CSI Releases Landmark Guidelines For Dyslipidemia Management

The Cardiological Society of India (CSI) has introduced the first-ever Indian guidelines for dyslipidemia management, addressing the unique challenges and variations in dyslipidemia prevalence across the nation with extensive Indian data.

Dyslipidemia, characterised by high total cholesterol, elevated LDL-cholesterol (bad cholesterol), high triglycerides, and low HDL-cholesterol (good cholesterol), is a critical risk factor for cardiovascular diseases like heart attacks, strokes, and peripheral artery disease. India faces alarmingly high dyslipidemia rates, with significant interstate variations, particularly in urban areas.

Pratap Chandra Rath, President of CSI, highlighted the silent but severe nature of dyslipidemia, emphasising proactive management and early detection. The new guidelines recommend non-fasting lipid measurements for risk estimation and treatment, a shift from traditional fasting measurements. Elevated LDL-C remains the primary target, but for patients with high triglycerides (>150 mg/dL), non-HDL cholesterol is the focus.

Durjati Prasad Sinha, Honorary General Secretary of CSI, noted that non-fasting lipid measurements make testing more convenient and accessible, encouraging more people to get tested and treated. The guidelines recommend the first lipid profile at age 18, or earlier with a positive family history of premature heart disease or familial hypercholesterolemia. The general population and low-risk individuals should maintain LDL-C levels below 100 mg/dL and non-HDL-C levels below 130 mg/dL. High-risk individuals, such as those with diabetes or hypertension, should aim for LDL-C below 70 mg/dL and non-HDL below 100 mg/dL.

J. P. S. Sawhney, Chairman of the Department of Cardiology at Sir Gangaram Hospital and Chairman of the Lipid Guidelines, explained that aggressive targets are suggested for very high-risk patients, including those with a history of heart attacks, angina, stroke, or chronic kidney disease. These patients should aim for LDL-C levels below 55 mg/dL or non-HDL levels below 85 mg/dL.

The guidelines emphasise lifestyle modifications as a cornerstone of dyslipidemia management. Given the dietary habits in India, reducing sugar and carbohydrate intake is recommended, as these contribute more to blockages compared to modest fat consumption. Regular exercise and yoga, which offer cardioprotective benefits and are culturally relevant, are also recommended.

S. Ramakrishnan, Professor of Cardiology at AIIMS, New Delhi, and co-author of the Lipid Guidelines, noted that high LDL-C and non-HDL-C can be controlled with a combination of statins and oral non-statin drugs. If goals are not achieved, injectable lipid-lowering drugs like PCSK9 inhibitors or Inclisiran are recommended.

The guidelines further read, for patients with high triglycerides (>150 mg/dL), non-HDL cholesterol is the target. Lifestyle changes, such as regular exercise, quitting alcohol and tobacco, and reducing sugar and carbohydrate intake, are crucial. In patients with heart disease, stroke, or diabetes, statins, non-statin drugs, and fish oil (EPA) are recommended. Triglycerides levels above 500 mg/dL require the use of Fenofibrate, Saraglitazor, and fish oil, the guidelines added.

Ashwani Mehta, Senior Consultant Cardiologist at Sir Ganga Ram Hospital and co-author of the Lipid Guidelines stressed the importance of identifying and treating genetic causes of dyslipidemia, such as familial hypercholesterolemia, early through cascade screening of family members. The guidelines also recommend evaluating lipoprotein (a) levels at least once, as elevated levels (>50 mg/dL) are associated with cardiovascular disease. The prevalence of elevated lipoprotein (a) is higher in India (25 per cent) compared to the Western world (15-20 per cent).

Desirable levels of lipids (in mg/dL) based on risk category:

• LDL Cholesterol: <100 (Low/Moderate Risk), <70 (High Risk), <55 (Very High Risk)

• Non-HDL Cholesterol: <130 (Low/Moderate Risk), <100 (High Risk), <85 (Very High Risk)

• HDL Cholesterol: >40 (Men), >50 (Women) for all risk categories

• Triglycerides: <150 for all risk categories

• Lipoprotein(a): <50 for all risk categories

Risk Categories:

• Low Risk: No cardiovascular risk factor

• Moderate Risk: Any one of major CAD risk factors (smoking/tobacco, hypertension, diabetes, dyslipidemia, family history of young heart attack)

• High Risk: Diabetes with 1 or more risk factors, hypertension with 1 or more risk factors, chronic kidney disease, familial hypercholesterolemia with no risk factor

• Very High Risk: Clinical evidence of blockage in arteries (angina, stroke, heart attack), diabetes >20 years/diabetes with complications, familial hypercholesterolemia with blockage of arteries.