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.