Morbidity and mortality associated with atherosclerotic peripheral artery disease: A systematic review.

BACKGROUND AND AIMS It is unclear whether improvements in the detection/treatment of peripheral artery disease (PAD) affect overall survival and morbidity. We undertook a systematic review to describe survival and morbidity in contemporary PAD cohorts. METHODS Electronic databases were searched for randomised and observational studies reporting mortality/morbidity events between 1 May 2003 and 31 December, 2017 in patients with PAD, diagnosed by intermittent claudication (IC), critical limb ischaemia (CLI), or an ankle brachial index (ABI) < 0.9. Pooled event rates for all-cause and cardiovascular (CV) mortality, non-fatal myocardial infarction (MI), non-fatal stroke, major CV events (MACE; non-fatal MI/stroke, CV death), and major amputation were calculated per 1000 person-years. RESULTS 124 eligible studies were identified (570,856 patients; 855,894 person-years of follow-up). Statin use was reported in 67% of the overall cohort and antiplatelet use in 79%. Pooled event rates for all-cause and CV mortality, MI, stroke, MACE, and major amputation were 113, 39, 20, 12, 71, and 70 per 1000 person-years, respectively. Compared with patients with an ABI <0.9, the presence of CLI was associated with increased rates of all-cause and CV mortality, MI, MACE, and major amputation. Event rates for stroke were similar between patients with an ABI <0.9 and CLI. CONCLUSIONS Our data show PAD patients have a high risk of all-cause and CV mortality, and imply the risk of stroke or MI is at least equivalent to the risk in patients with coronary artery disease. Moreover, our data underline the need for improved treatments to attenuate CV risk in PAD patients

White-coat and masked hypertension in children and adolescents: diagnosis, reproducibility and relationship with target-organ damage

