a study Published in the journal in June 2023 The Lancet Diabetes and EndocrinologyA study supported by the Indian Council of Medical Research (ICMR) found that the prevalence of dyslipidemia in India is at an alarming 81.2%. A total of 113,043 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 ranges for the various lipid markers have been modified based on individual risk assessment.
These guidelines also: Published In Indian Heart Journal.
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CSI Recommendations Based on Risk Level
The CSI recommends that the general population and low-risk individuals maintain LDL-C levels below 100 milligrams per deciliter and non-HDL-C (total cholesterol minus the good cholesterol) levels below 130 milligrams per deciliter, while high-risk individuals, such as those with diabetes or high blood pressure, should aim to keep their LDL-C levels below 70 milligrams per deciliter and non-HDL-C levels below 100 milligrams per deciliter.
The CSI recommends stricter guidelines for very high-risk patients, such as those with a history of heart attack, angina, stroke, or chronic kidney disease. It suggests that these patients should aim to keep their LDL-C levels below 55 milligrams per deciliter and non-HDL levels below 85 milligrams per deciliter.
The new guidelines, developed over a period of four years by 22 senior cardiologists from across India, move away from the conventional fasting approach and also recommend non-fasting lipid monitoring for risk estimation and treatment.
Raising LDL-C remains the primary goal, but for patients with high triglyceride levels (over 150 milligrams per deciliter), the focus will be on non-HDL cholesterol, according to the CSI.
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Young people in India at high risk of CVD
Dr JPS Sawhney, head 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 European guidelines but have been modified to suit the Indian context.
“Since dyslipidemia develops 10 years earlier in India compared to western countries, we felt the need to develop India-specific guidelines for dyslipidemia management. India has a high number of people with high cardiovascular disease risk factors at a young age and genetic predisposition to dyslipidemia,” he said.
He added that around 50 per cent of Indians who suffer heart attacks are under 50 years of age, of which 15-20 per cent are under 40 years of age.
“These figures are staggering and approximately 90 percent of these cases are preventable if individuals know their risk factors and make an effort to keep lipid levels below the recommended cut-off ranges,” 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 of a statin with an oral non-statin drug has been recommended for high-risk individuals.
“If the goal is not met, we will consider PCSK9 inhibitors and Inclisiran is recommended,” he said.
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Diet and lifestyle are the “cornerstones” of dyslipidemia management
The guidelines recommend that people with a family history of premature heart disease or hypercholesterolemia (high levels of “bad” cholesterol in the blood) have their first lipid profile tested at or before the age of 18.
Genetic causes of dyslipidemia, such as familial hypercholesterolemia, are more common in India than in other parts of the world. Hypercholesterolemia has a genetic cause in up to 25 percent of cases of dyslipidemia in India.
The guidelines also state that early identification and treatment of these cases through cascade screening of families is essential, noted Dr Ashwani Mehta, another co-author. The guidelines were released on Thursday.
In their guidelines, cardiologists emphasized that diet and lifestyle are the cornerstones of dyslipidemia management.
“Given Indian dietary habits, reduced intake of sugar and carbohydrates is recommended as they are more likely to cause blockages than moderate fat intake. Regular exercise and yoga, which have cardioprotective properties and are culturally appropriate, are also recommended,” the cardiologists said.
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Reduce carbs and increase healthy fats and protein
The cardiologists also said that severely restricting total dietary fat is not supported by evidence and that increased intake of complex unsaturated fats, which are part of the Mediterranean diet, is recommended.
Supplementation with omega-3 polyunsaturated fats (PUFAs) may help reduce atherosclerotic cardiovascular (ASCVD) events in people at moderate to high risk for high triglycerides.
The cardiologists add that a healthy calorie balance is achieved by reducing carbohydrates to about 50 percent of total calories (limiting sugar and refined carbohydrates) and adding in some healthy fats and protein.
According to current guidelines, moderate-to-vigorous exercise (40 to 80 percent of your heart rate reserve, or the difference between your peak heart rate and your resting heart rate) produces favorable changes in blood lipids and lipoproteins, and to reach the 150 minutes per week goal, moderate exercise daily, or at least five days per week, is ideal.
Cardiologists say exercise programs should be customized for each individual.
Yoga practice is being encouraged among Indians as it has many cardioprotective benefits, including improving lipid profiles.
But the cardiologists added that further trials were needed to prove its effectiveness.
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Recommendations for Medical Laboratories
The recommendations state that standardization of lipid estimation in medical laboratories across the country is urgently needed so that all eligible individuals can receive evidence-based lipid-lowering interventions.
Sawhney highlighted that of the approximately 300,000 diagnostic laboratories in the country, only 2,500 are accredited by the National Board for Accreditation of Testing and Calibration Laboratories.
“Most of the accredited laboratories have not given uniform reference ranges for lipid levels. We plan to onboard all biochemistry laboratories in the country to adopt the lipid profile ranges developed as part of the guidelines,” he said.
(Editor: Radifa Kabir)
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