Abstract
Introduction/Objectives: Although contemporary guidelines strongly support intensive low-density lipoprotein cholesterol (LDL-C) lowering and the use of advanced lipid biomarkers for cardiovascular risk stratification, implementation in daily clinical practice remains inconsistent. This study aimed to assess current practices, knowledge, and perceived barriers in dyslipidemia management across medical specialties. Methods: We conducted a cross-sectional, anonymous online survey from August to September 2025 among physicians actively involved in lipid management. The questionnaire evaluated the use of Systematic Coronary Risk Evaluation 2 (SCORE2)-based risk assessment, familiarity with LDL-C targets, treatment intensification strategies, awareness and use of apolipoprotein B (apoB) and lipoprotein(a) [Lp(a)], perceived barriers to LDL-C goal attainment, and responses to a standardized clinical vignette. Descriptive analyses and chi-square testing were conducted. Results: Ninety-five physicians completed the survey, the majority practicing in Europe (92.7%), including 83.2% from Portugal (41.1% general practice/family medicine; 14.7% cardiology; 14.7% internal medicine/geriatrics; 14.7% vascular surgery; 9.5% endocrinology). SCORE2 calculators were used "often" or "always" by 52.6%, with significant inter-specialty variation (p < 0.001). Familiarity with LDL-C targets was high (76.8%), and 89.4% reported frequent therapy intensification when goals were not achieved; however, consistent escalation ("always") differed markedly across specialties (p < 0.001). Although 69.5% were aware of recommendations for lifetime assessment of apoB/non-HDL-C/Lp(a), only 17.9% implemented them routinely. Most clinicians reported never or rarely using advanced biomarkers for residual risk assessment, and in a clinical vignette only 12.6% would consistently intensify therapy despite elevated Lp(a) and apoB (p = 0.004). Patient non-adherence (86.3%) was the most frequently perceived barrier. Conclusions: Despite the widespread awareness of LDL-C targets, important gaps persist in the consistent application of guideline-directed therapy and in the use of advanced biomarkers. The underutilization of apoB and Lp(a), together with therapeutic inertia and structural barriers, limits effective residual risk management. Bridging this gap will require coordinated efforts focused on implementation, access, and multidisciplinary care.