Background and objective: Accumulating evidence suggests that white-coat and masked hypertension are not uncommon among children and adolescents and are often being associated with subclinical target-organ damage. This objective of this study was to assess the long-term reproducibility of white-coat and masked hypertension diagnosis in children and adolescents based on home blood pressure (BP) measurements, the comparison with the diagnosis based on ambulatory BP monitoring and the relationship with cardiovascular risk factors and early markers of endothelium activation, inflammation and atherosclerosis.Subjects and Methods: A total of 48 children and adolescents at Arsakeio School of Palaio Psychico, Athens (27 boys, mean age 11.3±3.1 years) with elevated office and / or home BP recruited from a study in 778 healthy students, were reassessed after 17±4.9 months. The second assessment included office and home BP measurements, 24-hour ambulatory BP monitoring, blood tests (biochemical markers, adiponectin, leptin, homocysteine, high sensitivity CRP, ICAM-1, VCAM-1) pulse wave velocity measurement and cardiac ultrasound. In order to investigate the relationship with subclinical target-organ damage, 33 additional children and adolescents referred to Sotiria Hospital Hypertension Center for BP evaluation were included (total of 81 children and adolescents).Results: Diagnostic agreement between the two assessments for sustained, white-coat and masked hypertension were 83%, 79% and 65% respectively. The standard deviation (S.D.) of mean home BP was lower than that of office BP in both the initial (home BP 9.1/7.1mmHg, systolic/diastolic; office BP 13.1/8.0mmHg) and the second assessment (9.2/6.0 and 14.9/11.5 respectively). The S.D. of differences was lower for home BP (8.3/6.5mmHg, systolic/diastolic) than for office BP (13.9/10.7mmHg).The variation coefficient for home BP measurements was lower than that of office BP (for both systolic and diastolic BP). The concordance correlation coefficient of home BP was higher and the test-retest correlations were closer than for office BP (for both systolic and diastolic BP). Awake ambulatory BP was more closely associated with home than with office BP (for both systolic and diastolic BP). For the group of 81 children and adolescents investigated for subclinical target organ damage, average office BP was 122.1±15.1/71±12.9 mmHg (systolic/diastolic), home BP 121.3±11.5/69.4±6.6 mmHg and 24-hour ABP 118.9±12/66.6±6.1 mmHg. Left ventricular mass (LVM) was correlated with systolic BP (coefficient r 0.55/0.54/0.45 for 24-hour/daytime/nighttime ABP, 0.53 for home BP and 0.41 for office BP; all p<0.01). No significant correlations were found for diastolic BP. Pulse wave velocity was also significantly correlated with systolic BP (r=0.52/0.50/0.48 for 24-hour/daytime/nighttime ABP, 0.50 for home BP and 0.47 for office BP; all p<0.01). Only diastolic ABP and HBP was significantly correlated with PWV (r=0.30 and 0.28 respectively, p<0.05). In multivariate stepwise regression analysis (with age, gender, body mass index [BMI], clinic, home and 24-hour ambulatory systolic/diastolic BP and pulse pressure, clinic, home and 24-hour heart rate as independent variables), PWV was best predicted by systolic HBP (R2=0.22, beta±SE =0.06±0.01), while LVM was determined (R2=0.67) by 24-hour pulse pressure (beta=1.21±0.41), age (beta=2.93±1.32), 24-hour heart rate (beta=-1.27±0.41) and BMI (beta=1.78±0.70). Based on office and home BP measurements for diagnostic classification, children with sustained hypertension were older and had increased BMI and PWV, while those with masked hypertension had higher serum glucose levels, hsCRP, left ventricular mass and left ventricular mass index. Based on office and 24h ambulatory BP measurements, the above mentioned findings were confirmed, apart from the left ventricular mass that was higher in the sustained hypertension group and serum leptin levels that were higher in the white-coat hypertension group.No statistical significant differences between groups were identified in the other biochemical parameters, adhesion molecules and markers of early atherosclerosis. Conclusions: In children and adolescents the long-term reproducibility of home BP, obtained using validated automated devices, appears to be superior to that of carefully taken office measurements. Further research is needed to confirm these findings and establish the role of home BP monitoring in the diagnosis and management of pediatric hypertension. In children and adolescents, the reproducibility of the diagnosis of hypertension phenotypes defined by office and home BP measurements is limited (better for children with sustained HT). Therefore, repeated assessment of office and home BP is required for accurate diagnosis. Increased office and out-of-office BP is associated with adverse effects in children and adolescents regarding target organ damage at the level of the heart (left ventricular mass index) and the arteries (pulse wave velocity). Home BP is at least as closely correlated with target-organ damage as ambulatory BP and to a higher degree than clinic measurements.Further research is needed to confirm these findings and establish the role of home BP monitoring in the diagnosis and management of pediatric hypertension.