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A semi-systematic review on hypertension and dyslipidemia care in Egypt—highlighting evidence gaps and recommendations for better patient outcomes

A semi-systematic review on hypertension and dyslipidemia care in Egypt—highlighting evidence... Background: Both hypertension and dyslipidemia are considered as major modifiable risk factors of cardiovascular diseases (CVDs), and their prevalence in Egypt has increased in recent years. Evidence-based systematic evaluation of data on hypertension and dyslipidemia is critical for effective patient-centric management to reduce the overall risk of CVDs in Egypt. This semi-systematic review aimed to quantify and identify data gaps in the prevalence and distribution of patient journey touchpoints including awareness, screening, diagnosis, treatment, adherence, and control of hypertension and dyslipidemia to provide the basis for research prioritization, practice guidance, and health care reforms in Egypt. Main body: Structured search was conducted on MEDLINE and Embase to identify articles published in English between January 2010 and December 2019 that reported key patient journey touchpoints in hypertension and dyslipidemia management. Unstructured search was conducted on public or government websites with no date restriction. Data from all sources were extracted and presented descriptively. In total, 22 studies published between 1995 and 2020 on hypertension and dyslipidemia were included in the final analyses. The prevalence of hypertension in Egypt ranged from 12.1 to 59%. Studies reported awareness (37.5% and 43.9%), diagnosis (42% and 64.7%), treatment (24% and 54.1%), and adherence to antihypertensive medication (51.9%) to be low. Furthermore, the percentage of patients who had their blood pressure controlled ranged from 8 to 53.2%. The prevalence of dyslipidemia varied in the general population (range 19.2–36.8%) but was higher in patients with acute coronary syndrome (ACS) (50.9% and 52.5%) and coronary artery disease (58.7%). A national report indicated that 8.6% of the general population was screened for dyslipidemia; however, no data was available on the diagnosis and treatment rates. Among ACS patients, 73.9% were treated for dyslipidemia. Data indicated low levels of medication adherence (59%) among dyslipidemia patients, with overall low control rates ranging from 5.1 to 34.4% depending on CVD risk in populations including ACS patients. * Correspondence: ashrafreda5555@gmail.com Department of Cardiology, Menoufia University, Shebin El Kom, Egypt Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 2 of 14 Conclusion: Data on patient journey touchpoints of hypertension and dyslipidemia are limited in Egypt, indicating the need for more systematic and high-quality evidence-based studies covering different aspects of patient-centric management for better management of CVD and its risk factors. Keywords: Cardiovascular disease, Dyslipidemia, Egypt, Hypertension, Patient-centric, Prevalence, Touchpoints 1 Background was a lack of appropriate programs for the prevention Noncommunicable diseases (NCDs) were responsible for and timely detection of these two CVD risk factors [23]. 42 million deaths worldwide in 2019, with a majority of Owing to the lack of epidemiologic studies on preva- these deaths (18.6 million) attributed to cardiovascular lence or clinical trial data regarding the management of diseases (CVDs) [1]. There is an increasing focus on re- hypertension or dyslipidemia in Egypt, most of the treat- ducing mortality due to NCDs by 2030, as proposed by ment practices were adapted from the evidence-based the World Health Organization (WHO) under the Sus- guidelines of western countries, with modifications based tainable Development Goals [2]. Despite these efforts, on the cultural, economic, and social lifestyle of the re- there was an increase in CVD mortality rate in the low- gion [24]. Current epidemiology, practices, and overall and middle-income countries (LMICs) between 2000 status of hypertension and dyslipidemia in the local and 2012 [3], which contributed to 80% of global CVD population should advocate incremental reforms in the deaths [4]. health care sector, emphasizing on promoting patient Egypt, classified as an LMIC by the World Bank, re- awareness, incorporating screening programs, improved ported an annual mortality rate of 40% due to CVDs. Be- treatment, and control of these diseases in Egypt [24– ing the most populous country in the Middle East and 27]. The evaluation of the influence of health care ser- North African region, Egypt accounted for 15% of the vices on patients’ engagement along the common deter- CVD mortality for the entire region [5–7]. The high minants of patient journey touchpoints including CVD mortality in Egypt was attributed to increasing awareness, screening, diagnosis, treatment, adherence, urbanization in the country, accompanied by widening and control was recognized as the opportunity to ad- gaps in the socio-economic statuses, increasing dress the unmet needs [28]. However, there is a paucity westernization of lifestyles, and rising imbalance between of evidence-based, high-quality data on these patient- improved health services and accessibility to the popula- centric outcome measures that would support health tion [3, 8–12]. These changes explained the rise in the care professionals in managing CVDs at the national prevalence and possible complications in the manage- level. The first step to solve these hindrances is to collect ment of modifiable and preventable CVD risk factors and summarize the existing evidence on the broad re- such as hypertension and dyslipidemia [13]. The most search question, which can be done effectively using evi- recent global estimates suggested that hypertension af- dence mapping [29–31]. fected 1.13 billion people worldwide [14]. According to This semi-systematic review aimed at summarizing the the WHO global estimates, the prevalence of dyslipid- scientific evidence on the prevalence and patient journey emia among adults is also quite high at 39% [15]. In stages of hypertension and dyslipidemia in the Egyptian Egypt, a few population-based studies have estimated the population that would boost policy and practice im- prevalence of CVD risk factors; the most recent national provements in the country. survey reported the prevalence of hypertension and dys- lipidemia at 29.5% and 19.2%, respectively [16]. 2 Main text The management of hypertension in Egypt was af- 2.1 Methods fected by multiple factors such as an inconsistent ap- 2.1.1 Study design proach adopted by the physicians to measure blood We conducted a comprehensive semi-systematic data re- pressure, inadequate treatment, lower number of pa- view using structured and unstructured literature tients achieving target blood pressure, lower awareness searches for retrieval of data on prevalence and various of hypertension among patients, limited use of risk as- phases of patient-centric management (awareness, sessment tools to identify high-risk patients, patient screening, diagnosis, treatment, adherence, and control) noncompliance to treatment, lack of preventive centers, of hypertension and dyslipidemia in the Egyptian popu- and absence of national registries for CVD risk factors lation. The current review adopted the methodological [5, 17–20]. On the other hand, despite higher awareness approach described earlier in an associated protocol regarding dyslipidemia, patients were severely under- [32], with minor modifications to address variability in treated and were unable to reach the target lipid levels the data or lack of availability of data. while on treatment in Egypt [21, 22]. In addition, there Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 3 of 14 2.1.2 Search strategy which allowed inclusion of studies conducted on rele- We followed a multi-component search strategy. First, a vant subpopulations (e.g., patients presenting with acute structured search was conducted on the electronic data- coronary syndrome (ACS)) that could be translated to bases MEDLINE and Embase using relevant search the real-world setting in the context of prevention and strings including Medical Subject Heading (MeSH) management of these 2 risk factors. The shortlisted terms and their synonyms to identify different phases of studies from all sources were analyzed in detail before patient journey touchpoints for hypertension and dyslip- including in the final records. idemia in Egypt. The full search strategy is presented in Supplementary Table 1. An additional unstructured search was conducted in 2.1.5 Data extraction and synthesis the Incidence and Prevalence Database (IPD), the WHO Studies included in the final records were exported to and Ministry of Health websites, and Web search en- Microsoft Excel after manual screening, followed by re- gines (the search included a combination of the key trieval of relevant quantitative data including prevalence MeSH terms from the systematic literature search, with of hypertension and dyslipidemia, as well as different no restrictions on date limits identified in the additional phases of patient-centric management (awareness, searches). screening, diagnosis, treatment, adherence, and control). To ensure consistency with real-world experiences, 2.1.3 Inclusion and exclusion criteria extracted quantitative data were further reviewed and The structured search was restricted to systematic re- verified. views and/or meta-analyses, narrative reviews, random- ized controlled studies, and observational studies published in the English language from January 1, 2010, 2.2 Results to December 31, 2019. Studies with quantitative data on 2.2.1 Screening of studies for hypertension prevalence or at least one component of patient manage- A total of 277 articles from the structured searches and ment (awareness, screening, diagnosis, treatment, adher- 6 articles from the unstructured searches were retrieved ence, and control) involving human adult populations on the prevalence and the distribution of patient journey aged ≥18 years were included. Studies involving patient stages of hypertension. Most of the studies that were ex- population with hypertension or dyslipidemia, where cluded represented specific patient subgroups (pregnant hypertension was defined as average systolic blood pres- women, patients with other comorbidities, n = 117). sure ≥140 mmHg and/or average diastolic blood pres- Other studies were excluded for not focusing on hyper- sure ≥ 90 mmHg [33] and dyslipidemia was defined as tension (n = 106), not representing adult population (n average total cholesterol levels ≥ 5.0 mmol/L or ≥ 190.0 = 29), not reporting data on any of the phases of mg/dL [34], were included. patient-centric management (n = 8), non-availability of Studies were excluded if they did not focus on hyper- full-text article (n = 4), and published in a non-English tension or dyslipidemia or representative of the national language (n = 1). The search results and subsequent data population of Egypt. Case studies, letters to the editor, analysis at a later stage allowed inclusion of studies con- editorials, and studies on special population (pregnant ducted in the subgroup of patients presenting with ACS patients, patients with other comorbidities) were also and coronary artery disease (CAD). Twelve articles from excluded. the structured searches and all 6 articles from the un- structured searches were selected for detailed review. 