Managing High Cholesterol: India’s First-Ever Guidelines for Competitive Exam Preparation

The Cardiological Society of India (CSI) has released the first-ever guidelines for managing dyslipidemia, commonly known as high cholesterol. This development is crucial given the increasing incidence of heart attacks among India’s younger population.

Historical Context

India has witnessed a significant rise in cardiovascular diseases (CVD) over the past few decades. Historically, Indians have been more prone to heart diseases compared to Western populations, often experiencing these conditions a decade earlier. This trend has been attributed to a combination of genetic, environmental, and lifestyle factors.

Understanding Dyslipidemia

Dyslipidemia, also referred to as hyperlipidemia, involves abnormal levels of lipids (fats) in the blood. High levels of low-density lipoprotein (LDL) or “bad cholesterol” can lead to the formation of plaque in arteries, increasing the risk of strokes and heart attacks. If left untreated, high cholesterol can result in severe conditions such as coronary heart disease, carotid artery disease, sudden cardiac arrest, peripheral artery disease, and microvascular disease.

Key Recommendations from India’s Guidelines

1. Lipid Profile Evaluation: The first lipid profile should be conducted at the age of 18. For individuals with a family history of premature heart disease or hypercholesterolemia, testing should be done even earlier.

2. Cholesterol Levels:

   • General Public and Low-Risk Individuals: LDL-C should be below 100 mg/dL and non-HDL-C below 130 mg/dL.
   • High-Risk Individuals: Those with diabetes or hypertension should aim for LDL-C below 70 mg/dL and non-HDL-C below 100 mg/dL.
   • Very High-Risk Individuals: Those with a history of heart attacks, angina, stroke, or chronic kidney disease should maintain LDL-C levels below 55 mg/dL and non-HDL-C levels below 85 mg/dL.

3. Non-Fasting Lipid Measurements: The guidelines recommend non-fasting lipid measurements for risk estimation and treatment, marking a shift from traditional fasting measurements.

4. Treatment Options: High LDL-cholesterol and HDL-cholesterol can be managed with a combination of statins and oral non-statin drugs. Injectable lipid-lowering drugs like PCSK9 inhibitors or Inclisiran are recommended if these do not suffice.

5. Lifestyle Changes: Emphasis is placed on lifestyle modifications such as regular exercise, healthy eating, and quitting smoking. Reducing sugar and carbohydrate intake is particularly recommended due to their significant contribution to arterial blockages.

Importance of the Guidelines

The guidelines were necessitated by the alarming statistics showing that Indians have a 20-50% higher mortality rate from coronary artery disease compared to other populations. Dr. Pratap Chandra Rath, President of CSI, highlighted that dyslipidemia is a “silent killer” with no obvious symptoms, making it crucial for individuals to be aware of their lipid levels.

Summary

• First Lipid Profile: Recommended at age 18 or earlier for those with a family history of heart disease.
• Cholesterol Targets:
  • General Public: LDL-C < 100 mg/dL, non-HDL-C < 130 mg/dL.
  • High-Risk: LDL-C < 70 mg/dL, non-HDL-C < 100 mg/dL.
  • Very High-Risk: LDL-C < 55 mg/dL, non-HDL-C < 85 mg/dL.
• Non-Fasting Measurements: Recommended for risk estimation and treatment.
• Treatment: Combination of statins, oral non-statin drugs, and injectable lipid-lowering drugs.
• Lifestyle Changes: Regular exercise, healthy diet, reduced sugar and carbohydrate intake, and quitting smoking.
• Need for Guidelines: High prevalence of heart disease in India, with significant mortality rates.

These guidelines aim to provide a structured approach to managing high cholesterol, thereby reducing the risk of cardiovascular diseases among the Indian population.