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24 April 2017

Residual cardiovascular risk in the Middle East: a perfect storm in the making

Prof. Jean Charles Fruchart, Prof. Michel Hermans, Prof. Pierre Amarenco

An Editorial from the R3i Trustees
Prof. Jean Charles Fruchart, Prof. Michel Hermans, Prof. Pierre Amarenco Continuing our theme of residual cardiovascular risk in developing regions we turn our attention to countries in the Middle East and North Africa (MENA), a region in critical health flux. Already in 2010, ischaemic heart disease was the leading cause of death and disability in the region 1, driven by the dual epidemics of type 2 diabetes and obesity. Data from the International Federation of Diabetes show that more than 35 million people living in the MENA region have diabetes and this number is expected to double by 2040. One in 10 adults has diabetes, half of them undiagnosed 2. Furthermore, evidence that the prevalence of obesity and related cardiometabolic risk factors is increasing in children and adolescents 3, highlights a perfect storm for cardiometabolic disease in this region, overturning improvements in life expectancy and other health indicators previously reported.

Given the high cardiometabolic risk in the MENA region, residual cardiovascular risk is also an important issue, as highlighted in this month’s Focus article. In this study, individuals with a history of ischaemic stroke living in this region were shown to be at high risk of recurrent stroke and myocardial infarction (MI), which were more likely to be fatal. These events also tended to occur at an earlier age when compared with individuals living in non-Arab countries 4. What is especially notable in this study is that socioeconomic cardiovascular risk factors, such as unemployment, limited education and lack of health coverage were key contributors to the significant difference in the risk of recurrent events in this region; when adjustment was made for these factors, this difference was largely attenuated.

Why are socioeconomic factors so relevant to residual cardiovascular risk in this region? Clearly that question merits further evaluation. However, in the interim we need to bear in mind that the MENA region has been in a state of political flux, with the Arab uprisings and associated conflicts, which undoubtedly have impacted the economies in this region. Furthermore, the demographics of the region, with both ageing and population growth, adds to the economic disparities, even in the higher-income, oil-producing countries.

Unless urgent action is taken, the burden of cardiometabolic disease will challenge already stretched human and financial resources in the MENA region. Although 9% of the global diabetes population live in the MENA region, local governments spending amounts to only 3% of the world’s healthcare diabetes budget 2,5. Even with investment in health education, it is clear that patient knowledge lags behind. As highlighted in a recent survey among diabetes patients in the United Arab Emirates, misconceptions about diet and lifestyle and blood testing are prevalent 6. Medication adherence is also a recognized issue 7. Furthermore, while the number of smokers in Europe and the US continues to fall, the reverse trend is evident across the Middle East 8, which may help to explain why smoking remains a factor contributing to residual cardiovascular risk as in the study reported by Abboud et al (2017) 4.

Thus, as well as tackling issues linked to poverty and economic development, patient education is also a priority. Given that education underpins the mission of the Residual Risk Reduction Initiative, the Foundation has a key role to play in addressing the challenge of residual cardiovascular risk in the MENA region. There is much to do………………….


1. Mokdad AH, Jaber S, Aziz MI et al. The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet 2014;383:309-20.
2. International Diabetes Federation Facts and Figures.
3. Al-Daghri NM, Aljohani NJ, Al-Attas OS et al. Comparisons in childhood obesity and cardiometabolic risk factors among urban Saudi Arab adolescents in 2008 and 2013. Child Care Health Dev 2016;42:652-7.
4. Abboud H, Sissani L, Labreuche J et al. Specificities of ischemic stroke risk factors in Arab-speaking countries. Cerebrovasc Dis 2017;43:169–77.
5. Mokdad AH, Forouzanfar M, Daoud et al. Health in times of uncertainty in the eastern Mediterranean region, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Glob Health 2016;4(10):e704-13.
6. Hashim MJ, Mustafa H, Ali H. Knowledge of diabetes among patients in the United Arab Emirates and trends since 2001: a study using the Michigan Diabetes Knowledge Test. East Mediterr Health J 2017;22(10):742-8.
7. BMC Public Health. 2016 Aug 24;161:857. doi: 10.1186/s12889-016-3492-0. Improving adherence to medication in adults with diabetes in the United Arab Emirates.
8. UAE losing fight against smoking.