2.1.4 Study selection Further, 3 additional studies were considered as supple- Primary screening and data retrieval were performed by mentation to the shortlisted records. Finally, 4 articles the first independent reviewer on the basis of the titles from the structured searches [6, 25, 26, 35], 5 studies and abstracts. In the second level of screening, studies from the unstructured searches [8, 16, 20, 36, 37], and 2 were shortlisted by a second independent reviewer on supplementary studies were included in the final analysis the basis of the pre-defined eligibility criteria and full- [38, 39]. Ten studies were excluded because of the fol- text review; any disagreements between the reviewers lowing reasons: small sample size (n=1), meta-analysis were resolved through mutual scientific discussions. To (n=1), duplicate records (n=3), variable definition of account for the unavailability of data on hypertension hypertension (n=1), availability of similar national data and dyslipidemia at the national level, additional studies (n=1), questionnaire-based studies without proper defin- were considered appropriate for inclusion to supplement ition of hypertension (n=1), anecdotal data (n=1), or data collected from structured and unstructured studies focused on single-pill combination therapy (n=1). searches. Furthermore, a prominent deviation from the The literature search and study selection process is protocol was proposed to adopt a secondary approach, summarized in Fig. 1. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 4 of 14 Fig. 1 Flowchart of literature search results on hypertension. IPD, Incidence and Prevalence Databases; MOH, Ministry of Health; WHO, World Health Organization 2.2.2 Description of included studies: hypertension 37.5% [37]. The EHIS showed that 42% of the surveyed Three studies including a WHO Global Status Report on population was diagnosed with hypertension [38]. In a NCDs, a nationwide cross-sectional community-based systematic review of hypertension in 20 countries, 64.7% survey, and an Egyptian National Hypertension Project of the surveyed population was diagnosed with hyperten- reported prevalence of hypertension ranging from 26 to sion, whereas 54.1% received treatment and 39.5% re- 29.5% among Egyptian adults [16, 36, 37]. The preva- ported control of blood pressure in Egypt [25]. On the lence of high blood pressure in men and women among basis of the data from Egyptian National Hypertension the Egypt Health Issues Survey (EHIS) respondents at Project, 24% of hypertensive patients received treatment, the time of the survey were 16.7% and 17.2%, respect- whereas only 8% of the patients reported control of ively [38]. A systematic analysis of a national health blood pressure [37]. A multistage random sampling examination survey conducted by Ikeda et al. [25] re- technique at health insurance clinics in Egypt reported ported hypertension prevalence at 12.1% among individ- controlled blood pressure in 53.2% of the hypertensive uals aged between 35 and 49 years. In a multicenter, patients and adequate compliance to treatment in 51.9% cross-sectional study in Egyptian patients with ACS, the of the patients [20]. A nationwide Specialized Hyperten- prevalence of hypertension was estimated at 59% [6]. A sion Clinics (SHCs) screening and treatment initiative comparative study between elderly and younger patients reported that only 27.1% of the hypertensive patients with ACS revealed 49.1% incidence of hypertension had controlled blood pressure [8]. No study provided among the younger population (< 60 years) [35]. In a data on screening of hypertension in the Egyptian popu- retrospective study, hypertension was reported in 56.7% lation. The details of the studies included in the final of patients with CAD [26]. analysis are summarized in Table 1. The data obtained from the most recent EHIS [39] re- vealed that 43.9% of the Egyptian adult population was 2.2.3 Screening of studies for dyslipidemia aware of their hypertensive condition, whereas only A total of 251 articles from the structured searches and 22.7% of population could achieve blood pressure con- 4 articles from the unstructured searches were retrieved trol. Similarly, awareness about hypertension in the on prevalence and patient-centric management of dyslip- Egyptian National Hypertension Project was estimated at idemia for the Egyptian population. Studies representing Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 5 of 14 Table 1 Overview of studies for hypertension included in the final analysis (N = 11) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data as per the MAPS inclusion criteria Unstructured Global Status Report on Global status Adults (18+ years) 26.0% xx x x x x NA noncommunicable diseases: report tracking 2014 worldwide progress in prevention and control of NCDs Supplementary Egypt Health Issues Survey: Cross-sectional N = 16,671; individuals 17.2% xx 42.0% xx x record 2015 survey (15–59 years) (women) interviewed in the 16.7% survey. (men) Unstructured Egypt National STEPwise National cross- N = 6680; nationally 29.5% xx x x x x Survey For Noncommunicable sectional representative sample of Diseases Risk Factors Report; community- Egyptian adults (15-69 2017 based house- years). hold survey Registry of the Egyptian Nationwide N = 4701; controlled xx x x x x 27.1% specialized hypertension Specialized hypertension was clinics: patient risk profiles and Hypertension defined as BP < 140/90 geographical differences: El Clinics Registry mmHg in hypertensive Faramawy A; 2019 patients on antihypertensive medications. Data deviates from the MAPS inclusion criteria (year limit: 2010–2019) Unstructured Hypertension Prevalence, Cross-sectional N = 6733; survey 26.3% 37.5% xx 24.0% x 8.0% NA Awareness, Treatment, and nationwide participants (25 to 95 Control in Egypt. Results from survey years). the Egyptian National Hypertension Project (NHP): Ibrahim MM; 1995 Patterns and determinants of Multistage N = 316; hypertensive xx x x x 51.9% 53.2% treatment compliance among random patients attending hypertensive patients: Youssef sampling health insurance clinics RM; 2002 technique for prescription refills were randomly selected and interviewed. Supplementary Prevalence and determinants Cross-sectional N = 2869; participants x 43.9% xx x x 22.7% record of hypertension unawareness study using (≥18 years) were in Egyptian adults: a cross- data from the included if they sectional study of data from 2015 Egyptian measured blood the 2015 Egyptian Health Is- Health Issues pressure (systolic and/or sues Study: Soliman SS; 2020 Survey (EHIS) diastolic pressure ≥ 140/ 90 mmHg). Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 6 of 14 Table 1 Overview of studies for hypertension included in the final analysis (N = 11) (Continued) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data deviates from the MAPS inclusion criteria (definitions/special patient subgroups) Structured Lipid profile in Egyptian Retrospective N = 1000; CAD patients 56.7% x x x x x x Data extracted patients with coronary artery study of ranged from 19 to 90 from patients disease: Ibrahim MM; 2013 patients with years. with stable CAD CAD or had a history of MI Control of hypertension with Systematic N = 3342; Individuals 12.1% xx 64.7% 54.1% x 39.5% Hypertension medication: a comparative search of (35–49 years). definition is analysis of national surveys in national health based on 20 countries: Ikeda N; 2014 examination Systolic blood surveys from pressure (i.e., < 20 countries 140 mmHg) Comparative study between Retrospective N = 570; ACS patients 49.1 x x x x x x Data extracted elderly and younger patients registry were divided into 2 from younger with acute coronary syndrome: groups: elderly ≥ 60 patients (< 60 Obaya M; 2015 years; younger < 60 years) years. presenting with ACS; hypertension not defined The pattern of risk-factor pro- Multi-center, N = 1681; ACS patients 59.0% x x x x x x Data extracted file in Egyptian patients with observational, (≥18 years) having a on investigating acute coronary syndrome: cross-sectional history of hypertension ACS patients phase II of the Egyptian cross- study of ACS or blood pressure sectional CardioRisk project: patients (systolic and/or diastolic Reda A; 2019 pressure ≥140/90 mmHg). ACS, acute coronary syndrome; CAD, coronary artery disease; MI, myocardial infarction; NCD, noncommunicable diseases; NA, not applicable Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 7 of 14 specific patient subgroups (pregnant women, patients 2.2.4 Description of included studies: dyslipidemia with other comorbidities, n = 114), not reporting data On the basis of the nationwide survey data, the preva- on prevalence or any of the phases of patient-centric lence of hypercholesterolemia was 19.4%, 36.8%, and management (n = 57), not focusing on dyslipidemia (n = 19.2% in the Egyptian population during 2006, 2012, and 39), not representing adult population (n = 16), non- 2017, respectively [16, 41, 42]. However, cholesterol availability of full-text article (n = 8), lack of nationally- screening was poor, as reported in one nationwide sur- representative population (n = 3), case studies, letters to vey (8.6%) [16]. A nationwide, cross-sectional CardioRisk the editor, editorials (n = 2), duplicate records (n = 2), study conducted in patients with ACS reported in- and data not from the representative country (n=2) were creased low-density lipoprotein cholesterol (LDL-C) excluded. The findings of the initial data review indi- levels in 52.5% of the patients [6]. Similarly, another cated lack of data on dyslipidemia in the general popula- retrospective study reported a prevalence of dyslipidemia tion and thus necessitated inclusion of patient in 50.9% of younger patients (< 60 years) diagnosed with subgroups diagnosed with ACS or CAD at a later stage. ACS [35]. The high prevalence of dyslipidemia (58.7%) Eight articles from the structured searches, and all 4 arti- based on total cholesterol levels was also identified in cles from the unstructured searches were considered eli- Egyptian patients with CAD [26]. However, in a group gible for review. An additional survey-based study on of hypertensive Egyptians attending SHCs, the preva- NCDs risk factors in Egypt was supplemented to the lence of dyslipidemia was only 8.9% [8]. shortlisted records for assessment. Finally, 8 articles The results from both the Centralized Pan-Middle East from the structured searches [6, 8, 21–23, 26, 35, 40], 2 Survey on the under-treatment of hypercholesterolemia nationwide survey reports from the unstructured search (CEPHEUS) studies in Egypt indicated that most pa- [41, 42], and 1 additional study was included in the final tients were aware of their target cholesterol levels (76%) analysis [16]. Two of the selected studies were not con- or bad