indian lipid guideline 2016 dibu final
TRANSCRIPT
![Page 1: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/1.jpg)
Dr. Dibbendhu Khanra
INDIAN LIPID GUIDELINE
![Page 2: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/2.jpg)
Single problem
Single strategy
Statins
Single calculation
DON’T CHASE TARGETS
2013ACC/ AHA
![Page 3: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/3.jpg)
Paradigm Shift
New cholesterol treatment guidelines could double number of Americans taking statins
About 70 million Americans could take statins under new guidelines
![Page 4: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/4.jpg)
32 year male IT professionalOccasionally drinks/ smokesNon DM/ non HTN85 kgs/ Cant go to gymFather died of heart attack at 50 years of ageRecently marriedVery anxious of heart diseaseCAG normalLDL 100TG 350HDL 30ACC risk calculator: 2%
2016: an Indian story
Would you give statin or not? If given how long? What about the side effects?
![Page 5: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/5.jpg)
8 meetings153 experts18 states 30 cities
![Page 6: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/6.jpg)
INDIAN CVD
BURDEN?
![Page 7: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/7.jpg)
more than 60 million people with coronary heart diseases by 2015
The health & family welfare
ministry Projection
![Page 8: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/8.jpg)
CV Mortality: Trend in India
012345
1990 2000 2010 2020
2.263.01
3.84.77
CV M
orta
lity
(Mill
ions
)
Heart. 2008 Jan;94(1):16-26.
![Page 9: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/9.jpg)
MI at younger Age in Indians
http://www.cadiresearch.org/topic/asian-indian-heart-disease/cadi-india/premature-heart-disease
![Page 10: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/10.jpg)
Changing Epidemiology in India
10
Urbanization
DM,HT,DYSLIP
>Improved Life Expecta
ncy
Changing
dietary pattern
Reduced
physical
activity
Stress
• Increase inthe number ofCVD cases
World Development Indicators, World Bank.India’s Pace of Urbanization Speeds Up, Wall Street Journal, July 2011 Food and Nutrition in India: Facts and interpretation.Dreze J, et al. Economic & Political Weekly, February 2009. Smoking & Heart Disease. Cleveland Clinic. Joshi SR, et. al. India -Diabetes Capital of the World : Now Heading Towards Hypertension. Journal of Association of Physicians in India. 2007; 55:323-324 Xavier D, et.al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. The Lancet.2008;371(9622): 1435-1442. World Health Survey, World Health Organization.
• Earlier onsetof disease
![Page 11: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/11.jpg)
CAD in
Indians
![Page 12: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/12.jpg)
However westernized we
get,INDIANS are
still INDIANS, you know?
Oh, I see
![Page 13: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/13.jpg)
High smokingHigh BP
But
Heart diseases amongChinese , very low
& Japanese , the lowest
![Page 14: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/14.jpg)
TRADITIONAL
CV RISKSIN
INDIA?
![Page 15: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/15.jpg)
DIABETES IN INDIA
66 Million Cases35 Million
Undiagnosed8.6% Prevalence Over 1 Million
Deaths
IDF, Diabetes Atlas, 6th edition revision, 2014
![Page 16: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/16.jpg)
INTERHEART Study
Dyslipidemia is the most common risk factor
![Page 17: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/17.jpg)
Reducing Cholesterol benefits most
Relative risk reduction
2 yr event rate
Huang et al. Am J Med 2001;111:633-642Turner R.C. BMJ 1998;316:823-828He et al. JAMA 1999;282:2027-2034Antitrombotic Trialits BMJ 2002;324:71-86
![Page 18: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/18.jpg)
Men Women
Total cholesterol
![Page 19: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/19.jpg)
INDIAN DYSLIPIDEMIA
![Page 20: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/20.jpg)
Jaipur heart watch study
![Page 21: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/21.jpg)
ATHEROGENIC DYSLIPIDEMIA
Low HDL (Most common)High TG
High Lp(a)
High LDL is very uncommonApo B: Apo A1 is the best
biomrker
![Page 22: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/22.jpg)
Lipid screening at 20 years of age
![Page 23: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/23.jpg)
Asian-Indian
paradox
More severe
form with poor
outcome
![Page 24: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/24.jpg)
ACC/AHA risk
calculatorNot validated in
Indians10 year risk onlyOnly
conventional risk factors
Needs computer
![Page 25: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/25.jpg)
Indian doctors are better in auscultation than statistics
![Page 26: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/26.jpg)
NONTRADITIONA
LCV RISKS
ININDIA?
