DYSLIPIDEMIA

1. LIPID GUIDELINES
Presenter : Maj Rahul Prem MR
Moderator : Col J Muthukrishnan, SM

2. AIMS OF PRESENTATION
• 2013 ACC/AHA Guidelines
• 2016 ACC Expert Consensus decision pathway
• Lipid Association of India Expert Consensus Statement on
management of dyslipidemia in Indians 2016

3. INTRODUCTION
• CVD : single largest cause of death developed countries
• Leading cause of death and disability in developing countries
• Younger age in India
• Dyslipidaemia : common modifiable and easily controllable
risk factor

5. ACC/AHA 2013 GUIDELINES
• Focused on RCT related evidence
• Proven therapy rather than arbitrary lipid targets
• “Net ASCVD risk-reduction benefit of statins”

6. LIFESTYLE
• Heart – healthy lifestyle should be encouraged for all
• Dietery approaches to Stop Hypertension (DASH) or
Mediterranean style diet ( rich in vegetables, fruits, whole
grains, poultry etc)
• Regular exercise habits
• Avoidance of tobacco products
• Maintenance of a healthy weight

7. FOUR MAJOR STATIN BENEFIT GROUPS
• Individuals with clinical ASCVD
• Individuals with LDL >190mg/dl
• Individuals with DM, 40-75 y with LDL level 70-189mg/dl
and without clinical ASCVD
• Individuals without clinical ASCVD or DM with LDL
70-189mg/dl and estimated 10-year ASCVD risk >7.5%

9. http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

10. HIGH- MODERATE- AND LOW-INTENSITY STATIN THERAPY
High-Intensity Statin
Therapy
Moderate-Intensity Statin
Therapy
Low-Intensity Statin
Therapy
Daily dose lowers LDL–C on
average, by approximately
≥50%
Daily dose lowers LDL–C on
average, by approximately
30% to <50%
Daily dose lowers LDL–C on
average, by <30%
Atorvastatin 40–80 mg
Rosuvastatin 20 - 40 mg
Atorvastatin 10 – 20 mg
Rosuvastatin 5 – 10 mg
Simvastatin 20–40 mg
Pravastatin 40 – 80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg bid
Pitavastatin 2–4 mg
Simvastatin 10 mg
Pravastatin 10–20 mg
Lovastatin 20 mg
Fluvastatin 20–40 mg
Pitavastatin 1 mg

11. FOLLOWUP
• Assess adherence, response to therapy, adverse effects with in 4 –
12 weeks following statin initiation or change in therapy
• Anticipated response : apprx. > 50% reduction in LDL from baseline
with high intensity and 30 – 50 % reduction with moderate
intensity statin
• Less response : ↑ dose, add non statin therapy in selected high risk
individuals
• Intolerant to statin : Use maximally tolerated dose
• Baseline LFT
• CK if muscle symptoms
• Two LDL values < 40 mg/dl, can consider dose reduction
• New onset type 2 diabetes mellitus

12. LIMITATIONS
• No targets may reduce compliance
• Over treatment for primary primary prevention
• Clinician judgement for whom RCT evidence is insufficient
• No guidelines on addition of other lipid lowering drugs

14. OBJECTIVES
• Patient populations for consideration of non-statin therapy
• Situations for consideration of non-statin therapy
• Treatment options for patients who are truly statin intolerant
• If non-statin therapies are to be added, which agents or
therapies should be considered and in what order

16. ≥ 21 yrs
Stable ASCVD
No comorbidities
• Optional Non Statin :
Ezetemibe first/ BAS if
intolerance to
Ezetemibe
• Consider adding/
replacing with PCSK9
inhibitor second
• LDL target < 100 mg/dl

17. Clinical ASCVD with comorbidity
• Diabetes
• Recent (<3 months) ASCVD event
• ASCVD event while already taking a statin
• Poorly controlled other major ASCVD risk factors
• CKD not on hemodialysis

18. ≥ 21 yrs
Stable ASCVD
Comorbidities present
• Optional Non
Statin :
Ezetemibe first/
BAS if intolerance
to Ezetemibe
• Consider adding/
replacing with
PCSK9 inhibitor
second
• LDL target
< 70 mg/dl,
• Non HDL
< 100 mg/dl

19. ≥ 21 yrs
Clinical ASCVD
Base line LDL ≥ 190
mg/dl
No Secondary cause
• Optional Non Statin
: Ezetemibe / BAS
second line
• Consider PCSK9
inhibitor
• LDL target < 70
mg/dl
• Consider referral to
lipid specialist and
Nutritionist

20. ≥ 21 yrs
No Clinical ASCVD
Base line LDL ≥ 190
mg/dl
No Secondry cause
• Optional Non
Statin :
Ezetemibe /
BAS second line
• Consider PCSK9
inhibitor
• LDL target <
100 mg/dl
• Consider
referral to lipid
specialist and
Nutritionist

21. Age 40 – 75y
No Clinical ASCVD
Base line LDL
< 70 - 189 mg/dl
Diabetes
• Optional Non Statin :
Ezetemibe
• BAS second line
• No PCSK9 inhibitor
• LDL target < 100
mg/dl, Non HDL <
130 mg/dl

22. Age 40 – 75y
No Clinical ASCVD
Base line LDL
< 70 - 189 mg/dl
No Diabetes
• Optional Non
Statin :
Ezetemibe / BAS
second line
• No PCSK9
inhibitor
• LDL target < 100
mg/dl

23. Lipid Association of India:
Expert Consensus Statement on Management
of Dyslipidemia in Indians 2016

24. INDIAN VS WESTERN
• Indians at high risk of developing ASCVD
• Get the disease at an early age
• Have a more severe form of the disease
• Poorer outcome as compared to the western populations
• Access to health care is also not optimal in India
• Treatment of ASCVD expensive

25. DYSLIPIDAEMIA IN INDIA
• The prevalence is constantly increasing in Indians
• 10-15% in rural to 25-30% in urban populations
• Younger age
• Higher TG and lower HDL
• Lower total and LDL Cholesterol
• Atherogenic dyslipidemia
• Low BMI – moderate dose may suffice to decrease LDL by 50%
• Statin induced risk of DM

26. RISK STATIFICATION
• Primary Prevention
• Secondary Prevention
• Treatment Strategy

27. Pre-existing ASCVD
• H/o MI or documented CAD
• History of Stroke/ TIA/
hemodynamically significant
carotid plaque
• PAD (includes ankle-brachial
index <0.9)
• Atherosclerotic aortic
aneurysms
• Atherosclerotic Renal Artery
Stenosis

28. Major ASCVD Risk
• Age : ≥45y males
≥55 y in females
• Family history of early ASCVD
(<55 y in a male first degree
relative or <65 y of age in a
female first-degree relative)
• Current cigarette smoking or
tobacco use
• High blood pressure (≥140/90
mm Hg or on blood pressure
medication)
• Low HDL-C (males <40 mg/dL
and females <50 mg/dL)

29. RISK STATIFICATION

30. VERY HIGH RISK
• Pre-existing ASCVD
• Diabetes with
- evidence of end organ damage
- >2 other major ASCVD risk factors
• Familial homozygous hypercholesterolemia

31. HIGH RISK
• No Diabetes, ≥3 major ASCVD risk factors
• Diabetes with 0-1 other major ASCVD risk factors
and no evidence of end organ damage
• CKD stage 3B or 4
• Familial hypercholesterolemia (other than familial
homozygous hypercholesterolemia)
• Extreme of a single risk factor
e.g. LDL-C >190 mg/dL, strong family history of premature ASCVD, heavy smoker

32. Non conventional risk markers : High Risk
• CAC score >300 Agatston units
• Non-stenotic carotid plaque
• Lp(a) >50 mg/dL

33. MODERATE RISK
• 2 major ASCVD risk factors

34. Moderate risk : Non conventional risk
markers
• Coronary calcium score 100-299 Agatston units
• Increased carotid IMT or aortic pulse wave velocity
• Lipoprotein (a) 20-49 mg/dL
• Metabolic syndrome

