India gets lipid management guidelines: How to manage high cholesterol and prevent heart diseases

High cholesterol levels are a “silent killer”, notes the Cardiological Society of India (CSI), which has rolled out India’s first set of guidelines for the management of dyslipidemia. This is a health condition involving abnormal fat (lipid) levels in the blood, and is associated with a higher risk of heart diseases. Among other things, the guidelines recommend non-fasting lipid measurements to estimate the risks. This is a major shift from traditional fasting measurements. As per the CSI, which works towards the prevention and eradication of cardiovascular diseases, non-fasting lipid measurements make testing more convenient, and so more people may get tested.

What is dyslipidemia?

Dyslipidemia, a risk factor for cardiovascular disease, is an increased level of serum total cholesterol, low-density lipoprotein cholesterol and triglycerides, or a decreased serum high-density lipoprotein cholesterol concentration, according to research published in the Lipids in Health and Disease journal in 2020. The prevalence of dyslipidemia stands at 81.2 percent in India, as per a study published in the The Lancet Diabetes & Endocrinology journal in 2023. Low levels of HDL-cholesterol or (good cholesterol) were seen in people living in almost all the Indian states except Manipur, Gujarat, Rajasthan, and Telangana. As for the high LDL-cholesterol or bad cholesterol, it was found to be the highest in northern India, Goa, and Kerala.

“Dyslipidemia is a silent killer, often symptomless unlike hypertension and diabetes,” Dr Pratap Chandra Rath, President of Cardiological Society of India, said in a statement. According to him, elevated LDL-C remains the primary target, but for people with “high triglycerides ( more than 150 mg/dL), non-HDL cholesterol is the focus”.

Indian guidelines for dyslipidemia management

The Indian guidelines have come amid the rise of deaths due to heart diseases. Cardiovascular diseases were responsible for 26.6.percent of total deaths in India in 2017, compared with 15.2 percent in 1990, as per a study published in The Lancet in 2023.

Here are the guidelines:

1. Cholesterol levels

“The general population and low-risk individuals should maintain LDL-C levels below 100 mg/dL and non-HDL-C levels below 130 mg/dL,” said Dr Durjati Prasad Sinha, Honorary General Secretary, CSI. People living with diabetes and hypertension come under high-risk individuals. They should “aim for LDL-C below 70 mg/dL and non-HDL below 100 mg/dL,” said Dr Sinha. A person is also at extremely high risk of cardiovascular disease if they have had recurrent vascular events within two years. Some of the vascular events include peripheral artery disease, a condition in which narrowed arteries reduce blood flow to the arms or legs, and atherosclerosis or clogged arteries. The first lipid profile testing should be done at age 18, or earlier if a person has a positive family history of premature heart disease.

2. No traditional fasting measurements

It is recommended to take up non-fasting lipid measurements to estimate the risk and treatment instead of the traditional fasting measurements. “Non-fasting lipid measurements make testing more convenient and accessible, encouraging more people to get tested and treated,” said Dr Sinha.

3. Food choices

The doctors have advised people to avoid foods consisting of too much sugar and carbohydrate. These foods can contribute to more blockages in the heart in comparison to intake of modest fat.

4. Genetic dyslipidemia

Genetic dyslipidemia affects more than 5 million people in India. They should focus on managing their non-HDL cholesterol, which is a sum of bad cholesterol present in LDL and triglycerides). “Genetic causes of dyslipidemia, such as familial hypercholesterolemia, are more common in India than in other parts of the world. It is essential to identify and treat these cases early through cascade screening of family members,” said Dr Ashwani Mehta, Senior Consultant Cardiologist at Sir Ganga Ram Hospital, and co-author of the Lipid Guidelines.

5. Controlling high levels of cholesterol

High cholesterol can be controlled by using statins with oral non-statin medications. “If goals are not achieved, injectable lipid-lowering drugs like PCSK9 inhibitors or Inclisiran are recommended,” said Dr S. Ramakrishnan, Professor of Cardiology at AIIMS, and co-author of the Lipid Guidelines.

6. Evaluate lipoprotein levels at least once

The new guidelines recommend evaluating lipoprotein (a) levels at least once, as high levels (greater than 50 mg/dL) are linked with heart disease. The prevalence of elevated lipoprotein (a) is higher in India (25 percent) compared to countries in the West (15 to 20 percent), but there is no specific treatment for it.

7. High triglycerides

For people with high triglycerides (more than 150 mg/dL), lifestyle changes such as regular exercise, quitting alcohol and smoking or use of tobacco products, and reducing sugar and carbohydrate intake, are important. People with heart disease, diabetes, or stroke, statins, non-statin drugs, and fish oil are recommended. People with triglycerides levels above 500 mg/dL need to use fish oil, Fenofibrate, and Saraglitazor.