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Adverse cardiovascular (CV) events have declined in Western countries due at least in part to aggressive risk factor control, including dyslipidemia management. The American and European (Western) dyslipidemia treatment guidelines have contributed significantly to the reduction in atherosclerotic cardiovascular disease (ASCVD) incidence in the respective populations. However, their direct extrapolation to Indian patients does not seem appropriate for the reasons described below. In the US, mean low-density lipoprotein cholesterol (LDL-C) levels have markedly declined over the last 2 decades, correlating with a proportional reduction in CV events. Conversely, poor risk factor control and dyslipidemia management have led to increased CV and coronary artery disease (CAD) mortality rates in India. The population-attributable risk of dyslipidemia is about 50% for myocardial infarction, signifying its major role in CV events. In addition, the pattern of dyslipidemia in Indians differs considerably from that in Western populations, requiring unique strategies for lipid management in Indians and modified treatment targets. The Lipid Association of India (LAI) recognized the need for tailored LDL-C targets for Indians and recommended lower targets compared to Western guidelines. For individuals with established ASCVD or diabetes with additional risk factors, an LDL-C target of <50 mg/dL was recommended, with an optional target of ≤30 mg/dL for individuals at extremely high risk. There are several reasons that necessitate these lower targets. In Indian subjects, CAD develops 10 years earlier than in Western populations and is more malignant. Additionally, Indians experience higher CAD mortality despite having lower basal LDL-C levels, requiring greater LDL-C reduction to achieve a comparable CV event reduction. The Indian Council for Medical Research-India Diabetes study described a high prevalence of dyslipidemia among Indians, characterized by relatively lower LDL-C levels, higher triglyceride levels, and lower high-density lipoprotein cholesterol (HDL-C) levels compared to Western populations. About 30% of Indians have hypertriglyceridemia, aggravating ASCVD risk and complicating dyslipidemia management. The levels of atherogenic triglyceride-rich lipoproteins, including remnant lipoproteins, are increased in hypertriglyceridemia and are predictive of CV events. Hypertriglyceridemia is also associated with higher levels of small, dense LDL particles, which are more atherogenic, and higher levels of apolipoprotein B (Apo B), reflecting a higher burden of circulating atherogenic lipoprotein particles. A high prevalence of low HDL-C, which is often dysfunctional, and elevated lipoprotein(a) [Lp(a)] levels further contribute to the heightened atherogenicity and premature CAD in Indians. Considering the unique characteristics of atherogenic dyslipidemia in Indians, lower LDL-C, non-HDL-C, and Apo B goals compared to Western guidelines are required for effective control of ASCVD risk in Indians. South Asian ancestry is identified as a risk enhancer in the American lipid management guidelines, highlighting the elevated ASCVD risk of Indian and other South Asian individuals, suggesting a need for more aggressive LDL-C lowering in such individuals. Hence, the LDL-C goals recommended by the Western guidelines may be excessively high for Indians and could result in significant residual ASCVD risk attributable to inadequate LDL-C lowering. Further, the results of Mendelian randomization studies have shown that lowering LDL-C by 5-10 mg/dL reduces CV risk by 8-18%. The lower LDL-C targets proposed by LAI can yield these incremental benefits. In conclusion, Western LDL-C targets may not be suitable for Indian subjects, given the earlier presentation of ASCVD at lower LDL-C levels. They may result in greater CV events that could otherwise be prevented with lower LDL-C targets. The atherogenic dyslipidemia in Indian individuals necessitates more aggressive LDL-C and non-HDL-C lowering, as recommended by the LAI, in order to stem the epidemic of ASCVD in India., (© Journal of the Association of Physicians of India 2024.)

