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22 June 2017
Position paper on atherogenic dyslipidaemia in Latin America

This expert consensus paper from the Latin American Academy for the study of Lipids (ALALIP) highlights the importance of atherogenic dyslipidaemia as a major cardiovascular risk factor in this region.

Ponte-Negretti CI. Atherogenic dyslipidemia in Latin America: Prevalence, causes and treatment: Expert's position paper made by the Latin American Academy for the study of Lipids (ALALIP) endorsed by the Inter-American Society of Cardiology (IASC), the South American Society of Cardiology (SSC), the Pan-American College of Endothelium (PACE), and the International Atherosclerosis Society (IAS). Int J Cardiol 2017 May 18. doi: 10.1016/j.ijcard.2017.05.059. [Epub ahead of print]
Summary
Comments & References
STUDY SUMMARY
Objective: To analyse the prevalence of atherogenic dyslipidaemia in Latin America so as to make specific recommendations regarding the prevention, diagnosis and treatment of this dyslipidaemia in this region. 
Design: Systematic literature review with emphasis on publications related to Latin America using the Delphi methodology.1 Recommendations based on expert consensus were categorised as unanimous (100% acceptance), consensual (>80% agreement), or in disagreement (<80% agreement).
Study population:

Atherogenic dyslipidaemia was defined using the following criteria:

  • An increase in triglyceride-rich lipoproteins.
  • Normal or slight increase in low-density lipoprotein cholesterol (LDL-C) mass on serum but with a predominance of small dense LDL.
  • Elevated non-high-density lipoprotein cholesterol (non-HDL-C, defined as total cholesterol minus HDL-C) as a surrogate for all atherogenic lipoproteins.
  • Low levels of HDL-C
Key questions addressed:
  • Prevalence of atherogenic dyslipidaemia in Latin America, and comparison with other regions
  • Contributing reasons (socio-economic, cultural, diet, genetics/epigenetics)
  • Measures to improve the diagnosis, assessment and treatment of atherogenic dyslipidaemia in Latin America
Key findings:
  • Atherogenic dyslipidaemia is prevalent in Latin America; 34.1% to 53.3% of individuals have low HDL-C, and 25.5% to 31.2% have elevated triglycerides. The prevalence of this dyslipidaemia appears to be higher in Latin America than in other countries, as for example described by the US National Survey on Nutrition and Health (NHANES 2009–2010), with a reported prevalence of 30% for low HDLC and 24% for elevated triglycerides.2
  • Increased consumption of food with a high caloric density, cholesterol and trans fats; sedentary lifestyle and (possibly) epigenetic/genetic factors are contributors to this high prevalence.
  • Management: In patients with triglycerides <500 mg/dl, the initial focus is on lowering LDL-C with a statin to reduce global cardiovascular risk; non-HDL-C is a secondary target. Persistently elevated non-HDL-C levels in statin-treated patients should be managed with add-on ezetimibe, omega-3 fatty acids, fibrates or niacin, In patients with triglycerides ≥500 mg/dl the primary aim is to lower triglycerides to reduce the risk of pancreatitis by treatment with a fibrate, omega-3 fatty acids or niacin.
Conclusion: This consensus group highlighted the need for a global study of cardiovascular risk factors in Latin America to define the true prevalence of atherogenic dyslipidaemia in the region, the impact of this dyslipidaemia on atherosclerotic cardiovascular disease, and, as a consequence, to derive appropriate management strategies. 

COMMENT

While risk factors for cardiovascular disease are the same for men and women globally, their presentation in different regions of the world varies. Latin America is distinct from other regions in that there is a higher prevalence of abdominal obesity, hypercholesterolaemia and hypertension.3 On average, over 60% of the population of Latin America has central obesity/overweight; hypertension, type 2 diabetes mellitus and dyslipidaemia are 2-3-fold more common in these individuals than those at normal weight.4 This risk factor profile has been exacerbated by demographic, economic and social changes in Latin America over recent years. With increasing urbanization, the typical diet has shifted to increased consumption of calorie-dense processed food with high fat and sugar content, and lifestyle has become more sedentary. About one in 4 adult in the region has a metabolic syndrome, although this can be as high as one in 2 in some countries.5-7 Together, these factors have driven the escalation in cardiovascular disease, predominantly ischaemic heart disease, with the result that this is now the major cause of disability, morbidity and mortality in this region.8 


Atherogenic dyslipidaemia, the combination of elevated triglyceride-rich lipoproteins (and their remnants) and low HDL-C concentration, is recognized as an important contributor to lipid-related residual cardiovascular risk beyond LDL-C.9 Given the preponderance of obesity (especially central obesity) and type 2 diabetes in Latin America, atherogenic dyslipidaemia is likely to be an important factor underpinning the escalation of cardiovascular disease. Yet, as highlighted by this expert group, the prevalence of this dyslipidaemia in this region is not properly defined. Moreover, guidelines have focused on management of LDL-C as the major lipid target, without taking account of the distinct risk factor profile in this region. 


This consensus statement makes an urgent call to action to address these unanswered questions. The group proposes a treatment algorithm for patients at high to moderate global cardiovascular risk with atherogenic dyslipidaemia, depending on fasting plasma triglycerides, using a cut-off of 200 mg/dl (2.3 mmol/l) for high triglycerides. This consensus statement is very much a step in the right direction. Action is now needed to address the unmet challenges in defining the profile of atherogenic dyslipidaemia in countries across this region, as well as developing region-specific guidelines for assessment and management of this important contributor to lipid-related residual cardiovascular risk. 

References

1.  De Villiers M, De Villiers P, Athol K. The Delphi technique in health sciences education research. Med Teach 2005;27:639–43.

2. Beltrán-Sánchez H, Harhay MO, Harhay MM, McElligott S. Prevalence and trends of metabolic syndrome in the adult U.S. population, 1999–2010. J Am Coll Cardiol 2013;62:697–703.

3. Hernandez-Hernandez R. Obesity: the most influencing and modifiable risk factors in Latin America. J Hypertens 2016 Sep;34 Suppl 1 - ISH 2016 Abstract Book:e6.

4. Lanas F, Avezum A, Bautista LE, INTERHEART Investigators in Latin America, et al. Risk factors for acute myocardial infarction in Latin America: the INTERHEART Latin American study. Circulation 2007;115:1067–74. 

5. Márquez-Sandoval F, Macedo-Ojeda G et al. The prevalence of metabolic syndrome in Latin America: a systematic review. Public Health Nutr 2011;14:1702–13.

6. Miranda JJ, Herrera VM, Chirinos JA et al. Major cardiovascular risk factors in Latin America: a comparison with the United States. The Latin American Consortium of Studies in Obesity (LASO). PLoS ONE 2013;8:e54056.

7. de Carvalho Vidigal F, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health 2013;13:1198.

8. Lanas F, Serón P, Lanas A. Cardiovascular disease in Latin America: the growing epidemic. Prog Cardiovasc Dis 2014;57:262-7. 

9. Fruchart JC, Davignon J, Hermans MP et al. Residual macrovascular risk in 2013: what have we learned? Cardiovasc Diabetol 2014;13:26.

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