Prevalence of dyslipidaemia in statin-treated patients in South Africa: results of the DYSlipidaemia International Study (DYSIS)

Dyslipidemia in Adults with Type 2 Diabetes in a Rural Community in Ganadougou, Mali: A Cross-Sectional Study

Dyslipidemia is a disorder where abnormally lipid concentrations circulate in the bloodstream. The disorder is common in type 2 diabetics (T2D) and is linked with T2D comorbidities, particularly cardiovascular disease. Dyslipidemia in T2D is typically characterized by elevated plasma triglyceride and low high-density lipoprotein cholesterol (HDL-C) levels. There is a significant gap in the literature regarding dyslipidemia in rural parts of Africa, where lipid profiles may not be captured through routine surveillance. This study aimed to characterize the prevalence and demo-graphic profile of dyslipidemia in T2D in the rural community of Ganadougou, Mali. We performed a cross-sectional study of 104 subjects with T2D in Ganadougou between November 2021 and March 2022. Demographic and lipid profiles were collected through cross-sectional surveys and serological analyses. The overall prevalence of dyslipidemia in T2D patients was 87.5% (91/104), which did not differ by sex (P = .368). High low-density lipoprotein cholesterol (LDL-C) was the most common lipid abnormality (78.9%, [82/104]). Dyslipidemia was associated with age and hypertension status (P = .013 and.036, respectively). High total and high LDL-C parameters were significantly associated with hypertension (P = .029 and .006, respectively). In low-resource settings such as rural Mali, there is a critical need to improve infrastructure for routine dyslipidemia screening to guide its prevention and intervention approaches. The high rates of dyslipidemia observed in Gandadougou, consistent with concomitant increases in cardiovascular diseases in Africa suggest that lipid profile assessments should be incorporated into routine medical care for T2D patients in African rural settings.

The therapeutic management of South African dyslipidaemic patients at very high cardiovascular risk (CARDIO TRACK): a cross-sectional study

BACKGROUND

Dyslipidaemia is a major modifiable risk factor for atherosclerotic cardiovascular disease. At the time the study was conducted, guidelines recommended a low-density lipoprotein cholesterol (LDL-C) target of less than 1.8 mmol/l and a reduction of at least 50% if the baseline LDL-C was between 1.8 and 3.5 mmol/l in patients with either very high cardiovascular risk or established atherosclerosis. In South Africa, there is a paucity of data on attainment of LDL-C goal in patients with very high cardiovascular risk who are on maximum tolerated statin with or without ezetimibe.

OBJECTIVE

The aim was to assess the percentage of very high cardiovascular risk South African patients with dyslipidaemia not reaching an LDL-C goal of less than 1.8 mmol/l, despite maximum tolerated statin with or without ezetimibe.

METHODS

This was a multi-centre, observational, cross-sectional study conducted at 15 private healthcare sector sites and one public sector site. Adults (> 18 years) with very high cardiovascular risk of familial hypercholesterolaemia receiving stable, maximum-tolerated statin therapy for at least four weeks prior to their latest lipid profile were enrolled into the study, and electronic case report forms were completed after written informed consent was provided. LDL-C goal attainment was modelled, first assuming an increase in the statin dose to the registered maximum, followed by the addition of ezetimibe or a PCSK9-inhibitor.

RESULTS

In total, 507 patients were screened, of whom 492 were eligible for study participation. One patient was excluded from the analysis because of a missing LDL-C value. Most participants were male (male 329, 67%; female 162, 33%). Most patients were either obese (223, 46.0%) or overweight (176, 36.3%). Hypertension and diabetes mellitus were frequent co-morbidities and were found in 381 (77.6%) and 316 (64.4%) patients, respectively. Eighty (16.3%) patients reported current smoking. Only 68 (13.8%) patients were taking ezetimibe in addition to a statin. Reasons for not using ezetimibe included no requirement for ezetimibe in the opinion of the treating physician (229, 48.7%), cost (149, 31.7%), Physician's choice (39, 8.3%), or other (53, 11.3%). Only 161 (32.8%) of the patients attained their goal LDL-C level. In our modelling analysis, increasing the statin dose to the registered maximum and adding ezetimibe brought an additional 34.5% of patients to goal, while adding a PCSK9-inhibitor, irrespective of any other changes to lipid-lowering therapy brought over 90% of not-at-goal patients to goal.

