‑C., Current Data: Based on the large outcome trials with ezetimibe and antibodies against proprotein convertase subtilisin-kexin type 9 (PCSK9), the professional societies recommend LDL‑C target values depending on the individual cardiovascular risk. For patients with manifest atherosclerosis, the LDL‑C target value is < 55 mg/dL (1.4 mmol/L). The LDL‑C target values are only achieved in the minority of patients. The reasons for this include a lack of awareness among treating physicians, low medication adherence, restrictions in prescriptions and intolerance. On the basis of a healthy lifestyle, statins are the cornerstone of LDL-C-lowering treatment. If LDL‑C targets are not achieved, the cholesterol absorption inhibitor ezetimibe is additionally recommended. As a third step, PCSK9 antibodies are added. A novel drug to lower LDL‑C is the orally available bempedoic acid, which acts on the same metabolic pathway as statins but is specifically activated in the liver and not in the skeletal muscle. Another novel drug is inclisiran, which acts as an intracellular PCSK9 inhibitor through RNA interference. Inclisiran is administered subcutaneously only every 6 months and has potential advantages regarding adherence. According to the new recommendations, active substances should be combined and fixed-dose combinations should be used early for lowering of LDL‑C., Conclusion: Using established and novel LDL-C-lowering drugs, the recommended LDL‑C target values can be achieved in the majority of patients with a high cardiovascular risk., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Diabetic dyslipidemia is a major cause of the increased cardiovascular risk in diabetes. This lipid disorder is characterized by increased plasma triglycerides, increased remnant particles of triglyceride-rich lipoproteins, small dense LDL particles and reduced HDL cholesterol. The main pathogenetic triggers are obesity and insulin resistance. In addition to lifestyle measures, statins, ezetimibe and eventually PCSK9 inhibitors are available to treat diabetic dyslipidemia and to reduce the cardiovascular risk. Fibrates and omega-3 fatty acids currently do not play a significant therapeutic role. A consistent and target-oriented therapy of diabetic dyslipidemia is a prerequisite for a cardiovascular risk reduction in patients with diabetes, which has been well proven in clinical studies., Competing Interests: Vorträge, Reisekosten oder Beratungshonorare von: Sanofi, Amgen, MSD, Shire, Berlin-Chemie, Böhringer, Vitaflo, Biomarin, Genzyme, Akcea, Novartis, Daiichi-Sankyo., (Thieme. All rights reserved.)

The prevalence of nonalcoholic fatty liver disease (NAFLD) continues to increase worldwide, presently affecting 25% of the adult population, and is associated with an elevated risk of total and liver-specific mortality. NAFLD is a chronic disease and results from a combination of genetic, environmental and predominantly lifestyle-related causes. Therefore, NAFLD, similarly to cardiovascular disease, type 2 diabetes and many different types of cancer, can be considered a noncommunicable disease. Consequently, lifestyle intervention, particularly if associated with a large amount of weight loss, is considered highly effective and safe to treat NAFLD. For patients with advanced-stage NAFLD or that cannot lose weight, metabolically-based pharmacotherapy is effective to improve liver histology and cardiometabolic risk profile. If a moderate or advanced stage of liver fibrosis is present, additional antifibrotic therapy is necessary to halt the progression of the disease.

The treatment of elevated plasma lipids plays an important role in atherosclerosis prevention. Low-density lipoprotein (LDL) cholesterol lowering with statins and, if required, additional inhibition is of the utmost importance. Lifestyle modification plays only a minor role in LDL cholesterol lowering. Absolute cardiovascular risk determines whether and at what intensity lipid lowering therapy should be implemented. Thus, in patients at very high risk, an LDL cholesterol level <55 mg/dl (<1.4 mmol/l) and a 50% reduction from baseline should be achieved. With respect to elevated triglyceride concentrations, treatment goals are less clearly defined, despite the fact that elevated triglyceride concentrations are causally linked to atherosclerotic events. Lifestyle modification can significantly reduce triglyceride concentrations and are often more effective than specific triglyceride lowering medications. New lipid lowering drugs still need to prove their clinical benefit in endpoint trials.

