As India grapples with a sharp rise in early-onset heart disease, questions around who needs cholesterol-lowering treatment — and when — have never been more pressing. New global lipid guidelines have shifted the conversation from age-based thresholds to risk-based ones, but translating that shift into everyday clinical practice requires local expertise. Unnikrishnan S speaks to Dr Harikrishnan S, professor and head of cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, about how doctors decide when to start statins, why younger patients resist long-term medication, and what the latest treatment targets mean for high-risk patients in India. Edited excerpts:
Do you rely on age when deciding to start statins?
Age isn’t the deciding factor — risk profile is. Even a 30-year-old with high cholesterol should start statins if they’re diabetic, or have multiple risk factors like hypertension, family history, or smoking. Thresholds have also dropped: patients with a history of multiple heart attacks now have an LDL target as low as 30 mg/dL. Waiting until 40 to screen is often too late — risk factors are usually already established by then. That said, if there are no risk factors and LDL is around 130 mg/dL, diet and exercise alone can manage it — no medication needed.
What matters before screening and medication even come in?
Primordial prevention — building healthy habits before risk develops — ideally starting at the school level, since it shifts habits community-wide. Primary prevention means preventing disease through weight loss, exercise, and quitting smoking; secondary prevention is catching and treating disease that’s already there through screening. Common risk factors we see are smoking, sedentary lifestyles, and stress. Skipping breakfast and eating a heavy dinner is especially harmful — the body needs calories during active hours, not at night when it’s inactive and stores the excess as fat.
How hard is it to convince younger patients to start statins?
The first question is almost always: “Is this lifelong? Can I stop after two months?” We explain that it depends on lipid levels — once targets are hit, we can taper the dose gradually (say, from 18 mg down to 5 mg of atorvastatin). Skipping medication altogether isn’t a safe alternative — untreated high cholesterol can lead to kidney damage and vascular deposits. About 10–20% of patients, if free of complications, can eventually come off medication entirely.
