The South African Heart Foundation estimates that 195 South Africans die every day because of some form of heart disease. “Cardiovascular disease (CVD), of which coronary heart disease (CHD) is the most common, is the leading cause of death in middle-aged and older adults. Elevated low-density lipoprotein cholesterol (LDL-C) levels are strongly linked with CHD risk,” says Prof. Derick Raal, Head of the Endocrinology and Metabolism Division at the University of the Witwatersrand and the Charlotte Maxeke Academic Hospital.
The South African Heart Society (SAHA) and the Lipid and Atherosclerosis Society of Southern Africa (LASSA) have adopted the European Society of Cardiology (ESC)/ European Atherosclerosis Society (EAS) guidelines, which indicate that if a patient has suffered a heart attack or stroke, or has diabetes, then their LDL-C level, or ‘bad’ cholesterol level should be <1.8mmol/L.
A recently published South African study has revealed that despite being on cholesterol-lowering medication, a shocking 48% of patients do not reach their healthy low-density lipoprotein cholesterol (LDL-C) levels. This significantly increases their risk for the development or progression of cardiovascular disease (CVD) and puts them at risk for heart attack or stroke¹.
As the main sponsor of the study, AstraZeneca Pharmaceuticals, in collaboration with 69 local healthcare professionals, tested about 3 000 patients (average age 59 and 47.5% female) in the landmark CEPHEUS survey. As a real-world, non-interventional study, CEPHEUS (CEntralised Pan-South African survey on tHE Under-treatment of hypercholeSterolaemia) was conducted in 69 South African study centres across the country.
The primary goal of the study was to determine the percentage of patients who achieved the LDL-C goals according to available guidelines. Despite the widespread awareness of the guidelines, the results of the survey indicate that the control of hypercholesterolaemia, or high cholesterol, is not as good as it should be.
High cholesterol levels in black population
The lead clinical investigator heading up the study steering committee, Prof Raal, said a key objective of the study was to increase the representation of black African patients, as these patients were not well represented in previous cholesterol surveys.
"It has long been assumed that black South Africans don’t have cholesterol problems and don’t have heart attacks,” says Prof. Raal. “However with increased urbanisation and westernisation, cholesterol levels are increasing within our black South African population and we are starting to see more and more ischaemic heart disease within this group. For the purposes of this study, we therefore made every effort to include a fair representation of all racial groups."
Both doctors and patients were included in the survey. Doctor’s completed questionnaires to determine their views on the management of high cholesterol seen in their patients, and the overall attitude to diagnosis and treatment according to high blood cholesterol (dyslipidaemia) guidelines.
Patients underwent physical examinations and completed questionnaires which established: risk factors; awareness and perceptions of high cholesterol (hypercholesterolaemia); their understanding of the lipid-lowering drug (LLD) regimen, and with the importance of following the treatment plan. Physical examinations were limited to measurement of height, weight, waist circumference and blood pressure. A fasting blood sample was also drawn to evaluate the serum lipid profile and glucose level of each participant.
Inadequate lifestyle changes
When patients were asked about the treatments suggested by their doctor, when they were first diagnosed with high cholesterol levels, 64.2% had been prescribed lifestyle changes and medication (pharmacotherapy), 22.2% had only been prescribed medication, 14.4% were only advised to make lifestyle changes, and 1.2% had received neither medication nor lifestyle modification advice.
At the time of their assessment, most patients were receiving a single LLD (monotherapy), with the majority receiving statins. All of the patients taking multiple LLDs (combination therapy) received statins in combination with other drugs, mainly fibrates. Patients received cholesterol lowering therapy to prevent or manage heart disease and strokes.
From the results, researchers concluded that: inadequate lifestyle changes; failure to adhere to the prescribed medical treatment; and, poor long-term persistence with the prescribed therapy may have influenced poor goal attainment.
In addition, the study also found that lipid-lowering therapy was frequently left unaltered with a total of 64% of patients still on the same lipid-lowering medication/s and dose/s they started on. Most physicians used the South African guidelines, but according to the study, failure to reach healthy blood cholesterol levels, may have been due to additional concerns about drug toxicity, drug formulary constraints, and failure to check lipid levels once LLD’s had been started and to titrate LLD dosage when required.
Significantly, poor achievement of cholesterol goals, do not seem to correlate with a poor awareness among patients: patients surveyed understood the need to take their medication – particularly those who had previous cardiovascular events. Most patients were informed of their cholesterol level and had been given a healthy cholesterol level to aim for. Most patients were aware of the role of LDL-C in cardiovascular disease risk and were satisfied with the level of information provided by their doctors.
Poor achievement of healthy cholesterol goals is clearly a complex problem: continued education and awareness of the current treatment guidelines to doctors may address some of the doctor-related factors leading to poor lipid control, while patient-related factors can only be addressed at an individual level. Availability and affordability of lipid-lowering medication remains problematic for both private and public sector patients in South Africa.
“As a ‘silent killer’, patients who suffer with high cholesterol display no symptoms until they’ve suffered some sort of cardiovascular event. If there is a family history of heart disease or high cholesterol, patients must be adequately tested. This is especially important in our country as there is a high prevalence of inherited cholesterol disorders in our Afrikaner, Indian and Jewish populations. If cholesterol levels are high, patients need to be equipped with the knowledge and medical support to do something about it before it’s too late,” concludes Prof. Raal.
(References: Raal F, Schamroth C, Blom D, Marx J, Rajput M, Haus M, et al. CEPHEUS SA: a South African survey on the under-treatment of hypercholesterolaemia. Cardiovascular J Afr 2011; 22(5): 1-7. Published, September 2011.)
- (AstraZeneca Pharmaceuticals press release, January 2013)
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