Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Consensus Statement on Holistic Management of Angina

Worldwide, coronary heart disease (CHD), have assumed epidemic proportions. Increasing use of interventional therapy and a higher adherence to medical therapy have led to a 33% reduction in cardiac deaths at 5 years after hospital discharge. Angina pectoris is a common symptom of ischemic heart disease. The goals of anti-ischemia therapy in patients with stable coronary artery disease (CAD) include relieving angina symptoms, improving duration of exercise and quality of life, improving prognosis and preventing cardiovascular (CV) events. The consensus statement was devised with the help of multiple meetings held across India. Ten regional advisory board e-meetings were held in Mumbai, Delhi, Chennai, Kolkata, Ahmedabad, Cochin, Trivandrum, Lucknow, Bhopal and Varanasi. These meetings were attended by ten eminent experts from the field of cardiology from each region. Extensive literature review, intense discussions, and feedback from the cardiologists led to the development of the following consensus statements on definition, diagnosis, and management of angina, which have been reported in this article.

ACE inhibitors and beta blockers in chronic congestive cardiac failure: therapeutic basis

Congestive cardiac failure (CCF) is a common problem through out the globe and is associated with high morbidity and mortality. The rapid progression of the disease due to neurohormonal activation can be blunted by use of angiotensin-converting enzyme inhibitor (ACEI) and beta blockers (BB) with a major impact on morbidity and mortality. Besides CCF, they are also useful in asymptomatic left ventricular dysfunction (LVD) and in prevention of heart failure in high risk patients without LVD. Both ACEI and BB are highly underutilised therapy in CCF and there is an urgent necessity to spread message among the medical fraternity for their enhanced use.

Hypertensive heart disease

Hypertensive heart disease (HHD) is a common problem in clinical practice. Left ventricular hypertrophy (LVH) is pathognomonic of HHD. Echo-Doppler study is the modality of choice to document cardiac involvement in hypertension. 'Radiology of chest and electrocardiography (ECG) are highly insensitive. Magnetic resonance imaging (MRI) produces similar results like echo but is not cost-effective. LVH is not merely related to haemodynamic load but several other factors are also involved in its genesis. LVH is a powerful and independent prognostic determinant for future cardiovascular and coronary events. LVH can be regressed by drugs but the aim in future should be prevention of LVH rather than its regression.

Patterns of recovery of pulmonary functions in severe acute bronchial asthma

The recovery of pulmonary function were studied in fifty patients of acute bronchial asthma receiving a standard therapeutic regime. Sixty-two per cent of patients had achieved 50% of their total improvement in peak expiratory flow rate (PEFR) within 24 hours (fast responders) as against slow responders. Duration of asthma, characteristics of present exacerbation, mean pulse rate and presence of pulsus paradoxus on admission did not differ in fast and slow responders. The rise in PEFR within 4 hours of starting treatment was highly significantly correlated with a higher PEFR at 24 hours and a faster recovery. The mean arterial PaCO2 was higher (P less than 0.02) in slow responding group and they were slightly older (P less than 0.01), had lower mean FVC (P less than 0.01), mean FEV1 (P less than 0.02) and PEFR (P less than 0.001). The mean PaO2 of less than 80 mm Hg at 48 hours was more common in those with delayed recovery of PEFR.