![Page 27: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/27.jpg)
Coronary calcium
Both LDL-C and HDL-C were found to be independent predictors of CAC
CAC score >400 had 100% specificity
![Page 28: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/28.jpg)
CIMT
For 0.1 mm increase in CIMT the future risk of MI increased by 10-15% A 10% reduction in LDL-C per year accounted for a reduction of CIMT by 0.73 presence of carotid plaques is a marker of already existing ASCVD
![Page 29: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/29.jpg)
Aortic stiffness
![Page 30: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/30.jpg)
Lp(a)
more common among CAD patients with existing family history
Lp(a) levels in Asian Indian newborns were significantly higher than in Chinese in Singapore
Level > 20 mg/dL indicates increased ASCVD risk in Indians
![Page 31: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/31.jpg)
presence of obesity and/or metabolic syndrome in an individual who is otherwise at low 10-year risk of ASCVD should indicate high lifetime ASCVD risk.
Obesity/ MetS
![Page 32: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/32.jpg)
A 5-μmol/L tHcy increment elevates CAD risk by as much as cholesterol increases of 0.5 mmol/L (20 mg/dL)
Very high prevalence of hyperhomocystinemia (>15 µmol/L) in 75% of subjects in India, which was strongly correlated with cobalamin deficiency
impaired cobalamin status appears more important than folate deficiency among Asian Indians
Homocysteine
![Page 33: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/33.jpg)
CRP significant ASCVD risk reduction with statin in individuals with elevated CRP despite relatively normal LDL-C
A value of > 2 mg/l of hs-CRP indicates increased ASCVD risk.
When the value is >10 mg/L, it usually indicates a non-atherosclerotic cause of Inflammation
But Quality control and proper standardization of hs-CRP is challenging in India
![Page 34: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/34.jpg)
Risk factors
NO LDL
NO CRPNO
HOMOCYSTEINE
CACAortic stiffness
CIMTLp(a)MertS
![Page 35: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/35.jpg)
JBS3: Lifetime ASCVD risk calculator
Estimate lifetime riskValidated in indians
Non-conventional risk factors
<30% = LOW RISK30-44% = MODERATE
RISK>45% = HIGH RISK
![Page 36: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/36.jpg)
IdentifyHigh Riskpatients
AssessRisk factors
EstimateLifetime risk
The Indian Approach
![Page 37: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/37.jpg)
1. History of MI or documented CAD2. History of ischemic stroke or TIA3. hemodynamically significant carotid plaque4. Atherosclerotic peripheral arterial
disease(ABPI<0.9)5. Atherosclerotic aortic aneurysms6. Atherosclerotic renal artery stenosis
Pre-existing ASCVD
![Page 38: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/38.jpg)
30-44% risk
>45%
risk
Moderate risk
Highrisk
Indian risk
stratification
![Page 39: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/39.jpg)
SETTING THE
INDIAN TARGETS
![Page 40: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/40.jpg)
Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279
LDL: the lower the better
![Page 41: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/41.jpg)
High dose (ROSUVA)statin
regresses atherosclerosis
• LDL should be the primary target
• the lower LDL the better• LDL<50 mg/dl is safe
![Page 42: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/42.jpg)
4HPS Collaborative Group. Lancet. 2002;360:7-22. 5Shepherd J et al. N Engl J Med. 1995;333:1301-1307.6 Downs JR et al. JAMA. 1998;279:1615-1622.
14S Group. Lancet. 1994;344:1383-1389.2LIPID Study Group. N Engl J Med. 1998;339:1349-1357. 3Sacks FM et al. N Engl J Med. 1996;335:1001-1009.
Δ LDLN 4444 4159 20 536 6595 66059014
-35% -28% -29% -26% -25%-25%Secondary High Risk Primary
Patie
nts
Exp
erie
ncin
g M
ajor
CH
D
Eve
nts,
%
PlaceboStatin
19.4
12.310.2 8.7
5.5 6.8
28.0
15.9 13.
