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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 3  |  Page : 67-68

Cardiovascular diseases guideline-directed medical therapy in low- and middle-income countries: A call for action

King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ali Al Arini, Ar Rimayah, Riyadh, Saudi Arabia

Date of Submission07-Sep-2022
Date of Acceptance08-Sep-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Hisham A Badreldin
King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ali Al Arini, Ar Rimayah, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjcp.sjcp_17_22

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How to cite this article:
Badreldin HA, Alghnam S. Cardiovascular diseases guideline-directed medical therapy in low- and middle-income countries: A call for action. Saudi J Clin Pharm 2022;1:67-8

How to cite this URL:
Badreldin HA, Alghnam S. Cardiovascular diseases guideline-directed medical therapy in low- and middle-income countries: A call for action. Saudi J Clin Pharm [serial online] 2022 [cited 2023 Apr 1];1:67-8. Available from: http://www.sjcp.org/text.asp?2022/1/3/67/357708

Over the past several decades, there has been a transitional shift in the holistic prevalence of certain disease states. While the prevalence of communicable diseases has declined, the prevalence of non-communicable diseases (NCDs) has trended up in many low- and middle-income countries (LMICs). Cardiovascular diseases (CVDs) are one example of the NCDs that have trended up drastically in many LMICs.[1] This is mainly due to urbanization and a sedentary lifestyle, which led to an increase in NCDs in general and, more specifically, CVDs. It has been estimated that 80% of CVD deaths occur in LMICs, and close to 40% of these are considered preventable. The lack of resources to efficiently provide proven medicines is one apparent cause.[2]

In recent years, several pharmacotherapy agents were introduced, and they were able to reduce the risk of mortality and morbidity among patients with CVDs. One example is valsartan-sacubitril, which was investigated in the PARADIGM-HF trial in patients with heart failure with reduced ejection fraction (HFrEF). Valsartan-sacubitril significantly reduced the risk of CV mortality, all-cause mortality, and heart failure hospitalizations compared with the standard of care.[3] Similar results were observed in a newly introduced group of medications called sodium-glucose cotransporter 2 (SGLT-2) inhibitors. Several landmark trials showed that these agents could reduce the risk of mortality and morbidity in patients with heart failure.[4]

Prior to introducing these agents, a previous report originating from 46 centers in 11 Asian countries showed that guideline-directed medical therapies at recommended doses are underutilized in patients with HFrEF. Half of these countries were LMICs.[5] With that in mind, it is going to be extremely difficult to increase the uptake of these newer agents’ utilization in LMICs for many reasons. The primary reason is the variation in the infrastructure of the health system building blocks between LMICs and high-income countries (HICs).[6] In addition, even in HICs like the USA, recent evidence has shown that deferring the initiation of these medications carries over 70% chance that therapy will not be started within the following year.[7] At a national level, financing to procure these medications can be challenging. Even if these medications can be procured, these medications are expensive, and many patients may not be able to afford even cheaper medications at their current economic status. Moreover, not all clinicians may be aware of these clinical advancements in their field. Collectively, this could drastically limit the uptake of these agents in LMICs.

Several actions are needed to increase the number of individuals receiving these medications. First, LMIC health leaders should work with governmental and private sectors to seek affordable coverage plans for these medications. A unique example in Saudi Arabia has been implemented by the Council of Cooperative Health Insurance (CCHI). The CCHI will force all health insurance companies to provide coverage for all standard-of-care therapies included in the guidelines and shows positive outcomes in the private sector.[8] This will drastically expand the number of patients receiving these expensive yet life-saving medications. Second, global philanthropic agencies should work with national and international agencies to explore contributing or donating these agents to countries in need. Third, once available, several proactive programs should be instituted to increase the prescribers’ and patients’ awareness regarding the benefits of utilizing these agents. Fourth, initiatives and programs should be considered that would incorporate the skills of other healthcare workers, such as nurses and pharmacists, to support busy physicians in populous areas, increase the adoption of these agents, and enhance reaching target doses titration and adherence patterns. Fifth, global agencies that control drug registration should take serious actions to encourage the efforts of generic drug development, marketing, and delivery to improve patients’ access to these medications in LMICs. Sixth, when we examine the centers that took part in these landmark trials, we can observe that the majority of these centers were located in upper-middle and HICs. Therefore, it is crucial to include centers from LMICs in these clinical trials to increase the generalizability of these data toward those residing in LMICs. Also, it might reduce the cost and burden of conducting many real-world studies to investigate the safety and efficacy in these populations. Finally, many countries rely on North American or European clinical practice guidelines to formulate their care plans. Ultimately, these guidelines will advocate for using these newer agents. Because many LMICs may not have these agents in their national or institutional formularies, guideline steering committees may consider including sections that discuss the potential options and alternatives for those living in LMICs. The COVID-19 pandemic has shown us that we are interconnected much more than we previously imagined. Therefore, global efforts and actions should be implemented in many LMICs to tackle NCDs, not just CVDs, because what affects these countries will indirectly affect the other countries, including the HICs.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Coates MM, Kintu A, Gupta N, Wroe EB, Adler AJ, Kwan GF, et al. Burden of non-communicable diseases from infectious causes in 2017: A modelling study. Lancet Glob Health 2020;8:e1489-98.  Back to cited text no. 1
Prabhakaran D, Anand S, Watkins D, Gaziano T, Wu Y, Mbanya JC, et al; Disease Control Priorities-3 Cardiovascular, Respiratory, and Related Disorders Author Group. Cardiovascular, respiratory, and related disorders: Key messages from disease control priorities, 3rd edition. Lancet 2018;391:1224-36.  Back to cited text no. 2
McMurray JJ, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, et al; PARADIGM-HF Investigators and Committees. Angiotensin–neprilysin inhibition versus enalapril in heart failure. New Engl J Med2014;371:993-1004.  Back to cited text no. 3
Ferro EG, Elshazly MB, Bhatt DL. New antidiabetes medications and their cardiovascular and renal benefits. Cardiol Clin 2021;39: 335-51.  Back to cited text no. 4
Teng TK, Tromp J, Tay WT, Anand I, Ouwerkerk W, Chopra V, et al. Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: A cohort study. Lancet Global Health2018;6:e1008-18.  Back to cited text no. 5
Nickerson JW, Adams O, Attaran A, Hatcher-Roberts J, Tugwell P. Monitoring the ability to deliver care in low- and middle-income countries: A systematic review of health facility assessment tools. Health Policy Plan 2015;30:675-86.  Back to cited text no. 6
Greene SJ, Butler J, Fonarow GC. Simultaneous or rapid sequence initiation of quadruple medical therapy for heart failure-optimizing therapy with the need for speed. JAMA Cardiol 2021;6:743-4.  Back to cited text no. 7
CCHI Formulary. Available from: https://chi.gov.sa/AboutCCHI/CCHIprograms/Pages/IDF.aspx. [Last accessed on-09-7, 2022].  Back to cited text no. 8


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