The latest version of the "China Blood Lipid Management Guide" released, five major changes concern everyone!

Interviewed expert: Guo Yifang, Vice President of Hebei Provincial People's Hospital and Vice Chairman of the Hypertension Special Committee of the Chinese Medical Doctor Association

Global Times health client reporter Ren Linxian

On March 25, the "Guidelines for the Management of Chinese Blood Lipids (2023)" (hereinafter referred to as the "New Guidelines") was officially released, which is a major adjustment after 7 years based on the "Guidelines for the Prevention and Treatment of Dyslipidemia in Chinese Adults (2016 Revised Edition)" (hereinafter referred to as the "2016 Guidelines"), combined with the latest research data and clinical experience in recent years. This will also become the main programmatic document for the prevention and treatment of dyslipidemia in mainland China in the coming period. In response to the latest changes in the new version of the guidelines, the Global Times Health Client reporter interviewed Professor Guo Yifang, one of the members of the revision expert group and vice president of Hebei Provincial People's Hospital.

Change 1: The frequency of blood lipid screening has changed, and the key population of blood lipid testing has been added.

【Interpretation】Compared with the 2016 version of the guidelines, the new version of the guidelines further refines the blood lipid screening recommendations according to age and risk factors: adults under 40 years old should have a blood lipid test every 2~5 years, and adults aged 40 and above should be tested at least once a year. Include at least one test for Lp(a), which stands for lipoprotein (a) and is an independent risk factor for coronary heart disease.

The key objects of blood lipid examination are: (1) those with a history of atherosclerotic cardiovascular disease (ASCVD); (2) People with multiple risk factors for ASCVD (such as hypertension, diabetes, obesity, smoking, etc.); (3) Patients with a family history of early onset (referring to male first-degree immediate family members before the age of 55 or female first-degree immediate relatives suffering from ASCVD before the age of 65) or patients with familial hyperlipidemia; (4) Skin or tendon xanthoma and Achilles tendon thickening.

Change 2: The blood lipid management of special populations in the guidelines has added children and pregnant women, and the blood lipid management of the elderly over 75 years old has been discussed in more depth.

【Interpretation】The 2016 version of the guidelines mainly focuses on the management of dyslipidemia in general adults, and makes in-depth analysis and recommendations. In recent years, affected by factors such as dietary pattern changes, reduced physical activity and poor lifestyle, the incidence of dyslipidemia in mainland children and adolescents has increased significantly, with a detection rate of 20.3%~28.5%, coupled with the fact that some adult dyslipidemia is a continuation of dyslipidemia in children and adolescents, the new version of the guidelines recommends paying attention to, preventing and intervening in dyslipidemia from childhood, and recommends that lipid testing be included in the routine items of primary, junior high school and high school entrance physical examination. It is more in line with the strategic thinking of moving the defense line of cardiovascular disease forward.

The new guidelines recommend that children and adolescents with the following conditions should be screened for blood lipids: (1) women under 65 years of age or men under 55 years of age who are relatives of the first or second degree have a history of myocardial infarction, angina, stroke, coronary artery bypass grafting, stenting, angioplasty, and sudden death; (2) Parents' total cholesterol ≥ 6.2mmol/L, or a known history of lipid abnormalities; (3) There are cutaneous xanthelasma or tendon xanthelasma or lipocorneal arch; (4) Have diabetes, high blood pressure, obesity (2~8 years old) or overweight (12~16 years old), smoking behavior. In addition, people suspected of familial hypercholesterolemia should be screened for dyslipidemia.

Given that women with healthy pregnancies already have elevated lipids physiologically and the choice of drugs for the treatment of dyslipidemia is limited, the 2016 version of the guidelines does not address the management of lipids in pregnant women. However, in recent years, clinical practice has found that dyslipidemia in this special group is not uncommon. The harm associated with hypercholesterolemia is slow but severe and can lead to acute pancreatitis and mortality in 20% of pregnant women. Therefore, based on limited research evidence and pooling the wisdom of the expert group, the new guidelines make prudent recommendations for the clinical use of dyslipidemia in pregnant women, such as high-purity omega-3 fatty acids and fibrates with caution in patients with severe hypercholesterolemia (>5.6 mmol/L).