2 11.8 7.
9
10.9
Many CHD Events Still Occur in Statin Treated Patients
25-40% CVD Reduction Leaves High Residual RiskP = 0.003
P <0.001P = 0.003 P =
0.0001 P <0.001 P <0.001
![Page 43: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/43.jpg)
Residual CVD Risk with Intensive Statin Therapy Less, but Still Unacceptably High
Patie
nts
Exp
erie
ncin
g M
ajor
CVD
E
vent
s, %
PROVE IT-TIMI 222 IDEAL3
TNT4
nLDL-C* mg/dL
1Superko HR. Br J Cardiol. 2006;13:131-136. 2Cannon CP et al. N Engl J Med. 2004;350:1495-1504.3Pedersen TR et al. JAMA. 2005;294:2437-2445. 4LaRosa JC et al. N Engl J Med. 2005;352:1425-1435.
4162
8888
10,00195
*Mean or median LDL-C after treatment
62 104
81 101
77
Statistically significant, but clinically inadequate CVD reduction1
Standard statin therapyIntensive high-dose statin therapy
![Page 44: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/44.jpg)
Patients With Diabetes Have Particularly High Residual CVD Risk After Statin Treatment
Event Rate (No Diabetes)
Event Rate (Diabetes)
On Statin On Placebo On Statin On PlaceboHPS1* (CHD patients) 19.8% 25.7% 33.4% 37.8%
CARE2† 19.4% 24.6% 28.7% 36.8%
LIPID3‡ 11.7% 15.2% 19.2% 22.8%
PROSPER4§ 13.1% 16.0% 23.1% 18.4%
ASCOT-LLA5‡ 4.9% 8.7% 9.6% 11.4%TNT6║ 7.8% 9.7% 13.8% 17.9%
*CHD death, nonfatal MI, stroke, revascularizations†CHD death, nonfatal MI, CABG, PTCA‡CHD death and nonfatal MI§CHD death, nonfatal MI, stroke║CHD death, nonfatal MI, resuscitated cardiac arrest, stroke (80 mg versus 10mg atorvastatin)
1HPS Collaborative Group. Lancet. 2003;361:2005-2016. 2Sacks FM, et al. N Engl J Med. 1996;335:1001-1009. 3LIPID Study Group. N Engl J Med. 1998;339:1349-1357. 4Shepherd J, et al. Lancet. 2002;360:1623-1630. 5Sever PS, et al. Lancet. 2003;361:1149-1158.6Shepherd J, et al. Diabetes Care. 2006;29:1220-1226.
![Page 45: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/45.jpg)
Beyond targeting LDL there are several
atherogenic lipoproteins and LDL accounts for only about 75% of them
residual risk of ASCVD in statin-treated patients remains as high as 55%-70%.
It is thus evident that in order to reduce ASCVD effectively, we need to concentrate on all atherogenic lipoproteins, and not just LDL alone
Non HDL cholesterol
TG
Small
dense
LDL
![Page 46: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/46.jpg)
non-HDL-C has been shown to correlate well
with subclinical atherosclerosis
![Page 47: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/47.jpg)
Non-HDL-C is particularly informative in diabetics who tend to have higher TG levels
![Page 48: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/48.jpg)
predictive accuracy of non-HDL-C in patients with relatively low TG
(<200mg/dL)
![Page 49: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/49.jpg)
LDL-C lost its predictive value when TG levels exceeded
400mg/dL
Non-HDL-C seems to predict ASCVD risk
equally well regardless of TG levels
![Page 50: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/50.jpg)
increased non-HDL-C is associated
with increased risk of future CV events even if LDL-C is under
control with statin
![Page 51: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/51.jpg)
Better correlate of ASCVD than LDLIncludes TG and Lp(a)Does not need fastingCan be easily calculated by total cholesterol and
HDLSurrogate for small dense LDL
Non HDL cholesterol better than LDL?