cholesterol (75%) [23, 40]. Although compliance sidered for final analysis because of the availability of the to treatment of dyslipidemia in the CEPHEUS II study similar data in the STEPS Survey reports. The literature was reported at 59% [40], target LDL-C levels were search and study selection process are summarized in achieved in only 32.5% and 34.4% of the patients as re- Fig. 2. ported in the CEPHEUS I and CEPHEUS II results, Fig. 2 Flowchart of literature search results on dyslipidemia. IPD, Incidence and Prevalence Databases; MOH, Ministry of Health; WHO, World Health Organization Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 8 of 14 respectively [23, 40]. According to the DYSlipidemia variability in the proportion of patients treated for International Study (DYSIS)-Egypt, one-third of the pa- hypertension (24% and 54%) [25, 37], which was not tients who received chronic statin treatment had control consistent with the treatment rates reported for LMICs in LDL-C levels [21]. In the DYSIS II study, 73.9% of pa- (29%) and HICs (56%) [45]. In our review, patient com- tients with ACS received treatment for dyslipidemia, pliance to treatment for hypertension was reported at whereas the proportion of patients who achieved target 52%, which was higher than the patient compliance re- LDL-C levels varied within different risk categories, with ported in a recent study (41%) [46]. Lower compliance 5.1% at very high risk, 27.3% at high risk, 32.3% at mod- to anti-hypertensive medication could be attributed to erate risk, and 14.3% at low risk [22]. No study provided increased cost, side effects, monotherapy, and lack of ef- data on diagnosis of dyslipidemia in the Egyptian popu- ficacy [20]. Similarly, there is a wide variability in the lation. The details of the studies included in the final blood pressure control rates as reported in our review analysis are summarized in Table 2. ranging from as the lowest estimate of 8% to the highest estimate of 53% [8, 20, 25, 37, 39], whereas the control 2.3 Discussion rates were reported at 27% in LMIC and 51% in HICs This semi-systematic review, for the first time, presented [45]. This trend in the rates of awareness, treatment, ad- the evidence available and identified inconsistencies in herence, and control of hypertension in the Egyptian reporting the data on prevalence and patient journey population that mimicked the trends in LMICs might be stages (awareness, screening, diagnosis, treatment, ad- related to lack of compliance with evidence-based treat- herence, and control) of hypertension and dyslipidemia ment, unavailability of simplified recommendations, and in Egypt. Despite performing a comprehensive literature higher diagnostic thresholds limiting early detection and review, only 22 studies (11 studies each for hypertension treatment initiation [43, 47, 48]. and dyslipidemia) were found to be relevant for the final analysis. Data were available on prevalence and all 2.3.2 Comparison with other studies on dyslipidemia phases of patient-centric management of hypertension, According to the STEPS reports, the prevalence of dys- except screening rates, whereas data were available on lipidemia in the general population of Egypt fluctuated the prevalence and all phases of patient-centric manage- from 19.4% in 2006 to 36.8% in 2012 and reduced to ment of dyslipidemia, except diagnosis rates. 19.2% in 2017 [16, 41, 42]. Although reasons for wide variability in prevalence could not be identified, such 2.3.1 Comparison with other studies on hypertension evidence will be useful for future endeavors in planning The studies included in this review demonstrated a wide large-scale studies in implementing treatment interven- variability in the prevalence of hypertension, which tions or health care policies. Among Egyptian patients could be explained by differences in population charac- with ACS and CAD, the prevalence of dyslipidemia was teristics, subgroup analysis, and study methodologies. consistently higher within the range between 51 and The prevalence estimates were lower in the younger 59%, which reinforced the latter’s status as a major risk general population aged between 35 and 49 years (12%) factor in CVDs [6]. There was a correlation between the [25] and surveyed population aged < 60 years (17%) [38], 2 risk factors when a study in hypertensive patients re- whereas the estimates were higher ranging from 49 to ported prevalence of dyslipidemia in 9% of the patients 59% in subgroup studies of patients with ACS and CAD, [8]. It is imperative to identify such high-risk patients indicating hypertensive patients were more susceptible with the presence of multiple risk factors so that they to develop CVDs [6, 26, 35]. However, the prevalence of can be targeted for treatment to reduce CVDs. The hypertension in the general Egyptian population did not prevalence of dyslipidemia reported in the general Egyp- vary and ranges between 26 and 29.5% [16, 36, 37], tian population was much lower than that projected by which were comparable to the prevalence reported in the WHO (39%). Further, the prevalence of high choles- the LMICs (31%) [43] and the USA (29%) [44]. terol in Egypt was comparatively lower than that re- Our study demonstrated that the levels of awareness ported in the USA (55%) and UK (66%) [15]. Data from of hypertension (38% and 44%) [37, 39] in the Egyptian both the CEPHEUS studies indicated a higher level of population were comparable with those in LMICs (38%), awareness in patients about their cholesterol levels but markedly lower when compared with that in the (≥75%), with a moderate level of adherence to the thera- high-income countries (HICs) (67%) [45]. Consequently, peutic regimen (59%) [23, 40]. However, there was a the percentages of diagnosed hypertensive individuals in possibility of recall bias, which is commonly seen in sur- Egypt were 42% and 65% in 2 studies [25, 38], which vey studies. Similarly, the proportion of patients treated were comparable to the range reported for various (74%) was relatively higher when analyzed in a small co- LMICs (46–75%), but substantially lower compared to hort of patients suffering from ACS [22], which may not the USA (85%) [25]. Further, we observed a wide be representative of the overall Egyptian population. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 9 of 14 Table 2 Overview of studies for dyslipidemia included in the final analysis (N = 11) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data as per the MAPS inclusion criteria Unstructured Ministry of Health & National cross- N = 9780; participants 19.4% xx x x x x NA population, Egypt sectional (15–65 years) Preventive Sector survey Central Epidemiology and Disease Surveillance (ESU) Non- Communicable Disease Surveillance Unit (NCDSU); 2006 WHO and ARE-Ministry Multistage N = 5300; participants 36.8% xx x x x x NA of Health & Population: cluster sample (15–65 years) Egypt National STEP- design wise Survey of Non- Communicable Dis- eases Risk Factors 2011- 2012; 2012 Supplementary Egypt National National cross- N = 6680; nationally 19.2% x 8.6% xx x x NA Record STEPwise Survey For sectional representative sample of Noncommunicable community- Egyptian adults (15–69 Diseases Risk Factors based house- years). Report; 2017 hold survey Data deviates from the MAPS inclusion criteria (definitions/special patient subgroups) Structured The DYSlipidemia Cross- N = 1458; patients (≥ 45 xx x x x x 33.7% Control data International Study sectional, years) on stable statin extracted based on (DYSIS)-Egypt: A report observational, treatment. target LDL-C on the prevalence of multinational attainment lipid abnormalities in study Egyptian patients on chronic statin treatment: El Etriby A; Lipid profile in Egyptian Retrospective N = 1000; patients ranged 58.7% x x x x x x Data extracted from patients with coronary consecutive from 19 to 90 years. patients with stable artery disease: Ibrahim sampling of CAD or had a MM; 2013 patients with history MI CAD Centralized Pan-Middle Multicenter, N = 1043; subjects (≥ 18 x 76.0% xx x x 32.5% Control data East Survey on the observational years) were receiving extracted based on Under- Treatment of study lipid-lowering drug target LDL-C Hypercholesterolemia: treatment. attainment Results from the CE- PHEUS Study in Egypt: Reda A; 2014 Comparative study Comparative N = 570; patients were 50.9 x x x x x x Data extracted from Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 10 of 14 Table 2 Overview of studies for dyslipidemia included in the final analysis (N = 11) (Continued) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics between elderly and study divided into 2 groups: younger patients (< younger patients with between elderly ≥ 60 years; 60 year) presenting acute coronary elderly and younger < 60 years. with ACS; syndrome: Obaya M; younger dyslipidemia not 2015 patients with defined ACS Centralized Pan-Middle Observational, N = 896; Subjects (≥ 18 x 75.0% xx x 59.0% 34.4% Data extracted East Survey on the multicenter, years) receiving lipid- based on LDL-C Under- Treatment of cross-sectional lowering drug treatment. levels Hypercholesterolemia: survey Results from the CE- PHEUS II Study in Egypt: Reda A; 2017 Prevalence of lipid Prospective, N = 199; patients (≥ 18 xx x x 73.9% x 5.1% (very Data extracted on abnormalities and observational years) who were high risk; investigating cholesterol target value study of hospitalized for ACS and <70mg/ selected attainment in Egyptian patients receiving lipid-lowering dL) subpopulations (ACS patients presenting presenting treatment. 27.3% patients); control with an acute coronary with ACS (high risk; data extracted based syndrome: Sobhy M; < 100 mg/ on target LDL-C at- 2018 dL) tainment corre- 32. 