Primary prevention with statins in cardiovascular diseases: A Saudi Arabian perspective

Abstract

Cardiovascular disease (CVD) constitutes one of the major causes of deaths and disabilities, globally claiming 17.3 million lives a year. Incidence of CVD is expected to rise to 25 million by 2030, and Saudi Arabia, already witnessing a rapid rise in CVDs, is no exception. Statins are the drugs of choice in established CVDs. In the recent past, evidence was increasingly suggesting benefits in primary prevention. But over the last decade Saudi Arabia has a witnessed significant rise in CVD-related deaths. Smoking, high-fat, low-fiber dietary intake, lack of exercise, sedentary life, high blood cholesterol and glucose levels were reported as frequent CVD-risk factors among Saudis, who may therefore be considered for primary prevention with statin. The prevalence of dyslipidemia, in particular, indicates that treatment should be directed at reducing the disorder with lipid-modifying agents and therapeutic lifestyle changes. The recent American College of Cardiology (ACC)/American Heart Association (AHA) guidelines has reported lowering the low-density lipoprotein cholesterol (LDL-C) target levels, prescribed by the 2011 European Society of Cardiology (ESC)/the European Atherosclerosis Society (EAS). The new ACC/AHA guidelines have overemphasized the use of statin while ignoring lipid targets, and have recommended primary prevention with moderate-intensity statin to individuals with diabetes aged 40-75 years and with LDL-C 70-189 mg/dL. Treatment with statin was based on estimated 10-year atherosclerotic-CVD (ASCVD) risk in individuals aged 40-75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD or diabetes. Adoption of the recent ACC/AHA guidelines will lead to inclusion of a large population for primary prevention with statins, and would cause over treatment to some who actually would not need statin therapy but instead should have been recommended lifestyle modifications. Furthermore, adoption of this guideline may potentially increase the incidences of statin intolerance and side-effects. On the other hand, the most widely used lipid management guideline, the 2011 ESC/EAC guidelines, targets lipid levels at different stages of disease activity before recommending statins. Hence, the 2011 ESC/EAC still offers a holistic and pragmatic approach to treating lipid abnormalities in CVD. Therefore, it is the 2011 ESC/EAC guidelines, and not the recent ACC/AHA guidelines, that should be adopted to draw guidance on primary prevention of CVD in Saudi Arabia.

Time trends analysis of statin prescription prevalence, therapy initiation, dose intensity, and utilization from the hospital information system of Jinshan Hospital, Shanghai (2012–2018)

“…They also pointed out that the 2013 ACC/AHA guidelines may have overemphasized the statin therapy but without considering lipid targets which would lead to the inclusion of a large population for primary prevention with statins. Furthermore, this would cause overtreatment and potentially increase the incidences of statin-associated side effects and intolerance [8]. In addition, a statin prescription prevalence study reflects that the elderly population does not necessarily get the benefit from statin treatment for primary prevention of CVD [14].…”

“…The American College of Cardiology (ACC)/American Heart Association (AHA) 2013 guidelines (2013 ACC/AHA) cholesterol guidelines recommend that all patients with ASCVD should receive high-dose or moderate-dose statins therapy while ignoring lipid targets, and have recommended statin therapy to a specific group for primary and secondary prevention [7]. The 2016 European Society of Cardiology (ESC)/the European Atherosclerosis Society (EAS) (2016 ESC/EAC), the most widely used lipid management guideline, still targets lipid levels at different stages of disease activity before recommending statins [8]. Based on the 2007 Chinese Guidelines for the Management of Dyslipidemia in Adults, the 2016 Chinese guideline for the management of dyslipidemia in adults (referred to as "the new Guideline" hereafter) was released by Chinese Journal of Cardiology in 2016 formulated by a joint committee of multidisciplinary experts.…”

Time trends analysis of statin prescription prevalence, therapy initiation, dose intensity, and utilization

“…They also pointed out that the 2013 ACC/AHA guidelines may have overemphasized the use of statin while ignoring lipid targets, and would lead to the inclusion of a large population for primary prevention with statins. Furthermore, this would cause overtreatment and potentially increase the incidences of statin intolerance and sideeffects [7]. In addition, the observed statin prescribing for primary prevention in the elderly in a cohort study reflects the fact that this group may be less likely to benefit from statin treatment for primary prevention of CVD [13].…”

“…The 2016 European Society of Cardiology (ESC)/the European Atherosclerosis Society (EAS) (2016 ESC/EAC), the most widely used lipid management guideline, still target lipid levels at different stages of disease activity before recommending statins [7]. Based on the 2007 Chinese Guidelines for the Management of Dyslipidemia in Adults, the 2016 Chinese guideline for the management of dyslipidemia in adults (referred to as "the new Guideline" hereafter) was released by Chinese Journal of Cardiology in 2016 formulated by a joint committee of multidisciplinary experts.…”

Expert opinion on the applicability of dyslipidemia guidelines in Asia and the Middle East

“…For example, in Saudi Arabia, which has a large number of itinerant workers, CVD is associated with smoking, high fat and low fiber intake, lack of exercise and sedentary lifestyle, in addition to a predominance of low HDL-C and high levels of triglycerides. 2 , 23 , 25 , 33 An unusually high prevalence of low HDL-C has also been observed in the Philippines, 17 which presents an intriguing dilemma for possible treatment strategies. In Indonesia, one study showed the tremendous variation in lipid profiles among the Minangkabau, Sundanese, Javanese and Buginese ethnic groups.…”