Εισαγωγή, Σκοπός: Μελέτες έχουν δείξει ότι η υπέρταση «λευκής μπλούζας» και η «συγκαλυμμένη» υπέρτασης σε παιδιά και εφήβους δεν είναι σπάνιες και συχνά συνδέονται με ασυμπτωματικές βλάβες σε «όργανα-στόχους». Σκοπός της παρούσας μελέτης είναι η διερεύνηση της υπέρτασης λευκής μπλούζας και της συγκαλυμμένης υπέρτασης στα παιδιά και τους εφήβους, μέσω της αξιολόγησης της επαναληψιμότητας της διάγνωσης με βάση μετρήσεις ΑΠ στο σπίτι, της σύγκρισης της διάγνωσης με εκείνη που γίνεται βάσει της 24ωρης καταγραφής και της συσχέτισης με δείκτες βλάβης οργάνων-στόχων, παράγοντες καρδιαγγειακού κινδύνου και πρώιμους δείκτες ενεργοποίησης του ενδοθηλίου, χρόνιας φλεγμονής και αθηρωμάτωσης. Ασθενείς και μέθοδοι: 48 μαθητές στο Αρσάκειο Σχολείο (27 αγόρια, μέση ηλικία 11.3±3.1 έτη) με αυξημένη ΑΠ στο ιατρείο ή / και στο σπίτι σε προηγούμενη μελέτη επί 778 υγιών μαθητών, επανελέγχθηκαν 17±4.9 μήνες μετά. Ο επανέλεγχος περιελάμβανε μετρήσεις ΑΠ στο ιατρείο και το σπίτι, 24ωρη καταγραφή ΑΠ, εξετάσεις αίματος, μέτρηση της ταχύτητας σφυγμικού κύματος και διενέργεια υπερηχοκαρδιογραφήματος. Επιπλέον, για τη διερεύνηση της συσχέτισης με ασυμπτωματικές βλάβες οργάνων-στόχων, προστέθηκαν 33 (σύνολο 81) παιδιά και έφηβοι που παραπέμφθηκαν στο Κέντρο Υπέρτασης του Νοσ.Σωτηρία για έλεγχο. Αποτελέσματα: Κατά τις δύο αξιολογήσεις, η συμφωνία στις διαγνώσεις της εμμένουσας υπέρτασης, υπέρτασης λευκής μπλούζας και συγκαλυμμένης υπέρτασης υπολογίστηκε στο 83%, 79% και 65% αντίστοιχα. Η σταθερή απόκλιση της μέσης ΑΠ στο σπίτι ήταν χαμηλότερη από το ιατρείο τόσο στην αρχική (SD 9.1 / 7.1 mmHg για τη ΣΑΠ / ΔΑΠ, ιατρείου 13.1 / 8.0 mmHg) όσο και κατά την επαναληπτική αξιολόγηση (9.2 / 6.0 και 14.9 / 11.5 αντίστοιχα). Η σταθερή απόκλιση των διαφορών ήταν χαμηλότερη για το σπίτι (8.3/6.5 mmHg) σε σχέση με το ιατρείο (13.9/10.7). Ο συντελεστής μεταβλητότητας των επαναληπτικών μετρήσεων ήταν και πάλι χαμηλότερος για τις μετρήσεις στο σπίτι σε σχέση με τις μετρήσεις στο ιατρείο, κάτι που ίσχυε τόσο για τη ΣΑΠ, όσο και για τη ΔΑΠ. Ο συντελεστής αρμονικής συσχέτισης rXCb, όπως και το test-retest ήταν σταθερά υψηλότερα για τις μετρήσεις ΑΠ στο σπίτι σε σχέση με το ιατρείο (για τη ΣΑΠ και τη ΔΑΠ). Η συσχέτιση με τη μέση τιμή των ημερήσιων μετρήσεων της 24ωρης καταγραφής με τις μετρήσεις ΑΠ στο σπίτι ήταν ισχυρότερη συγκρινόμενη με τη συσχέτιση 24ωρης καταγραφής – ιατρείου (για ΣΑΠ και ΔΑΠ). Στην ομάδα των 81 εξεταζομένων για τη διερεύνηση της συσχέτισης με όργανα στόχους, η μέση τιμή της ΑΠ στο ιατρείο ήταν 122.1±15.1 / 71±12.9 mmHg (ΣΑΠ/ΔΑΠ), στο σπίτι 121.3±11.5 / 69.4±6.6 mmHg και στην 24ωρη καταγραφή ΑΠ 118.9±12/66.6±6.1 mmHg. Η ΜΑΚ συσχετίστηκε με τη ΣΑΠ (r= 0.55/ 0.54/ 0.45 για 24ωρη/ ημερήσια / νυκτερινή ABP, 0.53 για HBP και 0.41 για CBP, όλα με p<0.01). Δε διαπιστώθηκαν στατιστικά σημαντικές συσχετίσεις για τη ΔΑΠ. Η PWV συσχετίστηκε σημαντικά με τη ΣΑΠ (r=0.52/ 0.50/ 0.48 για την 24ωρη/ ημερήσια / νυκτερινή ABP, 0.50 για HBP και 0.47 για CBP, όλα με p<0.01). Μόνο η ΣΑΠ σε ABP και HBP συσχετίστηκε σημαντικά με το PWV (r=0.30 και 0.28 αντίστοιχα, p<0.05). Σε βηματική πολυπαραγοντική ανάδρομη ανάλυση (με την ηλικία, φύλο, ΔΜΣ, ΣΑΠ και ΔΑΠ σε ΗΒΡ, ΑΒΡ και τη διαφορική πίεση, καρδιακή συχνότητα σε ΑΒΡ, HBP και CBP, ως ανεξάρτητες μεταβλητές), η PWV μπορούσε να προβλεφθεί καλύτερα από τη ΣΑΠ στην HBP (R2=0.22, beta±SE =0.06±0.01), ενώ η ΜΑΚ (R2=0.67) από την 24ωρη διαφορική πίεση (beta=1.21±0.41), την ηλικία (beta=2.93±1.32), την 24-ωρη ΚΣ (beta=-1.27±0.41) και το ΔΜΣ (beta=1.78±0.70). Χρησιμοποιώντας ως κριτήριο διάγνωσης τις μετρήσεις ΑΠ σε ιατρείο και σπίτι, παρατηρήθηκε πως η ομάδα με εμμένουσα υπέρταση είχε μεγαλύτερη ηλικία, ΔΜΣ και υψηλότερη PWV, η ομάδα με φυσιολογική ΑΠ υψηλότερη HDL και εκείνη με συγκαλυμμένη υπέρταση αυξημένα επίπεδα γλυκόζης ορού, hsCRP, μεγαλύτερη ΜΑΚ και ΔΜΑΚ.Χρησιμοποιώντας ως κριτήριο διάγνωσης τις μετρήσεις ΑΠ σε ιατρείο και 24ωρη καταγραφή, τα παραπάνω ευρήματα επιβεβαιώθηκαν, εκτός της ΜΑΚ που βρέθηκε υψηλότερη στην ομάδα της εμμένουσας υπέρτασης, ενώ το επίπεδο λεπτίνης ήταν υψηλότερο στην ομάδα με υπέρταση λευκής μπλούζας. Στους λοιπούς βιοχημικούς δείκτες, μόρια προσκόλλησης και πρώιμους δείκτες αθηρωμάτωσης δε διαπιστώθηκαν στατιστικά σημαντικές διαφορές μεταξύ των ομάδων διάγνωσης.Συμπεράσματα: Η μακροχρόνια επαναληψιμότητα της ΑΠ στο σπίτι με τη χρήση πιστοποιημένου ηλεκτρονικού πιεσομέτρου υπερέχει από την μέτρηση ΑΠ στο ιατρείο. Η συμφωνία στη διάγνωση υπερέχει στα παιδιά με εμμένουσα υπέρταση. Η επαναληψιμότητα για τη διάγνωση της υπέρτασης «λευκής μπλούζας» και της συγκαλυμμένης υπέρτασης όπως καθορίζεται από τις μετρήσεις ΑΠ σε ιατρείο και σπίτι είναι περιορισμένη. Ως εκ τούτου, απαιτούνται επανειλημμένες μετρήσεις ΑΠ σε σπίτι και ιατρείο για την ασφαλή διάγνωση. Στα παιδιά και τους εφήβους η αυξημένη ΑΠ σε ιατρείο και εκτός ιατρείου συσχετίζεται με δείκτες ασυμπτωματικής βλάβης σε όργανα-στόχους, στην καρδιά (ΔΜΑΚ) και τις αρτηρίες (PWV). Η τιμή της ΑΠ στο σπίτι συσχετίζεται ισχυρά με τις βλάβες στα όργανα-στόχους, τουλάχιστον όσο η 24ωρη καταγραφή ΑΠ και ισχυρότερα από τις μετρήσεις στο ιατρείο.Απαιτείται περισσότερη ερευνητική εργασία στο αντικείμενο για να επιβεβαιωθούν αυτά τα ευρήματα και να καθιερωθεί η αξία των μετρήσεων ΑΠ στο σπίτι για τη διάγνωση και την παρακολούθηση της υπέρτασης σε παιδιά και εφήβους

