New Delhi: Amid growing concerns around the alarming rise in cardiovascular events in the country, the Cardiological Society of India (CSI) – the largest network of cardiologists – has released the first ever Indian guidelines for the management of dyslipidemia, the biggest risk factor behind strokes and heart attacks, which are cardiovascular diseases (CVDs).
Dyslipidemia refers to abnormal levels of lipids in the bloodstream characterised by high total cholesterol, elevated LDL-cholesterol (low density lipoprotein-cholesterol or bad cholesterol), high triglycerides, and low HDL-cholesterol (high density lipoprotein-cholesterol or good cholesterol).
A study published in June 2023 in the journal The Lancet Diabetes & Endocrinology, and supported by the Indian Council of Medical Research (ICMR), showed that the national prevalence of dyslipidemia stands at an alarming 81.2 percent in India. A total of 1,13,043 people participated in the study, which was conducted between October 2008 and December 2020.
For the first time, the CSI guidelines are aimed at clinicians, individuals and medical laboratories. The cut-off range for various lipid markers has been modified based on risk assessment for individuals.
These guidelines have also been published in the Indian Heart Journal.
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CSI recommendations based on risk level
The CSI has recommended that the general population and low-risk individuals maintain LDL-C levels below 100 milligrams per decilitre and non-HDL-C (total cholesterol minus good cholesterol) levels below 130 milligrams per decilitre. On the other hand, high-risk individuals, such as those with diabetes or hypertension, should aim for LDL-C below 70 milligrams per decilitre and non-HDL-C below 100 milligrams per decilitre.
The CSI has recommended strict guidelines for very high-risk patients, which include those with a history of heart attacks, angina, stroke, or chronic kidney disease. They should aim for LDL-C levels below 55 milligrams per decilitre and non-HDL levels below 85 milligrams per decilitre, the CSI suggested.
In a shift from traditional fasting measurements, the new guidelines, developed by 22 senior cardiologists from different parts of India over a period of four years, also recommended non-fasting lipid measurements for risk estimation and treatment.
Elevated LDL-C remains the primary target, but for patients with high triglycerides (>150 milligrams per decilitre), non-HDL cholesterol is the focus, the CSI said.
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Higher risk of CVD in Indians at a younger age
Dr J.P.S. Sawhney, chairman of the Department of Cardiology at Sir Ganga Ram Hospital, New Delhi, and chairman of the lipid guideline drafting committee, told ThePrint that the new guidelines are partly based on the European guidelines but have been modified in the Indian context.
“The need to develop India-specific dyslipidemia management guidelines was felt as it develops 10 years earlier among Indians as compared to the western population. In India, there is a higher cardiovascular disease risk factor at a younger age, and a higher number of people are genetically susceptible to dyslipidemia,” he said.
He added that nearly 50 percent of Indians who suffer heart attacks are less than 50 years of age and 15-20 percent of them are under 40.
“These numbers are astounding and nearly 90 percent of these cases can be prevented if individuals know their risk factors and work to keep their lipid levels below the suggested cut-off range,” he said.
Dr S. Ramakrishnan, professor of cardiology at the All India Institute of Medical Sciences, New Delhi, and co-author of the guidelines, told ThePrint that for the first time, combination therapy with statins and oral non-statin drugs have been recommended for high-risk individuals.
“If goals are not achieved, then injectable lipid-lowering drugs like PCSK9 inhibitor or Inclisiran are recommended,” he said.
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Diet and lifestyle are ‘cornerstone’ of dyslipidemia management
The guidelines recommended the first lipid profile at age 18 or earlier for those with a positive family history of premature heart disease or hypercholesterolemia, which refers to high levels of bad cholesterol in the blood.
Genetic causes of dyslipidemia, such as familial hypercholesterolemia, are more common in India than in other parts of the world. In up to 25 percent cases of dyslipidemia in India, hypercholesterolemia serves as a genetic cause.
The guidelines also said that it is essential to identify and treat these cases early through cascade screening of family members, Dr Ashwani Mehta, another co-author, pointed out at the launch of the guidelines Thursday.
The cardiologists emphasised in the guidelines that diet and lifestyle are a cornerstone of dyslipidemia management.
“Given the dietary habits in India, reducing sugar and carbohydrate intake is recommended, as these contribute more to blockages than modest fat consumption. Regular exercise and yoga, which offer cardioprotective benefits and are culturally relevant, are also recommended,” the cardiologists said.
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Reduce carbs, add healthy fats and proteins
The cardiologists also said that severely restricting on total fats in the diet is not backed by evidence, and an increased intake of combination unsaturated fats – which are a part of Mediterranean diets – is recommended.
Omega-3 poly-unsaturated fats (PUFA) supplementation may be useful in reducing atherosclerotic cardiovascular events (ASCVD) events in moderate to high-risk individuals with high triglycerides.
The cardiologists added that a healthy calorie distribution is achieved by reducing carbohydrates to approximately 50 percent of total calories (restricting sugars and refined carbohydrates) and adding some healthy fats and proteins.
According to the latest guidelines, moderate to vigorous intensity physical activity (40-80 percent heart rate reserve, which refers to the difference between the peak heart rate and resting heart rate) leads to favourable changes in blood lipids and lipoproteins, and moderate-intensity physical activity should ideally be performed daily or at least five days every week to achieve the target of 150 minutes per week.
The exercise program should be personalised to each individual, cardiologists have said.
They have encouraged yoga practice among Indians due to numerous cardioprotective effects. These include possible lipid improvement.
The cardiologists, however, added that more trials are needed to prove its efficacy.
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Recommendations for medical labs
There is an urgent need for the standardisation of lipid estimation in medical laboratories across the country so that every eligible individual can receive evidence-based lipid lowering interventions, the recommendations said.
Sawhney underlined that out of nearly 3 lakh diagnostic labs in the country, a dismal 2,500 are accredited by the National Accreditation Board for Testing and Calibration Laboratories.
“Most of the accredited laboratories do not show uniform reference range for lipid levels. We plan to onboard all biochemistry laboratories in the country to adopt the lipid profile range developed as part of the guidelines,” he said.
(Edited by Radifah Kabir)
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