The recently updated 2019 European Society of Cardiology/European Atherosclerosis Society Guidelines for the management of dyslipidaemias set new, ambitious goals for lipid lowering based on recently generated evidence from large outcome trials. Noninvasive imaging as well as measurement of lipoprotein(a) as a non-traditional risk factor is advocated for the refinement of risk stratification. A highly potent statin - defined as a drug that lowers LDL-cholesterol by 50 % from baseline - is recommended as the standard choice of treatment, whenever medical lipid lowering is indicated. Combining different therapeutic strategies such as a statin with ezetimibe and/or a Proproteinkonvertase Subtilisin Kexin Type 9 inhibitor allows to achieve the new treatment targets. If needed, lipid apheresis can complement the medical armamentarium. Moreover, lipid apheresis remains the only approved treatment modality for lowering lipoprotein(a), however medical treatments are under current investigation., Competing Interests: Kyrill S. Rogacev war Angestellter des MVZ Schwerin West, einem Unternehmen von B Braun viamedis.Ulrich Laufs: Vortragshonorare von Amgen, Daiichi-Sankyo, Sanofi, (© Georg Thieme Verlag KG Stuttgart · New York.)

Hyper- and dyslipidemia contribute to cardiovascular morbidity and mortality in diabetic patients. Pharmacological therapy to lower LDL cholesterol has convincingly shown to reduce cardiovascular risk in diabetic patients. The present article represents the recommendations of the Austrian Diabetes Association for the use of lipid-lowering drugs in diabetic patients according to current scientific evidence.

The frequency of non-alcoholic fatty liver disease (NAFLD) has continously increased over the last few decades in parallel with the increasing prevalence of metabolic syndrome. With the increasing frequency of obesity and type 2 diabetes an increase in non-alcoholic steatohepatitis (NASH) is also to be expected. The NASH-associated liver cirrhosis and primary hepatocellular carcinoma (HCC) are indications for liver transplantation (LTX), which is gaining importance in Germany. In contrast, liver cirrhosis as a result of alcoholic steatohepatitis (ASH) is already the leading cause for LTX in Germany. A significant number of patients with ASH cirrhosis develop HCC. Less common causes of hepatic steatosis are secondary and include chemotherapy-associated steatohepatitis (CASH). In this article the causes, diagnostics and novel therapeutic approaches for the various forms of steatosis are discussed.

In clinical trials, the reduction of LDL-cholesterol (LDL-C) with statins reduces the incidence rate of cardiovascular events by approximately one third. This means, that a sizeable "residual risk" remains. Besides high lipoprotein (a), disorders in the metabolism of triglyceride-rich lipoproteins and high density liproteins have been implicated as effectors of the residual risk. Both lipoprotein parameters correlate inversely with each other. Therefore, the etiological contributions of triglycerides and / or of HDL for developing cardiovascular disease can hardly be estimated from either observational studies or from intervention studies. The largely disappointing results of intervention studies with inhibitors of the cholesteryl ester transfer protein and in particular the available set of genetically-epidemiological studies suggest that in the last decade, the importance of HDL cholesterol has been overvalued, while the importance of triglycerides has been underestimated. High triglycerides not always atherogenic, but only if they are associated with the accumulation relatively cholesterol-enriched, incompletely catabolized remnants of chylomicrons and very low density lipoproteins (familial type III hyperlipidemia, metabolic syndrome, diabetes mellitus). The normalization of the concentration of triglycerides and remnants by inhibiting the expression of apolipoprotein C3 is hence a new, promising therapeutic target., (© Georg Thieme Verlag KG Stuttgart · New York.)

Proprotein convertase subtilisin/kexin type 9 (PCSK 9) is a key regulator of cholesterol homeostasis acting via degradation of the low density lipoprotein (LDL) receptor. Loss of function PCSK 9 mutations result in very low LDL cholesterol serum levels and protection from cardiovascular disease whereas gain of function mutations increase serum LDL cholesterol. Based on in vitro and in vivo data antibodies targeting PCSK 9 have now emerged as a novel treatment option in patients with cardiovascular disease. This review briefly summarizes the biochemistry and function of PCSK9 and the results from recent phase II trials.