Long-term reproducibility of home vs. office blood pressure in children and adolescents: the Arsakeion school study

This study compared the long-term reproducibility of home blood pressure (BP) in comparison with office BP in children and adolescents. Forty-eight subjects (27 boys, mean age 11.3 +/- 3.1 (s.d.) years) recruited from the Arsakeion school study because of elevated office and/or home BP were assessed with office (1 visit, mercury sphygmomanometer) and home BP measurements (3 days, electronic devices) in two assessments 17 +/- 4.9 months apart (range 10-26 months). Home and office BP were compared on the basis of the following criteria: (a) s.d. of mean BP; (b) s.d. of differences; (c) variation coefficient (CV); (d) concordance correlation coefficient (CCC); (e) test-retest correlations; (f) correlation with ambulatory BP. (a) The s.d. of mean home BP was lower than that of office BP in both the initial (home BP 9.1/7.1 mm Hg, systolic/diastolic; office BP 13.1/8.0 mm Hg) and the second assessment (9.2/6.0 and 14.9/11.5 respectively). (b) The s.d. of differences was lower for home BP (8.3/6.5 mm Hg, systolic/diastolic) than for office BP (13.9/10.7 mm Hg). (c) The CV of home BP (5.3/6.6, systolic/diastolic) was lower than that of office BP (8.2/10.9). (d) The CCC of home BP (0.54/0.50, systolic/diastolic) was higher than that of office BP (0.51/0.41). (e) Test-retest correlations were closer for home BP (r=0.58/0.52, systolic/diastolic) than for office BP (0.51/0.44). (f) Awake ambulatory BP was more closely associated with home (r=0.77/0.40, systolic/diastolic) than with office BP (0.65/0.24). These data suggest that in children and adolescents the long-term reproducibility of home BP is superior to that of office measurements

Validation of the Microlife BPA100 Plus device for self-home blood pressure measurement according to the International Protocol

