Expert opinion on the applicability of dyslipidemia guidelines in Asia and the Middle East

Figures & data

Table 1 Dyslipidemia prevalence and groups at increased risk in Asia and the Middle East

	Asia						Middle East
	People’s Republic of China	Indonesia	Malaysia	Philippines	Taiwan	Thailand	Egypt	Saudi Arabia	UAE
Overall prevalence in adults	54% overall	High TC, 43%; high TG, 26%; high LDL-C, 83%; low HDL-C, 23%	48% overall	High TC 46.9%; high LDL-C 47.2%; low HDL-C 71.3%; high TG 38.6%	High TC, 13% males, 10% females; high TG, 21% males, 8% females	66.5% overall; high LDL-C 29.6%; high TG 38.6%; low HDL-C 47.1%	76% overall	High TC, 8.5%; high TG, 8.5%; high LDL-C, 7.4% low HDL-C, 48.7%	44–75% overall
Groups at increased risk	Han Chinese, males, age, family history, college education, current smoker, overweight and obesity, HYT and DM	Minangkabau females >40 years, and Sundanese males <40 years	Risk is increased in females vs. males	Risk is increased in females vs. males	Increased risk of high TG in males vs. females	Female sex, increasing age, urban living	–	Increasing age	Male sex, increasing age
References	10–13	14,15	16	17	18	19	2	20	2,21

Abbreviations: DM, diabetes mellitus; HDL-C, high-density lipoprotein cholesterol; HYT, hypertension; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triglycerides; UAE, United Arab Emirates.

Table 2 Clinical practice guidelines applicable to the management of dyslipidemia among local populations in Asia and the Middle East

	Asia						Middle East
	People’s Republic of China	Indonesia	Malaysia	Philippines	Taiwan	Thailand	Egypt	Saudi Arabia	UAE
National guidelines	2016 Prevention and Treatment Guideline of Dyslipidemia in Chinese Adults	2015 Indonesian Dyslipidemia Management Guidelines	2017 Malaysian Dyslipidemia Guidelines	2015 Philippine CPG in the Management of Dyslipidemia	2017 Taiwan Lipid Guideline for High Risk Patients	2016 RCPT Clinical Practice Guideline on Pharmacologic Therapy of Dyslipidemia for Atherosclerotic Cardiovascular Disease Prevention	No national guidelines currently available	No national guidelines currently available	No national guidelines currently available
References	34	35	36	37	38	39	–	–	–

Abbreviations: CPG, Clinical Practice Guideline; RCPT, Royal College of Physicians of Thailand; UAE, United Arab Emirates.

