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Lower the better
Dr. Asim Biswas

MBBS, MD ( Cardiology)
Registrar, CCU, SBMCH
To Whom it may concern ….
• Non communicable diseases (NCDs) are the cause of
59% mortality
• Going to account for 72% of total mortality by 2030 in
South Asia
• The region which constitutes 24% of the world’s
population.
CV diseases burden
• 27 % of all deaths worldwide
• one death every 40 seconds
Incidence, Prevalence, Hospitalization, Morbidity and
Mortality from CAD among South Asians are 50 to
300% higher than in Europeans, Americans & other
Asians regardless of gender, religion or social class.
INTERHEART, a global case control study, involving
15152 cases of 1st AMI & 14820 controls in 52
countries showed
Median age of 1st MI South Asian 53 years

China & western Europe 63 years
Karthikeyan G et al. JACC 2009; 53:244-53

Middle East 12.6%
Africa 10.9%
MI South Asia 9.7%
occurring at ≤ 40 years China 1.2%
South America 1.0%
Central &
Eastern Europe 0.9%

Bangladesh perspective
INTERHEART Study
Even among the South Asians, Bangladesh fare worst.
Bangladeshis suffer first AMI at the youngest age 51.9 (±11) years whereas
Oldest patients of first AMI lived in Nepal (age 58.9 (±11.8) years).
Bangladesh has the highest prevalence for most risk factors within the five
south asian countries.
- Current & former smoking (59.9% compared to 34.6% in Indians)
- Elevated ApoB100/Apo-I ratio (59.7% as compared to 36.5% in Indians)
- Abdominal Obesity (43.3% as compared to 19.5% in Indians)
- History of Hypertension (14.3% as compared to 11.4% in Indians)
INTERHEART Study
Among the South Asians, Bangladesh also had the lowest prevalence
of protective factors:
- Regular moderate to high intensity physical activity (1.3% vs 6.8% in

Indians)
- Daily intake of fruits & vegetables (8.6% vs 37.5% in Indians)
In Bangladesh
From 1986 to 2006, age standardized CVD mortality
rates increase by 30-fold (from 16 death/100,000 to
483 deaths/100,000) in males and 47-fold (from 7
deaths/100,000 to 330 deaths/100,000) in females
Dyslipidemia in Bangladesh?
Bangladesh 2008 25+ years sex based
27
26.5 26.4
26
25.7
25.5
25 24.9
24.5
24
Both sexes Male Female
http://apps.who.int/gho/data/view.main.2467?lang=en
Double Jeopardy…
Many Bangladeshis are in double jeopardy from nature
& nurture – nature having been provided by the
genetically determined low HDL & Diabetes excess, and
nurture through an unhealthy life style associated with
affluence, urbanization and mechanization.
Effect of dyslipidemia lowering on CVD
• 1 % decrease in LDL cholesterol reduces risk by about 1 %.
• every 1 mg/dl increase in HDL cholesterol, there is a 2%
decrease of CHD in men & 3 % decrease in women.
• Based on Framingham study, Every change of 10 mg/dl in the
HDL Cholesterol Level is associated with 50% change in the
risk.
Beneficiary group
Classified into 4 statin benefit groups:
Secondary prevention:
1. Individuals with clinical ASCVD
Primary prevention:
2. Individuals with primary elevation of LDL–C > 190 mg/dl
3. Individuals 40- 75 years of age with diabetes with LDL-C 70-189
mg/dl
4. Individuals without clinical ASCVD or diabetes who are 40 – 75 years
of age with LDL-C 70-189 mg/dl and an estimated 10 year ASCVD risk of
7.5 % or higher.
• Lower the better ?
ASCVD risk assessment
http://tools.acc.org/ASCVD-Risk-Estimator-Plus/
Management
Scopes for Guidelines
• Third Report of the National Cholesterol Education Program
(NCEP) Expert Panel on Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel III), 2002.
• 2018 AHA/ACC Guideline on the Management of Blood

Cholesterol
Management Plan
• Target setting
• Therapeutic Lifestyle Change (TLC)
• Medication
• Treatment of cause
• Monitoring for response
• Numbers are not the measuring parameters for
the “Normal” and “Abnormal” lipid levels
• Lipid levels are to be considered in the context of

the clinical condition of the patient
No more target to
treat (LDL goal!)
The LOWER, the
BETTER!
Target setting
• Primary Target: LDL

• Clinical ASCVD: <70mg/dl or >50% reduction from
baseline
• Otherwise : < 100 mg/dl
• Other
• HDL: > 60mg/dl
• Total Cholesterol: <200 mg/dl
• Non-HDL: 30 mg /dl higher than LDL
• TG: < 150 mg/dl
Drugs
• Statins: HMG-CoA reductase inhibitor
• Ezetimibe: Cholesterol Absorption Inhibitor
• Fibrates
• Bile Acid Sequestrants
• Niacin
• Microsomal Triglyceride Transfer Protein Inhibitor
• Oligonucleotide inhibitor of apo B-100
• LDL apheresis
• PCSK9 inhibitors
Efficacy of drug
Drug Class Lipid/lipoprotein effects
HMG-CoA reductase LDL-C ↓ 18–55%
inhibitors (statins) HDL-C ↑ 5–15%
TG ↓ 7–30%
Bile acid sequestrants LDL-C ↓ 15–30%
HDL-C ↑ 3–5%
TG—no change or increase
Nicotinic acid LDL-C ↓ 5–25%
HDL-C ↑ 15–35%
TG ↓ 20–50%
Fibric acids LDL-C ↓ 5–20%
HDL-C ↑ 10–20%
TG ↓ 20–50%
Strategy
First benefit group
Strategy
Second benefit group: Primary prevention if LDL >190 mg/dl
Statin
Moderate >> High intensity
Ezetimabe
Bile Acid sequestrant
PCSK9-I
Side effects of statin
Compelling to stop
• Rhabdomyolysis: CK > 10XUNL+ renal Injury
• ALT : > 3X UNL
Monitoring of therapeutic
response
Where I am?
• Do I know my Lipid profile?
• Have I assessed my CV risk yet?
• Do I adopt healthy life style ?
• Should I take Statin ?
Thank You

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Lower the better

Dr. Asim Biswas

Median age of 1st MI South Asian 53 years

Karthikeyan G et al. JACC 2009; 53:244-53

Karthikeyan G et al. JACC 2009; 53:244-53

- Regular moderate to high intensity physical activity (1.3% vs 6.8% in

• 2018 AHA/ACC Guideline on the Management of Blood

• Lipid levels are to be considered in the context of

• Primary Target: LDL

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