CONCLUSIONS

Most study participants were not at LDL-C goal despite maximum-tolerated statin, highlighting the need for treatment intensification in this high-risk population. Although intensifying treatment by adding a PCSK9-inhibitor brought more patients to goal, the initial addition of ezetimibe would be more reasonable, given the cost of PCSK9-inhibitors.

Drug Treatment of Hyperlipidemia in Chinese Patients: Focus on the Use of Simvastatin and Ezetimibe Alone and in Combination

Elevated serum low-density lipoprotein cholesterol (LDL-C) is a major risk factor for coronary heart disease (CHD). Many guidelines recommend LDL-C as a primary treatment target, and statins represent the cornerstone of treatment for lipid management. Recently revised guidelines recommend even more intense management of LDL-C, especially in patients at moderate and high risk. However, LDL-C levels in the Chinese population differ from those in Western populations, and the benefits and safety of the maximum allowable dose of statins have yet to be determined. Furthermore, in practice, many patients do not achieve the increasingly stringent LDL-C goals. Consequently, alternative approaches to lipid management are required. Combination therapy with ezetimibe and a statin, which have complementary mechanisms of action, is more effective than statin monotherapies, even at high doses. Several clinical studies have consistently shown that combination therapy with ezetimibe and simvastatin lowers LDL-C more potently than statin monotherapies. Moreover, the safety and tolerability profile of the combination therapy appears to be similar to that of low-dose statin monotherapies. This review discusses the role of simvastatin in combination with ezetimibe in controlling dyslipidemia in Chinese patients, particularly the efficacy and safety of combination therapy in light of recently published clinical data.

Therapeutic Management of Dyslipidemia Patients at Very High Cardiovascular Risk (CARDIO TRACK): Protocol for the Observational Registry Study

BACKGROUND

Dyslipidemia is a major modifiable risk factor for atherosclerotic cardiovascular disease. Current South African guidelines recommend titrating lipid-lowering therapy (LLT) to low-density lipoprotein cholesterol (LDL-C) targets stratified by cardiovascular risk. The LDL-C goal for very high-risk patients is <1.8 mmol/L. In international studies, approximately 30% of patients do not achieve this goal despite receiving maximally tolerated statin doses. There is, however, a paucity of data on LDL-C goal achievement in very high-risk South African patients receiving maximal statin doses.

OBJECTIVE

The goal of the research it to assess LDL-C goal achievement in, and clinical characteristics of, very high cardiovascular risk dyslipidemic patients receiving maximal tolerated statin doses with or without ezetimibe.

METHODS

This is an observational, cross-sectional South African registry study that plans to include up to 30 sites and 500 study participants. Adult patients with very high cardiovascular risk status receiving stable, maximally tolerated statin doses (with or without ezetimibe) will be eligible for inclusion.

RESULTS

Funding has been awarded and enrollment began on November 15, 2017, and was completed on April 13, 2018, with 507 participants. Database lock was done on June 21, 2018. The statistical analysis has commenced and we expect the final clinical study report to be completed by October 2018.

CONCLUSIONS

This study will document the adequacy of LLT in those at highest risk and will thus fill an important data gap in South Africa. This data may be useful in assessing the need for novel LLTs like proprotein convertase subtilisin/kexin 9 inhibitors that substantially lower cholesterol levels in addition to optimal statin therapy.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/9248.

Increasing Prescription Length Could Cut Cardiovascular Disease Burden And Produce Savings In South Africa

South Africa's rates of statin use are among the world's lowest, despite statins' demonstrated effectiveness for people with a high blood cholesterol level or history of cardiovascular disease. Almost 5 percent of the country's total mortality has been attributed to high cholesterol levels, fueled in part by low levels of statin adherence. Drawing upon experience elsewhere, we used a microsimulation model of cardiovascular disease to investigate the health and economic impacts of increasing prescription length from the standard thirty days to either sixty or ninety days, for South African adults on a stable statin regimen. Increasing prescription length to sixty or ninety days could save 1,694 or 2,553 lives per million adults, respectively. In addition, annual per patient costs related to cardiovascular disease would decrease by $152.41 and $210.29, respectively. Savings would largely accrue to patients in the form of time savings and reduced transportation costs, as a result of less frequent trips to the pharmacy. Increasing statin prescription length would both save resources and improve health outcomes in South Africa.

Factors influencing low-density lipoprotein cholesterol target achievement in primary care - Results from DYSIS China

BACKGROUND

Primary care facilities are the base for hypercholesterolemia treatment. However, data regarding the effectiveness of lipid management in primary care are lacking.

METHODS AND RESULTS

To evaluate lipid management in the primary care setting in China, we compared patients' characteristics and lipid management outcomes between 6100 outpatients treated at primary care versus 19,217 patients in non-primary settings using data from the DYSlipidemia International Study-China (DYSIS-CHINA). Compared to patients treated at non-primary hospitals, patients who received treatment at primary settings were younger, thinner, and were more likely to be female and to have a family history of premature CVD. Overall, 26.8% of very high-risk and 40.8% of high-risk patients achieved the LDL-C target with primary care treatment, whereas these target rates were 41.2% (p<0.001) and 58.6% (p<0.001), respectively, among patients treated at non-primary hospitals. High-dose statin therapy was underused in primary care patients compared to non-primary hospital patients (p<0.001). Logistic regression analysis showed that female gender, diabetes, and obesity were negative factors, whereas life-style modification and use of high-dose statin (40mg/d simvastatin equivalent) were favorable factors in predicting LDL-C target attainment in the primary care setting.

CONCLUSION

Sedentary life style, alcohol drinking, and use of suboptimal statin dosage are key factors that unfavorably affect the LDL-C target rate among patients treated at primary care facilities in China. Sufficient training for primary care physicians regarding proper statin use and support for the combined use of a statin with ezetimibe could promote LDL-C target attainment in primary care.

Persistent lipid abnormalities in statin-treated coronary artery disease patients with and without diabetes in China

BACKGROUND

We evaluate the prevalence of persistent lipid abnormalities and statin use in Chinese coronary artery disease patients with and without diabetes.

METHODS AND RESULTS

In this cross-sectional observational study, 8965 outpatients from 200 clinical departments of 122 hospitals in 27 provinces nationwide of China who had coronary artery disease and were taking a statin were consecutively enrolled and divided into two groups based on diabetes status. The European Society of Cardiology/European Arthrosclerosis Society Guidelines for the management of dyslipidemias and the Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults were used to compare the control rates of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides (TG). Among the 8965 participants, 33.3% had been diagnosed with diabetes mellitus. According to the ESC Guidelines, the percentage of patients with not at goal LDL cholesterol did not differ significantly between patients with diabetes and those without diabetes (71.9% vs. 72.7%, P=0.46). The percentages of patients with not-at-goal levels of HDL and TG were 42.9% vs. 34.4% (P<0.001) and 39.1% vs. 34.3% (P<0.001) among patients with diabetes and those without, respectively. Only approximately 10% of patients in both groups had optimal LDL-C, HDL-C, and TG levels. Compared with patients without diabetes, patients with diabetes were more likely to have mixed dyslipidemia. Atorvastatin (47.0%) and simvastatin (34.4%) were the two most frequently used statins, and the average statin dosage was 29.09mg/day (simvastatin equivalent). Less than 1% of patients were treated with another lipid-lowering drug in combination with a statin.

CONCLUSIONS

Although international guidelines highly recommend intensive lipid modulation in patients with coronary artery disease, persistent dyslipidemia is still prevalent among these patients in China, even with statin treatment.