Lipid clinics treatment

Treatment optimisation according to country income level

Healthy lifestyle counselling and treatment optimisation for hyperlipidaemia align with the Sustainable Development Goal no 3 of the United Nations for 2030: to ensure healthy lives and promote well-being. The objective is to reduce mortality from non-communicable diseases by a third by 2030 and to improve environmental health. Below we describe how best to achieve this in different countries, as access to healthy lifestyle counselling and different types of lipid-lowering therapies for ASCVD prevention differ substantially based on country income level (Figure 8).

• Low and lower-middle income countries
• Upper-middle income
• High-income

Low and lower-middle income countries

In lower-middle-income countries, 50% of the world’s population lives but less than 5% of global healthcare spending occurs^{45, 46}. In low-income countries, healthcare spending is also very limited, despite representing <10% of the world’s population. Lower-middle-income countries are located in South, Central and South-East Asia and Africa, including for example India, Pakistan, Nigeria, Ghana, Cambodia, Kyrgyzstan, and Uzbekistan. Low-income countries are mainly in Africa, as well as Afghanistan, Syria, and Yemen.

Lipid clinics must prioritise the most cost-effective interventions for common hyperlipidaemia within available resources. For rare, severe hyperlipidaemias, the main challenge is access to therapies that often require special pathways such as compassionate use.

• Lifestyle improvement
  Heart-healthy eating, regular physical activity, weight control, and smoking cessation should be the cornerstone of all lipid clinic programs to reduce ASCVD risk. A healthy diet is particularly important for hypertriglyceridemia, while its effect on LDL cholesterol may be modest. Lifestyle factors such as diet, calorie intake, alcohol consumption, and physical activity should be recorded systematically.
  Dietary counselling should be tailored to the condition but generally focus on reducing trans fats, saturated fats, and added sugars, while increasing fruits, vegetables, legumes, and whole grains. This should be adapted to locally available foods and cooking practices⁴⁷, which can be challenging⁴⁸.
  Physical activity counselling should include community-based initiatives such as walking groups, active transport, and workplace interventions requiring minimal infrastructure⁴⁹. Smoking cessation support should be systematically offered, particularly in settings with less tobacco regulation⁵⁰.
• Low-cost drugs
  When economically feasible, statins should be offered to all individuals at high or very high ASCVD risk according to guidelines^{3, 4}. If availability is limited, primary prevention should be restricted to very high-risk individuals (e.g. diabetes or heterozygous FH^{51, 52}) to prioritise those with greatest benefit, in line with WHO recommendations⁵³. Primary care systems should ensure access to high-intensity statins even in remote areas. Although statins were added to the WHO Essential Medicines List in 2007, only about one in ten eligible individuals used them for primary prevention in low- and middle-income countries in 2022⁵⁴.
  All patients with established ASCVD should receive statins, ideally at high intensity⁵¹, yet only one in five eligible people for secondary prevention were reported using statins in 2022 in low and middle income countries⁵⁴. Access to LDL and/or non-HDL cholesterol measurement should be improved to allow at least annual monitoring and support adherence. In cases of statin intolerance, the maximum tolerated dose should be used. Ezetimibe is the preferred second-line agent and may be feasible in many low- and lower-middle-income countries due to increasing generic availability^{55, 56}.
• Middle- and high-cost drugs
  If affordable, bempedoic acid may be considered for use with statin-intolerant and/or very high-risk patients. PCSK9 inhibitor antibodies should be reserved for selected patients such as those with ASCVD and high residual LDL cholesterol despite optimal combination of statins and ezetimibe, because they may be accessed only under discounted pricing, donor support, or externally funded agreements.
• Homozygous FH, familial chylomicronaemia syndrome
  Patients with homozygous FH, severe heterozygous FH, and familial chylomicronaemia syndrome should be referred to centralized hubs with specialized expertise. Access to LDL apheresis, highly specialized medication (lomitapide, evinacumab), or liver transplantation (when LDL apheresis is inaccessible) should depend on international partnerships and compassionate-use pathways, due to drastically limited public funding. Familial chylomicronaemia syndrome may be partly controlled by severe fat restriction in the diet.

Conclusion

Due to the scarcity of lipid clinics in low- and lower-middle-income countries and the challenges of LDL-C monitoring in remote areas, a network should connect internists, cardiologists, endocrinologists, and biologists to existing referral centres.

Management must balance effectiveness and affordability. Key priorities are lifestyle counselling, weight control, universal statins for secondary prevention, and targeted primary prevention. Expensive therapies should be reserved for exceptional cases, ideally supported by international mechanisms such as scientific guidance from atherosclerosis societies, WHO, and pharmaceutical companies. This pragmatic approach offers a sustainable path for long-term cardiovascular health gains.

Upper middle-income countries

Upper-middle-income countries represent over 30% of the world’s population but account for around 15% of healthcare spending^{45, 46} . They are located in Asia, Africa, the Middle East, Latin America, and parts of Eastern Europe (e.g. China, Brazil, South Africa, Turkey). In most of these countries, ASCVD incidence is rising, further challenged by limited healthcare resources, high prevalence of risk factors such as smoking, obesity, and diabetes, and insufficient access to preventive therapies⁵⁷.