3% sponding to (moderate different risk risk; < 115 categories mg/dL) 14.3% (low risk; < 130 mg/ dL) The pattern of risk- Multi-center, N = 1681; participants 52.50% x x x x x x Data extracted on factor profile in Egyp- observational, (≥18 years) having a investigating ACS tian patients with acute cross-sectional history of lipid-lowering patients; coronary syndrome: study of pa- therapy or LDL-C > 70 dyslipidemia phase II of the Egyptian tients present- mg/dL (> 1.81 mmol/L). definition is based cross-sectional CardioR- ing with ACS on LDL-C levels isk project: Reda A; Registry of the Nationwide N = 4701; dyslipidemia 8.90% x x x x x x Data extracted on Egyptian specialized Specialized considered when LDL ≥ investigating hypertension clinics: Hypertension 130 mg/dL, HDL ≤ 50 hypertensive patient risk profiles and Clinics mg/dL in women and ≤ patients based on geographical Registry 40 mg/dL in men, and TG LDL-C, HDL, and TG differences: El ≥150 mg/dL or if the levels Faramawy A; 2019 patient was receiving a lipid-lowering agent ACS, acute coronary syndrome; HDL, high-density lipoprotein; CAD, coronary artery disease; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; NA, not applicable; TG, triglycerides Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 11 of 14 Although the treatment rates of dyslipidemia were facilitate workshops, seminars, and availability of inter- higher, the overall control rates were lower in the national manuals for PHCs [61]. Although the WHO general population as well as in patients with ACS, has recognized Egypt’s commitment in scaling up PHC ranging from 20 to 34% [21–23, 40]. These lower facilities [62], the imbalance in care services across dif- control rates could be attributed to a lack of imple- ferent regions and socioeconomic groups necessitated mentation of evidence-based guidelines, clinical iner- the adoption of comprehensive strategies leading to ef- tia, and patients’ non-compliance to the prescribed fective national health care reforms [63]. To achieve treatment [49]. Similarly, less affordability to costly these reforms, the overall burden of hypertension and medications and “ceiling effect” on LDL-C lowering dyslipidemia in the Egyptian population should be esti- by statin therapy could be the reason for poor control mated using a risk assessment approach. In the absence rates in the lipid levels [50, 51]. of recommendations for opportunistic screening for CVD risk assessment in the general population, the 2.3.3 Implications for practice and patient-centric European guidelines emphasized the importance of sys- recommendations tematic screening for CVD risk assessment in individuals Suboptimal control of hypertension reflected lack of who are at high risk due to positive family history for education and limited medical access in Egypt, indicat- CVD risk factors [64]. Such an approach in addition to ing the need for collaborative efforts from health author- the periodic data collection to estimate the precise ities, medical community, and pharma companies to prevalence of risk factors and integration of population- promote patient education and national level campaigns based surveillance programs into the national health in- [19, 52]. Further, there is a need for specialized hyper- formation systems targeted toward detection, treatment, tension clinics in Egypt to improve quality and accessi- and control of CVDs could be rigorously followed as bility to health care services for the patients [11]. Egypt proposed in the WHO’s Global Action Plan [65]. For de- is now steadily progressing with its recent initiative to cades, Egypt’s health care sector has struggled to address develop a nationwide screening program “100 Million the public health crisis owing to underinvestment in Healthy Lives” accompanied by awareness and treatment public hospitals, unreliable private health care, inad- campaigns for NCDs such as hypertension and diabetes” equate health insurance, and issues related to equity by [53]. Thus, it would be crucial to publish these reliable race/ethnicity, gender, and other socioeconomic status and meaningful findings allowing the use of the credible measured by education, income, or occupation [66, 67]. information to aid policymakers to identify the target However, recently the Egyptian government has priori- population for their interventions and policies. More- tized health care services for all citizens ensuring over, extending the campaign to dyslipidemia would im- mandatory coverage eliminating existing disparities part a comprehensive coverage of the CVD landscape in through “The Universal Health Coverage Project” [68]. Egypt. In addition to these measures, there is a need to In Egypt, barriers were identified toward execution of conduct large epidemiological studies encompassing cul- smoking prevention measures such as lack of enforce- tural and ethnic contexts and studies comparing ment of smoke-free laws and lack of penalties for viola- evidence-based treatment and current treatment ap- tors [69]. National health policies and community proaches in Egypt to improve the rates of awareness, programs targeting the concurrent risk factors such as treatment, and control of dyslipidemia [54, 55]. Similarly, smoking cessation, improvement in lifestyle, and innova- awareness promotion, early identification, timely treat- tions within the context of patient-centric care, increas- ment, and cost-effective management of hypertension ing health communications, and enabling treatment and dyslipidemia could be achieved by an integrated ap- adherence monitoring could be meaningful measures for proach between affordable primary health care (PHC) hypertension and cholesterol management [70]. The im- services and family- or community-level focus [56–60], plementation of an electronic monitoring system and considering the medical resources constraint in Egypt. the use of eHealth communication were found to be Although there were significant advances in the emer- complicated and seemed to be underused [71]. Despite gency management of CVDs, primary preventive care the designing of several eHealth applications, successful was offered by the general practitioners (GPs), whereas implementation remained a challenge in Egypt due to specialists focused on secondary preventive measures for lack of patient acceptance, financial constraints, and lim- CVDs. Owing to a lack of formal education on cardiac ited infrastructure, especially in the rural areas [72]. primary prevention, there is a need for restructuring However, Egypt’s approach to digitize health services has curriculum in cardiology training with more focus on witnessed an accelerated transformation with the emer- primary preventive measures [5]. Moreover, physician’s ging use of artificial intelligence to diagnose diseases and lack of familiarity with diagnostic guidelines and practice provide treatment solutions via telehealth and telemedi- recommendations indicated that there is a need to cine, enabling better handling of medical data during the Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 12 of 14 COVID-19 pandemic [73]. This holistic approach of hypercholesterolemia; CAD: Coronary artery disease; DYSIS: DYSlipidemia International Study; EHIS: Egypt Health Issues Survey; GP: General practitioner; translating digital interventions to the most vulnerable HICs: High-income country; IPD: Incidence and Prevalence Database; patients with greater CVD risk factors can be adopted LMIC: Low- and middle-income country; LDL-C: Low-density lipoprotein into the National eHealth policy as well in the future. cholesterol; MeSH: Medical Subject Heading; NCDs: Non-communicable diseases; PHC: Primary health care; SHC: Specialized hypertension clinic; SBP: Systolic blood pressure; WHO: World Health Organization 2.4 Limitations Our review has some limitations. Data on key patient 4 Supplementary Information journey touchpoints were not consistently available in all The online version contains supplementary material available at https://doi. articles, and thus, pooled estimates of synthesized data org/10.1186/s42506-021-00096-9. could not be reported. Furthermore, case studies and Additional file 1: Table S1. Search Strategy for Structured Search studies conducted on some patient subgroups (e.g., preg- nant women, adolescents) were excluded, and therefore, Acknowledgements we might have missed evidence to describe some of the The authors would like to thank Aditi Karmarkar, Pfizer Upjohn and Utsavi observations in our review. In addition, exclusion of pa- Samel, Viatris for supporting as independent reviewers and Tanaya Bharatan, tients with other comorbidities especially diabetes might Pfizer Upjohn, for critically reviewing the draft. Medical writing and editorial support were provided by Ramu Periyasamy and Soumya Chatterjee, have underestimated the actual prevalence of hyperten- Indegene Pvt. Ltd, and the study was sponsored by Upjohn – A legacy Pfizer sion because of the increased occurrence of hypertension Division. in patients with diabetes. Additionally, this study is lim- ited by inclusion of dyslipidemia studies based only on Authors’ contributions AR was involved in the study design, acquisition, analysis, interpretation of the levels of total cholesterol and not considering other dyslipidemia data, and critical review of the manuscript. HR was involved in variables such as triglycerides, low-density lipoprotein, the study design, acquisition, analysis and interpretation of hypertension and high-density lipoprotein. It is important to note that data, and critical review of the manuscript. KS was involved in the conception, acquisition of data, and analysis of hypertension and evidence maps can provide a brief overview of topic; dyslipidemia data, and review of the manuscript. MA was involved in the however, no information on efficacy of any individual conception, acquisition of data, and analysis of hypertension and treatment intervention was provided for patients with dyslipidemia data, and review of the manuscript. All authors have read and approved the final manuscript. hypertension or dyslipidemia. Furthermore, in this semi- systematic review of articles, critical appraisal for the Funding quality of findings was not assessed in the included This study was sponsored by Upjohn – A legacy Pfizer Division. studies. Availability of data and materials The dataset generated and analyzed during the current study is not publicly 3 Conclusion available as the dataset is proprietary, but is available from the corresponding author on reasonable request. This study complemented the existing literature on prevalence and provided insights on different phases of Declarations patient-centric management of hypertension and dyslip- idemia in Egypt. The findings supported the need for op- Ethics approval and consent to participate Not applicable portunistic screening for CVD risk factors when visiting a PHC facility, which in turn could result in early diag- Consent for publication nosis and improve treatment outcomes. The need for Not applicable multi-disciplinary commitment from government, pol- Competing interests icymakers, health care professionals, and other stake- AR and HR declare that they have no competing interests. KS is employed in holders toward the prevention of CVD risk factors, Pfizer Upjohn and MA is employed in Viatris. promotion of lifestyle interventions, and overall disease Author details management systems is crucial. Finally, this study may Department of Cardiology, Menoufia University, Shebin El Kom, Egypt. 2 3 provide a basis for research prioritization and recom- Department of Cardiology, National Heart Institute, Cairo, Egypt. Legacy employee, Research, Development and Medical, Pfizer Upjohn, Dubai, United mendations and guidance to practice and amend health Arab Emirates. Medical Affairs, Viatris, Cairo, Egypt. policies for the management of hypertension and dyslip- idemia in Egypt. The current study reinforces the need Received: 5 March 2021 Accepted: 16 November 2021 to generate more high-quality data at national-level on prevalence of hypertension and dyslipidemia along with References patient journey touchpoints to validate the conclusion of 1. Collaborators. G 2019 D and I. Global burden of 369 diseases and injuries in our findings. 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204–22. https://doi. 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A semi-systematic review on hypertension and dyslipidemia care in Egypt—highlighting evidence gaps and recommendations for better patient outcomes

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Abstract

Background: Both hypertension and dyslipidemia are considered as major modifiable risk factors of cardiovascular diseases (CVDs), and their prevalence in Egypt has increased in recent years. Evidence-based systematic evaluation of data on hypertension and dyslipidemia is critical for effective patient-centric management to reduce the overall risk of CVDs in Egypt. This semi-systematic review aimed to quantify and identify data gaps in the prevalence and distribution of patient journey touchpoints including awareness, screening, diagnosis, treatment, adherence, and control of hypertension and dyslipidemia to provide the basis for research prioritization, practice guidance, and health care reforms in Egypt. Main body: Structured search was conducted on MEDLINE and Embase to identify articles published in English between January 2010 and December 2019 that reported key patient journey touchpoints in hypertension and dyslipidemia management. Unstructured search was conducted on public or government websites with no date restriction. Data from all sources were extracted and presented descriptively. In total, 22 studies published between 1995 and 2020 on hypertension and dyslipidemia were included in the final analyses. The prevalence of hypertension in Egypt ranged from 12.1 to 59%. Studies reported awareness (37.5% and 43.9%), diagnosis (42% and 64.7%), treatment (24% and 54.1%), and adherence to antihypertensive medication (51.9%) to be low. Furthermore, the percentage of patients who had their blood pressure controlled ranged from 8 to 53.2%. The prevalence of dyslipidemia varied in the general population (range 19.2–36.8%) but was higher in patients with acute coronary syndrome (ACS) (50.9% and 52.5%) and coronary artery disease (58.7%). A national report indicated that 8.6% of the general population was screened for dyslipidemia; however, no data was available on the diagnosis and treatment rates. Among ACS patients, 73.9% were treated for dyslipidemia. Data indicated low levels of medication adherence (59%) among dyslipidemia patients, with overall low control rates ranging from 5.1 to 34.4% depending on CVD risk in populations including ACS patients. * Correspondence: ashrafreda5555@gmail.com Department of Cardiology, Menoufia University, Shebin El Kom, Egypt Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 2 of 14 Conclusion: Data on patient journey touchpoints of hypertension and dyslipidemia are limited in Egypt, indicating the need for more systematic and high-quality evidence-based studies covering different aspects of patient-centric management for better management of CVD and its risk factors. Keywords: Cardiovascular disease, Dyslipidemia, Egypt, Hypertension, Patient-centric, Prevalence, Touchpoints 1 Background was a lack of appropriate programs for the prevention Noncommunicable diseases (NCDs) were responsible for and timely detection of these two CVD risk factors [23]. 42 million deaths worldwide in 2019, with a majority of Owing to the lack of epidemiologic studies on preva- these deaths (18.6 million) attributed to cardiovascular lence or clinical trial data regarding the management of diseases (CVDs) [1]. There is an increasing focus on re- hypertension or dyslipidemia in Egypt, most of the treat- ducing mortality due to NCDs by 2030, as proposed by ment practices were adapted from the evidence-based the World Health Organization (WHO) under the Sus- guidelines of western countries, with modifications based tainable Development Goals [2]. Despite these efforts, on the cultural, economic, and social lifestyle of the re- there was an increase in CVD mortality rate in the low- gion [24]. Current epidemiology, practices, and overall and middle-income countries (LMICs) between 2000 status of hypertension and dyslipidemia in the local and 2012 [3], which contributed to 80% of global CVD population should advocate incremental reforms in the deaths [4]. health care sector, emphasizing on promoting patient Egypt, classified as an LMIC by the World Bank, re- awareness, incorporating screening programs, improved ported an annual mortality rate of 40% due to CVDs. Be- treatment, and control of these diseases in Egypt [24– ing the most populous country in the Middle East and 27]. The evaluation of the influence of health care ser- North African region, Egypt accounted for 15% of the vices on patients’ engagement along the common deter- CVD mortality for the entire region [5–7]. The high minants of patient journey touchpoints including CVD mortality in Egypt was attributed to increasing awareness, screening, diagnosis, treatment, adherence, urbanization in the country, accompanied by widening and control was recognized as the opportunity to ad- gaps in the socio-economic statuses, increasing dress the unmet needs [28]. However, there is a paucity westernization of lifestyles, and rising imbalance between of evidence-based, high-quality data on these patient- improved health services and accessibility to the popula- centric outcome measures that would support health tion [3, 8–12]. These changes explained the rise in the care professionals in managing CVDs at the national prevalence and possible complications in the manage- level. The first step to solve these hindrances is to collect ment of modifiable and preventable CVD risk factors and summarize the existing evidence on the broad re- such as hypertension and dyslipidemia [13]. The most search question, which can be done effectively using evi- recent global estimates suggested that hypertension af- dence mapping [29–31]. fected 1.13 billion people worldwide [14]. According to This semi-systematic review aimed at summarizing the the WHO global estimates, the prevalence of dyslipid- scientific evidence on the prevalence and patient journey emia among adults is also quite high at 39% [15]. In stages of hypertension and dyslipidemia in the Egyptian Egypt, a few population-based studies have estimated the population that would boost policy and practice im- prevalence of CVD risk factors; the most recent national provements in the country. survey reported the prevalence of hypertension and dys- lipidemia at 29.5% and 19.2%, respectively [16]. 2 Main text The management of hypertension in Egypt was af- 2.1 Methods fected by multiple factors such as an inconsistent ap- 2.1.1 Study design proach adopted by the physicians to measure blood We conducted a comprehensive semi-systematic data re- pressure, inadequate treatment, lower number of pa- view using structured and unstructured literature tients achieving target blood pressure, lower awareness searches for retrieval of data on prevalence and various of hypertension among patients, limited use of risk as- phases of patient-centric management (awareness, sessment tools to identify high-risk patients, patient screening, diagnosis, treatment, adherence, and control) noncompliance to treatment, lack of preventive centers, of hypertension and dyslipidemia in the Egyptian popu- and absence of national registries for CVD risk factors lation. The current review adopted the methodological [5, 17–20]. On the other hand, despite higher awareness approach described earlier in an associated protocol regarding dyslipidemia, patients were severely under- [32], with minor modifications to address variability in treated and were unable to reach the target lipid levels the data or lack of availability of data. while on treatment in Egypt [21, 22]. In addition, there Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 3 of 14 2.1.2 Search strategy which allowed inclusion of studies conducted on rele- We followed a multi-component search strategy. First, a vant subpopulations (e.g., patients presenting with acute structured search was conducted on the electronic data- coronary syndrome (ACS)) that could be translated to bases MEDLINE and Embase using relevant search the real-world setting in the context of prevention and strings including Medical Subject Heading (MeSH) management of these 2 risk factors. The shortlisted terms and their synonyms to identify different phases of studies from all sources were analyzed in detail before patient journey touchpoints for hypertension and dyslip- including in the final records. idemia in Egypt. The full search strategy is presented in Supplementary Table 1. An additional unstructured search was conducted in 2.1.5 Data extraction and synthesis the Incidence and Prevalence Database (IPD), the WHO Studies included in the final records were exported to and Ministry of Health websites, and Web search en- Microsoft Excel after manual screening, followed by re- gines (the search included a combination of the key trieval of relevant quantitative data including prevalence MeSH terms from the systematic literature search, with of hypertension and dyslipidemia, as well as different no restrictions on date limits identified in the additional phases of patient-centric management (awareness, searches). screening, diagnosis, treatment, adherence, and control). To ensure consistency with real-world experiences, 2.1.3 Inclusion and exclusion criteria extracted quantitative data were further reviewed and The structured search was restricted to systematic re- verified. views and/or meta-analyses, narrative reviews, random- ized controlled studies, and observational studies published in the English language from January 1, 2010, 2.2 Results to December 31, 2019. Studies with quantitative data on 2.2.1 Screening of studies for hypertension prevalence or at least one component of patient manage- A total of 277 articles from the structured searches and ment (awareness, screening, diagnosis, treatment, adher- 6 articles from the unstructured searches were retrieved ence, and control) involving human adult populations on the prevalence and the distribution of patient journey aged ≥18 years were included. Studies involving patient stages of hypertension. Most of the studies that were ex- population with hypertension or dyslipidemia, where cluded represented specific patient subgroups (pregnant hypertension was defined as average systolic blood pres- women, patients with other comorbidities, n = 117). sure ≥140 mmHg and/or average diastolic blood pres- Other studies were excluded for not focusing on hyper- sure ≥ 90 mmHg [33] and dyslipidemia was defined as tension (n = 106), not representing adult population (n average total cholesterol levels ≥ 5.0 mmol/L or ≥ 190.0 = 29), not reporting data on any of the phases of mg/dL [34], were included. patient-centric management (n = 8), non-availability of Studies were excluded if they did not focus on hyper- full-text article (n = 4), and published in a non-English tension or dyslipidemia or representative of the national language (n = 1). The search results and subsequent data population of Egypt. Case studies, letters to the editor, analysis at a later stage allowed inclusion of studies con- editorials, and studies on special population (pregnant ducted in the subgroup of patients presenting with ACS patients, patients with other comorbidities) were also and coronary artery disease (CAD). Twelve articles from excluded. the structured searches and all 6 articles from the un- structured searches were selected for detailed review. 