The various contemporary therapeutic options for coronary artery disease (CAD) require differentiated, individualized treatment strategies. The foundations of CAD therapy are lifestyle modifications targeted on the individual risk profile of the patients. Pharmacological therapy of CAD should prevent secondary coronary events (e.g. platelet aggregation inhibitors and statins) and reduce angina in symptomatic patients (e.g. short-acting nitrates, beta blockers, calcium channel blockers and if necessary ivabradine and ranolazine). Revascularization therapy has to be performed promptly in patients with acute coronary syndromes; however, in patients with stable CAD the decision to perform revascularization therapy has to consider symptoms, detection of ischemia and if appropriate intracoronary assessment of hemodynamic relevance of an intermediate stenosis (fractional flow reserve). The differential indications of percutaneous coronary intervention compared to coronary artery bypass grafting depend on the severity of coronary artery disease and the morphology (SYNTAX score), comorbidities and the will of the individual patient. The international guidelines emphasize the value of an interdisciplinary treatment decision in a "heart team". In summary, differential therapy of CAD has become challenging in the current clinical practice; future developments will probably further improve individualized strategies to treat patients with CAD.

The treatment of dyslipidemia is a cornerstone of atherosclerosis prevention. Statin-based reduction of LDL cholesterol plays a central role in this context. Whether and to what extent other lipids such as triglycerides, HDL-cholesterol, lipoprotein(a) should also be addressed is still under discussion. However, in the treatment of hypertriglyceridemia and combined hyperlipoproteinemia, life-style modification plays a significant role. Important issues are correct classification of the dyslipidemia, a LDL-cholesterol target based on the absolute risk of the patient, and a therapeutic strategy that also includes treatment of other risk factors. If statin therapy not sufficient to reach the treatment target, combination therapy with ezetimibe, bile acid binding substances, fibrates or ω-3 fatty acids should be discussed, considering the lipid profile, the overall risk, and potential side effects. Patients with severe LDL hypercholesterolemia or greatly elevated lipoprotein(a) levels should be considered for regular lipid apheresis if the cardiovascular disease is progressing.

Cardiovascular disease is also the most frequent cause of mortality in the elderly population. Invasive diagnostic and therapeutic interventions are performed at an increasing rate in older patients in order to maintain functional capacities and, thus, an adequate quality of life. Thus, strategies to prevent cardiovascular events (e.g., lipid lowering therapy) are also of great importance in elderly. With respect to the side effects of statin therapy, the risk of drug interaction has to be considered, as well as myopathy. Discrepant study results exist about the influence of statins on cognitive function. Retrospective analyses indicate that statin therapy might be related to an increased risk for type.2 diabetes in certain risk groups. The indication for statin therapy should, therefore, consider the risk profile and especially the individual situation of the older patient.

Dyslipidemia is one of the main modifiable cardiovascular risk factors. There is strong evidence for the efficacy of lipid-lowering drugs in secondary prevention, as well as in primary prevention for patients at high cardiovascular risk. In primary prevention, indication for lipid-lowering interventions should be based on an individual assessment of the cardiovascular risk and on the LDL cholesterol level, despite less strong evidence for the efficacy of drug-based interventions in low risk patients. Treatment consists of statins, as well as lifestyle modifications such as body weight control and increased physical exercise. The latter constitute the primary intervention in patients at low cardiovascular risk. Secondary dyslipidemias due to an underlying medical condition and familial dyslipidemias such as Familial Hypercholesterolemia and Familial Combined Hyperlipidemia should be identified and treated accordingly, taking into account that the risk scoring systems are not appropriate in these situations.

Hyper- and Dyslipidemia contribute to cardiovascular morbidity and mortality in diabetic patients. Pharmacological therapy with statins has convincingly shown to reduce cardiovascular risk in diabetic patients. The present article represents the recommendations of the Austrian Diabetes Association for the use of lipid-lowering drugs in diabetic patients according to current scientific evidence.