Objective: In 2016, the Lipid Association of India (LAI) developed a cardiovascular risk assessment algorithm and defined low-density lipoprotein cholesterol (LDL-C) goals for prevention of atherosclerotic cardiovascular disease (ASCVD) in Indians. The recent refinements in the role of various risk factors and subclinical atherosclerosis in prediction of ASCVD risk necessitated updating the risk algorithm and treatment goals., Methods: The LAI core committee held twenty-one meetings and webinars from June 2022 to July 2023 with experts across India and critically reviewed the latest evidence regarding the strategies for ASCVD risk prediction and the benefits and modalities for intensive lipid lowering. Based on the expert consensus and extensive review of published data, consensus statement IV was commissioned., Results: The young age of onset and a more aggressive nature of ASCVD in Indians necessitates emphasis on lifetime ASCVD risk instead of the conventional 10-year risk. It also demands early institution of aggressive preventive measures to protect the young population prior to development of ASCVD events. Wide availability and low cost of statins in India enable implementation of effective LDL-C-lowering therapy in individuals at high risk of ASCVD. Subjects with any evidence of subclinical atherosclerosis are likely to benefit the most from early aggressive interventions., Conclusions: This document presents the updated risk stratification and treatment algorithm and describes the rationale for each modification. The intent of these updated recommendations is to modernize management of dyslipidemia in Indian patients with the goal of reducing the epidemic of ASCVD among Indians in Asia and worldwide., Competing Interests: Declaration of competing interest Raman Puri: Boehringer Ingelheim, Novartis Manish Bansal: Sun Pharmaceuticals, USV, Dr Reddy's Labs, Cipla, Eris Lifesciences, Intas Pharmaceuticals, AstraZeneca Pharma India, Novartis Vimal Mehta: Institutional research grants from Amgen, Boehringer Ingelheim, Novo Nordisk, Eli Lilly, LIB Therapeutics, AstraZeneca, Torrent P Barton Duell: Advisory activities: Akcea/Ionis, Esperion, Regeneron, Kaneka, Novo Nordisk. Institutional grants: Regeneron, Regenxbio, Retrophin/Travere Nathan Wong: Research support through UC Irvine: Regeneron, Novo Nordisk, Novartis, Eli Lilly, Consultant: Novartis, Ionis, Agepha SS Iyengar: Reddy's Lab, Amgen, Emcure, Glenmark, Boehringer Ingelheim, Pfizer, Novartis Devaki Nair: Novartis, Daichi Sankyo Krishnaswami Vijayaraghavan: Amgen, AstraZeneca, Boehringer Ingelheim, Esperion, Novo Nordisk, Pfizer V Mohan: Servier, MSD, Novo Nordisk, Novartis, Eli Lilly, USV, Lifescan J & J, Sanofi Aventis, Merck, Boehringer Ingelheim, Abbott, Several Indian Pharmaceutical companies Shashank Joshi: Biocon, Cadilla, Twin Health, Glenmark, Torrent, Marico, MSD, Novo Nordisk, Sanofi, Boehringer Ingelheim, Abbott, AstraZeneca, USV, Alkem, Serdia Saumitra Ray: Merck, Novartis, Boehringer Ingelheim, Astra Zeneca, Novartis Sandeep Bansal: Novo Nordisk, Vascular Innovations Co. Ltd, Bayer, Portico India, ICMR SN Narasingan: IPCA, Novartis, USV, Torrent, SUN Pharma J C Mohan: Novartis, Lupin, Sun pharmaceuticals, Astra Zeneca, Intas, Le Servier, Sanofi Other authors report no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

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., Competing Interests: Conflict of interest Raman Puri: Boehringer Ingelheim, Novartis Vimal Mehta: Institutional research grants from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, LIB Therapeutics, Novo Nordisk, Torrent P Barton Duell: Advisory activities: Akcea/Ionis, Esperion, Novo Nordisk, Regeneron, Kaneka. Institutional grants: Regeneron, Regenxbio, Retrophin/Travere V Mohan: Research or educational grants from Abbott, AstraZeneca, Boehringer Ingelheim, Dr. Reddy's Lab, Johnson and Johnson, Lifescan, MSD, Novartis, Novo Nordisk, Roche Diabetes Care India Private Ltd, Sanofi-Aventis, USV, other Indian pharmaceutical companies S. S. Iyengar: Dr. Reddy's Lab, Amgen, Emcure, Glenmark, Boehringer Ingelheim, Pfizer, Novartis Vinod Mittal: Boehringer Ingelheim, USV, Cipla, Intas, Emcure, MacLeods S N Narasingan: USV, Novo Nordisk, Eris, Glenmark, Torrent, Boehringer Ingelheim J.B. Chemicals and Pharmaceuticals Nathan D. Wong: Amgen, Amarin, Novartis, Esperion SK Wangnoo: Sanofi- Aventis, Nova Nordisk, Boehringer Ingelheim, Astra Zeneca The other authors report no conflict of interest., (Copyright © 2022. Published by Elsevier Inc.)

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., (© Journal of the Association of Physicians of India 2011.)

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 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. Nonstatin 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 with 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)., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

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., (© Journal of the Association of Physicians of India 2011.)

Diabetes mellitus (DM) is a pandemic disease and an important cardiovascular (CV) risk factor. The atherogenic dyslipidemia in diabetes (ADD) is characterized by high serum triglycerides, high small dense LDL levels, low HDL levels and postprandial lipemia. Insulin resistance is a primary cause for ADD. Though statins are highly effective for CVD prevention in DM but a significant residual CV risk remains even after optimal statin therapy. Fibrates, niacin and omega-3 fatty acids are used in addition to statin for treatment of ADD (specifically hypertriglyceridemia). All these drugs have some limitations and they are far from being ideal companions of statins. Many newer drugs are in pipeline for management of ADD. Dual PPAR α/γ agonists are in most advanced stage of clinical development and they have a rational approach as they control blood glucose levels (by reducing insulin resistance, a primary factor for ADD) in addition to modulating ADD. Availability of dual PPAR α/γ agnosits and other drugs for ADD management may improve CV outcomes and decrease morbidity and mortality in diabetic patients in future., (Copyright © 2013 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Blockade of the renin-angiotensin system by angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers has been shown to be effective in treating hypertension and heart failure. There are currently seven angiotensin II receptor blockers in clinical practice, olmesartan medoxomil being the newest agent in the class. This article reviews the pharmacokinetics, pharmacodynamics, safety, efficacy, clinical use, dosing and cost of olmesartan medoxomil. The information given here is based on published data from human studies regarding the efficacy and safety of this drug, as well as studies comparing it with other drugs. The use of olmesartan medoxomil (10-40 mg) has consistently helped achieve a double-digit reduction both in systolic and diastolic blood pressure, a reduction which is maintained for one year. The data on its use for heart failure and atherosclerosis are limited and mostly experimental. It is an effective and well-tolerated agent, with a long duration of action, and single daily dose may be used to treat hypertension.

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 (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.

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.