Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20–30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ?30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

ACE inhibitors and beta blockers in chronic congestive cardiac failure: therapeutic basis.

Congestive cardiac failure (CCF) is a common problem through out the globe and is associated with high morbidity and mortality. The rapid progression of the disease due to neurohormonal activation can be blunted by use of angiotensin-converting enzyme inhibitor (ACEI) and beta blockers (BB) with a major impact on morbidity and mortality. Besides CCF, they are also useful in asymptomatic left ventricular dysfunction (LVD) and in prevention of heart failure in high risk patients without LVD. Both ACEI and BB are highly underutilised therapy in CCF and there is an urgent necessity to spread message among the medical fraternity for their enhanced use.

Hypertensive heart disease.

Hypertensive heart disease (HHD) is a common problem in clinical practice. Left ventricular hypertrophy (LVH) is pathognomonic of HHD. Echo-Doppler study is the modality of choice to document cardiac involvement in hypertension. 'Radiology of chest and electrocardiography (ECG) are highly insensitive. Magnetic resonance imaging (MRI) produces similar results like echo but is not cost-effective. LVH is not merely related to haemodynamic load but several other factors are also involved in its genesis. LVH is a powerful and independent prognostic determinant for future cardiovascular and coronary events. LVH can be regressed by drugs but the aim in future should be prevention of LVH rather than its regression.

Patterns of recovery of pulmonary functions in severe acute bronchial asthma.

The recovery of pulmonary function were studied in fifty patients of acute bronchial asthma receiving a standard therapeutic regime. Sixty-two per cent of patients had achieved 50% of their total improvement in peak expiratory flow rate (PEFR) within 24 hours (fast responders) as against slow responders. Duration of asthma, characteristics of present exacerbation, mean pulse rate and presence of pulsus paradoxus on admission did not differ in fast and slow responders. The rise in PEFR within 4 hours of starting treatment was highly significantly correlated with a higher PEFR at 24 hours and a faster recovery. The mean arterial PaCO2 was higher (P less than 0.02) in slow responding group and they were slightly older (P less than 0.01), had lower mean FVC (P less than 0.01), mean FEV1 (P less than 0.02) and PEFR (P less than 0.001). The mean PaO2 of less than 80 mm Hg at 48 hours was more common in those with delayed recovery of PEFR.