Type 2 diabetes is a complex metabolic disease associated with a high risk of vascular disease and certain entities of cancer. An early starting multifactorial intervention is mandatory in order to improve the prognosis of the patients. Of highest priority is the lowering of LDL-cholesterol (Target value < 100 mg/dl or < 70 mg/dl when vascular complications are present) and of the very often increased blood pressure values (target values 130-135/80 mm Hg). A successful blood glucose lowering therapy is often only possible when antidiabetic drugs are used in combination. The antidiabetic therapy has to be individualized concerning the HbA1target value and the selection of the antidiabetic drugs in relation to age of the patients and presence or absence of co-morbidities. Severe events of hypoglycemia should be avoided, since these are associated with an increased cardiovascular risk and mortality.

In the multifactorial process of atherogenesis not only increased LDL-cholesterol but also decreased HDL-cholesterol and raised triglycerides correlate closely to cardiovascular events. Multiple studies have demonstrated a high prevalence of dyslipidemia and the metabolic syndrome in Germany.Statins remain first-line therapy for the treatment of dyslipidemia. However, despite therapy a relevant cardiovascular risk remains. Therefore, it is important to also aim for an adequate treatment of hypertriglyceridemia and also to raise HDL-levels. Many combination therapies have been shown to be effective in treating dyslipidemia. Adding Omega-3-fatty acids, nicotinic acid/laropiprant or a fibrate to statin monotherapy provide additional beneficial lipid-modifying effects for combined dyslipidemia. In the future a recommendation for the treatment of mixed hyperlipoproteinemia with decreased HDL, raised triglycerides and LDL-cholesterol shall have to be added to our guidelines.

Lipodystrophy syndromes are a heterogenous group of congenital and acquired disorders with generalized or partial absence of subcutaneous adipose tissue. They are associated with severe metabolic abnormalities such as insulin resistance, diabetes mellitus, and hypertriglyceridemia that may result in life-threatening acute pancreatitis, steatohepatitis, and cardiovascular disease. Conventional lipid-lowering and antihyperglycemic medications may be insufficient to control severe metabolic abnormalities. The adipose tissue-derived hormone leptin has been investigated as a novel therapeutic option for severe lipodystrophy and significantly improves metabolic abnormalities in these patients. In Germany, leptin treatment for lipodystrophic patients with severe metabolic abnormalities is offered free of charge by the University Medicine Leipzig within a compassionate use program.

Prevention is a major contributor to the decline in cardiovascular morbidity and mortality. Cardiovascular diseases still are the leading cause of death (42%) in Germany and indicate unmet preventive needs. Limitations of healthy lifestyle, the basis of many recommendations, include insufficient compliance and efficacy in individual cases. In their latest metaanalysis the Cholesterol Treatment Trialists' Collaborators showed updated estimates of treatment effects of statins including more or less intensive regimens.The average reduction in major vascular events was 21% per 1.0 mmol/l reduction in LDL cholesterol. Appropriateness of receiving lipid modulating treatment in the population will be discussed in the light of controversial recommendations in treatment strategies. Residual risk in statin treated patients may be ameliorated by options beyond LDL-lowering. Suggestions for clinical practice are provided on the background of clinical relevant characteristics of current lipid lowering drugs and future developments are outlined.

