Addressing the media at Asian Heart Institute, Dr Srinath Reddy, President of the Public Health Foundation of India and the World Heart Federation spoke candidly that India is unique in terms of CVD risk profile.
Early onset of MI in India (age 52) vis-à-vis China (63 years) and US (62 years), make India a unique ethnographic class when it comes to cholesterol guidelines.
The draft British guidelines UK (JBS3) has stated that doctors who were earlier meant to offer statin tablets to people who have a 20 per cent chance of developing cardiovascular disease over 10 years (based on risk factors such as their age, sex, whether they smoke and what they weigh) will be lowered to those who have even a 10 per cent risk.
Cholesterol guidelines released by AHA in Nov 2013, liberalised the use of statins by taking the guidelines to people who even have a 7.5 per cent risk.
However, statins are associated with excessive risk of diabetes occurrence according to clinical trial analyses; and this is the reality in India.
The NZ and British Guidelines focus more on the absolute risk (multiple risk factors for one patient) whereas the AHA guidelines focus on the relative risk (how one patient is more at risk than another). Hence the former are more useful for India.
The NZ guidelines, which came into force about 10 years before the AHA guidelines, also emphasise reducing the total risk profile, including hypertension and multiple risk factors.
The following specific gaps exists in the 2013 AHA guidelines:
- Treatment goals for LDL-C and non-HDL-C are no longer recommended.
- High-intensity and moderate-intensity statin treatment is emphasised, and low-intensity statin therapy is nearly eliminated. (this is what India needs)
- Nonstatin therapies have been markedly de-emphasised.
- No guidelines are provided for treating high triglyceride levels.
To be applicable to India, the cholesterol guidelines will have to consider absolute (multiple) risk factors such as
- Early life influences
- Higher percentage of body fat/ preferential deposition of fat in the upper body
- Insulin resistance
- Diabetes
- HDL
- Small dense LDL: Small, dense LDL particles, prevalent in Indian populations has been associated with increased risk for CHD
- High Triglyderide levels
- Increasing urbanisation and lifestyle diseases.
Indian CVD profile is also unique because for any given level of Total/LDL cholesterol, the risk factor increases if
- TC: HDL ratio is high
- Small dense LDL is higher
Both of which is true in Indian populations.
Policy interventions key going forward
Dr Ramakanta Panda added, “WHO estimates a loss of productivity amounting to $240 billion due to CVD. Its clear that as a nation we have to focus on prevention rather than cure alone.”
In India, better cholesterol guidelines will have to be supported by
- Small reductions in risk factor levels: this can be done effectively by raising the taxes on tobacco, percentage of salt in processed foods and Banning smoking in public places etc. There is a huge economic argument for prevention. When achieved across the whole population, this will result in a large reduction of CVD events.
- Drug therapy to reduce risk is most cost-effective in persons who are a high risk of adverse events in the next 10 years. This has to be integrated into the existing healthcare system. Indian patients as such respond very well to statin, but other risk factors have to be considered.
- Best results are achieved through a combination of population based prevention (policy for prevention) and high risk individual management approaches (cure).