2.1.4 Study selection Further, 3 additional studies were considered as supple- Primary screening and data retrieval were performed by mentation to the shortlisted records. Finally, 4 articles the first independent reviewer on the basis of the titles from the structured searches [6, 25, 26, 35], 5 studies and abstracts. In the second level of screening, studies from the unstructured searches [8, 16, 20, 36, 37], and 2 were shortlisted by a second independent reviewer on supplementary studies were included in the final analysis the basis of the pre-defined eligibility criteria and full- [38, 39]. Ten studies were excluded because of the fol- text review; any disagreements between the reviewers lowing reasons: small sample size (n=1), meta-analysis were resolved through mutual scientific discussions. To (n=1), duplicate records (n=3), variable definition of account for the unavailability of data on hypertension hypertension (n=1), availability of similar national data and dyslipidemia at the national level, additional studies (n=1), questionnaire-based studies without proper defin- were considered appropriate for inclusion to supplement ition of hypertension (n=1), anecdotal data (n=1), or data collected from structured and unstructured studies focused on single-pill combination therapy (n=1). searches. Furthermore, a prominent deviation from the The literature search and study selection process is protocol was proposed to adopt a secondary approach, summarized in Fig. 1. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 4 of 14 Fig. 1 Flowchart of literature search results on hypertension. IPD, Incidence and Prevalence Databases; MOH, Ministry of Health; WHO, World Health Organization 2.2.2 Description of included studies: hypertension 37.5% [37]. The EHIS showed that 42% of the surveyed Three studies including a WHO Global Status Report on population was diagnosed with hypertension [38]. In a NCDs, a nationwide cross-sectional community-based systematic review of hypertension in 20 countries, 64.7% survey, and an Egyptian National Hypertension Project of the surveyed population was diagnosed with hyperten- reported prevalence of hypertension ranging from 26 to sion, whereas 54.1% received treatment and 39.5% re- 29.5% among Egyptian adults [16, 36, 37]. The preva- ported control of blood pressure in Egypt [25]. On the lence of high blood pressure in men and women among basis of the data from Egyptian National Hypertension the Egypt Health Issues Survey (EHIS) respondents at Project, 24% of hypertensive patients received treatment, the time of the survey were 16.7% and 17.2%, respect- whereas only 8% of the patients reported control of ively [38]. A systematic analysis of a national health blood pressure [37]. A multistage random sampling examination survey conducted by Ikeda et al. [25] re- technique at health insurance clinics in Egypt reported ported hypertension prevalence at 12.1% among individ- controlled blood pressure in 53.2% of the hypertensive uals aged between 35 and 49 years. In a multicenter, patients and adequate compliance to treatment in 51.9% cross-sectional study in Egyptian patients with ACS, the of the patients [20]. A nationwide Specialized Hyperten- prevalence of hypertension was estimated at 59% [6]. A sion Clinics (SHCs) screening and treatment initiative comparative study between elderly and younger patients reported that only 27.1% of the hypertensive patients with ACS revealed 49.1% incidence of hypertension had controlled blood pressure [8]. No study provided among the younger population (< 60 years) [35]. In a data on screening of hypertension in the Egyptian popu- retrospective study, hypertension was reported in 56.7% lation. The details of the studies included in the final of patients with CAD [26]. analysis are summarized in Table 1. The data obtained from the most recent EHIS [39] re- vealed that 43.9% of the Egyptian adult population was 2.2.3 Screening of studies for dyslipidemia aware of their hypertensive condition, whereas only A total of 251 articles from the structured searches and 22.7% of population could achieve blood pressure con- 4 articles from the unstructured searches were retrieved trol. Similarly, awareness about hypertension in the on prevalence and patient-centric management of dyslip- Egyptian National Hypertension Project was estimated at idemia for the Egyptian population. Studies representing Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 5 of 14 Table 1 Overview of studies for hypertension included in the final analysis (N = 11) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data as per the MAPS inclusion criteria Unstructured Global Status Report on Global status Adults (18+ years) 26.0% xx x x x x NA noncommunicable diseases: report tracking 2014 worldwide progress in prevention and control of NCDs Supplementary Egypt Health Issues Survey: Cross-sectional N = 16,671; individuals 17.2% xx 42.0% xx x record 2015 survey (15–59 years) (women) interviewed in the 16.7% survey. (men) Unstructured Egypt National STEPwise National cross- N = 6680; nationally 29.5% xx x x x x Survey For Noncommunicable sectional representative sample of Diseases Risk Factors Report; community- Egyptian adults (15-69 2017 based house- years). hold survey Registry of the Egyptian Nationwide N = 4701; controlled xx x x x x 27.1% specialized hypertension Specialized hypertension was clinics: patient risk profiles and Hypertension defined as BP < 140/90 geographical differences: El Clinics Registry mmHg in hypertensive Faramawy A; 2019 patients on antihypertensive medications. Data deviates from the MAPS inclusion criteria (year limit: 2010–2019) Unstructured Hypertension Prevalence, Cross-sectional N = 6733; survey 26.3% 37.5% xx 24.0% x 8.0% NA Awareness, Treatment, and nationwide participants (25 to 95 Control in Egypt. Results from survey years). the Egyptian National Hypertension Project (NHP): Ibrahim MM; 1995 Patterns and determinants of Multistage N = 316; hypertensive xx x x x 51.9% 53.2% treatment compliance among random patients attending hypertensive patients: Youssef sampling health insurance clinics RM; 2002 technique for prescription refills were randomly selected and interviewed. Supplementary Prevalence and determinants Cross-sectional N = 2869; participants x 43.9% xx x x 22.7% record of hypertension unawareness study using (≥18 years) were in Egyptian adults: a cross- data from the included if they sectional study of data from 2015 Egyptian measured blood the 2015 Egyptian Health Is- Health Issues pressure (systolic and/or sues Study: Soliman SS; 2020 Survey (EHIS) diastolic pressure ≥ 140/ 90 mmHg). Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 6 of 14 Table 1 Overview of studies for hypertension included in the final analysis (N = 11) (Continued) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data deviates from the MAPS inclusion criteria (definitions/special patient subgroups) Structured Lipid profile in Egyptian Retrospective N = 1000; CAD patients 56.7% x x x x x x Data extracted patients with coronary artery study of ranged from 19 to 90 from patients disease: Ibrahim MM; 2013 patients with years. with stable CAD CAD or had a history of MI Control of hypertension with Systematic N = 3342; Individuals 12.1% xx 64.7% 54.1% x 39.5% Hypertension medication: a comparative search of (35–49 years). definition is analysis of national surveys in national health based on 20 countries: Ikeda N; 2014 examination Systolic blood surveys from pressure (i.e., < 20 countries 140 mmHg) Comparative study between Retrospective N = 570; ACS patients 49.1 x x x x x x Data extracted elderly and younger patients registry were divided into 2 from younger with acute coronary syndrome: groups: elderly ≥ 60 patients (< 60 Obaya M; 2015 years; younger < 60 years) years. presenting with ACS; hypertension not defined The pattern of risk-factor pro- Multi-center, N = 1681; ACS patients 59.0% x x x x x x Data extracted file in Egyptian patients with observational, (≥18 years) having a on investigating acute coronary syndrome: cross-sectional history of hypertension ACS patients phase II of the Egyptian cross- study of ACS or blood pressure sectional CardioRisk project: patients (systolic and/or diastolic Reda A; 2019 pressure ≥140/90 mmHg). ACS, acute coronary syndrome; CAD, coronary artery disease; MI, myocardial infarction; NCD, noncommunicable diseases; NA, not applicable Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 7 of 14 specific patient subgroups (pregnant women, patients 2.2.4 Description of included studies: dyslipidemia with other comorbidities, n = 114), not reporting data On the basis of the nationwide survey data, the preva- on prevalence or any of the phases of patient-centric lence of hypercholesterolemia was 19.4%, 36.8%, and management (n = 57), not focusing on dyslipidemia (n = 19.2% in the Egyptian population during 2006, 2012, and 39), not representing adult population (n = 16), non- 2017, respectively [16, 41, 42]. However, cholesterol availability of full-text article (n = 8), lack of nationally- screening was poor, as reported in one nationwide sur- representative population (n = 3), case studies, letters to vey (8.6%) [16]. A nationwide, cross-sectional CardioRisk the editor, editorials (n = 2), duplicate records (n = 2), study conducted in patients with ACS reported in- and data not from the representative country (n=2) were creased low-density lipoprotein cholesterol (LDL-C) excluded. The findings of the initial data review indi- levels in 52.5% of the patients [6]. Similarly, another cated lack of data on dyslipidemia in the general popula- retrospective study reported a prevalence of dyslipidemia tion and thus necessitated inclusion of patient in 50.9% of younger patients (< 60 years) diagnosed with subgroups diagnosed with ACS or CAD at a later stage. ACS [35]. The high prevalence of dyslipidemia (58.7%) Eight articles from the structured searches, and all 4 arti- based on total cholesterol levels was also identified in cles from the unstructured searches were considered eli- Egyptian patients with CAD [26]. However, in a group gible for review. An additional survey-based study on of hypertensive Egyptians attending SHCs, the preva- NCDs risk factors in Egypt was supplemented to the lence of dyslipidemia was only 8.9% [8]. shortlisted records for assessment. Finally, 8 articles The results from both the Centralized Pan-Middle East from the structured searches [6, 8, 21–23, 26, 35, 40], 2 Survey on the under-treatment of hypercholesterolemia nationwide survey reports from the unstructured search (CEPHEUS) studies in Egypt indicated that most pa- [41, 42], and 1 additional study was included in the final tients were aware of their target cholesterol levels (76%) analysis [16]. Two of the selected studies were not con- or bad cholesterol (75%) [23, 40]. Although compliance sidered for final analysis because of the availability of the to treatment of dyslipidemia in the CEPHEUS II study similar data in the STEPS Survey reports. The literature was reported at 59% [40], target