Atherosclerotic cardiovascular disease remains the leading cause of death in Portugal, with low-density lipoprotein cholesterol (LDL-C) representing one of the most firmly established causal and modifiable drivers.

The 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) dyslipidemia guidelines and the 2021 ESC prevention guidelines translated this biology into risk-stratified LDL-C targets, coupled with the more granular SCORE2 and SCORE2-OP algorithms, as confirmed by the 2025 Focused Update of the 2019 ESC/EAS Guidelines.1–4 More than five years later, the distance between these recommendations and everyday practice remains wide. In this issue, Teixeira et al. shine a much-needed regional light on this distance through the LANTERN Algarve study.5

Using electronic health records from nine Family Health Units, the authors characterized 2904 adults deemed to have dyslipidemia by administrative codes. The picture was sobering, but familiar. Using the SCORE2/OP, 79% were classified as high or very high risk, yet only 15.7% reached their LDL-C goal, and 88% of high/very-high-risk patients remained above target. Almost one third (29.9%) received no lipid-lowering therapy at all, and nearly half were on low- or moderate-intensity statin monotherapy; high-intensity statins or ezetimibe combinations together accounted for barely 14.4% of prescriptions.5 Among patients on low/moderate-intensity monotherapy, 85% missed their target, which illustrates the ceiling effect of undertreatment.

What elevates LANTERN above a further confirmation of the treatment gap is its head-to-head comparison of the legacy SCORE with SCORE2/OP in the same patients. The authors show that 54.4% were reclassified upward in risk. Because SClínico®, the primary-care record program, still relied on the original SCORE at the time of the study, this figure quantifies a systematic underestimation of cardiovascular risk that was hard-wired into the very tool clinicians used. This is a novel and policy-relevant contribution as it converts a methodological upgrade into a concrete number of patients whose risk category would change overnight along with target and treatment intensity. The Portuguese Cholesterol Roadmap of the World Heart Federation had already flagged embedding modern risk tools and closing the treatment gap as national priorities;6 LANTERN supplies the empirical weight that this agenda needed.

The findings align closely with earlier work. The multinational SANTORINI study found roughly four in five high/very-high-risk Europeans off target.7 The Portuguese cohort of SANTORINI, recently published in this journal, echoed this gap, with LDL-C goal attainment that actually worsened over one year (30.4% to 22.6%), in contrast to the improvement seen across the rest of Europe.8 The Portuguese LATINO cohort reported goal attainment of only 7% and 3% in high- and very-high-risk patients, respectively.9 LANTERN differs in deliberately sampling a dyslipidaemia-coded population that includes older adults and patients in secondary prevention, which explains its higher risk distribution and makes its undertreatment signal more concerning, particularly in people in whom the decision to intensify therapy could be more challenging.

The design of the study should be cautiously interpreted. As a cross-sectional analysis of the most recently available laboratory value, it cannot establish a temporal link between a given therapy and the LDL-C observed. Adherence, dosing granularity, and the clinical rationale for non-intensification are unavailable. Newer agents (PCSK9 inhibitors, inclisiran, bempedoic acid) were also absent, reflecting both real access constraints and the limits of routine coding. One barrier the authors rightly raise, which is statin intolerance, deserves particular attention. Much of what is labeled intolerance might be attributable to the nocebo/drucebo effect: meta-analysis of statin-intolerant patients found a high incidence of muscle symptoms even when patients received placebo,10 reframing intolerance as frequently manageable through structured rechallenge and communication rather than as a hard therapeutic ceiling. Undertreatment driven by misattributed adverse effects is, above all, a modifiable problem.

The practical implications are clear. When 85% of patients on low/moderate-intensity monotherapy miss target, treating high- and very-high-risk patients with statin–ezetimibe combination therapy is the logical corollary of both the guidelines and the data LANTERN presents. Equally important are the system-level levers: embedding SCORE2/OP directly in SClínico®, EHR-based alerts, audit-and-feedback cycles, wider use of affordable fixed-dose combinations, and structured roles for community pharmacists. Patient-facing strategies that address risk misperception and statin-related fears should run in parallel, since therapeutic inertia is as much a behavioral as a pharmacological challenge.

LANTERN did what a good regional study should: it shone a light upon, in fine and uncomfortable detail, a gap we already suspected but infrequently measured. The task now is to ensure that better risk assessment reliably translates into better-treated patients. Otherwise, the lantern will keep revealing the same darkness.