Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV

Approach to Lipid Management in the Patient With Diabetes

Diabetes is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk, a leading cause of morbidity and mortality. Disordered lipid metabolism is a major contributor to ASCVD risk in diabetes. Dyslipidemia in type 2 diabetes is characterized by hypertriglyceridemia, low high-density lipoprotein cholesterol and the presence of small, dense low-density lipoprotein particles. Statins have demonstrated longstanding benefit for reducing ASCVD risk in individuals with diabetes. Newer agents for add-on therapies to statins are now available for additional cardiovascular risk reduction. In this clinical overview, we review the pathogenesis of dyslipidemia in both type 1 and 2 diabetes and provide an update on the management of lipids in the individual with diabetes. We discuss the importance of appropriate risk stratification and individualized treatment selection and the need to avoid therapy inertia to mitigate cardiovascular risk. We also address lipid-related effects of glycemic-lowering therapies.

Association of vitamin B12 deficiency and hyperhomocystinemia with acute coronary syndromes - A case series

Acute coronary syndromes (ACS) are the most common presentation of atherosclerotic cardiovascular diseases in the emergency department. Numerous risk factors such as smoking, low High Density Lipoprotein (HDL) levels, metabolic syndrome, high triglycerides, diabetes, etc. have been implicated in the development of coronary artery disease and ACS. The management tools instead of focusing on the reversal of the above risk factors relies on lipid lowering drugs. Our series of patients suffering from ACS shows a possible association with low serum vitamin B12, high homocysteine, high Triglyceride, low HDL, low cholesterol and low LDL levels. There needs to be a paradigm shift in managing patients of ACS and the advice prescribed to them at the time of discharge. It would be prudent for emergency physicians to test for vitamin B12 and homocysteine levels in ACS patients.

The relevance of remnant cholesterol as a guide for lipid management in Indian subjects undergoing coronary revascularization

BACKGROUND

The atherogenic potential of remnant cholesterol, which refers to the cholesterol content of triglyceride-rich, non-low-density lipoprotein (LDL) particles in circulation, has gained increasing attention recently. Unfortunately, very limited information is available regarding remnant cholesterol levels in Indian subjects.

METHODS

This was a retrospective study conducted at a premier, tertiary care center in North India. A total of 3064 consecutive subjects [mean age 61.3 ± 10.3 years, 2550 (83.2%) men] with newly diagnosed coronary artery disease (CAD) undergoing coronary revascularization were included. Enzymatic assays were used for measuring various lipid parameters. Remnant cholesterol was calculated by subtracting LDL cholesterol (LDL-C) and high-density lipoprotein cholesterol from total cholesterol. A value >30 mg/dL was considered elevated.

RESULTS

The mean LDL-C was 79.1 ± 33.1 mg/dL with 46.4% of all subjects having LDL-C <70 mg/dL and only 16.9% having LDL-C <50 mg/dL. The median remnant cholesterol level was 17.0 mg/dL (interquartile range 12.0-24.0 mg/dL) with only 11.9% of subjects having values >30 mg/dL. Only 4.5% of the patients with LDL-C <70 mg/dL and 2.9% of those with LDL-C <50 mg/dL had elevated remnant cholesterol. These proportions were significantly greater in patients with serum triglycerides >200 mg/dL.

CONCLUSION

Our study shows that in a North-Indian population with CAD, elevated remnant cholesterol was present in only a small proportion. The prevalence of elevated remnant cholesterol decreased further as the LDL-C control improved. These findings suggest that elevated remnant cholesterol may not be a clinically relevant therapeutic target in most patients with LDL-C below the currently recommended goals.