LDL-C levels were search and study selection process are summarized in achieved in only 32.5% and 34.4% of the patients as re- Fig. 2. ported in the CEPHEUS I and CEPHEUS II results, Fig. 2 Flowchart of literature search results on dyslipidemia. IPD, Incidence and Prevalence Databases; MOH, Ministry of Health; WHO, World Health Organization Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 8 of 14 respectively [23, 40]. According to the DYSlipidemia variability in the proportion of patients treated for International Study (DYSIS)-Egypt, one-third of the pa- hypertension (24% and 54%) [25, 37], which was not tients who received chronic statin treatment had control consistent with the treatment rates reported for LMICs in LDL-C levels [21]. In the DYSIS II study, 73.9% of pa- (29%) and HICs (56%) [45]. In our review, patient com- tients with ACS received treatment for dyslipidemia, pliance to treatment for hypertension was reported at whereas the proportion of patients who achieved target 52%, which was higher than the patient compliance re- LDL-C levels varied within different risk categories, with ported in a recent study (41%) [46]. Lower compliance 5.1% at very high risk, 27.3% at high risk, 32.3% at mod- to anti-hypertensive medication could be attributed to erate risk, and 14.3% at low risk [22]. No study provided increased cost, side effects, monotherapy, and lack of ef- data on diagnosis of dyslipidemia in the Egyptian popu- ficacy [20]. Similarly, there is a wide variability in the lation. The details of the studies included in the final blood pressure control rates as reported in our review analysis are summarized in Table 2. ranging from as the lowest estimate of 8% to the highest estimate of 53% [8, 20, 25, 37, 39], whereas the control 2.3 Discussion rates were reported at 27% in LMIC and 51% in HICs This semi-systematic review, for the first time, presented [45]. This trend in the rates of awareness, treatment, ad- the evidence available and identified inconsistencies in herence, and control of hypertension in the Egyptian reporting the data on prevalence and patient journey population that mimicked the trends in LMICs might be stages (awareness, screening, diagnosis, treatment, ad- related to lack of compliance with evidence-based treat- herence, and control) of hypertension and dyslipidemia ment, unavailability of simplified recommendations, and in Egypt. Despite performing a comprehensive literature higher diagnostic thresholds limiting early detection and review, only 22 studies (11 studies each for hypertension treatment initiation [43, 47, 48]. and dyslipidemia) were found to be relevant for the final analysis. Data were available on prevalence and all 2.3.2 Comparison with other studies on dyslipidemia phases of patient-centric management of hypertension, According to the STEPS reports, the prevalence of dys- except screening rates, whereas data were available on lipidemia in the general population of Egypt fluctuated the prevalence and all phases of patient-centric manage- from 19.4% in 2006 to 36.8% in 2012 and reduced to ment of dyslipidemia, except diagnosis rates. 19.2% in 2017 [16, 41, 42]. Although reasons for wide variability in prevalence could not be identified, such 2.3.1 Comparison with other studies on hypertension evidence will be useful for future endeavors in planning The studies included in this review demonstrated a wide large-scale studies in implementing treatment interven- variability in the prevalence of hypertension, which tions or health care policies. Among Egyptian patients could be explained by differences in population charac- with ACS and CAD, the prevalence of dyslipidemia was teristics, subgroup analysis, and study methodologies. consistently higher within the range between 51 and The prevalence estimates were lower in the younger 59%, which reinforced the latter’s status as a major risk general population aged between 35 and 49 years (12%) factor in CVDs [6]. There was a correlation between the [25] and surveyed population aged < 60 years (17%) [38], 2 risk factors when a study in hypertensive patients re- whereas the estimates were higher ranging from 49 to ported prevalence of dyslipidemia in 9% of the patients 59% in subgroup studies of patients with ACS and CAD, [8]. It is imperative to identify such high-risk patients indicating hypertensive patients were more susceptible with the presence of multiple risk factors so that they to develop CVDs [6, 26, 35]. However, the prevalence of can be targeted for treatment to reduce CVDs. The hypertension in the general Egyptian population did not prevalence of dyslipidemia reported in the general Egyp- vary and ranges between 26 and 29.5% [16, 36, 37], tian population was much lower than that projected by which were comparable to the prevalence reported in the WHO (39%). Further, the prevalence of high choles- the LMICs (31%) [43] and the USA (29%) [44]. terol in Egypt was comparatively lower than that re- Our study demonstrated that the levels of awareness ported in the USA (55%) and UK (66%) [15]. Data from of hypertension (38% and 44%) [37, 39] in the Egyptian both the CEPHEUS studies indicated a higher level of population were comparable with those in LMICs (38%), awareness in patients about their cholesterol levels but markedly lower when compared with that in the (≥75%), with a moderate level of adherence to the thera- high-income countries (HICs) (67%) [45]. Consequently, peutic regimen (59%) [23, 40]. However, there was a the percentages of diagnosed hypertensive individuals in possibility of recall bias, which is commonly seen in sur- Egypt were 42% and 65% in 2 studies [25, 38], which vey studies. Similarly, the proportion of patients treated were comparable to the range reported for various (74%) was relatively higher when analyzed in a small co- LMICs (46–75%), but substantially lower compared to hort of patients suffering from ACS [22], which may not the USA (85%) [25]. Further, we observed a wide be representative of the overall Egyptian population. Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 9 of 14 Table 2 Overview of studies for dyslipidemia included in the final analysis (N = 11) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics Data as per the MAPS inclusion criteria Unstructured Ministry of Health & National cross- N = 9780; participants 19.4% xx x x x x NA population, Egypt sectional (15–65 years) Preventive Sector survey Central Epidemiology and Disease Surveillance (ESU) Non- Communicable Disease Surveillance Unit (NCDSU); 2006 WHO and ARE-Ministry Multistage N = 5300; participants 36.8% xx x x x x NA of Health & Population: cluster sample (15–65 years) Egypt National STEP- design wise Survey of Non- Communicable Dis- eases Risk Factors 2011- 2012; 2012 Supplementary Egypt National National cross- N = 6680; nationally 19.2% x 8.6% xx x x NA Record STEPwise Survey For sectional representative sample of Noncommunicable community- Egyptian adults (15–69 Diseases Risk Factors based house- years). Report; 2017 hold survey Data deviates from the MAPS inclusion criteria (definitions/special patient subgroups) Structured The DYSlipidemia Cross- N = 1458; patients (≥ 45 xx x x x x 33.7% Control data International Study sectional, years) on stable statin extracted based on (DYSIS)-Egypt: A report observational, treatment. target LDL-C on the prevalence of multinational attainment lipid abnormalities in study Egyptian patients on chronic statin treatment: El Etriby A; Lipid profile in Egyptian Retrospective N = 1000; patients ranged 58.7% x x x x x x Data extracted from patients with coronary consecutive from 19 to 90 years. patients with stable artery disease: Ibrahim sampling of CAD or had a MM; 2013 patients with history MI CAD Centralized Pan-Middle Multicenter, N = 1043; subjects (≥ 18 x 76.0% xx x x 32.5% Control data East Survey on the observational years) were receiving extracted based on Under- Treatment of study lipid-lowering drug target LDL-C Hypercholesterolemia: treatment. attainment Results from the CE- PHEUS Study in Egypt: Reda A; 2014 Comparative study Comparative N = 570; patients were 50.9 x x x x x x Data extracted from Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 10 of 14 Table 2 Overview of studies for dyslipidemia included in the final analysis (N = 11) (Continued) Search type Study: first author; Brief study Sample size (N); Prevalence Awareness Screening Diagnosis Treatment Adherence Control Remarks publication date design characteristics between elderly and study divided into 2 groups: younger patients (< younger patients with between elderly ≥ 60 years; 60 year) presenting acute coronary elderly and younger < 60 years. with ACS; syndrome: Obaya M; younger dyslipidemia not 2015 patients with defined ACS Centralized Pan-Middle Observational, N = 896; Subjects (≥ 18 x 75.0% xx x 59.0% 34.4% Data extracted East Survey on the multicenter, years) receiving lipid- based on LDL-C Under- Treatment of cross-sectional lowering drug treatment. levels Hypercholesterolemia: survey Results from the CE- PHEUS II Study in Egypt: Reda A; 2017 Prevalence of lipid Prospective, N = 199; patients (≥ 18 xx x x 73.9% x 5.1% (very Data extracted on abnormalities and observational years) who were high risk; investigating cholesterol target value study of hospitalized for ACS and <70mg/ selected attainment in Egyptian patients receiving lipid-lowering dL) subpopulations (ACS patients presenting presenting treatment. 27.3% patients); control with an acute coronary with ACS (high risk; data extracted based syndrome: Sobhy M; < 100 mg/ on target LDL-C at- 2018 dL) tainment corre- 32. 