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VOLUME 12 NUMBER 1 • JULY 2015
33
SA JOURNAL OF DIABETES & VASCULAR DISEASE
RESEARCH ARTICLE
years before their counterparts from the developed nations.
16
These
factors indicate that it is imperative to address all cardiovascular risk
factors aggressively if there is to be any curtailment of the looming
epidemic.
This survey, representing patients in a developing country,
indicates that a large proportion of patients on LLDs are not
reaching the accepted LDL-C goals. While these percentages are
not dissimilar to those from other studies in Europe, they are below
what is currently achieved in North America. The percent of patients
at goal in North America has risen over the course of six years, from
the NHANES survey of 1999/2000 and the follow up conducted
in 2005/2006, indicating that increased awareness and education
can result in a greater percentage of patients reaching LDL-C goals,
despite the targets becoming more stringent.
The current study indicates both ethnic and gender variances in
cardiovascular risk-factor distribution and control in South Africa.
Smoking was less prevalent in those of African ancestry and very
few black females were smokers. In general black subjects used
fewer cigarettes than their Caucasian counterparts (possibly due
to economic constraints). The South African Heart of Soweto study
confirms that African patients have the lowest smoking prevalence,
with patients of mixed ancestry twice as likely, and Caucasian
patients three-fold more likely to be current smokers.
17
In the
current study of patient on LLDs, patients of mixed ancestry had
the highest prevalence of smoking among both males and females,
followed by Asian males.
The majority of black subjects did not have a family history of
premature heart disease, which probably reflects the evolution of the
epidemiological transition in an urbanising population, compared
to Caucasians, Asians and patients of mixed ethnicity. The Heart of
Soweto study also noted that African patients were least likely to
be diagnosed with CAD, and showed similar data to CEPHEUS SA
for the Asian patients, who had the highest prevalence of a family
history of vascular disease.
Control of DM was particularly poor in both male and female
African subjects compared with their ethnic counterparts. This
may have been due to differences in access to guideline-based
management protocols. Despite a high prevalence of the metabolic
syndrome in African females, with poor control of DM, their TG
levels were the lowest of all subjects – male and female.
The Heart of Soweto study noted that patients of African descent
had significantly lower total cholesterol (TC), LDL-C and triglyceride
(TG) levels compared to other ethnicities.
17
These patients were not
receiving LLDs. In CEPHEUS SA, in the African-ancestry group, the
TGs were not elevated despite a high prevalence of DM with poor
control. This would lend credence to the finding that this population
group may inherently have low TG levels, and the influence of DM
on TGs may be muted.
The Heart of Soweto study confirmed a high prevalence of
obesity in patients of African ancestry (43% of the patients having
a body mass index greater than 30 kg/m
2
). This substantial burden
of obesity among African subjects points to an elevated risk for the
future development of DM. Given that DM in this group is poorly
controlled, the ameliorating influence of lipid-lowering therapy on
future cardiovascular risk could potentially be undermined, or at
the very least minimised.
The number of African-ancestry patients who had CAD was low
in proportion to the other ethnic groups; however these percentages
reflect a change in the prevalence of a disease that was previously
considered to be rare in this population. Other studies from South
Africa have indicated a prevalence of CAD of less than 10% in
the African population.
18
The prevalence of CAD in African subjects
receiving LLDs in the current study was 15.9%.
The INTERHEART Africa study noted that patients of African
ancestry presented with myocardial infarction a mean of 3.8 years
earlier than patients from the overall INTERHEART study, and also
found no inter-ethnic or gender differences.
1,19
Although data for
the INTERHEART Africa study were drawn from patients from sub-
Saharan countries, more than 80% of subjects were from South
Africa, indicating that the data may be comparable to the current
CEPHEUS SA study.
Limitations
This study had the same limitations that apply to many surveys that
differ fundamentally from formal prospective studies. The study
population was drawn from those already on LLDs and cannot be
extrapolated to the general population. Although attempts were
made to sample patients from as wide a spectrum as possible,
potential selection bias may still have occurred. All centres were
located in urban areas, and the applicability to patients of rural
origin cannot be assumed.
The public sector provides healthcare to about 80% of the
South African population but it made up only about one-third of
the sample. Similarly, the study population does not strictly reflect
the ratios of the different ethnic groups residing in South Africa.
However all previous studies on lipid-lowering therapy in South
Africa were predominantly Caucasian based. Private sector patients
were recruited from a wide variety of both specialist and non-
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BilocorCo5/6,25.
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Bilocor Co 10/6,25.
Each film coated tablet contains 10 mg bisoprolol fumarate and 6,25 mg hydrochlorothiazide.
Reg No.: RSA S3 44/7.1.3/1012. NAM NS2 13/7.1.3/0262. For full prescribing information, refer to the package
insert approved by the Medicines Control Council,2 November 2012.
1)
PapademetriouV,
et al
.Efficacy of Low-Dose
Combination of
Bisoprolol/Hydrochlorothiazide
Compared With
Amlodipine
and
Enalapril
in Men and Women With
Essential Hypertension.American Journal of Cardiology. 1998 Jun 1;81:1363-1365.
BRB113/07/2015.
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