Table 3 Major features of international dyslipidemia guidelines

	ACC/AHA 2013	NICE 2014	IAS 2013	ESC/EAS 2016
Risk score	Pooled cohort equations to estimate 10-year risk of fatal and non-fatal CHD and CVA	QRISK2 to estimate 10- year risk of fatal and non- fatal CHD, CVA and PAD	FRS to estimate lifetime risk of non-fatal and fatal CVD	SCORE chart to estimate 10-year risk of fatal CVD
Step 1	Identify statin benefit groups, eg: ASCVD history;  • LDL-C ≥190 mg/dL, age ≥21 years  • DM, age 40–75 years, LDL-C ≥70 mg/dL  • ≥7.5% ASCVD risk, age 40–75 years, LDL-C ≥70 mg/dL	Identify statin benefit groups, eg:  • T1DM  • CKD stage III  • Risk score >10%  • Age >85 years  • Familial hyperlipidemia	Stratify CVD risk, eg:  • High: ≥45% lifetime risk of CVD; DM with major risk factor; familial hyperlipidemia; CKD  • Moderately high: 30–44% lifetime risk of CVD; DM alone; MS; CKD	Stratify CVD risk, eg:  • Very high: documented CVD; DM with target organ damage; severe CKD; SCORE ≥10%  • High: markedly elevated single risk factors; moderate CKD; SCORE ≥5% and <10%  • Moderate: SCORE ≥1% and <5%  • Low: SCORE <1%
Step 2	Determine adequacy of treatment effect:  • High-intensity statin: >50% reduction of LDL-C  • Moderate-intensity statin: 30–50% reduction of LDL-C	Determine adequacy of treatment effect:  • >40% reduction of non-HDL-C	Determine target:  • High to moderately high: LDL-C <100 mg/dL or non-HDL-C <130 mg/dL (may be lower for very high risk)  • Moderate to low: LDL-C <130 mg/dL or non-HDL-C <160 mg/dL	Determine target:  • Very high: LDL-C <70 mg/dL or ≥50% reduction if baseline LDL-C is between 70 and 135 mg/dL  • High: LDL-C <100 mg/dL or ≥50% reduction if baseline LDL-C is between 100 and 200 mg/dL  • Moderate-low: LDL-C <115 mg/dL
Step 3	Follow-up lipids:  • 1–3 months after initiation of therapy; every 3–12 months as indicated thereafter	Follow-up lipids:  • 3 months after initiation of therapy; annually when target achieved	Treat according to risk:  • High: statin therapy and lifestyle change  • Moderately high: lifestyle change, consider initiating statin therapy  • Moderate: lifestyle change, consider statin therapy if LDL-C >160 mg/dL  • Low: lifestyle change only	Treat according to risk:  • ESC/EAS 2016 and 2011 guidelines differ in that the latest guidelines show a considerable increase in the emphasis given to the importance of healthy lifestyle as a strategy to reduce cardiovascular risk; however, a statin and dose should be chosen that can provide required reduction in LDL-C to reach goal
Step 4	Options if treatment effect inadequate:  • Reinforce lifestyle changes, adherence to medication  • Exclude secondary causes  • Add non-statin agent	Options if treatment effect inadequate:  • Reinforce lifestyle changes, adherence to medication  • Up-titrate statin dose		Follow-up lipids and options if target not reached:  • 8 ± 4 weeks after initiation; 8 ± 4 weeks after adjusting treatment until within target range; annually when target met  • Up-titration of statin dose, consider drug combinations

Note: Adapted with permission from Hendrani AD, Adesiyun T, Quispe R, et al. Dyslipidemia management in primary prevention of cardiovascular disease: current guidelines and strategies. World J Cardiol. 2016;8(2):201–210.⁷

Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CHD, coronary heart disease; CKD, chronic kidney disease; CVA, cerebrovascular accident; CVD, cardiovascular disease; DM, diabetes mellitus; ESC/EAS, European Society of Cardiology/European Atherosclerosis Society; FRS, Framingham Risk Score; HDL-C, high-density lipoprotein cholesterol; IAS, International Atherosclerosis Society; LDL-C, low-density lipoprotein cholesterol; MS, metabolic syndrome; NICE, National Institute for Health and Care Excellence; PAD, peripheral artery disease; SCORE, systematic coronary risk evaluation; T1DM, type 1 diabetes mellitus.

Table 4 Typical patient scenarios and management recommendations by the expert panel

Patient scenarios	Recommendations by expert panel
Primary prevention	All adults ≥18 years old with a 10-year risk of ASCVD ≥7.5% (or 10% according to the Thai CV risk score) or LDL-C ≥190 mg/dL are candidates for primary prevention
Elderly (>75 years)	Statins may be prescribed, with caution, taking into consideration polypharmacy and comorbidities in this population
Chronic kidney disease	Statin therapy is beneficial in pre-dialysis patients. The statin dose should be adjusted according to eGFR
Type 2 diabetes	All type 2 diabetes patients should receive statin therapy
Documented CVD	Statin therapy with a target LDL-C ≤70 mg/dL or ≥50% reduction
Patient with ACS	Maximum tolerated dose of statin with a target LDL-C ≤70 mg/dL. If the target is not achieved, add ezetimibe. In case of intolerance, decrease the statin dose and add ezetimibe
Family history of premature IHD with LDL-C <190 mg/dL	Family history is an important additional risk factor and thus treatment with statin therapy should be considered

Abbreviations: ACS, acute coronary syndrome; ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; IHD, ischemic heart disease; LDL-C, low-density lipoprotein cholesterol.

HendraniADAdesiyunTQuispeRDyslipidemia management in primary prevention of cardiovascular disease: current guidelines and strategiesWorld J Cardiol20168220121026981215

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