Objective: Current guidelines recommend that only validated devices for blood pressure measurement should be used. This study presents the validation results of the Microlife BPA100 Plus monitor for self-home blood pressure measurement, according to the European Society of Hypertension International Protocol. Methods: Fifteen study participants were included in phase 1 and an additional 18 in phase 2 (total 33). Simultaneous blood pressure measurements were taken by two trained observers (Y tube connected mercury sphygmomanometers) four times, sequentially with three measurements taken using the tested device. Absolute differences between observer and device blood pressure were classified into three zones (within 5, 10 and 15 mmHg). The number of readings with a difference within 5 mmHg was calculated for each individual. Results: In phase 1, the device produced 32, 42 and 43 measurements within 5, 10 and 15 mmHg, respectively, for systolic blood pressure and 31, 45 and 45 for diastolic blood pressure. In phase 2.1, the device produced 71, 87 and 96 measurements within 5, 10 and 15 mmHg, respectively, for systolic blood pressure, and 71, 98 and 99 measurements for diastolic blood pressure. In phase 2.2, 26 participants had at least two of their differences within 5 mmHg and three participants had no differences within 5 mmHg for systolic blood pressure, whereas for diastolic blood pressure 24 and three participants, respectively. Mean systolic blood pressure differences were -2.0 +/- 6.0 mmHg and diastolic blood pressure differences were 3.1 +/- 4.1 mmHg. Conclusions: The Microlife BPA100 Plus device for self-home blood pressure measurement comfortably passes the validation requirements of the International Protocol and therefore can be recommended for clinical use in the adult population

Ambulatory arterial stiffness index, pulse pressure and pulse wave velocity in children and adolescents

Arterial stiffness, assessed by carotid-femoral pulse wave velocity (PWV) or indirectly by pulse pressure (PP) or ambulatory arterial stiffness index (AASI), is an independent predictor of cardiovascular disease in adults. However, in children limited evidence is available. This study investigated the usefulness of AASI and PP as indices of arterial stiffness in children and adolescents, by taking PWV as the reference method. Eighty-two children and adolescents (mean age 13.1 +/- 2.9 years) had 24-h ambulatory blood pressure (ABP) monitoring, PWV measurement and echocardiography. Compared with normotensives, subjects with hypertension (n=16) had higher 24-h ABP, 24-h PP and PWV, but not AASI. 24-h, PP was strongly correlated with age, weight, height, 24-h systolic ABP, PWV, left ventricular mass (LVM), LVM index, stroke volume and inversely with 24-h heart rate. AASI was also correlated with weight, height, systolic ABP and LVM, yet these associations were weaker than those of PP, and no significant correlations were found with PWV or LVM index. Moreover, closer agreement of PWV was observed with 24-h PP (71%, kappa 0.21) than with 24-h AASI (61%, kappa -0.06) in detecting subjects at the top quartile of the respective distributions. In children and adolescents, 24-h PP compared with AASI appears to be more closely associated with: (i) arterial stiffness assessed by PWV; (ii) target organ damage assessed by LVM index; and (iii) the presence of essential hypertension. These data suggest that the usefulness of AASI as an index of arterial stiffness in the pediatric population is questionable. Hypertension Research (2010) 33, 1272-1277; doi: 10.1038/hr.2010.178; published online 30 September 201

Validation of the Microlife WatchBP Home device for self home blood pressure measurement according to the International Protocol

Objective Current guidelines recommend that self monitoring of blood pressure at home should only be performed using validated devices. This study assessed the accuracy of the Microlife WatchBP Home device for self home blood pressure measurement according to the European Society of Hypertension International Protocol. Methods Thirty-three participants were included (15 in phase 1 and an additional 18 in phase 2). Simultaneous blood pressure measurements were taken by two observers (Y-tube-connected mercury sphygmomanometers) four times sequentially, with three measurements taken using the tested device. Absolute differences between observer and device measurements were classified into three zones (within 5, 10 and 15 mmHg). The number of measurements with a difference within 5 mmHg was calculated for each individual. Results In phase 1, the device produced 38, 43 and 43 measurements within 5, 10 and 15 mmHg, respectively, for systolic blood pressure and 35, 45 and 45 for diastolic blood pressure. In phase 2.1, the device produced 75, 91 and 97 measurements within 5, 10 and 15 mmHg for systolic, and 74, 93 and 99 for diastolic blood pressure. In phase 2.2, 30 participants had at least two of their differences within 5 mmHg and two participants had no differences within 5 mmHg for systolic blood pressure, whereas for diastolic blood pressure the number of participants were 27 and three, respectively. Mean difference for systolic blood pressure was -0.3 +/- 5.6 mmHg and for diastolic -2.4 +/- 4.8 mmHg. Conclusions The Microlife WatchBP Home device for self home blood pressure measurement fulfills all the validation criteria of the International Protocol and can, therefore, be recommended for clinical use in the adult population

EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study.

To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement. An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52-56] achieved their risk-based 2016 goal and 33% (95% CI 32-35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate-high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination). Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk

EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study

Aims To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement. Methods and results An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52-56] achieved their risk-based 2016 goal and 33% (95% CI 32-35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate-high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination). Conclusion Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk