st st 8 Supplement to Journal of The Association of Physicians of India ■ Published on 1 of Every Month 1 November, 2020 Lipid Association of India Expert Consensus Statement on Management of Dyslipidemia in Indians 2020: Part III Expert Consensus Panel: Raman Puri, Chairman1, Vimal Mehta, Co-Chair2, SS Iyengar, Co-Chair3, SN Narasingan, Co-Chair4, P Barton Duell5, GB Sattur6, Krishnaswami Vijayaraghavan7, JC Mohan8, SK Wangnoo9, Jamshed Dalal10, D Prabhakar11, Rajeev Agarwal12, Manish Bansal13, Jamal Yusuf2, Saibal Mukhopadhyay2, Sadanand Shetty14, Prabhash Chand Manoria15, Avishkar Sabharwal16, Akshayaya Pradhan17, Rahul Mehrotra18, Sundeep Mishra19, Sonika Puri20, A Muruganathan21, Abdul Hamid Zargar22, Rashida Melinkari Patanwala23, Soumitra Kumar24, Neil Bardoloi25, KK Pareek26, Aditya Kapoor27, Ashu Rastogi28, Devaki R Nair29, Altamash Shaikh30, Chandra Mani Adhikari31, Muhammad Shoaib Momen Majumder32, Dheeraj Kapoor33, Madhur Yadav34, MR Mubarak35, AK Pancholia36, Rakesh Kumar Sahay37, Rashmi Nanda38, Nathan D Wong39 Introduction proposed by Lipid Association of India regarding various interventions based (LAI),8 identification and application on scientific evidence. The section on ndia is in the middle of an epidemic of lipid markers like lipoprotein (a) low LDL-C levels sums the evidence to Iof atherosclerotic cardiovascular [Lp(a)] and apolipoprotein B (apo the present date and gives justification disease (ASCVD) which is showing B) for risk stratification and control for lower proposed LDL-C goals. Since no signs of abating.1,2 Coronary artery of vascular inflammation. Since hypertriglyceridemia as a component disease (CAD) manifests almost a significant residual risk persists even of atherogenic dyslipidemia is highly decade earlier in India than in Western after high-intensity statin therapy9 and prevalent, a section on triglycerides countries.3 Further, the incidence further lowering of LDL-C beyond that discusses the evidence and gives of CAD is increasing most rapidly achieved by statins has been shown recommendations for approach to among patients younger than 40 years to further reduce CV risk by addition patients with hypertriglyceridemia. of age. About 10%-25% of myocardial of non-statin lipid-lowering drugs in Increased Lp(a) levels are also highly 10-12 infarctions (MI) in India occur before recent large randomized trials, LAI prevalent but are a neglected entity. 4,5 13 the age of 40 years and more than proposes lower LDL-C goals. Hence, the section on Lp(a) deliberates 50% of CAD-associated deaths in India The foundation for prevention on the evidence and recommends 3-5 occur before the age of 50 years. of ASCVD is appropriate lifestyle universal screening of Lp(a) to estimate Although multiple risk factors changes. The section on lifestyle CV risk. The section on C-reactive including smoking, sedentary lifestyle, changes guides the physicians protein discusses the current evidence obesity, hypertension and diabetes are all important contributors to ASCVD, dyslipidemia is the major condition 1Chairman, Sr. Consultant Cardiologist, Indraprastha Apollo Hospitals, New Delhi; 2Co-Chair, Professor Department of Cardiology, necessary for the atherosclerotic GB Pant Hospital, New Delhi; 3Co-Chair, Sr. Consultant and Head, Department of Cardiology, Manipal Hospital, Bangalore, 4 process. Alarmingly, the prevalence Karnataka; Co-Chair, Former Adjunct Professor of medicine, The Tamil Nadu Dr MGR Medical University and Managing Director, SNN Specialities Clinic, Chennai, Tamil Nadu; 5Professor of Medicine, Knight Cardiovascular Institute and Division of Endocrinology, of dyslipidemia [defined according Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA; 6Sr. Consultant Physician and Diabetologist, to National Cholesterol Education Sattur Medical Care, Hubli, Karnataka; 7Clinical Professor of Medicine, University of Arizona and Adjunct Professor of Medicine, Programme (NCEP) guidelines]6 in Midwestern University, Glendale, Arizona, USA; 8Consultant Cardiologist, Fortis Hospital, New Delhi; 9Consultant Endocrinologist, Indians is very high with 79% of subjects Indraprastha Apollo Hospitals, New Delhi; 10Consultant Cardiologist, Kolilaben Ambani Hospital, Mumbai, Maharashtra; 11Sr. 12 having at least one lipid abnormality, Consultant, Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu; Sr. Consultant Cardiologist, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh; 13Associate Director, Department of Cardiology, Medanta Hospital, Gurugram, Haryana; 14Head with decreased high density lipoprotein of Department of Cardiology, K.J. Somaiya Super-speciality Institute, Mumbai, Maharashtra; 15Director, Heart and Critical Care cholesterol (HDL-C) levels in 72.3% Hospital, Bhopal, Madhya Pradesh; 16Division of Geriatrics, Hackensack University Medical Centre, USA; 17Sr. Consultant, Department subjects, hypertriglyceridemia in 29.5% of Cardiology King George’s Medical University, Lucknow, Uttar Pradesh; 18Director and Head Non-Invasive Cardiology, Max Super 19 20 subjects and elevated low density speciality Hospital, Saket, New Delhi; Professor of Cardiology, AIIMS, New Delhi; Assistant Professor, Dept. of Nephrology/ Transplant, Rutgers Robert wood Johnson University, USA; 21Sr. Consultant Internal Medicine, AG Hospital, Tirupur, Tamil Nadu; lipoprotein cholesterol (LDL-C) levels 22Medical Director, Center for Diabetes & Endocrine Care, National Highway, Gulshan Nagar, Srinagar, Jammu and Kashmir; 23Sr. 7 in 11.8% of subjects. Hence, optimal Consultant, Department of Internal Medicine, Sahyadri Speciality Hospital, Pune, Maharashtra; 24Prof. and Head, Department of management of dyslipidemia is key Cardiology, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal; 25Managing Director and HOD, Cardiology, Excel Care to stem the epidemic of ASCVD along Hospital, Guwahati, Assam; 26Head of Department of Medicine, SN Pareek Hospital, Kota, Rajasthan; 27Professor of Cardiology, Sanjay 28 with control of other risk factors. Gandhi PGIMS, Lucknow, Uttar Pradesh; Assistant Professor, Department of Endocrinology & Metabolism, PGIMER Chandigarh, Punjab; 29Sr. Consultant Department of Lipidology and Chemical pathologist, Royal Free Hospital, London, UK; 30Sr. Consultant, The appropriate approach to Endocrinology, Diabetology and Metabolic Physician, Mumbai, Maharashtra; 31Consultant Cardiologist, Shahid Gangalal National management of dyslipidemia includes Heart Centre, Kathmandu, Nepal; 32Consultant, Dept. of Rheumatology & Medicine, Bangabandhu Shiekh Mujib Medical University, 33 34 identification of subjects with Bangladesh; Head of Department of Endocrinology, Artemis Hospital, Gurgaon, Haryana; Director Professor of Medicine, Lady Harding Medical College, New Delhi; 35Consultant Cardiologist, Lanka Hospital, Colombo, Sri Lanka; 36Head of Department of dyslipidemia, increasing the usage and Medicine, Clinical and Preventive Cardiology, Arihant Hospital and Research Center, Indore, Madhya Pradesh; 37Professor and adherence of statins in suitable subjects, Head of Department of Endocrinology, Osmania Medical College, Hyderabad; 38Consultant, Cardiac Care Centre, South Extension, focus on achievement of LDL-C goals New Delhi; 39Professor and Director, Heart Disease Prevention Program, Division of Cardiology, University of California Irvine, USA st st Supplement to Journal of The Association of Physicians of India ■ Published on 1 of Every Month 1 November, 2020 9 on the role of inflammation in ASCVD validation cohort was taken comprising 3. Prabhakaran D, Jeemon P, Roy A. Cardiovascular diseases in India: Current epidemiology and future directions. and gives criteria for its use in clinical physicians from across the country Circulation 2016; 133:1605-20. practice. Most importantly, the risk of (May 2020 and July 2020). To ensure 4. Yusuf S, Hawken S, Ounpuu S, et al, for the INTERHEART ASCVD events may be underestimated that the recommendations in this Investigators. Effect of potentially modifiable risk factors by use of LDL-C alone to estimate statement reflected expert opinion associated with myocardial infarction in 52 countries (the INTERHEART study): case control study. Lancet 2004; CV risk especially in subjects with among lipid specialists throughout 364:937-52. atherogenic dyslipidemia. Normal India, a series of 19 meetings were 5. Ardeshna DR, Bob-Manuel T, Nanda A, Sharma A, Skelton or mildly elevated LDL-C levels may conducted in 13 cities involving 162 IV WP, Skelton M, Khouzam RN. Asian-Indians: a review of give a sense of complacency regarding expert health care providers over 11 coronary artery disease in this understudied cohort in the United States. Ann Transl Med 2018; 6:12. doi: 10.21037/ estimation and management of lipid months. Subsequently a total of 55 atm.2017.10.18. risk. Hence LAI proposes that apo B webinars (duration 150 minutes each) 6. Executive summary of the Third Report of the National be universally measured to estimate were held across the country over 3 Cholesterol Education Program (NCEP). Expert Panel the true risk. Because one molecule months period between May 2020 and on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; of apo B is present on all atherogenic July 2020 involving local physicians 285:2486-97. lipoprotein particles, apo B levels will where new Indian guidelines were 7. Joshi SR, Anjana RM, Deepa M, Pradeepa R, Bhansali A, et clearly categorize these