Cardiovascular Journal of Africa: Vol 30 No 5 (October 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 5, September/October 2019 248 AFRICA
Education of the public about FH is appropriate, given its
prevalence and severity, but should be preceded by education
of healthcare providers who need to consider the differential
diagnosis and tailor management accordingly. Given our limited
resources and the treatable high risk of FH, this condition should
receive no less support than other conditions with similar risk of
morbidity and mortality, expense of symptomatic treatment, and
negative impact on families.
While genetic confirmation is desirable and is relatively
efficient owing to founder effects, clinical diagnosis suffices in
most cases. In a small proportion of severe and problematic
cases, referral to specialised clinics is recommended. A national
network of clinics should be supported by at least one dedicated
laboratory to ensure an accurate diagnosis and appropriate use
of treatment, especially if expensive. Since neither the public nor
private sector currently provides such an important service, the
National Health Insurance system under consideration will do
well to consider arrangements for severe lipid disorders.
Compared with the ambitious scale for improving healthcare
in general, severe dyslipidaemias affect smaller numbers of
patients, require relatively small numbers of staff, require a single
laboratory for the country and can serve both the public and
private sectors of healthcare at the same referral centres. Expert
evaluations will not only improve management and outcome but
will also highlight relevant research needs for the future.
Severe dyslipidaemias should be recognised and assessed for
judicious use of intervenional strategies, including new therapeutic
agents, to ensure best health for the people of South Africa.
References
1. Blom DJ, Breedt J, Burgess L, Ebrahim IO, Ellis G, Soma P, et al. Long-
term safety and efficacy of alirocumab in South African patients with
heterozygous familial hypercholesterolaemia: the ODYSSEY Open-
Label Extension study. Cardiovasc J Afr 2019; 30(5): 279–284.
2. Marais AD, Kotze MJ, Raal FJ, et al. Familial hypercholesterolaemia
workshop for leveraging point-of-care testing and personalized medicine
in association with the Lipid and Atherosclerosis Society of Southern
Africa. Cardiovasc J Afr 2019; 30(5): 00–00.
3. 3. Familial hyperchcolesterolemia [FH]: Report of aWHOConsultation.
World Health Organization, Human Genetics Programme, Division of
Noncommunicable Diseases. WHO/HGN/FH/CONS/98.7. Geneva,
1998[4
4. Firth JC, Marais AD. Familial hypercholesterolaemia: the Cape Town
experience. S Afr Med J 2008; 98(2): 99–104.
5. Haq IU, Jackson PR, Yeo WW, Ramsay LE. Sheffield risk and treat-
ment table for cholesterol lowering for primary prevention of coronary
heart disease . Lancet 1995; 346: 1467–1471.
6. Klug E, Raal FJ, Marais AD, Smuts CM, Schamroth C, Jankelow D,
et al. South African dyslipidaemia guideline consensus statement: 2018
update. A joint statement from the South African Heart Association
(SA Heart) and the Lipid and Atherosclerosis Society of Southern
Africa (LASSA). S Afr Med J 2018; 108(11b): 973–1000.
7. Santos RD, Gidding SS, Hegele RA, et al. Defining severe famil-
ial hypercholesterolaemia and the implications for clinical manage-
ment: a consensus statement from the International Atherosclerosis
Society Severe Familial Hypercholesterolemia Panel. Lancet Diabetes
Endocrinol 2016; 4: 850–861.
8. Talmud PJ, Shah S, Whittall R, Futema M, Howard P, Cooper JA, et
al. Use of low-density lipoprotein cholesterol gene score to distinguish
patients with polygenic and monogenic familial hypercholesterolaemia:
a case-control study. Lancet 2013; 38: 1293–1301.
9. Hartgers ML, Besseling J, Stroes ES, et al. Achieved LDL cholesterol
levels in patients with heterozygous familial hypercholesterolemia: A
model that explores the efficacy of conventional and novel lipid-lower-
ing therapy. J Clin Lipidol 2018; 12: 972–980.
Daily 4-in-1 polypill could cut cardiovascular disease risk in low-income countries
A study has shown that a daily pill containing four medicines
can cut the number of heart attacks and strokes by a third.
The polypill contains blood-thinning aspirin, a cholesterol-
lowering statin and two drugs to lower blood pressure.
The researchers in Iran and the UK said the pill had
a huge impact but cost just pennies a day. They suggest
giving it to everyone over a certain age in poorer countries,
where doctors have fewer options and are less able to assess
individuals.
The report says the study was based in more than 100
villages in Iran and about 6 800 people took part. Half the
people were given the polypill and advice on how to improve
their lifestyle, with the other half just getting the advice.
After five years, there were 202 major cardiovascular
events in the 3 421 people getting the polypill and 301 in the
3 417 not getting the pill. At this rate, giving the preventative
drug combination to 35 people would prevent one of them
developing a serious heart problem over the course of five
years.
‘We’ve provided evidence in a developing or middle-
income country, and that’s a lot of countries, that this is a
strategy worth considering,’ Professor Tom Marshall, from
the University of Birmingham, is quoted in the report as
saying.
The drug was given to people over the age of 50 whether
they had had a previous heart problem or not. ‘Given the
polypill’s affordability, there is considerable potential to
improve cardiovascular health and to prevent the world’s
leading cause of death,’ said Dr Nizal Sarrafzadegan of
Isfahan University of Medical Sciences, Iran.
In the UK and other wealthier countries, doctors have
the time to assess the needs of individual patients and a wide
choice of different drugs, such as statins, to choose from. ‘In
the UK, the advantages would be more marginal and you
would probably want a clinical trial to see any benefits over
what is offered at the moment,’ said Marshall.
The report says the idea of the polypill has been around
since 2001 but this is the first major trial to prove its
effectiveness. The drug however is not licensed in the UK and
would be tricky to get approved.
Source: Medical Brief 2019