The spectrum of the dyslipidemia in Colombia: The PURE study

doi:10.1016/j.ijcard.2018.10.090

International Journal of Cardiology

Volume 284, 1 June 2019, Pages 111-117

https://doi.org/10.1016/j.ijcard.2018.10.090 Get rights and content

Highlights

•
The prevalence of dyslipidemia is an important health problem (87.7%) in Colombian adults.
•
There were greater differences in the prevalence of dyslipidemia in the four sampled regions, dyslipidemia was higher in males, rural residents, people with lower education/income.
•
The most common lipid abnormality nationally was high non HDL-c (75.3%), a relevant cardiovascular risk factor.

Abstract

Background

Dyslipidemia is a major risk factor for cardiovascular diseases (CVD). Worldwide, a third of ischemic heart disease is due to abnormal cholesterol levels and it is the most common cause of cardiovascular deaths in Colombia. In Colombia, no representative, large-scale study has assessed the prevalence of dyslipidemia. The aim of the present analysis was to identify the magnitude of the problem in Colombia, a middle-income-country with large regional, geographic, and socio-economical differences.

Material and methods

The sample comprised 6628 individuals aged 35 to 70 years (mean age 50.7 years, 64.1% women) residing in the four Colombian regions.

Results

The overall prevalence of dyslipidemia was 87.7% and was substantially higher among participants older than 50 years, male, rural residents, and those with a lower level of education (66.8%), and with a lower income (66.4%). High non HDL-c was the most common abnormality (75.3%). The values of total cholesterol and non-HDL-cholesterol were higher in areas with the lowest health needs index than in the areas with intermediate and highest health need index, the isolated HDL-c value was much lower.

Conclusion

Colombia has a high prevalence of abnormalities of the lipid profile. The causes of the high rates of dyslipidemia were not well define in this study, but were more common in rural and poorer regions and among those with lower socio-economical status. Strategies to tackle the adverse lipid profile to reduce CVD are needed in Colombia, particularly in rural areas and among the areas with the higher health need index.

Introduction

Cardiovascular disease (CVD) is the most common cause of mortality, associated with 17.5 million deaths worldwide [1]. Its prevalence is higher in low-middle income (LMIC) than in high income countries (HIC), the former contributing to 80% of global CVD mortality [1]. In Colombia, a middle-income South American country, CVD is also the principal cause of mortality [2]. CVD risk factors have been well documented in international studies such as INTERHEART [3] and INTERSTROKE [4] which showed that dyslipidemia is one of the main risk factors for the disease. According to guidelines, dyslipidemia is characterized by one or more of the following abnormalities: elevated total cholesterol (TC), elevated low density lipoprotein cholesterol (LDL-c), low levels of high density lipoprotein cholesterol (HDL-c), and high levels of triglycerides (TG) [5]. The World Health Organization (WHO) estimated that high TC causes 2.6 million deaths and 29.7 million disability adjusted life years (DALYS) [6]. They also found clear regional differences in the prevalence of lipid abnormalities, reporting that hypercholesterolemia was highest in Europe (54%) and the Americas (48%) and lowest in South East Asian (29.0%) and Africa (22.6%) [6]. Moreover, it has been shown that atherogenic dyslipidemia (high levels of TG and LDL-C small and dense, and low levels of HDL-c) is highly prevalent in Latin American countries [7].

Several studies have assessed the prevalence of dyslipidemia in Colombia [[8], [9], [10], [11]], yet these studies were not large-scale and did not involve multiple regions of the country. The present study consists of an analysis of the spectrum of dyslipidemia in a large sample of the Colombian participants drawn from 10 departments, and enrolled into the Prospective Urban-Rural Epidemiology (PURE) study.

Section snippets

Study design and participants

The Prospective Urban Rural Epidemiology (PURE) study is coordinated by the Population Health Research Institute (PHRI, Hamilton, ON, Canada). The design has been previously published [12]. The Ethics Committee of the Cardiovascular Foundation of Colombia approved the study. Participants included urban and rural communities from four areas of Colombia that encompass geographical, ethnic, and socio-economical variations. These areas included the Atlantic area (Departments of Atlántico, Bolívar,

Results

Table 1 shows the socio-demographic characteristics of the subjects with some type of lipid abnormalities. Of the 6628 individuals aged 35 to 70 (mean age 50.7 years, 64.1% women). 87.7% [95% CI: 86.9–88.5%] presented at least one abnormality in the lipid profile as described in methods. The prevalence was higher in men (96.2% [95% CI: 94.4–96.9%]) that in women (82.9% [95% CI: 81.8–84.1%]). We observed a higher prevalence of lipid abnormalities in participants over 50 years old (92.2%; 95% CI:

Discussion

The main finding of this study was the very high prevalence of dyslipidemia in the Colombian population aged between 35 and 70 years, with 87.7% of the sample having at least one type of lipid abnormality. High Non-HDL-C was the most prevalent alteration (75.3%), followed by low HDL-c (57.1%), hypertriglyceridemia (49.7%) and total hypercholesterolemia (48.5%). We also noted large regional differences in the prevalence of some of these abnormalities, such as high TC values in the areas with the

Acknowledgements

The main PURE study and its components are funded by the Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and through unrestricted grants from several pharmaceutical companies with major contributions from AstraZeneca Canada [Canada], Sanofi-Aventis [France and Canada], Boehringer Ingelheim [Germany and Canada], Servier, and financial support of COLCIENCIAS (Grant 6566-04-18062) in Colombia.

Conflict of interest

The authors declare no conflict of interest.

Authorship responsibility

We confirm that this work is original and has not been published elsewhere nor is it currently under consideration for publication elsewhere. PJL, PAC, DDC, SGG, and CC contributed to the preparation, analysis and interpretation of data for the work. SY designed the study, conceived and initiated the Prospective Urban Rural Epidemiology (PURE) study, supervised its conduct and data analysis. SR coordinated the worldwide PURE study and reviewed and commented on drafts of the report. All other

