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without measuring on treatment LDL . ACC/AHA < 200 mg/dl of triglyceride. Clinicians need to focus
Guidelines2013 raised several questions that need to on the residual risk contributed by high triglycerides
be answered . 5 . Meta-analysis of 5 landmark trials (ACCORD, BIP,
FIELD, HHS, VAHIT) with 7389 patients with diabetes
Indian Scenario on Lipids and Lipoproteins : India and or CVD, concluded that lowering TG in people
Heart WATCH Study which evaluated for dyslipidemia who had elevated levels > 200mg/dl with PPAR alpha
prevalence in a population of 6400 subjects revealed agonists-Fibrates reduced.
higher TG levels with low HDL –c with normal or
marginally elevated LDL –c levels . CV events by 25% In different studies in the last
6.
2-3 decades , TG reduction, with or without statin,
High prevalence of Metabolic syndrome among has shown to cause significant risk reduction in
urban subjects in India was highlighted in a multisite patients with high TG and low HDL-C (Atherogenic
study : 33.3% of men and 40.4% of women are having Dyslipidemia) . Triglycerides can be measured in
2
7
metabolic syndrome features with constellation of the non-fasting or fasting states. RCTs showing CV
multiple risk factors .Atherogenic dyslipidemia was benefit of triglyceride reduction are scanty . Lowering
typically seen in this study . triglycerides reduces the risk of CVD is still debated .
8
Saroglitazar, a novel lipid lowering drug which has
ICMR – INDIAB Study 2014 : Prevalence of Dyslipidemia both PPAR alpha and gamma agonistic activity has
in urban and rural India was evaluated in this study . shown in clinical trials to lower triglycerides markedly
Higher prevalence of TG [29.5%] with higher prevalence in diabetics. This is a promising molecule which
of low HDL [72.3%] and 13.9% subjects were seen with has been approved in India for managing diabetic
Hypercholesterolemia . dyslipidemia.
Non HDL-C is a better indicator of residual Role of HDL-C : Trials to raise HDL-C levels by using
risk than LDL-C CETP Inhibitors like Torcetrapib ,failed to show
beneficial effects in spite of having a favorable HDL
Meta analysis of 62,154 statin-treated patients in rise in number of studies . Therapeutic Lifestyle
8 trials [4S, AFCAPS, LIPID, CARDS, TNT, IDEAL, Changes, such as smoking cessation, weight loss
SPARCL, JUPITER ] published between 1994 and 2008 ,physical activity ,moderate alcohol consumption
revealed the following: 1 SD increase in LDL-C, Apo B ,w-3 fatty acids have been found to show beneficial
and Non HDL increase the risk of CV events by 13% , effects in increasing HDL . However, there is still lack
14% , and 16% respectively indicating the strength of of evidence that raising HDL reduces CV Risk . HDL-C
association with CVD is greater for non HDL-C than for is not recommended as a target of therapy .
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LDL-C and ApoB . People who had LDL levels < 100
3
mg/dl with Non-HDL level of > 130 mg/dl had hazard Role of Lp(a): Lp(a) >50mg/dl independently predicts
ratio of 1.32 indicating CV risk of 32% when compared the presence of symptomatic & angiographic CAD.
to people who had uncontrolled LDL levels of > 100 Primary objective is to treat LDL and Non-HDL
mg/dl with Non HDL level of < 130mg/dl had hazard aggressively with high dose statin . Niacin is the only
ratio of 1.02 indicating CV risk of 2% . Conclusion : Non drug that lowers Lp(a). Novel Lipid lowering drugs like
HDL-C is associated with increased risk for future CV Apo B blockade by AntiSense Oligonucleotide (ASO) [
events , even if LDL is under control with statins. Mipomersen ] MTP Inhibitor [ Lomitapide ] and PCSK9
inhibitors [ Evolocumab ] have shown reduction in
Role of Apo-B : Apo-B is the key atherogenic lipoprotein Lp (a) with marked reduction of LDL – c . European
which is a more sensitive measure of risk than LDL-c Atherosclerosis Society recommends screening for
.It provides information on LDL particle size which is elevated Lp(a) in those at moderately high or high
difficult to measure directly . A recent analysis of the ASCVD risk .
combined data set from the TNT and IDEAL studies International Atherosclerosis Society: Global
showed that on-treatment level of apo-B was clearly recommendations for the management of
superior to that of LDL-c as a predictor of CV events, dyslipidemia : LDL –C and Non-HDL-C as target of
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but it was not superior to non - HDL-c . Therapy : LDL is the major atherogenic lipoprotein and
4
VLDL is an additional atherogenic lipoprotein . Non-
Role of Triglycerides: Prove IT-TIMI 22 trial conducted HDL includes LDL + VLDL .LDL –C is the traditional
in ACS patients stressed the role of high triglyceride
as a risk factor after reaching the LDL goal of 70mg/ primary target for clinical intervention and Non-HDL-C
is also an appropriate target for clinical intervention
dl with high dose Atorvastatin 80 mg/day. People who
had >200 mg/dl of triglyceride had higher CV risk of based on huge body of evidence . Advantages of
Non-HDL –C as Target : It does not require fasting for
sudden cardiac death, fatal and non-fatal reinfarction
in a 30 day follow up compared with people who had accurate measurement. Non HDL subsumes most

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