Background: A hospital-based screening project (HSP) in Austria found 47% of high-risk patients (LDL-C < 100 mg/dl) and 24% of very high-risk patients (LDL-C < 70 mg/dl) at goal. Separate data for the sexes were not reported. We analyze whether LDL-C goal attainment in patients with manifest atherosclerosis and/or diabetes on stable lipid-lowering treatment differs between private practice and hospital and between men and women., Patients and Methods: From September to November 2007, 49 Austrian centers (36 private practice, 13 hospitals) documented vascular morbidity, lipid levels, and lipid lowering treatment in patients with high risk (atherosclerosis or diabetes, n = 978) and very high risk (coronary heart disease and diabetes or acute coronary syndrome, n = 322)., Results: 75% and 25% of the 1300 patients were high and very high risk, respectively. LDL-C goals of < 100 and < 70 mg/dl, respectively, were attained by 45.4% and 26.4% of patients (p < 0.001). A similar percentage of patients with very high risk was found in men and women (26.4% vs. 22.9%, NS) and goal attainment was not influenced by sex (high risk: 47.2% (m) vs. 43.8% (w), NS and very high risk: 29.1% (m) vs. 22.4% (w), NS). In patients with high risk, 41.6% treated in private practice vs. 57.9% treated in the hospital were at goal (p < 0.001). In patients with very high risk, 15.9% treated in private practice vs. 45.2% treated in the hospital were at goal (p < 0.001). Lower goal-attainment in private practice occurred despite significantly more intensive lipid intervention and probably reflects higher baseline LDL-C. LDL-C > 100 mg/dl leads to a more aggressive lipid lowering in approx. 70% of patients, irrespective of whether they are treated in private practice or in the hospital. LDL-C between 70 and 100 mg/dl, however, leads to a more aggressive lipid lowering in < 5% of patients, irrespective of whether they are high or very high risk., Conclusion: As observed in EUROASPIRE III for other European countries, there is substantial potential for improvement in lipid control in Austrian cardiovascular high-risk patients, irrespective of whether they are treated in private practice or in the hospital.

LDL cholesterol plays a central role in atherogenesis and LDL lowering statin therapy significantly reduces cardiovascular risk in patients with diabetes. Therefore, LDL cholesterol in current guidelines is the primary target of lipid intervention. All patients with type 2 diabetes should reach an LDL cholesterol of <100 mg/dl, the very-high risk patients with both diabetes and coronary artery disease an LDL cholesterol <70 mg/dl. Given the overwhelming body of evidence for the efficacy of statin therapy with respect to cardiovascular event prevention, LDL cholesterol should primarily be lowered by statins. Many very-high risk patients will require high-dose statin therapy to meet the stringent treatment goal of LDL cholesterol <70 mg/dl. Importantly, patients with type 2 diabetes typically exhibit a pattern of dyslipidemia with high triglycerides, low HDL cholesterol, and small, atherogenic LDL particles, which is a strong predictor of vascular events in patients with diabetes. Despite the currently limited evidence from large clinical endpoint-trials additional treatment of this diabetic dyslipidemia with niacin or fibrates therefore appears a promising option at least in the very-high risk patients with the combination of diabetes and coronary artery disease.

Diabetes mellitus type 2 is reaching epidemic proportions in western societies. The treatment of diabetic dyslipidemia to prevent cardiovascular disease is of increasing clinical and scientific interest. In the pathogenesis of this disease plasma triglycerides play a central role. Triglyceride rich particles by themselves are not considered atherogenic; however, they are hydrolysed to chylomicron and VLDL remnant particles. Furthermore, mediated by cholesteryl ester transfer protein (CETP), atherogenic small dense LDL particles (sdLDL) emerge, and HDL cholesterol decreases. All these factors yield into a significantly increased atherogenesis and cardiovascular risk. Weight reduction and low fat diets have shown positive effects in general, but a specific therapy to treat diabetic dyslipidemia is still missing. Studies so far have failed to show a reliable benefit for fibrates and for nicotinic acid. Thus, statin therapy to decrease LDL cholesterol to target is the essential treatment for diabetic dyslipidemia to reduce cardiovascular risk. Other lipid lowering drugs can be added optionally.