• Lifestyle improvement
  For upper-middle income countries, lifestyle modification remains a top priority. However, such interventions face many challenges including:
  • Lack of awareness in the population about the benefits of lipid and cardiovascular risk factors control
  • Implementing comprehensive programs to promote smoking cessation and reduce alcohol consumption
  • Setting large-scale campaigns promoting overall healthy lifestyle, particularly healthy eating habits and regular physical activity, whereas a shift of the populations toward the cities is observed⁵⁸
  • Ensuring access to primary cardiovascular prevention and healthcare providers (both physicians and nurses) in rural areas, given that rural residence is an established determinant of worse prognosis
  • Establishing population-based screening programs adapted to local resources
  • Creating strict post-discharge pathways for secondary prevention
  • While diet, physical activity, and smoking cessation are key preventive measures, they may be limited by the affordability of healthy foods and weaker regulation of tobacco advertising in upper middle-income countries.
• Low-cost drugs
  Lipid-lowering therapies are indicated in high-risk individuals and those with severe hyperlipidaemia. Statins are first-line, with generic atorvastatin and rosuvastatin being the most widely used and cost-effective^{59, 60}; ezetimibe is also available in many countries. Primary prevention should prioritise high-risk groups (e.g. diabetes, severe hypertension, heterozygous FH), with focus on screening, affordable therapy, and risk factor management⁶¹.
• Middle- and high-cost drugs
  If LDL cholesterol remains above target on the maximum tolerated statin dose, therapy should be escalated by adding non-statin agents with proven cardiovascular benefit, such as ezetimibe, bempedoic acid, and/or PCSK9 inhibitor monoclonal antibodies, alone or in combination. The choice depends on the additional LDL reduction needed, cost, patient preference, and availability^{3, 4}.
  PCSK9 inhibitors (e.g. evolocumab, alirocumab) may be used in very high-risk patients with insufficient control in secondary prevention⁵⁵. Icosapent ethyl and fibrates may be considered in hypertriglyceridemic patients already on high-intensity statins.
• Highest-cost drugs and apheresis
  Accessing these expensive treatments presents several challenges, including establishing referral pathways that direct patients with rare and severe lipid disorders to dedicated national or regional lipid clinics, depending on the specific funding available^{3, 11, 62}.

Conclusions

Upper-middle-income countries face significant barriers to effective hyperlipidaemia management, including weak reimbursement systems, delayed approvals, and limited infrastructure for lipid monitoring. Pragmatic solutions involve centralized procurement of generics, strengthening local pharmaceutical production, and adopting cost-saving strategies such as fixed-dose polypills. Nurse-led lipid clinics, digital tools, and structured referral pathways can improve access, particularly in rural areas.
Ultimately, the most sustainable approach combines strong nationwide prevention campaigns, prioritization of lifestyle interventions, and targeted use of therapies in secondary prevention and very high-risk primary prevention patients. Such strategies will balance affordability, sustainability, and equity in cardiovascular prevention.

High-income countries

High-income countries represent <20% of the world’s population but account for >80% of healthcare spending, with the USA alone contributing 44%^45,46. These countries are located in North America, Europe, the Middle East, Asia-Pacific, and parts of Latin America (e.g. USA, Germany, Australia).

In most of these countries, ASCVD incidence is declining, particularly in age-standardized mortality rates. However, overall prevalence remains high, as the disease has shifted to older age groups.

• Lifestyle imporvement
  Implementation of lifestyle improvements in high-income countries remains challenging, especially among low-income subpopulations⁶³. Promoting physical activity to prevent obesity, metabolic syndrome, and type 2 diabetes mellitus is difficult due to low long-term adherence⁵⁸. Adherence to healthy diets (e.g. plant-based, Nordic, or Mediterranean) can also be limited by the cost of foods such as fruits, vegetables, and fish. Smoking control is more effective due to public smoking bans, high tobacco prices, advertising restrictions, and access to substitutes⁶⁴.
• Low-cost drugs
  Access to care, lipid testing, and generic drugs is generally good. Key challenges are:
  • To optimize screening strategies to improve early access to lipid-lowering treatment and prevent the development of ASCVD
  • To improve adherence to lifestyle improvement and lipid-lowering drugs, especially in primary prevention. The revisionism regarding statin prescriptions remains a challenge⁶⁵
  • To combat therapeutic inertia by implementing current guidelines
  • To confront fake news about statins
  • To tailor expensive treatments for the patients with the highest absolute risk, to contain the number needed to treat at a reasonable low level and thus ensure optimal treatment efficiency
  • To maintain a high level of clinical research to optimize the treatment options
• Middle-cost drugs
  Regarding bempedoic acid and icosapent ethyl, price negotiations with health authorities often result in a delay of several years in market access in many countries⁶⁶.
• High-cost drugs
  In most high-income countries, PCSK9 inhibitor drugs are subject to severe prescription restrictions for reimbursement, with a much more limited scope of use than that recommended by EAS/ESC dyslipidaemia guidelines^{3, 4}. This leaves many heterozygous FH patients without access to these treatments.
• Highest cost drugs
  Access to expensive therapies for very rare hyperlipidaemias is possible in several high-income countries under strict conditions, sometimes involving national lipid clinic staff. The small number of patients allows access for conditions such as familial chylomicronaemia syndrome and homozygous FH. However, patients with severe heterozygous FH and multifactorial chylomicronaemia often lack access outside clinical trials^{67, 68}. Lipid clinic networks are therefore important for establishing registries to highlight unmet needs in these patient groups.

Conclusions

Despite good access to generic drugs, therapeutic inertia creates a gap between guidelines and real-world practice. Lipid clinic networks therefore play a key educational role. Even in high-income countries, access to new treatments is often delayed, and national registries and patient organizations are important for identifying unmet needs and supporting access to costly therapies.

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