![Page 52: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/52.jpg)
Memories of ATPIII targets
![Page 53: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/53.jpg)
strong linear association between TG levels and CHD risk
Do not underestimate high TG
![Page 54: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/54.jpg)
Small dense LDLLarge LDL
AtherogenicTG>250
Phenotype BTG <100
Phenotype A
At a fasting TG concentration <100 mg/dL, 85% of the population has pattern A (less
atherogenic)
At a fasting TG concentration >250 mg/dL, 85% will have pattern B (highly atherogenic)
![Page 55: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/55.jpg)
Non-fasting TG Clinically unimportant increase in TG concentrations, by 0·2–0·4 mmol/L (18-36 mg/dL) on average, two to six hours after eating normal meals.
even a non-fasting concentration predicts increased CV risk
Indian patients are unpredictable
![Page 56: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/56.jpg)
U shaped relation: HDL & CV risk
631,762 individuals with no prior cardiac
conditions, with a mean follow up of
4.9 years,
• very high levels of HDL-C were associated with an increased risk of death from both CV and non-CV causes, compared with intermediate HDL-C levels.
![Page 57: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/57.jpg)
Prevalence of low HDL-C levels was much higher in the South Asian populations than in the other populations (82% vs 60% of acute MI cases)
increaseing HDL-C was associated with a mere 13% reduction in MI risk in South Asians as compared to 23% risk reduction in the other Asians
The patients with low HDL-C are three times more likely to die after an acute coronary event
INTERHEART: HDL in Indians
![Page 58: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/58.jpg)
THERAPY FOR
INDIAN DYSLIPIDAE
MIA
![Page 59: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/59.jpg)
![Page 60: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/60.jpg)
SmokingIt is never too late to
quit smoking. After quitting smoking,
the ASCVD risk decreases by 50% within 2 years.
Alcohol consumption was not found to be protective among South Asians
INTERHEARTAlcohol
![Page 61: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/61.jpg)
![Page 62: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/62.jpg)
Vegetarians are not protected
![Page 63: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/63.jpg)
Eat baked or boiled fish at least twice per
week
![Page 64: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/64.jpg)
As per the ICMR in 2014, 392 million people were inactive
in India which represented nearly 1/3rd of our population.
![Page 65: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/65.jpg)
Mr. Modi, is it true that there
are 4 billion lazy people in India?
Yes, that’s why I invented
WORLD YOGA DAY
![Page 66: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/66.jpg)
Yoga may help in improving lipid profile in patients suffering
from ESRDBairey Merz CN, Dwyer J, Nordstrom CK, Walton KG, Salerno JW, Schneider RH. Psychosocial stress and cardiovascular disease: Pathophysiological links.
Behav Med 2002; 27:141-147
![Page 67: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/67.jpg)
![Page 68: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/68.jpg)
Treatment of 1000 patients with a statin for five years would prevent 18 major ASCVD event (Cochrane)
Reduction of 1 mmol per liter (39 mg/dl) in LDL-C levels yielded 21% risk reduction irrespective of LDL baseline (CTT)
In individuals with 5-year risk of major vascular events <10%, each 1 mmol/L reduction in LDL-C produced an absolute reduction in major vascular events of about 11 per 1000 over 5 years (CTT)
Those who achieved LDL-C <50 mg/dL had 65% reduction in the risk of major CV events (JUPITER)
23% of the subjects reached LDL-C level of <40 mg/dL with no adverse effects (JUPITER)
Statin
![Page 69: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/69.jpg)
Statin
![Page 70: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/70.jpg)
PURE - 10 yrs community based observational study
underuse of low-cost medicines for secondary prevention among participants with a history of CVD
70The PURE Study: a prospective epidemiological survey. Lancet 2011;378:1231–43.
