All these guidelines recommend lifestyle changes and an appropriate
control of all risk factors associated with ASCVD (Table 4). The
guidelines recognize that LDL-C is directly related with ASCVD and
highlight the importance of statins and other therapies in order to
reduce LDL-C levels. Risk stratification in a multivariant analysis
includes LDL-C levels and other risk factors to determine the treatment
objective. Furthermore, guidelines emphasize that high-risk and very
high-risk patients will largely benefit from reduction in LDL-C levels
through combination of new pharmacologic interventions. Finally, most
agree that achieving lower levels of LDL-C is safe.
In concordance with international guidelines, several countries in LATAM
have created their own national guidelines sharing these same basic
concepts. Local guidelines reflect epidemiological data, socioeconomic
factors, group experiences, pharmacoeconomic analysis and drug
availability. Thus, it is critical that local guidelines are utilized in
order to determine treatment objectives for patients within each country
(53). Furthermore, national guidelines should assess the risk
stratification based on population demographics and recommend associated
LDL-C goals (49-50, 54-56).
Despite scientific evidence recommendations in clinical practice
regarding the benefit of the use of lipid-lowering therapy (LLT),
worldwide use of these medications is low even in patients who have
suffered a cardiovascular event (3). The Prospective Urban Rural
Epidemiology (PURE) study included 5,650 participants with a history of
ischemic heart disease (IHD) and 2,292 with a history of stroke from 17
countries with different income levels. The overall use of
cardiovascular proven effective secondary preventive drugs was low,
especially for statins where the use was 14.6%. These percentages were
higher in high-income countries where statins use was 66.5%, with the
lowest use in low-income countries reported to be 3.3%. Importantly,
country-level factors (e.g., economic status, income) affect rates of
drug use more than individual-level factors (e.g., age, gender, level of
schooling, smoking status, body-mass index, hypertension and diabetes)
supporting socioeconomic status as a major determinant of these drugs
(3).
A sub-study of PURE analyzed statin use in South America and showed that
usage in post-IHD patients was only 18% and in previous stroke 9.8%
(57). Multivariate analyses revealed markers of wealth had the largest
impact in the use of these medications. Thus, socioeconomic status
affects the use of secondary prevention medication increasing
inequalities for low- and middle-income countries (LMICs) (58).
In cardiovascular primary prevention, the EPICO study found that statins
in patients with high cholesterol were used in low rates (40.4%) and in
lower doses than those recommended by guidelines (simvastatin 20mg),
thus leading to inefficient control of LDL-C (59). The preliminary
results of PINNACLE-Brazil show that, despite the relatively high
prescription rate of statin therapy (81%), LDL-C targeted level for
ASCVD secondary prevention was not achieved in the majority of patients
(60). As an example of this situation, in Mexico, only 20% of the
hypercholesterolemic patients are being treated adequately (28).
There are many therapeutic interventions that require efforts from the
public health perspective in order to prevent ASCVD risk. These
interventions have proven to decrease cardiovascular risk and have to be
accompanied by lipid lowering drugs to ensure LDL-C levels are at the
lowest possible (SOURCE). The general objectives of these complementary
interventions are listed on Table 4.