Jian-Jun LI?

Division of Cardio-Metabolic Center, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China

Atherosclerotic cardiovascular disease(ASCVD) is the leading cause of death among urban and rural residents in China,and elevated low-density lipoprotein cholesterol(LDL-C) is a causal risk factor for ASCVD.[1,2]Considering the increasing burden of ASCVD, lipid management is of the utmost importance.Within 7 years interval, Chinese guideline for lipid management(2023) (lipid guideline 2023) has simultaneously been published in both Chinese Journal of Cardiology, Chinese Circulation Journal in Chinese language and Frontiers in Pharmacology in English, which has widely been acclaiming at home and abroad.[3]

In fact, lipid guideline 2023 was revised from 2016 Chinese guidelines for the management of dyslipidemia in adults [lipid guideline 2016], which was also performed by Joint Expert Committee for guideline revision consisting mainly of specialists from the National Cardiovascular Disease Expert Committee,together with the Chinese Society of Cardiology, the Chinese Society of Endocrinology, the Chinese Diabetes Society, the Chinese Society of Laboratory Medicine and the Chinese Stroke Association.[4]The aim of this committee was to guide clinical practice to comprehensively improve the level of lipid management in China by promoting cardiovascular disease (CVD)prevention and treatment.Notably, the revision of lipid guideline 2023 was all along abided by following principles: (1) preserving classic contents of lipid guideline 2016 and learning from international lipid guideline’s strong points to enrich our one; (2)Supplementing the issues of the most concerns in lipid fields; (3) adding the new information or evidence regarding the marketed lipid-lowering drugs and randomized clinical trials with a great influence on lipid management; (4) exhibiting the lipid-related studies performed by Chinese scholars as much as possible if necessary; and (5) writing in fille after achieving a consensus concerning debatable issue at lipid domain.

The brilliant spots of lipid guideline 2023 are freshly of rather Chinization, which are characterized by a series of chains.Firstly, in this guideline,ASCVD risk stratification was recommended to use the flow chart for overall risk assessment of ASCVD in Chinese adults based on a long-term cohort study in Chinese population, which was classified into primary and secondary preventions and updated the risk assessment process in the 2016 version of the guidelines by combining the latest research evidence with national and international guidelines and consensus.[5,6]Although ASCVD risk assessment is relatively complex process, which is involved in multiple indexes and systemic evaluation, the flow chat of ASCVD risk assessment in lipid guideline 2023 was more simple, clear and easy to handle in real world practice.

Secondly, a moderate-intensity statin was recommended as a basis for cholesterol-lowering strategy in lipid guideline 2023, which was quite different from the lipid-related guidelines of Western countries.[4,6]This policy was combined with the fact that the tolerance of high-dose statins in Chinese is poorer than that in European and the American people,the use of high-intensity or high-dose statin treatment was not recommended, and as such it is recommended to start with conventional doses or moderate-intensity statins.Additionally, for statin intolerant individuals, the natural lipid-lowering agent Xuezhikang (XZK) (Chinese Traditional Medicine) can be used as initial lipid-lowering therapy, which has been demonstrated to be good safety and has shown clinical benefit in secondary prevention studies in the Chinese population.[7,8]When LDL-C targets are not achieved with statins or XZK,non-statin lipid-lowering agents such as cholesterol absorption inhibitors, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can be added as a combination.[4]

Moreover, the lipid guideline 2023 contained more studies from Chinese scholars, which included every aspects of lipid field.As is well-known, the Chinese population, including children and adolescents, has experienced a significant change in the lipid levels and a marked increase in the prevalence of dyslipidemia.[9]The prevalence of adult dyslipidemia in China has also remained high in recent years.The results of the 2018 national survey demonstrated that the prevalence of dyslipidemia among adults aged ≥ 18 years was 35.6%.[9]A recent follow-up study of 9,944 ASCVD patients including chronic coronary heart disease, ischemic stroke and peripheral vascular disease suggested that 26% of Chinese ASCVD patients were at very-high risk and the target LDL-C rate was only 13%.[5]About lipid screening in Chinese population, it is recommended to increase the detection and awareness of dyslipidemia by encouraging health screening services to include lipid testing as a routine item and including lipid testing for children and adolescents as a routine item in primary,middle and high school entry physical examinations.And also, the novel diagnostic criteria including statin intolerance and familial hypercholesterolemia (FH) for Chinese population has firstly covered by lipid guideline 2023.Besides, lipid management for specific populations was also a bright point of lipid guideline 2023.These patients with certain coexisting diseases (e.g., hypertension, diabetes, chronic kidney disease, stroke), special physiological states (pregnancy, children, elderly people of advanced age), and special lipid metabolism abnormalities (FH).Their lipid metabolism status and response to drug therapy are somewhat specific, so a more individualized lipid management strategy is needed.In a world, these domestic information in regard of lipid management in the Chinese population may help to understand the importance of lipid control and improving the prevention and treatment of ASCVE in China.

Finally, compared with lipid guideline 2016, the lipid guideline 2023 was made noticeable progress in writing style, which was declined to more tabulation consisting of twenty tables and eleven taking home massage (key points).For example, we developed a new table for patients with FH covering all the key points regarding diagnosis and treatment.Especially, early detection and diagnosis for early initiation and lifelong adherence to cholesterol-lowering therapy are fundamental therapeutic measures to prevent cardiovascular complications in patients with FH.It is worth pointing out that genetic diagnosis of FH can be expanded with genetic tests for lysosomal acid lipase, signal transducing adaptor protein 1, apolipoprotein E (ApoE), ATP-binding cassette sub-family G, member 5 (ABCG5) and ABCG8 in addition to routine LDL receptor, ApoB, PCSK9 and LDLRAP1 genetic tests, which can help in diagnosis and differential diagnosis[10,11].

In conclusion, research on blood lipids has made breakthroughs around the world in recent years.Hence, a revision of China guidelines for lipid management is imperative, especially since the target lipid levels in the general population vary in respect to the risk of ASCVD.The lipid guideline 2023 still recommended LDL-C as the primary target for lipid control and moderate intensity statin therapy in adjunct with a heart-healthy lifestyle, be used as an initial line of treatment, followed by cholesterol absorption inhibitors or/and PCSK9 inhibitors, as necessary, which also provided guidance for lipid management across various age groups, from children to the elderly.The lipid guideline 2023 is the product of the expert’s hard work and wisdom, which should be to comprehensively improve the management of lipids and promote the prevention and treatment of ASCVD by guiding clinical practice.

DISCLOSURE

Acknowledgements

Author would like to thanks for all participants who made a substantial, direct, and intellectual contribution to the work of Chinese guideline for lipid management (2023).

Fundings

This work partly supported by CAMS Major Collaborative Innovation Project (2016-I2M-1-011).