Gender-Specific Perspectives on National and Global Dyslipidemia Guidelines

European society of cardiology (ESC) and european atherosclerosis society (EAS) guidelines

The 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines used the original SCORE system for 10-year risk estimation. Systematic COronary Risk Evaluation (SCORE2) and SCORE2-OP – sex-specific, competing-risk–adjusted models published in 2021 – were subsequently incorporated into ESC documents and are referenced in the 2025 focused update.^[11,12] Routine lipid screening is recommended for men over 40 years and for women over 50 years or after menopause, acknowledging the protective effect of premenopausal status. Treatment thresholds and LDL-C targets are the same for both sexes. Statins are recommended for primary prevention in women at high risk and for secondary prevention under the same indications as in men. No sex-specific dosing adjustments are proposed, but the guidelines emphasize shared decision-making and careful management of perceived statin intolerance. To achieve these goals, the guidelines recommend highest-tolerated statin dose, adding ezetimibe if targets are not met, and considering PCSK9 inhibitors when combination therapy is insufficient. Lipid-lowering therapy should be avoided when pregnancy is planned, during pregnancy, and while breastfeeding. In severe familial hypercholesterolemia (FH), bile-acid sequestrants or LDL apheresis are possible alternatives. Recently, the 2025 ESC guidelines for the management of cardiovascular disease (CVD) during pregnancy further emphasize a tailored, woman-centered approach, supporting women’s autonomy in making reproductive decisions in high-risk pregnancies.^[13]

American heart association (AHA) and american college of cardiology (ACC) guidelines

The 2018 AHA/ACC cholesterol^[14] and 2019 primary prevention^[15] guidelines use the Pooled Cohort Equations, which incorporate sex as a core variable. Unlike the ESC/EAS approach, which sets absolute LDL-C targets, AHA/ACC emphasizes percentage reductions (30–50%) depending on baseline risk. Women-specific risk enhancers including premature menopause, preeclampsia, gestational diabetes, preterm birth, and small-for-gestational-age delivery, are explicitly recognized and support earlier statin initiation in women at borderline risk. For secondary prevention, the guidelines recommend high-intensity statin therapy for all adults with established ASCVD, unless contraindicated. If LDL-C remains ≥70 mg/dL despite maximally tolerated statin therapy, ezetimibe is the next step, with PCSK9 inhibitors considered in very-high-risk patients when LDL-C goals are still not achieved. These treatment recommendations apply equally to women and men. Reproductive considerations are central to the guidance. Statins are contraindicated during pregnancy and lactation, and women planning pregnancy should discontinue statin therapy one to two months before conception. Counseling on reliable contraception is essential for women of childbearing potential who are prescribed statins, and therapy should be stopped immediately if pregnancy occurs.

Asian pacific society of cardiology consensus

The 2022 Asian Pacific Society of Cardiology (APSC) consensus^[16] recommendations offer a unified framework for dyslipidemia management across the diverse Asia-Pacific region. The document emphasizes individualized assessment of cardiovascular risk, recognizing that epidemiology, resources, and healthcare access vary widely between countries. Rather than introducing novel sex-specific strategies, the consensus adopts a risk-based approach to LDL-C lowering that is closely aligned with international standards. High-intensity statins are first-line therapy for chronic coronary syndrome, with LDL-C reduction targets of ≥50% from baseline and <1.8 mmol/L, or <1.4 mmol/L for very-high-risk patients. Early addition of ezetimibe or PCSK9 inhibitors is recommended if goals are not met. Regarding women, the consensus does not propose separate LDL-C thresholds or sex-specific dosing regimens. Instead, it reinforces principles consistent with other global guidelines. Lipid-lowering therapy should be avoided when pregnancy is planned, during pregnancy, and throughout breastfeeding. In situations of severe FH where treatment cannot be delayed, bile acid sequestrants or LDL apheresis may be considered alternatives. No further distinctions are made for female-specific risk modifiers such as premature menopause or pregnancy complications, which are increasingly highlighted in Western guidance.

Sociedad latinoamericana de cardiología intervencionista (SOLACI)

SOLACI does not issue independent dyslipidemia guidelines but disseminates and contextualizes international recommendations. Local practice generally adapts ESC/EAS and AHA/ACC thresholds to regional epidemiology and healthcare capacities. For women, SOLACI follows global recommendations, including avoidance of lipid-lowering therapy during pregnancy and lactation. However, it does not address female-specific risk enhancers such as pregnancy complications or premature menopause.^[17]

Japan

The 2022 guidelines of the Japan Atherosclerosis Society (JAS)^[18] are based on the Hisayama risk model, which incorporates sex as a variable. In Japan, women experience fewer acute myocardial infarctions than men, but cardiovascular mortality rises steeply after the age of 70. LDL-C thresholds are uniform for both men and women: <160 mg/dL for low risk, <140 mg/dL for moderate risk, and <100–120 mg/dL for high risk, with a target of <70 mg/dL for secondary prevention. Statins are contraindicated during pregnancy, with bile acid sequestrants or LDL apheresis as alternatives for severe FH. The Japan Atherosclerosis Society (JAS) guidelines emphasize the importance of screening and cascade testing for FH, though underdiagnosis in women remains a major challenge. Compared with Western standards, LDL-C targets are higher, reflecting Japan’s epidemiology where cancer, not CVD, is the leading cause of death in women.^[19] As a result, Japan’s approach highlights the interplay between population-specific epidemiology, life expectancy, and public health priorities.