![Page 71: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/71.jpg)
WOSCPOS: 20 years follow-up45-64 year old men (n= 6595) with high LDL
cholesterol were randomized to receive pravastatin 40mg once daily or placebo for an average of 4.9 years. And followed up for 20 years (without statin)
Men allocated to pravastatin had - reduced all-cause mortality - 21% decrease in cardiovascular death- 18% for any coronary event (p=0.002), - 24% for myocardial infarction (p=0.01) and - 35% for heart failure (p=0.002)
Statin: Legacy Effect
![Page 72: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/72.jpg)
![Page 73: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/73.jpg)
Atorva=Rosuva
![Page 74: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/74.jpg)
HOPE 3Rosuvastatin for primary prevention
![Page 75: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/75.jpg)
SATURN
![Page 76: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/76.jpg)
Statin doses
Statin Statin Vices
![Page 77: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/77.jpg)
Statin & DM
treatment of 255 people with statins for 4 years would result in to 1 additional case of diabetes mellitus
risk of new onset diabetes with intensive statin therapy is approximately 3 per 1000 patient-years and with moderate intensity statin therapy 1 per 1000 patient-years
Its true frequency is unknown; however, reported incidence is around 10%. Routine monitoring is not needed
Statin & muscle symptoms
![Page 78: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/78.jpg)
FibratesA meta-analysis of 18
trials providing data for 45058 participants, including 2870 major CV events, 4552 coronary events, and 3880 deaths
It was found that fibrates could reduce the risk of major CV events predominantly by prevention of coronary events
patients with higher baseline TG and lower HDL-C levels benefited from fenofibrate therapy in addition to pre-existing simvastatin (ACCORD)
![Page 79: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/79.jpg)
Look for reversible causesEg.DM, hypothyroidsm, CKD, immuocomprised
LSM
TG<500
TG>500
Statin
Achieve LDL target
Achieve non HDL cholesterol
Non-statin drugs
Fibrate
Achieve TG target
Statin
Achieve LDL and non HDL cholesterol target
Hyper
TG
![Page 80: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/80.jpg)
Rising HDLDrugs Trials Outcome Comment
Rosuvastatain ASTEROID, ARBITER, METEOR
Positive Also regression of atherosclerosis
NIACIN HATSARBITER 2ARBITER 3
Positive In combination to statin
HPS2THRIVEAIMHIGH
Negative In combination to statin
FIBRATE FIELD Positive 27% redction in cardiac events
ACCORD Positive In combination to statin
CETP Inh TorcetrapibDalcetrapib
Negative Harmful
AnacerapibEvacetrapib
Ongoing
![Page 81: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/81.jpg)
Curing atheroclerosis
![Page 82: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/82.jpg)
THEINDIAN
LIPID POLICY
![Page 83: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/83.jpg)
Need policies
![Page 84: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/84.jpg)
Screen all adults at 20 years of age/college entry
“magnificent seven”1. No tobacco2. Physical activity: ≥150 min moderate intensity or
equivalent exercise per week 3. Body-mass index <23 kg/m24. Healthy diet: achieving at least four of the five important
dietary components, focusing on fruits and vegetables, fish, fibre, and sodium intake and sweetened beverage intake
5. LDL-C level should be below 100mg/dl6. Blood pressure: <120/80 mmHg 7. Fasting plasma glucose level: <100 mg/d
25 X 25
![Page 85: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/85.jpg)
Recommendations made in the consensus statement
are not a mandate to the medical community
8 meetings153 experts18 states 30 cities
![Page 86: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/86.jpg)
Multiple problem
Multiple strategy
StatinsNon-
statinsYoga
Multiple calculation
Set Target According To Risk
2016Indian
guideline
Risk countingNon-traditional risk
factorsJBS3 – lifetime
Non-fastingNon-HDL
cholesterol
![Page 87: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/87.jpg)
![Page 88: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/88.jpg)
32 year male IT professionalOccasionally drinks/ smokesNon DM/ non HTN85 kgs/ Cant go to gym Father died of heart attack at 62 years of ageRecently marriedVery anxious of heart diseaseCAG normalLDL 100TG 350HDL 30
2016: an Indian storyMajor RF
Moderate RF
Moderate Risk
Major RF
Lp (a)40CIMT normalCAC 250A
High Risk
StatinAt least 5 years
![Page 89: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/89.jpg)
Questions answered
TGNon HDL cholLifetime CV riskNon-traditional risksnoninvasive imaging
20 vs 40Atorva vs rosuvaHF, hemodialysis
INDIAN LIPID GUIDELINEQuestions unanswered
![Page 90: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/90.jpg)
complex lots of investigation till not validated not evidence based statinization
MADE IN INDIA
![Page 91: Indian lipid guideline 2016 dibu final](https://reader035.vdocuments.us/reader035/viewer/2022062400/587303051a28ab99088b4b77/html5/thumbnails/91.jpg)
Thank You