The 2016 version of the guidelines provides a brief introduction to dyslipidemia in people over 80 years of age and does not give specific recommendations. The new guidelines update the management of blood lipids in the elderly aged 75 years and above, especially suggesting that the treatment of this group should pay attention to the assessment of existing cardiovascular disease, liver and kidney function, multiple medications, frailty, prolongation of life expectancy and other factors and patient wishes, if the benefits outweigh the risks, the treatment should be started cautiously.

Change 3: Evaluation criteria for initiating treatment – The evaluation process and criteria for atherosclerotic cardiovascular disease (ASCVD) have changed.

【Interpretation】Cardiovascular risk assessment is the basis for determining the strategy and intensity of dyslipidemia intervention. The new version of the guidelines makes important changes to the risk assessment process of ASCVD, especially the concept of "ultra-high risk", classifying patients who have had ≥ 2 serious ASCVD events or 1 serious ASCVD event and ≥ 2 high-risk factors into the ultra-high-risk group, and proposes a more stringent low-density lipoprotein cholesterol (LDL-C) control target (<1.4 and a >50% reduction from baseline). A serious ASCVD event is defined as recent acute coronary syndrome, prior myocardial infarction, ischaemic stroke, and symptomatic peripheral vascular disease with prior revascularization or amputation. High-risk factors include early-onset coronary heart disease, diabetes, hypertension, smoking, etc. This change is based on the results of several newly acquired randomized clinical trials in recent years. More and more evidence shows that lowering cholesterol to a lower level in people with severe cardiovascular risk can benefit more, and compared with the previous version of the guidelines, we now have more types of cholesterol-lowering drugs, and it is easier to achieve the control goal of lowering to lower cholesterol, so the revision of the new version of the guidelines is highly scientific, necessary, feasible and practical, reflecting the new concept of "lower is better" cholesterol management.

Change 4: In terms of therapeutic use, formally recognize the importance and future trend of combination drugs.

【Interpretation】Compared with the guidelines of European and American countries, the biggest feature of the mainland guidelines is that they use "moderate dose statins" as the main means of cholesterol-lowering treatment. Although increasing statin doses can help further reduce cholesterol levels, considering that the mainland population has poor tolerance for high-dose statins, the mainland has always advocated "conventional dose statins as the basis, if necessary, combined with non-statin drugs" as the basic strategy to achieve cholesterol standards. The balanced metabolism of cholesterol is a very complex process, involving liver synthesis, intestinal absorption, LDL receptor capture on the surface of liver cells, etc. These links do not exist in isolation, but depend on each other, compensate for each other, and influence each other. Because of this, the cholesterol-lowering effect of monotherapy with any mechanism of action has a certain limit, and the combined application of cholesterol-lowering drugs with different mechanisms of action can better exert cholesterol-lowering effects, help to obtain greater cholesterol reduction at a smaller cost of adverse reactions, thereby increasing cholesterol compliance and further reducing the risk of adverse cardiovascular events. For example, statins in combination with cholesterol absorption inhibitors can affect cholesterol synthesis and absorption, respectively.

Change 5: Greater emphasis on the cornerstone of lifestyle interventions.

【Interpretation】Active and effective lifestyle intervention is a key measure for the treatment of dyslipidemia, hypertension, diabetes and other risk factors, and any drug treatment should be based on lifestyle intervention. This issue cannot be overemphasized. Compared with the 2016 guidelines, the new guidelines continue to emphasize the importance of measures such as reasonable diet, moderate physical activity, weight control, smoking cessation, and alcohol restrictions, which will help to continuously increase the importance of doctors and patients. ▲

Responsible editor: Zheng Ronghua

Editor-in-chief: Ding Wenjun