Consensus Statements on Dyslipidemia in Indian Women

Preamble

Despite significant advances in lipid management and cardiovascular prevention, women, particularly in low- and middle-income countries like India, remain underdiagnosed, undertreated, and underrepresented in lipid research.^[1-4] Recent epidemiological studies indicate that up to 81.2% of Indian women have at least one lipid abnormality, with 52–67% exhibiting low high-density lipoprotein-cholesterol (HDL-C), 25–30% elevated low-density lipoprotein cholesterol (LDL-C), and over 30% elevated triglycerides – clearly demonstrating that this is not an academic concern but a widespread publichealth challenge.^[5] Global data also report a high prevalence of low HDL-C (40–52%) and hypertriglyceridemia (~25%), further highlighting the burden among women worldwide.^[6]

Existing global and national dyslipidemia guidelines, such as the American College of Cardiology/American Heart Association (ACC/AHA), the European Society of Cardiology/European Atherosclerosis Society, and the Canadian Cardiovascular Society, provide broad frameworks but seldom address the unique biological, hormonal, and sociocultural determinants of lipid disorders in Indian women.^[7,8] However, women face a unique combination of common risk factors, along with gender-specific ones.^[9,10] Table 1 summarizes the traditional and female-specific risk factors. The exploration of dyslipidemia in women warrants comprehensive attention within clinical practice.^[9,10]

Indian data show distinct patterns of atherogenic dyslipidemia,^[11,12] earlier onset of metabolic risk,^[13] and suboptimal awareness and treatment adherence^[14,15] among women. Furthermore, female-specific factors including pregnancy-related complications,^[16-19] premature menopause,^[20] and polycystic ovary syndrome (PCOS) also contribute to an increased cardiovascular risk profile in women.^[21] They are under-recognized in cardiovascular risk assessment.

Recognizing these persistent gaps, this consensus was developed through a structured expert panel to provide pragmatic, evidence-informed recommendations that reflect the realities of Indian clinical practice. This consensus aims to close the gender gap in dyslipidemia recognition, risk assessment, and management among Indian women. This consensus goes beyond traditional clinical recommendations.

It represents a paradigm shift toward preventive, life-course cardiovascular care for Indian women, a silent but essential revolution aimed at shifting healthcare from disease treatment to proactive health promotion.

Epidemiology of dyslipidemia in Indian women

Dyslipidemia is a major, modifiable determinant of atherosclerotic cardiovascular disease (ASCVD) in women. A systematic review and meta-analysis of 206 studies (98.5% cross-sectional) revealed global prevalences of 24.5%, 27.16%, 40.53%, and 21.03% for hypertriglyceridemia, hypercholesterolemia, low HDL-C, and high LDL-C, respectively.^[6] Table 2 provides the representative prevalence data of lipid level abnormalities.^[22]

Emerging mechanistic and biomarker insights

Recent research highlights that the pathophysiology of dyslipidemia in Indian women extends beyond conventional lipid fractions. Elevated lipoprotein(a), remnant cholesterol, and non-HDL-C contribute significantly to atherogenic burden and residual risk, even when LDL-C appears optimal.^[23,24]

Race and ethnicity

Race and ethnicity are important determinants of dyslipidemia and cardiovascular risk. South Asians, including Indian women, exhibit a distinct lipid phenotype characterized by lower HDL-C, higher triglycerides, small dense LDL particles, and elevated lipoprotein(a) compared with Western populations. However, the SHARE study comparing multiple ethnic groups found that Asian Indians had higher LDL-C, lower HDL-C, and pro-inflammatory small dense dysfunctional high-density lipoprotein (HDL) particles than Europeans and Chinese, despite similar HDL-C concentrations.^[22]

The Cardiology Society of India (CSI) and the Lipid Association of India (LAI), therefore, recommend their own risk-stratification algorithm until a dedicated Indian tool is validated.^[25]

Life-stage biology amplifies these population risks.^[26] Figure 1 provides the life-course lipid trajectory in women.

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Figure 1:

Life-course lipid trajectory in women. A conceptual schema based on aggregated data from observational studies showing patterns of lipid changes (LDL-C, HDL-C, and TG) across key female life stages: pregnancy, postpartum, perimenopause, and menopause. (LDL-C: Low-density lipoprotein cholesterol, HDL-C: High-density lipoprotein cholesterol, TG: Triglycerides.)

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Taken together, these data underscore the need for early and repeated screening of high-risk women and for India-specific risk assessment and management strategies to reduce the^[27-29] heavy burden of dyslipidemia-related cardiovascular disease. Further large, nationally representative studies are needed to confirm these patterns across India’s diverse regions.