India

The 2022 guidelines from the Lipid Association of India and the Research Society for the Study of Diabetes in India^[20] were developed in response to the country’s high burden of premature ASCVD. These recommendations reflect India’s unique epidemiological profile, characterized by earlier onset of disease and elevated cardiometabolic risk. Women with type 2 diabetes are automatically categorized as high risk, reflecting their disproportionate vulnerability to vascular complications. LDL-C targets are particularly aggressive: <50 mg/dL for very high-risk patients, with optional lowering to <30 mg/dL in extreme-risk cases such as FH with coronary disease. Statins are contraindicated in pregnancy, breastfeeding, and in women planning pregnancy without reliable contraception. For severe FH, bile acid sequestrants and LDL apheresis are recommended as safe alternatives. Given the absence of randomized trials in pregnancy, the guidelines avoid prescriptive thresholds for women but advise trimester-based lipid monitoring when therapy is initiated. Overall, India’s approach highlights an assertive strategy tailored to its distinctive epidemiology, with special emphasis on women with diabetes and FH.

The Indian Thyroid Society clearly integrates thyroid-related dyslipidemia and ASCVD risk assessment into lipid-management recommendations.^[21] Women experience a unique overlap between thyroid dysfunction, dyslipidemia, and CVD risk throughout their lifespan. Thyroid disorders – particularly hypothyroidism – are significantly more common in women due to autoimmune predisposition and hormonal transitions during pregnancy, postpartum, and menopause. These life-stage changes intensify alterations in lipid metabolism, leading to higher LDL-C, triglycerides, Lp(a), and increases in small-dense and oxidized LDL particles. Notably, more than 90% of women with overt hypothyroidism exhibit hyperlipidemia, and 2–5% of those with subclinical hypothyroidism progress to overt disease each year. When Thyroid-stimulating hormone (TSH) exceeds 10 mIU/L, cardiovascular risk increases substantially in women, supporting early initiation of levothyroxine therapy, followed by repeat lipid evaluation. Importantly, while the guideline emphasizes the need to reassess lipid profiles after achieving euthyroidism, it does not specify numerical lipid-control targets, instead referring clinicians to standard lipid-management guidelines for goal-setting. Normalizing thyroid function is particularly important before starting statins, as hypothyroidism heightens susceptibility to statin-associated myopathy. Given that Asian women often present with an atherogenic lipid phenotype and face earlier CVD onset compared with Western populations, routine thyroid screening and coordinated assessment of thyroid function and lipid profiles – especially around pregnancy and menopause – are essential strategies for cardiovascular prevention in women.

United Kingdom

The 2023 National Institute for Health and Care Excellence (NICE) guidelines^[22] take a pragmatic approach that differs from the fixed LDL-C thresholds widely used elsewhere. For primary prevention, the focus is on achieving at least a 40% reduction in non-High-density lipoprotein cholesterol (HDL-C) from baseline, rather than a set LDL target. For secondary prevention, stricter goals are specified: LDL-C ≤2.0 mmol/L (77 mg/dL) or non-HDL-C ≤2.6 mmol/L. These thresholds apply equally to men and women. Nonetheless, registry data consistently show that women with established CVD are less likely than men to achieve intensive lipid lowering. With respect to pregnancy, NICE advises discontinuing statins at least three months before conception and avoiding their use during breastfeeding.

Canada

The 2021 Canadian Cardiovascular Society guidelines^[23] incorporate sex differences into cardiovascular risk assessment. Using a Framingham-based tool, they highlight female-specific risk enhancers including preeclampsia, gestational diabetes, and premature menopause, that warrant earlier initiation of statin therapy even when traditional risk estimates appear modest. Lipid screening is recommended for both men and women from age 40, with particular emphasis on women whose reproductive history places them at increased risk.

Poland

The 2021 Polish Lipid Association guidelines^[24] provide one of the most detailed accounts of dyslipidemia management during pregnancy and lactation. They note the physiological rises in triglycerides, LDL-C, and lipoprotein(a) during pregnancy, all of which contribute to heightened obstetric risk. Statins should be discontinued at least three months before conception and are contraindicated during pregnancy and lactation, although in cases of severe homozygous FH, continuation may be considered under expert supervision. Bile acid sequestrants remain the only pharmacologic agents regarded as safe, with LDL apheresis available as an additional option. The guidelines also emphasize effective contraception, preferring low-estrogen oral contraceptives, intrauterine devices, or barrier methods, since high-estrogen formulations may adversely affect lipids. Women with FH are strongly advised to undergo preconception counseling, reflecting both maternal safety concerns and the high probability of transmitting FH to offspring. Poland’s framework highlights the importance of anticipating and managing reproductive implications in women with dyslipidemia.

United States

The National Lipid Association (NLA) has issued dedicated consensus guidance^[25] for women of reproductive potential. It underscores the elevated risks of preeclampsia, gestational diabetes, and pancreatitis in women with dyslipidemia, while emphasizing shared decision-making, lifestyle optimization, and careful pharmacotherapy planning across preconception, pregnancy, and lactation. This document reflects a growing recognition that reproductive health and cardiovascular risk are closely linked for women, requiring proactive and individualized management strategies. The American Association of Clinical Endocrinology (AACE)^[26] complements this perspective by focusing on women in midlife. Menopause is identified as a key transition point associated with an increasingly atherogenic lipid profile. Although hormone replacement therapy is not recommended for cardiovascular prevention, it may be considered for symptom management in selected cases. The guidelines also highlight polycystic ovary syndrome (PCOS), which is associated with elevated triglycerides and reduced HDL-C, and call for active lipid management in affected women. By addressing both menopause and PCOS, AACE underscores how hormonal transitions across the lifespan shape women’s cardiovascular risk and therapeutic needs.