New guidelines and evidence for prevention and treatment of dyslipidemia and atherosclerotic cardiovascular disease in China

The “2016 Chinese guideline for the management of dyslipidemia in adults” (the new Guide for short) released by Chinese Journal of Cardiology is based on the 2007 “Guide for Dyslipidemia Prevention in Chinese Adults” (the 2007 Hyperlipidemia Guide for short) and is the result of a year's effort and work by a team of specialists.¹

The public release of the 2007 Hyperlipidemia Guide has had a positive effect on control and management of hyperlipidemia and atherosclerotic cardiovascular disease (ASCVD). In the past decade, there has been a paradigm shift in international and domestic research and the viewpoints in this field; thus, a new guide for dyslipidemia is imperative.

The group of specialists who have formulated the guides, from the 1997 “Recommendations for Dyslipidemia Prevention” to the first dyslipidemia guideline in China, until the formulation of this new Guide, have adhered to three principles. First, they used international guides as a reference with an emphasis on the data and evidence from Chinese research, without blind obedience to foreign guides. Second, they adhered to the public welfare and scientific nature of the guide, with no interference of various business interests. Third, they embody authority, as the formulation process for the guide brought together specialists in the field; scientific democracy was fully upheld, evidence was thoroughly collected and evaluated, and authorization was granted by the Disease Prevention and Control Bureau of the National Health and Family Planning Commission, China.

New situations and challenges faced during formulation of the new Guide

• 1.The 2007 Hyperlipidemia Guide was primarily based on results from Chinese epidemiological studies conducted over many years, with the highlight being based on the risk stratification for cardiovascular diseases (including stroke) formulated using our own data; owing to the high incidence of ischemic stroke in China, the weight of hypertension in the risk stratification was increased. Presently, randomized double-blind clinical studies of dyslipidemia interventions focused on ASCVD in China are still limited, the only study is Xuezhikang, a partially purified red yeast rice under controlled pharmaceutical manufacturing conditions, contains a family of naturally occurring statins (monacolins)–most prominently monacolin K, which is identical to the lipid-lowering therapy lovastatin (Mevacor), addressing the secondary prevention of myocardial infarction. Since 2007, an increasing number of domestic and international organizations have been conducting studies on dyslipidemia interventions. Only the HPS-2 THRIVE results reported by a Chinese/European collaborative group have been used for over 12,000 Chinese patients.
• 2.The new Guide for cholesterol and ASCVD published by the American College of Cardiology (ACC) and the American Heart Association (AHA) at the end of 2013 subverts the American Adult Treatment Panel (ATP) system and recommends the removal of low density lipoprotein cholesterol (LDL-C) and other interventional targets of dyslipidemia. The guide lists 4 categories of patients that require statin treatment and recommends intervention with high doses of a high-potency statin. This led to consistent questioning and opposition by the American National Lipid Association, the European Society of Cardiology, the European Atherosclerosis Society, the International Atherosclerosis Society, and leading Chinese scholars in the field.
• 3.In the recent years, a series of incorrect viewpoints regarding dyslipidemia intervention and ASCVD prevention driven primarily by business interests, have emerged in China. One example is the growing number of the much-hyped small-scale, short follow-up, exploratory studies in which observations act as substitutes for endpoints. These one-sided exaggerated claims of multiple effects (such as anti-inflammatory effects) outside the primary role of statins in lowering the cholesterol suggest the sequential use of 80 mg atorvastatin during the perioperative period of percutaneous coronary intervention (PCI) and acute coronary syndrome (ACS). More seriously, this misconception is already widely accepted in several country-level hospitals.

The Chinese new Guide is clear, raises the banners of public welfare and science, adheres to the characteristic evidence from Chinese studies without following the ACC/AHA, and strictly rejects and resists intervention related to business interests.

Main highlights of the new Guide

• 1.It does not agree with the recommendations of the ACC/AHA, and clearly adheres to interventional LDL-C target values established by the ASCVD risk stratification. Following extensive discussion and voting, it was recommended that the interventional LDL-C target value for the secondary prevention of ASCVD be lowered from <2.0 mmol/L (80 mg/dl) in 2007 to <1.8 mmol/L (70 mg/dl). Besides, in order to fully uphold scientific democracy, Prof. Zhao Shuiping, the Second Xiangya Hospital of Central South University, was invited to present his opinions about not changing the target value of <2.0 mmol/L (80 mg/dl) in detail.²
• 2.The new Guide adheres to the scientific theories and laws about cholesterol known for a hundred years, and rejects one-sided excessive emphasis on the multiple effects of statin intervention.
• 3.The new Guide is based on Chinese data and evidence, and emphasizes that most Chinese patients do not need and cannot tolerate the high-potency high-dose statin treatment recommended by the ACC/AHA. It clearly indicates that the appropriate unified treatment regimen for Chinese patients is to use low-potency doses of statins, and drug combinations only when needed.
• 4.The ACS and PCI are not singled out, and the sequential use of high-potency, high doses of statins is not recommended.

We congratulate all the authors on the publication of the new Guide, and are grateful to the cardiovascular specialists for their dedication to the project. The publication of the new Guide marks the recognition of a successful historic collaboration with the China Cholesterol Education Program (CCEP). The study, promulgation, and implementation of the new Guide are the mission and responsibility of our group and the CCEP. We hope that after the National Conference on Health and Wellness, the New Guide can mark a new stage in the prevention of ASCVD.

Edited by Wei-Zhu Liu