Unique female risk determinants

However, women face a unique combination of common risk factors, along with gender-specific ones [Table 3].^[9,10,30,31] The exploration of dyslipidemia in women warrants comprehensive attention within clinical practice.^[9,10,26]

Numerous pregnancy-related complications have been identified as potential precursors to an elevated risk of ASCVD later in life.^[17,32-34]

A Korean study documented a relationship between height and dyslipidemia, revealing that short stature is significantly inversely associated with dyslipidemia in both Korean adolescents and adults.^[35] Among adolescents, this inverse relationship between height and dyslipidemia exhibited sex-related differences. Specifically, the risk of hypercholesterolemia, hypertriglyceridemia, and hyper-LDLcholesterolemia was linked to height in boys, whereas only hyper-LDL-cholesterolemia showed a significant association with height in girls. In adults, all four types of dyslipidemia were confirmed to be negatively impacted by short stature in both men and women.^[35]

Autoimmune conditions such as rheumatoid arthritis, systemic lupus erythematosus, and antiphospholipid syndrome affect women far more often than men and significantly increase long-term cardiovascular risk. The chronic inflammation associated with these disorders alters lipid behavior; HDL-C levels usually decrease, triglycerides rise, and LDL particles become more susceptible to oxidation, all of which accelerate plaque formation in blood vessels.^[20] These problems may worsen during disease flares or with corticosteroid therapy, which is why major guidelines classify women with autoimmune diseases as a higher-risk group.^[36-39]

Because of this, it is essential to check lipid levels early, right at the time of diagnosis, and to repeat them more frequently, especially when the disease is active or steroid doses increase, so that dyslipidemia can be identified and treated promptly.

Formation of an expert panel

To develop these recommendations, we assembled a group of 75 experienced clinicians from across India, including cardiologists, endocrinologists, lipid specialists, obstetricians–gynecologists, and primary care physicians. All had long-standing clinical practice and academic experience and were chosen to reflect a broad geographic and professional mix.

We used a modified Delphi process to build consensus. The group worked through three structured rounds of review and voting held over several months. In each round, panel members rated their level of agreement with draft statements. A statement was accepted once at least 80% of the members agreed to it. Points of disagreement were discussed and revised before the next round.

These formal steps, combined with a review of current evidence and responses to 20 key clinical questions, helped ensure that the final statements reflect both shared expert judgment and published data.

Questionnaire of 20 key clinical questions with pooled expert responses

A 20-item questionnaire [Supplementary File 1] was developed based on the literature gaps and clinical challenges identified during preparatory meetings. Each question addressed a critical aspect of dyslipidemia management in women, such as:

• Optimal age and frequency of lipid screening,

• Life-stage-specific changes (puberty, pregnancy, and menopause),

• Management of familial hypercholesterolemia (FH),

• Statin safety during pregnancy and lactation,

• Preferred pharmacologic and lifestyle interventions.

The questionnaire was distributed electronically to all panelists and to a broader group of practicing clinicians nationwide. Responses were collated and analyzed for convergence and variation. Items with consistent agreement (>80%) were advanced to consensus statements.

Integration of answers into final statements

Each question’s pooled responses were cross-checked against current evidence and harmonized with the narrative literature review. The final consensus statements – encompassing screening, risk assessment, pharmacotherapy, and life-stage-specific recommendations – represent the intersection of published data and expert clinical insight, ensuring both scientific validity and practical applicability in the Indian context.

Screening and risk assessment

Conventional tools for predicting ASCVD risk, such as the pooled cohort equations (PCE), tend to underestimate risk among South Asians because they were excluded from the derivation cohort.^[25] Consequently, these tools are not recommended for implementation in Indian subjects.

While the QRESEARCH cardiovascular risk algorithm (QRISK 3) score performs better than the pooled cohort equations (PCE) in risk assessment for Indians, the lack of a dedicated, population-derived risk calculator continues to limit precision.^[25,40]

Indian urban surveys demonstrate that 25–30% of adult women have dyslipidemia, and up to 40% remain undiagnosed or untreated, underscoring the need for region-specific risk recalibration.^[5,41] Moreover, artificial intelligence-based and polygenic risk-score models are now being validated through ICMR and Apollo-led initiatives (2024–2025) to enable individualized ASCVD prediction tailored to Indian women [Table 4].^[42]

Despite clear recommendations in the CSI’s 2023 guidelines to use non-fasting lipid profiles for routine screening and to begin lipid assessment at age 18 (or sooner in those with risk-enhancing family histories), actual compliance with these guidelines in clinical practice is still inadequate. CSI suggests a goal LDL-C <100 mg/dL and non-HDL-C <130 mg/dL in general or low-risk individuals, while emphasizing robust lifestyle modification as foundational therapy.