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Cardiovascular diseases (CVDs) remain the leading cause of worldwide death, accounting for significant morbidity, mortality, disability, and reduced quality of life. The global prevalence of cardiovascular (CV) risk factors, such as type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity, has grown exponentially in the last decades, particularly in low-medium income countries, and it's projected to increase rapidly in the coming years as the population progressively ages, leading to increased cardiovascular disease (CVD) and associated mortality. In fact, data from the global burden of disease study shows that CV mortality, associated disability-adjusted life years (DALYs), and years of life lost (YLL) have increased steadily, nearly doubling from 1990 to 2019.
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Las enfermedades cardiovasculares (ECV) siguen siendo la causa principal de muerte a nivel mundial, con una gran significación en términos de morbilidad, mortalidad, incapacidad y reducción de la calidad de vida. La prevalencia global de factores de riesgo cardiovascular (CV), tales como diabetes mellitus tipo 2, hipertensión, dislipidemia y obesidad ha crecido exponencialmente en las últimas décadas, particularmente en los países con rentas bajas-medias, previéndose que se incremente rápidamente en los años venideros a medida que la población envejezca, originando un incremento de las ECV y la mortalidad asociada. De hecho, los datos procedentes del estudio sobre carga global de la enfermedad muestran que la mortalidad CV, los años de vida ajustados por discapacidad (DALY), y los años de vida perdidos (YLL) asociados se han incrementado de manera constante, y casi doblándose desde 1990 a 2019.
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Thus, determination of the lipid profile is greatly recommended to introduce rapid management approaches to prevent the damaging effect of dyslipidaemia associated with pregnancy.13 Dyslipidaemia has a high global prevalence in all populations (including pregnant women) ranging from 21.7% to 87.7%14–17 and 11.9%–45.7% in Africa.18 In Nigeria, the prevalence of dyslipidaemia was reported to be 71.1%,19 while in Kano State specifically, the prevalence was found to be approximately 40%.20,21
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Progression from mid-pregnancy to delivery is associated with an increased risk of maternal dyslipidaemia and cardiovascular diseases among pregnant women.
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To evaluate presence of risk factors for cardiovascular diseases (CVD) and type 2 diabetes mellitus (DM2) in a group of health care workers.
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But the explanation of this increase remains unknown. Although several recent transversal studies address the risk factors of CVD in Colombia,44-47 no studies have tackled the evolution along time for these risk factors. Similarly, although gaps between healthcare insurance coverage and health provisions in Colombia have been described,12 there are no recent longitudinal studies on the evolution of healthcare access that can explain our findings.44-47
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The official death database for the period 1998 to 2015, codified by cause of death for CVD (International Classification of Diseases, Tenth Revision: I00-I99) was analyzed (men = 279 537, women = 292 122). We compared Healthcare Insurance Coverage (HIC) fluctuations with the trends and annual percentage changes (APCs) in CVD age-standardized mortality rates (ASMRs), the rate ratios of the ASMR to educational level, and the Relative Index of Inequality (RII), which was used to measure the educational inequalities.
Mortality from CVD is higher in men than in women (ASMR/men = 148.2; 95% CI: 147.6-148.7 vs ASMR/women = 139.4; 95% CI: 138.9-139.9). People with a lower educational level have an increased risk of dying prematurely owing to CVD, the higher inequalities being those for young women (RII = 2.62; 95% CI: 2.60-2.64). Inequalities by educational level (APC of the RII) grew at a rate of 2.5% per year in men and 1.7% in women, despite the steady increase of HIC throughout the period. From 1998 to 2011, there was a significant decrease in mortality rates owing to CVD (APC = −2.4% and APC = −2.1% for men and women, respectively). As of 2011, there was an increase only for men (APC = +3.9%).
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Los datos sobre la distribución de las dislipidemias en Colombia son limitados. El objetivo primario de este estudio fue describir la frecuencia de las dislipidemias; los objetivos secundarios fueron: la frecuencia de comorbilidades cardiovasculares, el uso de estatinas y otros hipolipemiantes, la frecuencia de intolerancia a estatinas, el porcentaje de pacientes en metas de c-LDL, y estimar la distribución del riesgo cardiovascular (RCV).
Estudio transversal con recolección de datos retrospectiva que incluyó a 461 pacientes con diagnóstico de dislipidemia tratados en 17 centros cardiovasculares de alta complejidad en las 6 principales áreas geográficas y económicas de Colombia.
La media (DE) de edad de los pacientes incluidos fue de 66,4 (±12,3) años. El 53,4% (246) eran mujeres. Las dislipidemias se distribuyeron así: dislipidemia mixta (51,4%), hipercolesterolemia (41,0%), hipertrigliceridemia (5,4%), hipercolesterolemia familiar (3,3%) y c-HDL bajo (0,7%). El medicamento más prescrito fue atorvastatina (75,7%), seguido de rosuvastatina (24,9%). El 55% del total de pacientes y el 28,6% de aquellos con enfermedad coronaria no estaban en metas de c-LDL a pesar del tratamiento. La frecuencia de intolerancia a estatinas fue del 2,6%.
La dislipidemia mixta y la hipercolesterolemia son las dislipidemias más frecuentes. Un porcentaje considerable de pacientes en tratamiento, incluidos aquellos con enfermedad coronaria, no lograron sus objetivos de c-LDL. Este inadecuado control lipídico influye en el RCV y requiere un cambio en las estrategias terapéuticas, intensificando el tratamiento con estatinas o adicionando nuevos fármacos en los pacientes con mayor RCV.
Data is scarce on the distribution of different types of dyslipidaemia in Colombia. The primary objective was to describe the frequency of dyslipidaemias. The secondary objectives were: frequency of cardiovascular comorbidity, statins and other lipid-lowering drugs use, frequency of statins intolerance, percentage of patients achieving c-LDL goals, and distribution of cardiovascular risk (CVR).
Cross-sectional study with retrospective data collection from 461 patients diagnosed with dyslipidaemia and treated in 17 highly specialised centres distributed into six geographic and economic regions of Colombia.
Mean (SD) age was 66.4 (±12.3) years and 53.4% (246) were women. Dyslipidaemias were distributed as follows in order of frequency: mixed dyslipidaemia (51.4%), hypercholesterolaemia (41.0%), hypertriglyceridaemia (5.4%), familial hypercholesterolaemia (3.3%), and low c-HDL (0.7%). The most prescribed drugs were atorvastatin (75.7%) followed by rosuvastatin (24.9%). As for lipid control, 55% of all patients, and 28.6% of those with coronary heart disease, did not achieve their personal c-LDL goal despite treatment. The frequency of statin intolerance was 2.6% in this study.
Mixed dyslipidaemia and hypercholesterolaemia are the most frequent dyslipidaemias in Colombia. A notable percentage of patients under treatment with lipid-lowering drugs, including those with coronary heart disease, did not achieve specific c-LDL goals. This poor lipid control may worsen patient's CVR, so that therapeutic strategies need to be changed, either with statin intensification or addition of new drugs in patients with higher CVR.

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The spectrum of the dyslipidemia in Colombia: The PURE study

Highlights

Abstract

Background

Material and methods

Results

Conclusion

Introduction

Section snippets

Study design and participants

Results

Discussion

Acknowledgements

Conflict of interest

Authorship responsibility

Lancet

Int. J. Cardiol.

Prev. Med.

J. Am. Coll. Cardiol.

Lancet Diabetes Endocrinol.

Lancet

Lancet

Lancet

Rev. Esp. Cardiol.

Rev. Colomb. Cardiol.

Global status report on non-communicable diseases 2014

Analisis de la situación en Colombia 2013

Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study

Lancet

Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults

Circulation

WHO|global health observatory (GHO)

Risk factors for cardiovascular and chronic diseases in a coffee growing population

Rev. Salud Publica. (Bogota)

Cardiovascular risk factors in an urban Colombia population

Rev. Salud Publica. (Bogota)

Prevalence and impact of cardiovascular risk factors in Bucaramanga, Colombia: results from the Countrywide Integrated Non-Communicable Disease Intervention Programme (CINDI/CARMEN) baseline survey

Eur. J. Cardiovasc. Prev. Rehabil.