Puri Raman, Mehta Vimal, Duell P Barton, Nair Devaki, Mohan Jagdish Chander, Yusuf Jamal, Dalal Jamshed J, Mishra Sundeep, Kasliwal Ravi R, Agarwal Rajeev, Mukhopadhyay Saibal, Wardhan Harsh, Khanna Narendra Nath, Pradhan Akshaya, Mehrotra Rahul, Kumar Amit, Puri Sonika, Muruganathan Arumugam, Sattur Gururaj Balvantrao, Yadav Madhur, Singh Harinder Pal, Agarwal Rajesh Kumar, Nanda Rashmi
Indraprastha Apollo Hospitals, New Delhi, India.
G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India.
J Clin Lipidol. 2020 Mar-Apr;14(2):e1-e13. doi: 10.1016/j.jacl.2020.01.006. Epub 2020 Jan 24.
Rates of atherosclerotic cardiovascular disease (ASCVD) are strikingly high in India compared to Western countries and are increasing. Moreover, ASCVD events occur at a younger age with only modest hypercholesterolemia, most commonly with low levels of high-density lipoprotein cholesterol. The course of ASCVD also appears to be more fulminant with higher mortality.
In light of these issues, the Lipid Association of India (LAI) endeavored to develop revised guidelines with more aggressive low-density lipoprotein cholesterol (LDL-C) goals in secondary prevention and for patients with familial hypercholesterolemia compared to guidelines in the United States and other countries.
Owing to the paucity of clinical outcomes data in India, it was necessary to place major emphasis on expert opinion as a complement to randomized placebo-controlled data generated mostly in non-Indian cohorts. To facilitate this process, the LAI conducted a series of 19 meetings among 162 lipid specialists in 13 cities throughout India over a period of 11 months before formulating this expert consensus statement.
The LAI recommends an LDL-C goal <50 mg/dL in all patients in secondary prevention or very high-risk primary prevention but proposes an optional goal ≤30 mg/dL in category A extreme-risk patients (eg, coronary artery disease + familial hypercholesterolemia) and a recommended goal ≤30 mg/dL in category B extreme-risk patients [coronary artery disease + (1) diabetes and polyvascular disease/≥3 major ASCVD risk factors/end organ damage, or (2) recurrent acute coronary syndrome within 12 months despite LDL-C <50 mg/dL, or (3) homozygous familial hypercholesterolemia].
More aggressive LDL-C goals are needed for prevention of ASCVD in India, as described in this expert consensus statement. Use of statins and ezetimibe needs to increase in India in combination with improved control of other ASCVD risk factors. Proprotein convertase subtilisin kexin type 9 inhibitors can improve LDL-C goal achievement in patients with refractory hypercholesterolemia.
与西方国家相比，印度的动脉粥样硬化性心血管疾病（ASCVD）发病率极高且呈上升趋势。此外，ASCVD事件在较年轻的年龄段发生，且往往仅伴有轻度高胆固醇血症，最常见的是高密度脂蛋白胆固醇水平较低。ASCVD的病程似乎也更为迅猛，死亡率更高。
鉴于这些问题，印度脂质协会（LAI）努力制定修订后的指南，与美国和其他国家的指南相比，在二级预防以及家族性高胆固醇血症患者中设定更积极的低密度脂蛋白胆固醇（LDL-C）目标。
由于印度临床结局数据匮乏，有必要将重点主要放在专家意见上，以此作为对大多来自非印度队列的随机安慰剂对照数据的补充。为推动这一过程，LAI在制定本专家共识声明之前的11个月内，在印度13个城市的162名脂质专家中组织了一系列19场会议。
LAI建议，所有二级预防患者或极高危一级预防患者的LDL-C目标<50mg/dL，但对于A类极高危患者（如冠心病+家族性高胆固醇血症），建议可选目标≤30mg/dL；对于B类极高危患者[冠心病+（1）糖尿病和多血管疾病/≥3个主要ASCVD危险因素/终末器官损害，或（2）尽管LDL-C<50mg/dL但在12个月内复发急性冠状动脉综合征，或（3）纯合子家族性高胆固醇血症]，建议目标≤30mg/dL。
如本专家共识声明所述，印度需要更积极的LDL-C目标来预防ASCVD。印度需要增加他汀类药物和依泽替米贝的使用，并更好地控制其他ASCVD危险因素。前蛋白转化酶枯草溶菌素9型抑制剂可提高难治性高胆固醇血症患者的LDL-C目标达成率。