The CSI 2023 clinical practice guidelines and the LAI-2023 update provide general guidance on dyslipidemia in Indian patients; however, they do not fully address female-specific risk factors.^[25,43] This consensus statement was therefore developed to fill that gap.^[44]

Age to start routine lipid testing

Our consensus recommends that all Indian women have at least one lipid profile between the ages of 20 and 39 years, ideally in the early 20s, and that testing be repeated every 4–6 years, or sooner if abnormalities are detected [Table 5].

This Indian consensus is broadly in line with the 2019 ACC/AHA guideline on primary prevention of cardiovascular disease, which advises measuring major risk factors, including a lipid profile, starting at age 20 and at least every 4–6 years.^[40,45]

By recommending an early, baseline lipid profile and structured re-testing at key reproductive and hormonal milestones, these statements aim to address the higher lifetime cardiovascular risk observed in Indian women.

Subclinical atherosclerosis in women – role of imaging and biomarkers

The early identification of subclinical atherosclerosis provides a critical opportunity for timely intervention in women, who often present with atypical symptoms and delayed cardiovascular risk recognition [Table 6].^[24,46]

Lipoprotein(a) (Lp[a]) remains a powerful and independent determinant of residual ASCVD risk, especially in South Asians.^[47,48]

High-risk and life-stage scenarios

As described before, high-risk patients require early and high doses of statin to decrease the lifetime risk of Cardiovascular diseases (CVD) [Table 7 and Figure 2].^[26] To support patient awareness and improve adherence, a public-friendly infographic summarizing key messages for women is included [Table 8 and Figure 3].

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Figure 2:

Clinical algorithm for dyslipidemia management in Indian women. This infographic presents a simplified, office-friendly clinical workflow for dyslipidemia screening, risk stratification, female-specific risk reclassification, treatment escalation, and life-stage-based follow-up for Indian women. (APOs: Adverse pregnancy outcomes, ASCVD: Atherosclerotic cardiovascular disease, FH: Familial hypercholesterolemia, PCOS: Polycystic ovary syndrome, TG: Triglycerides, LDL-C: Low-density lipoprotein cholesterol, Lp(a): Lipoprotein(a)).

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Figure 3:

Women and heart health: Five things every woman should know. Infographic designed for patient education and community awareness to promote early lipid testing, identification of female-specific cardiovascular risk factors, lifestyle modification, and timely follow-up across the life course. (PCOS: Polycystic ovary syndrome.)

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Quantitative lipid targets and outcome metric

Lipid-management goals should be individualized according to the cardiovascular risk category. Given the high cardiometabolic burden and smaller body habitus of Indian women, slightly lower LDL-C and non-HDL-C thresholds are reasonable. The suggested targets for clinical practice are mentioned in Tables 9 and 10.

HDL-C >50 mg/dL and triglycerides <150 mg/dL remain desirable secondary targets.

Process and outcome metrics for implementation should include:

• Percentage of high-risk women achieving LDL-C goal within 6 months of therapy

• Statin adherence and persistence at 12 months

• Proportion of postpartum and menopausal women screened annually.

Regular audits of these indicators within hospital- and community-based lipid programs can help monitor the real-world effectiveness and equity of cardiovascular prevention in women.^[49-56]

Management

Implementation in Indian healthcare settings

The practical application of these consensus recommendations requires integration into routine clinical workflows across India’s diverse healthcare system, from large tertiary centers to primary and community clinics, which requires robust digital and public health integration [Table 14]. The panel identified several practical steps for implementation.

Alignment with national consensus and risk tools

The current national (CSI and LAI) consensus provides an evidence-based ASCVD risk assessment and lipid management algorithm tailored to Indian epidemiology and healthcare realities.^[25] Our expert group has developed an India-specific consensus for life-stage-oriented screening and management of dyslipidemia in women. While existing tools, such as the LAI 2023 algorithm, have incorporated risk factors and female-specific enhancers (premature menopause, pregnancy complications, and PCOS), this consensus provides independent, focused recommendations to address gaps and offer practical guidance tailored to women [Figure 4].

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Figure 4:

Risk-based lipid management algorithm incorporating female-specific risk enhancers. (PCOS: Polycystic ovary syndrome, FH: Familial hypercholesterolemia, PCSK 9: Proprotein convertase subtilisin/Kexin type 9).

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