35. LOW RISK
• 0-1 major ASCVD risk factors
• Assess lifetime ASCVD in these patients
• www.jbs3risk.com
• If ≥ 30% consider as moderate risk group

37. LDL CHOLESTROL
• Lower the Better
• More aggressive lowering of LDL-C level to 50 mg/dL or less -
significant reduction in atheroma volume and CV events
• No ↑ risk of cancer, hemorrhagic stroke, non-CV death or
neurocognitive dysfunction with very low LDL-C levels

38. NON HDL CHOLESTROL
• Non HDL Cholestrol = Total Cholestrol – LDL Cholestrol
• Non-HDL-C as a co-primary target, as important as LDL-C, for
lipid lowering therapy in Indians

39. GOALS IN INDIAN CONTEXT
Risk Category Treatment Goal Consider Drug Therapy
LDL Cholestrol
(mg/dl)
Non HDL Cholestrol
(mg/dl)
LDL Cholestrol
(mg/dl)
Non HDL Cholestrol
(mg/dl)
Very High Risk < 50 <80 ≥ 50 ≥ 80
High Risk <70 <100 ≥ 70 ≥ 100
Moderate
Risk
<100 <130 ≥ 100 ≥ 130
Low Risk <100 <130 ≥ 130* ≥ 160*
* After an adequate initial non pharmacological intervention of 3 months
Non HDL within 30 mg/dl of LDL Cholestrol
Journal of The Association of Physicians of India March
2016 supplement

40. HYPERTRIGLYCERIDEMIA
• Reversible causes : Treat
• Lifestyle Modification for all :
Regular exercise
Maintenance of proper body weight
Avoidance of alcohol
Diet with reduced saturated fat and refined carbohydrates
• TG < 500 mg/dL : Statins
• First achieve LDL-C target
• If TG is still > 200mg/dL calculate non-HDL-C level, if above
goal, add a non-statin drug to achieve the non-HDL-C goal

41. HYPERTRIGLYCERIDEMIA
• Keep TG <150 mg/dL, preferably <100mg/dL.
• If TG > 500mg/dL:
Objective - reduce the risk of pancreatitis
Start with a non-statin drug
Add statin to achieve LDL-C and Non HDL-C goals
• Fibrates
• High dose omega-3 fatty acids

42. LOW HDL CHOLESTROL
• Independent risk factor for ASCVD
• Statins raise HDL-C levels by 5% to 15%
• Recommended to increase HDL even if LDL is normal/ low
• Niacin not recommended
• If TG also high, fibrates can be added

43. PRIMARY PREVENTION
• Screen for ASCVD all adults at 20 years of age/college entry
• Assess ASCVD risk and discuss the health program
• Follow the “ magnificent seven”

44. “MAGNIFICIENT
SEVEN”
NO
TOBACCO
PHYSICAL
ACTIVITY
BMI
<23kg/m2
HEALTHY
DIET
LDL-C
<100mg/
dl
BP
<120/80
MMHg
FPG<100
mg/dl

45. THERAPEUTIC LIFESTYLE
Physical Activity :
• Avoid inactivity
• For substantial benefit 150 m/week moderate intensity , or 75
m/week of vigorous-intensity aerobic physical activity
• Performed in episodes of at least 10 minutes, and preferably,
it should be spread throughout the week
• For additional and more extensive health benefits, increase
aerobic physical activity to 300 m/week of moderate-intensity,
or 150 m/week of vigorous-intensity aerobic physical activity
• Muscle strengthening activities

46. THERAPEUTIC LIFESTYLE
Diet :
• Dietary pattern that emphasizes intake of vegetables, fruits,
whole grains, low-fat dairy products, poultry, fish, legumes,
non tropical vegetable oils, nuts, etc
• Limit intake of sweets, sugar sweetened beverages, and red
meat

48. Alcohol :
• Alcohol intake should preferably be avoided
• For patients who drink, alcohol should not exceed 1 drink
per day for women or up to 2 drinks per day for men
Tobacco :
• Complete Abstinence
Stress Management :
• Yoga
• Meditation
THERAPEUTIC LIFESTYLE

49. THANK YOU