3% sponding to (moderate different risk risk; < 115 categories mg/dL) 14.3% (low risk; < 130 mg/ dL) The pattern of risk- Multi-center, N = 1681; participants 52.50% x x x x x x Data extracted on factor profile in Egyp- observational, (≥18 years) having a investigating ACS tian patients with acute cross-sectional history of lipid-lowering patients; coronary syndrome: study of pa- therapy or LDL-C > 70 dyslipidemia phase II of the Egyptian tients present- mg/dL (> 1.81 mmol/L). definition is based cross-sectional CardioR- ing with ACS on LDL-C levels isk project: Reda A; Registry of the Nationwide N = 4701; dyslipidemia 8.90% x x x x x x Data extracted on Egyptian specialized Specialized considered when LDL ≥ investigating hypertension clinics: Hypertension 130 mg/dL, HDL ≤ 50 hypertensive patient risk profiles and Clinics mg/dL in women and ≤ patients based on geographical Registry 40 mg/dL in men, and TG LDL-C, HDL, and TG differences: El ≥150 mg/dL or if the levels Faramawy A; 2019 patient was receiving a lipid-lowering agent ACS, acute coronary syndrome; HDL, high-density lipoprotein; CAD, coronary artery disease; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; NA, not applicable; TG, triglycerides Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 11 of 14 Although the treatment rates of dyslipidemia were facilitate workshops, seminars, and availability of inter- higher, the overall control rates were lower in the national manuals for PHCs [61]. Although the WHO general population as well as in patients with ACS, has recognized Egypt’s commitment in scaling up PHC ranging from 20 to 34% [21–23, 40]. These lower facilities [62], the imbalance in care services across dif- control rates could be attributed to a lack of imple- ferent regions and socioeconomic groups necessitated mentation of evidence-based guidelines, clinical iner- the adoption of comprehensive strategies leading to ef- tia, and patients’ non-compliance to the prescribed fective national health care reforms [63]. To achieve treatment [49]. Similarly, less affordability to costly these reforms, the overall burden of hypertension and medications and “ceiling effect” on LDL-C lowering dyslipidemia in the Egyptian population should be esti- by statin therapy could be the reason for poor control mated using a risk assessment approach. In the absence rates in the lipid levels [50, 51]. of recommendations for opportunistic screening for CVD risk assessment in the general population, the 2.3.3 Implications for practice and patient-centric European guidelines emphasized the importance of sys- recommendations tematic screening for CVD risk assessment in individuals Suboptimal control of hypertension reflected lack of who are at high risk due to positive family history for education and limited medical access in Egypt, indicat- CVD risk factors [64]. Such an approach in addition to ing the need for collaborative efforts from health author- the periodic data collection to estimate the precise ities, medical community, and pharma companies to prevalence of risk factors and integration of population- promote patient education and national level campaigns based surveillance programs into the national health in- [19, 52]. Further, there is a need for specialized hyper- formation systems targeted toward detection, treatment, tension clinics in Egypt to improve quality and accessi- and control of CVDs could be rigorously followed as bility to health care services for the patients [11]. Egypt proposed in the WHO’s Global Action Plan [65]. For de- is now steadily progressing with its recent initiative to cades, Egypt’s health care sector has struggled to address develop a nationwide screening program “100 Million the public health crisis owing to underinvestment in Healthy Lives” accompanied by awareness and treatment public hospitals, unreliable private health care, inad- campaigns for NCDs such as hypertension and diabetes” equate health insurance, and issues related to equity by [53]. Thus, it would be crucial to publish these reliable race/ethnicity, gender, and other socioeconomic status and meaningful findings allowing the use of the credible measured by education, income, or occupation [66, 67]. information to aid policymakers to identify the target However, recently the Egyptian government has priori- population for their interventions and policies. More- tized health care services for all citizens ensuring over, extending the campaign to dyslipidemia would im- mandatory coverage eliminating existing disparities part a comprehensive coverage of the CVD landscape in through “The Universal Health Coverage Project” [68]. Egypt. In addition to these measures, there is a need to In Egypt, barriers were identified toward execution of conduct large epidemiological studies encompassing cul- smoking prevention measures such as lack of enforce- tural and ethnic contexts and studies comparing ment of smoke-free laws and lack of penalties for viola- evidence-based treatment and current treatment ap- tors [69]. National health policies and community proaches in Egypt to improve the rates of awareness, programs targeting the concurrent risk factors such as treatment, and control of dyslipidemia [54, 55]. Similarly, smoking cessation, improvement in lifestyle, and innova- awareness promotion, early identification, timely treat- tions within the context of patient-centric care, increas- ment, and cost-effective management of hypertension ing health communications, and enabling treatment and dyslipidemia could be achieved by an integrated ap- adherence monitoring could be meaningful measures for proach between affordable primary health care (PHC) hypertension and cholesterol management [70]. The im- services and family- or community-level focus [56–60], plementation of an electronic monitoring system and considering the medical resources constraint in Egypt. the use of eHealth communication were found to be Although there were significant advances in the emer- complicated and seemed to be underused [71]. Despite gency management of CVDs, primary preventive care the designing of several eHealth applications, successful was offered by the general practitioners (GPs), whereas implementation remained a challenge in Egypt due to specialists focused on secondary preventive measures for lack of patient acceptance, financial constraints, and lim- CVDs. Owing to a lack of formal education on cardiac ited infrastructure, especially in the rural areas [72]. primary prevention, there is a need for restructuring However, Egypt’s approach to digitize health services has curriculum in cardiology training with more focus on witnessed an accelerated transformation with the emer- primary preventive measures [5]. Moreover, physician’s ging use of artificial intelligence to diagnose diseases and lack of familiarity with diagnostic guidelines and practice provide treatment solutions via telehealth and telemedi- recommendations indicated that there is a need to cine, enabling better handling of medical data during the Reda et al. Journal of the Egyptian Public Health Association (2021) 96:32 Page 12 of 14 COVID-19 pandemic [73]. This holistic approach of hypercholesterolemia; CAD: Coronary artery disease; DYSIS: DYSlipidemia International Study; EHIS: Egypt Health Issues Survey; GP: General practitioner; translating digital interventions to the most vulnerable HICs: High-income country; IPD: Incidence and Prevalence Database; patients with greater CVD risk factors can be adopted LMIC: Low- and middle-income country; LDL-C: Low-density lipoprotein into the National eHealth policy as well in the future. cholesterol; MeSH: Medical Subject Heading; NCDs: Non-communicable diseases; PHC: Primary health care; SHC: Specialized hypertension clinic; SBP: Systolic blood pressure; WHO: World Health Organization 2.4 Limitations Our review has some limitations. Data on key patient 4 Supplementary Information journey touchpoints were not consistently available in all The online version contains supplementary material available at https://doi. articles, and thus, pooled estimates of synthesized data org/10.1186/s42506-021-00096-9. could not be reported. Furthermore, case studies and Additional file 1: Table S1. Search Strategy for Structured Search studies conducted on some patient subgroups (e.g., preg- nant women, adolescents) were excluded, and therefore, Acknowledgements we might have missed evidence to describe some of the The authors would like to thank Aditi Karmarkar, Pfizer Upjohn and Utsavi observations in our review. In addition, exclusion of pa- Samel, Viatris for supporting as independent reviewers and Tanaya Bharatan, tients with other comorbidities especially diabetes might Pfizer Upjohn, for critically reviewing the draft. Medical writing and editorial support were provided by Ramu Periyasamy and Soumya Chatterjee, have underestimated the actual prevalence of hyperten- Indegene Pvt. Ltd, and the study was sponsored by Upjohn – A legacy Pfizer sion because of the increased occurrence of hypertension Division. in patients with diabetes. Additionally, this study is lim- ited by inclusion of dyslipidemia studies based only on Authors’ contributions AR was involved in the study design, acquisition, analysis, interpretation of the levels of total cholesterol and not considering other dyslipidemia data, and critical review of the manuscript. HR was involved in variables such as triglycerides, low-density lipoprotein, the study design, acquisition, analysis and interpretation of hypertension and high-density lipoprotein. It is important to note that data, and critical review of the manuscript. KS was involved in the conception, acquisition of data, and analysis of hypertension and evidence maps can provide a brief overview of topic; dyslipidemia data, and review of the manuscript. MA was involved in the however, no information on efficacy of any individual conception, acquisition of data, and analysis of hypertension and treatment intervention was provided for patients with dyslipidemia data, and review of the manuscript. All authors have read and approved the final manuscript. hypertension or dyslipidemia. Furthermore, in this semi- systematic review of articles, critical appraisal for the Funding quality of findings was not assessed in the included This study was sponsored by Upjohn – A legacy Pfizer Division. studies. Availability of data and materials The dataset generated and analyzed during the current study is not publicly 3 Conclusion available as the dataset is proprietary, but is available from the corresponding author on reasonable request. This study complemented the existing literature on prevalence and provided insights on different phases of Declarations patient-centric management of hypertension and dyslip- idemia in Egypt. The findings supported the need for op- Ethics approval and consent to participate Not applicable portunistic screening for CVD risk factors when visiting a PHC facility, which in turn could result in early diag- Consent for publication nosis and improve treatment outcomes. The need for Not applicable multi-disciplinary commitment from government, pol- Competing interests icymakers, health care professionals, and other stake- AR and HR declare that they have no competing interests. KS is employed in holders toward the prevention of CVD risk factors, Pfizer Upjohn and MA is employed in Viatris. promotion of lifestyle interventions, and overall disease Author details management systems is crucial. Finally, this study may Department of Cardiology, Menoufia University, Shebin El Kom, Egypt. 2 3 provide a basis for research prioritization and recom- Department of Cardiology, National Heart Institute, Cairo, Egypt. Legacy employee, Research, Development and Medical, Pfizer Upjohn, Dubai, United mendations and guidance to practice and amend health Arab Emirates. Medical Affairs, Viatris, Cairo, Egypt. policies for the management of hypertension and dyslip- idemia in Egypt. The current study reinforces the need Received: 5 March 2021 Accepted: 16 November 2021 to generate more high-quality data at national-level on prevalence of hypertension and dyslipidemia along with References patient journey touchpoints to validate the conclusion of 1. Collaborators. G 2019 D and I. Global burden of 369 diseases and injuries in our findings. 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204–22. https://doi. 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Journal

Journal of the Egyptian Public Health AssociationSpringer Journals

Published: Dec 1, 2021

Keywords: Cardiovascular disease; Dyslipidemia; Egypt; Hypertension; Patient-centric; Prevalence; Touchpoints

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