Introduction: The efficacy of a multifactorial intervention with antihypertensive drugs, statins and acetylsalicylic acid was shown in the STENO 2 trial of diabetic patients with microalbuminuria. But how good is clinical practice in Germany? The DIG (Diabetes in Germany) study was an prospective survey, analysing the quality of risk factor control and treatment patterns of type 2 diabetics over 4 years between 2002 and 2007., Methods: A total of 4020 type 2 diabetics (aged 35 - 80 years) were recruited by 238 physicians across Germany. Their medical history, risk factor profile and clinical data were recorded. The quality of control of diabetes, hypertension or hyperlipidemia and the use of aspirin were assessed in 2914 patients at baseline and after 3,7 years., Results: The mean HbA (1c) value was 6,98 % at baseline and 7,03 at the study end. 42,9 % at the beginning vs. 36,9 % at follow-up had HbA (1c) values above the target level of 6,5 %. Mean blood pressure was 139,3/80.0 compared with 137,3/79.9 mm Hg (p < 0,01), while 24,1 % and 27,0 %, respectively had values above the target level. Mean LDL-cholesterol levels were 3,23 mmol/l and 2,93 mmol/l, respectively, but only 23,2 % and 30,4 % of patients, respectively, reached target levels. There was a significant increase in the use of antihypertensive drugs, statins and acetylsalicylic acid over the four-year period., Conclusion: Type 2 diabetics in Germany received an acceptable level of treatment for hyperglycaemia, but still more than 60 % of the patients have HbA (1c) values higher than 6,5 %. There are serious deficits in the management of hypertension, hypercholesterolemia and the use of aspirin. Because intensive, multifactorial care of type 2 diabetics leads to reduced rates of death and cardiovascular disorders, these results indicate that the early and meticulous implementation of current treatment guidelines remains a major challenge.

Dyslipidemia is one of the most important cardiovascular risk factors. Accordingly preventive measures to normalize lipids are of great importance. The indication for a lipid lowering therapy according to current guidelines focuses on the identification of a patient's global risk, i.e. the contribution of all major cardiovascular risk factors. The selection of the lipid lowering therapy should be appropriate for the kind of lipid disorder. This may be a special challenge with respect to target values and safety aspects. Statins in monotherapy are generally considered safe drugs. Higher dosages may be associated with liver toxicity and muscle problems. Lifestyle management should underpin all lipid management strategies.

A significant reduction in cardiovascular mortality has been achieved during the last decade. New techniques and materials for early coronary intervention have contributed significantly to reduce early mortality after myocardial infarction. Secondary prevention determines further progress; it combines evidence-based medical treatment as well as lifestyle modifications. ACE inhibitors, angiotensin receptor blockers, and beta-blocker positively affect elevated blood pressure, left ventricular remodeling, and electrical stability. Statins decrease LDL and increase HDL cholesterol. Acetylsalicylic acid and clopidogrel are indicated for antiplatelet therapy. Lifestyle modifications unite a diet rich in polyunsaturated fatty acids, moderate physical activity, weight reduction, and smoking cessation.

Fabry's disease is a rare X-linked lysosomal storage disorder leading to an accumulation of globotriaosylceramides in the lysosomes of all tissues. The disease is characterized by a progressive involvement of important vital organs like the kidneys, the cerebrovascular system and the heart. Within the scope of this article an overview of Fabry's cardiomyopathy, the necessary cardiac diagnostic tests and, in addition, the new concept of enzyme replacement therapy is given.

Objective: A large abdominal girth is a measure for abdominal obesity that is associated with many cardiometabolic risk factors and ultimately with an unfavourable prognosis. In this context, the objective of this survey was, to document the frequency of concomitant cardiometabolic risk factors such as diabetes and dyslipidaemia in primary care, to quantify the cross-section of all three risk factors and to investigate the medical care situation of the patients., Methods: For the survey, an open surveillance study design was chosen. Privately practicing physicians of different specializations documented the comorbidities and the medications taken in patients with abdominal obesity (based on waist circumference [men > or = 102, women > or = 88 cm]). The data were evaluated qualitatively and assessed exploratively., Results: A total of 3,945 participating doctors documented 53,147 patients with large abdominal girth. In 71% of the cases, these patients also had type 2 diabetes mellitus. In 76% of the cases, the patients had dyslipidaemia and in 35% of the cases, all three risk factors occurred concomitantly. Taking multiple medications such as antihypertensives, antidiabetic and lipid-lowering agents and thrombocyte aggregation inhibitors, was common. However, the target values, for example, for blood sugar (HbA1c < 6.5 or < 7.0%) frequently could not be achieved with the conventional strategies., Conclusion: Abdominal obesity (based on abdominal girth) is an important risk factor for cardiovascular disease. It often occurs together with type 2 diabetes mellitus, (atherogenic) dyslipidaemia and arterial hypertension. Available therapeutic strategies are not always sufficient for achieving the recommended metabolic values.