Abstract

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality across the world. Though effective drugs are available for management of dyslipidemia, our achievement of lipid targets is far from optimal. In this multidisciplinary opinion piece, we call for greater attention to lipid health in metabolic care. We suggest various reasons, both patient-centric and physician-centric, which must be tackled to improve lipid care. Social marketing, strengthening of primary health care, continuing medical education, user-friendly teaching, and motivational therapeutics may help improve lipid management. “Lipid conversations”, such as this communication, will help improve the lipid legacy, or lipid karma, of our population, and contribute to “Lipid longevity”.

Keywords: ASCVD, atherosclerosis, cardiovascular disease, cholesterol, dyslipidemia, LDL cholesterol

LIPID LADEN CHALLENGE

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality across the world¹. Ischemic heart disease and stroke are now the top two causes of death in most countries. Dyslipidemia is one of the major determinants of these conditions. While the concepts of “hit early, hit hard” and glycemic legacy are well acknowledged and appreciated, the adverse effects of cumulative low-density lipoprotein (LDL) exposure are not widely understood, and are therefore underrated. Data from across the world shows suboptimal prescription of statins, and far from optimal achievement of LDL targets². This state of affairs is true not only for general practices, but also for specialist care, which focuses on people living with diabetes or with high-risk ASCVD patients.

The INTER-HEART and INTERSTROKE studies demonstrated that lipid abnormalities are a much stronger contributor to acute myocardial infarction and stroke than other diseases such as diabetes, hypertension, and obesity^3,4. Unfortunately, less attention is paid to lipid health in metabolic circles. Relatively more emphasis is laid on glucose, blood pressure, and weight in the metabolic clinic. This is a paradox, because dyslipidemia is generally considered an easier disease to tackle, and eulipidemia, an easier target to achieve.

DECIPHERING THE DISCORDANCE

This may be explained by various biopsychosocial factors. The asymptomatic nature of ASCVD (until the first vascular event occurs) differentiates it from hyperglycemia and hypertension, which present with multiple symptoms and signs. A diagnostic label of diabetes or heart failure generates various emotions, both positive and negative, which influence health care seeking and adhering behavior. Such emotions do not occur with dyslipidemia. Social factors play a role, too. There is a translation for sugar in every language of the world, but not for cholesterol. In Asian languages, therefore, high cholesterol is presented as an artificially constructed phrase, which may not have the desired impact. Even when cholesterol is discussed, it is considered part of nutritional counseling, rather than a pharmacological target⁵.

Biopsychosocial factors impact health care, too. The spirit of person-centered care is often used to focus on patient-expressed priorities⁶. Such priorities are usually linked to symptoms, such as pain or discomfort, or to readily identifiable disease states, like diabetes and obesity. Dyslipidemia does not lead directly to any of these. On the contrary, it is possible that conventional lipid-lowering therapy may cause discomfort, pain, or worsening of glucose control.

There is relatively less focus on lipid biology in continuing medical education programs. This may be because of competing topics, such as contemporary developments in obesity, diabetes, and cardio-reno-hepatic pharmacotherapeutics. These academic factors, coupled with personal and peer attitudes regarding the desirability of degree of lipid control, contribute to therapeutic inertia regarding lipid management. The everchanging definitions of eulipidemia, and controversies in risk stratification, add to the suboptimal treatment of lipid levels^7,8.

LIPID-SMART SOULTIONS

Understanding the barriers to intensive lipid management is necessary if one has to build bridges to improve lipid health. Table 1lists various reasons, both patient-centric and physician-centric, which influence attitudes towards metabolic health. These attitudes, in turn, inform our behaviors and choices.

MACRO LEVEL

Social marketing strategies are important in enhancing community awareness of lipid health. These should be clubbed with existing efforts at metabolic health optimization⁹. It may be prudent to list high cholesterol or abnormal cholesterol as a distinct disease, along with coronary artery disease, diabetes heart failure, and obesity, while crafting awareness campaigns. Community medicine specialists need to be involved during such planning. This will also facilitate active usage of lipid-lowering drugs, such as statins, at primary health care level. These, and other strategies, are listed in Table 2. We need to create a lipid registry in high-risk population like individuals with diabetes, hypertension, cerebrovascular accident, coronary artery disease, and chronic kidney disease. Such registry can act as a critical tool to identify the management gaps, personalize the lipid care and strategize evidence-based policy reforms and quality improvements (Table 3).

CKD = Chronic kidney disease; ASCVD = Atherosclerotic cardiovascular disease; CVA = Cerebrovascular accident; ApoE = Apolipoprotein E; PCSK9 = Proprotein convertase subtilisin/kexin type 9; NCD = Noncommunicable disease; LMICs = Low- and middle-income countries.

MESO LEVEL

While social marketing is necessary to optimize societal attitudes at a macro level, medico-marketing is required to sensitize health care professionals to the need for lipid control. Lipid biology and lipid management should be discussed at all relevant continuing medical education programs.

These include those that cater not only to cardiology, endocrinology, and internal medicine, but neurology, nephrology and related specialties as well.

MICRO LEVEL

Lipid therapeutics can be made more interesting, and user-friendly, by using simple analogies and similes to explain lipid physiology and pathology. Proverbs and metaphors can be utilized to encourage timely usage of lipid-lowering therapy. We must remind ourselves that is it the vasculature, and its cholesterol layer, which links these seemingly disparate organs, in health as well as disease.

Best practices on motivational therapeutics may be taken from obesity and diabetes management. These will include mastering “lipid conversations”, encouraging adherence to therapy, and handholding individual patients as they journey towards healthier metabolic health. Concepts such as lipid legacy, lipid karma, and cholesterol cutting, similar to glycemic memory, metabolic karma, and cost cutting, can be used to encourage proactive efforts towards lipid control. All these will lead to a state of optimal health, which we describe as “Lipid longevity”.

SUMMARY

We need action to fight ASCVD, and the morbidity and premature mortality that it is associated with. One simple way is to ensure healthy lipid levels for all. We call for bringing lipid health to the center stage of metabolic health, at both preventive and curative levels. Successful advocacy for lipid health will automatically translate into comprehensive cardiometabolic health for our fellow citizens.

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