Identifying Drug Prescription in Newly Diagnosed Hypertension Patients in India

This study evaluated initial antihypertensive drug prescription patterns in Indian healthcare settings. An observational, cross-sectional, prospective prescription registry analyzed prescriptions for 4723 newly diagnosed hypertension patients. Additionally, it investigated the extent to which physicians adhered to either European or Indian hypertension guidelines. Angiotensin receptor blockers (ARBs) were the most commonly prescribed drugs, given to 79% of patients, followed by calcium channel blockers (CCBs) at 55%. Diuretics and beta-blockers (BBs) were prescribed to 27% and 17% of patients, respectively. Monotherapy was administered to 35% of patients, while combination therapies were more prevalent, with dual therapy at 51% and regimens involving three or more drugs prescribed to 14%. Among multi-drug treatments (n = 3082, 65%), 98% received fixed-dose combination tablets. The most common combinations were ARB + CCB (26%), ARB + diuretic (12%), and ARB + CCB + diuretic (8%). Key predictors for an increasing number of prescribed drugs included statin use/dyslipidemia, age, blood pressure level, and diabetes. Non-adherence to hypertension guidelines was evident as 1364 patients classified from moderate to very high risk received monotherapy. Of these, 496 patients had grade 2 or 3 hypertension. Additionally, 88 patients received the undesirable combination of ACEi + ARB, and 267 (15.9%) type 2 diabetes mellitus (T2DM) patients did not receive RAS-blockers (146 on monotherapy). The findings reveal a trend toward utilizing ARBs, CCBs, and combination tablets, indicating improved adherence to guidelines. However, a significant number of patients did not receive appropriate treatment, highlighting areas for improvement in prescription practices.

One in Five Atherosclerotic Cardiovascular Disease Events in Individuals With Diabetes Attributed to Elevated Remnant Cholesterol

AIMS

Elevated remnant cholesterol (= the cholesterol carried in triglyceride-rich lipoproteins) is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and is common in individuals with diabetes. We tested the hypothesis that ASCVD in individuals with diabetes can be partly attributed to elevated remnant cholesterol.

MATERIALS AND METHODS

We included 3806 individuals with diabetes identified among 107,243 individuals from the Copenhagen General Population Study and used multivariable adjusted Poisson regression to estimate the fraction of ASCVD attributable to elevated remnant cholesterol. Elevated remnant cholesterol was defined as levels higher than those observed in individuals with non-high-density lipoprotein (non-HDL) cholesterol < 2.6 mmol/L (100 mg/dL), the European guideline goal. Results were replicated in the UK Biobank.

RESULTS

During 15 years of follow-up, 498 patients were diagnosed with ASCVD, 172 with peripheral artery disease, 185 with myocardial infarction and 195 with ischaemic stroke. In individuals with non-HDL cholesterol < 2.6 mmol/L (100 mg/dL) and in all individuals with diabetes, median remnant cholesterol levels were 0.5 mmol/L (20 mg/dL) and 0.8 mmol/L (31 mg/dL). The fraction of events attributable to elevated remnant cholesterol was 19% (95% confidence interval: 10%-28%) for ASCVD, 21% (5%-37%) for peripheral artery disease, 24% (10%-37%) for myocardial infarction and 17% (1%-31%) for ischaemic stroke; in the UK Biobank, corresponding values were 16% (9%-22%), 25% (12%-36%), 17% (8%-25%) and 7% (0%-19%), respectively.

CONCLUSIONS

One in five ASCVD events in individuals with diabetes can be attributed to elevated remnant cholesterol. It remains to be determined in clinical trials if remnant cholesterol-lowering therapy may prevent ASCVD.

Attainment of low-density lipoprotein cholesterol goals in patients undergoing coronary revascularization in the contemporary clinical practice

This study aimed to assess the effectiveness of current lipid-lowering therapy in achieving low-density lipoprotein cholesterol (LDL-C) goals in Indian patients undergoing coronary revascularization. Consecutive subjects (n = 1275, mean age 60.0 ± 9.7 years, 87.2 % men) with newly diagnosed coronary artery disease and undergoing coronary revascularization during the period 1 Jan 2023 to 31 Dec 2023 were included. After a median follow-up of 99 days (interquartile range 91-109 days), the mean LDL-C was 63.9 ± 24.3 mg/dL with 67.5% and 29.9% of subjects having LDL-C <70 mg/dL and <50 mg/dL, respectively. These proportions were 70.8% and 32.1% for patients treated with high-intensity statin therapy (rosuvastatin 20-40 mg/d or atorvastatin 40-80 mg/d). Among patients treated with rosuvastatin 40 mg/d and ezetimibe 10 mg/d, 53.3% achieved LDL-C <50 mg/dL. These findings underscore the need for greater usage of combination lipid-lowering therapy and agents with high LDL-C lowering efficacy.