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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 1, January/February 2019
AFRICA
15
Management of low-density lipoprotein cholesterol
levels in South Africa: the International ChoLesterol
management Practice Study (ICLPS)
Dirk J Blom, Frederick Raal, Aslam Amod, Poobalan Naidoo, Yen-yu (Evelyn) Lai, for the ICLPS SA
study group
Abstract
The International Cholesterol Management Practice Study
(ICLPS) South Africa investigated achievement of European
Society of Cardiology (ESC)/European Atherosclerosis
Society (EAS) guideline low-density lipoprotein cholesterol
(LDL-C) targets in real-world clinical practice. Demographic
data, clinical characteristics, cardiovascular risk factors, lipid-
modifying medications, lipid values and investigator’s assess-
ment of cardiovascular risk were recorded for 396 patients on
stable lipid-modifying therapy. Most (98.7%) patients received
statins; 25.1% of statin-treated patients were receiving high-
intensity statins. Overall, 41.4% of patients achieved their
LDL-C target; among 354 (89.4%) patients in whom cardio-
vascular disease risk, based on ESC Systematic Coronary
Risk Estimation (SCORE) was calculated, achievement rate
was 14.3% for moderate-risk (
n
=
7), 59.3% for high-risk (
n
=
123) and 32.3% for very high-risk patients (
n
=
223). Half
of Asian (54.7%) and black African (53.2%) patients were at
LDL-C target compared with 29.8% of European/Caucasian
and 27.3% of ‘other’ patients. Improved guideline adherence
and greater use of combination therapy may increase LDL-C
goal achievement.
Keywords:
LDL-C goal, lipid-modifying therapy, cardiovascular
risk, statin
Submitted 9/7/18, accepted 22/10/18
Published online 16/1/19
Cardiovasc J Afr
2019;
30
: 15–23
www.cvja.co.zaDOI: 10.5830/CVJA-2018-054
Despite improvements in its identification, prevention and
treatment, cardiovascular disease (CVD) remains the world’s
leading cause of morbidity and mortality.
1
Furthermore, Africa
in general, and South Africa specifically, are experiencing
an increasing burden of CVD.
2,3
Dyslipidaemia is a major
risk factor for atherosclerotic CVD and the primary goal of
dyslipidaemia treatment is to reduce levels of low-density
lipoprotein cholesterol (LDL-C) to targets recommended by
clinical practice guidelines.
4,5
Statins are the preferred choice of
lipid-modifying therapy (LMT) because of their proven efficacy
and safety, and their relatively low cost.
6,7
Addition of another
LMT, such as ezetimibe or bile-acid sequestrant, to statin
therapy is an option for patients who are not at target LDL-C
on statins alone; however, these non-statin therapies have limited
efficacy in lowering LDL-C.
5
More effective LMTs, such as the
proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors
alirocumab
8
and evolocumab,
9
are not yet approved for use in
South Africa.
Large studies conducted predominantly in Western Europe
and North America have shown that LDL-C levels remain
elevated in many patients at high cardiovascular risk, despite
the wide availability of statins.
10-12
Similar results were reported
for the CEntralised Pan-South African survey on tHE
Undertreatment of hypercholesterolaemia (CEPHEUS SA)
13
and the DYSlipidaemia International Study (DYSIS),
14
which
found that less than half of patients treated for dyslipidaemia
achieved their LDL-C goals. Several factors may contribute to
the under-treatment of dyslipidaemia in South Africa, including
limited availability and lack of affordability of statins, use of
low doses, frequent use of low-potency statins, statin intolerance,
non-adherence to therapy and inadequate response to treatment.
In the public health sector, treatment is limited by restrictive
formularies that allow for only modest statin doses to be
prescribed for most patients. In the private sector, restrictions
imposed by medical funders make it difficult for many patients to
access high-intensity statins. Many funders require titration from
low-dose to high-dose statins for reimbursement; however, dose
titration is infrequent in practice. For example, in CEPHEUS
SA, of 2 996 patients with dyslipidaemia treated with LMT
for three months or longer, 63.5% had remained on their initial
starting treatment and dose at the time of assessment, and only
8.7% had had their dose increased.
13
Medical funders frequently
Department of Medicine, Division of Lipidology and Hatter
Institute for Cardiovascular Research in Africa, University
of Cape Town, Cape Town, South Africa
Dirk J Blom PhD, MB ChB, FCP (SA), MMed (Int Med),
Dirk.blom@uct.ac.zaCarbohydrate and Lipid Metabolism Research Unit,
Faculty of Health Sciences, University of Witwatersrand,
Johannesburg, South Africa
Frederick Raal, FRCP, FRCPC, FCP (SA), Cert Endo, MMED, PhD
The Centre for Diabetes and Endocrinology, Life Chatsmed
Garden Hospital, Woodhurst, Chatsworth, South Africa
Aslam Amod, MB ChB, FCP (SA), Cert Endocr&Metab (SA), FRCP
(London)
Sanofi-Aventis, Midrand, South Africa
Poobalan Naidoo, BPharm (Hons), MB BCh, MMed Sci
(Pharmacol)
Yen-yu (Evelyn) Lai, MB BCh