A multidisciplinary expert consensus on the management of dyslipidemias in Cameroon: recommendations for clinical practice

¹Faculty of Medicine and Biomedical Sciences, Cardiology, University of Yaounde I, Yaounde, Cameroon, ²Faculty of Medicine and Biomedical Sciences, Internal Medicine and Endocrinology, University of Yaounde I, Yaounde, Cameroon, ³Faculty of Medicine and Pharmaceutical Sciences, Neurology, University of Douala, Douala, Cameroon, ⁴Faculty of Medicine and Biomedical Sciences, Internal Medicine and Nephrology, University of Yaounde I, Yaounde, Cameroon, ⁵Faculty of Medicine and Pharmaceutical Sciences, Internal Medicine and Nephrology, University of Douala, Douala, Cameroon, ⁶Faculty of Medicine and Biomedical Sciences, Internal Medicine and Cardiology, University of Yaounde I, Yaounde, Cameroon, ⁷Faculty of Medicine and Pharmaceutical Sciences, Cardiology, University of Dschang, Dschang, Cameroon, ⁸Faculty of Medicine and Pharmaceutical Sciences, Cardiology, University of Ebolowa, Ebolowa, Cameroon, ⁹Faculty of Health Sciences, Cardiology, Université des Montagnes, Bangangte, Cameroon, ¹⁰Faculty of Medicine and Pharmaceutical Sciences, Nephrology, University of Douala; Douala, Cameroon, ¹¹Faculty of Medicine and Biomedical Sciences, Nephrology, University of Yaounde I, Yaounde, Cameroon, ¹²Faculty of Health Sciences, Internal Medicine and Cardiology, University of Bamenda, Bamenda, Cameroon, ¹³Faculty of Health Sciences, Endocrinology and Diabetology, University of Bamenda, Bamenda, Cameroon, ¹⁴Neurology, Jamot Hospital, Yaounde, Cameroon, ¹⁵District Hospital of Obala, Endocrinology and Diabetology, Obala, Cameroon

^&Corresponding author
Samuel Kingue, Faculty of Medicine and Biomedical Sciences, Cardiology, University of Yaounde I, Yaounde, Cameroon

Meeting Report    

Introduction

Dyslipidemias are defined by abnormalities in circulating lipid concentrations, including an elevation of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), or a decrease in high-density lipoprotein cholesterol (HDL-C). Beyond their numerical values, these abnormalities are central to the pathogenesis of atherosclerosis [1].

The burden of dyslipidemias in Cameroon: sub-Saharan Africa is distinguished by a distinctive lipid profile where the elevation of total cholesterol (~25.5%) is surpassed by the prevalence of hypo-HDL-cholesterolemia (31.2%), often exacerbated by infectious factors such as HIV and chronic inflammatory processes [2,3]. In Cameroon, this trend is particularly marked in urban areas where more than half of the adult population (56.1%) presents at least one lipid abnormality, mainly characterized by the association of low HDL-C levels and moderate hypertriglyceridemia correlated with abdominal obesity [4]. This clinical reality reveals, however, a strong territorial heterogeneity, with a striking disparity between metropolises and rural areas like the Bamboutos, where the prevalence drops to approximately 8%, illustrating the determining influence of urbanization and lifestyle changes on the national metabolic profile [5,6]. Cameroonian experts agree on a hospital prevalence of dyslipidemia close to historical WHO estimates (22%) [7]. However, endogenous data [8] reveal rates of lipid abnormalities reaching 65.4% in specialized cardiology settings, underscoring the importance of better statistical documentation and systematic screening [8-10].

Cardiovascular risk factors and complications of atherosclerosis in Cameroon: dyslipidemia does not evolve in isolation in Cameroon. It integrates into a "cluster" of risks: arterial hypertension (HTA) is present in nearly 30% of adults, often associated with type 2 diabetes [4]. The deleterious impact of HIV and the first generations of antiretroviral treatments on lipid metabolism constitutes a major risk multiplier specific to the national context [9]. Far from being a mere theoretical hypothesis, atherosclerosis now constitutes a tangible clinical reality in Cameroon, solidly supported by contemporary paraclinical evidence. Angiographic data from the Shisong Cardiac Centre notably reveal the presence of complex atheromatous coronary lesions affecting increasingly younger patients [6,9]. Parallelly, evaluations by carotid ultrasound conducted in the metropolises of Yaounde and Douala confirm this trend by objectifying a frequent increase in intima-media thickness (IMT) in hypertensive and diabetic subjects, testifying to an already generalized subclinical atherosclerosis within these high-risk populations [10]. The consequences of these untreated lipid disorders impose a growing burden on the Cameroonian health system, manifested by an alarming incidence of ischemic strokes, often severe, and by the emergence of acute coronary syndromes (ACS). The latter, once considered rare in sub-Saharan Africa, are today in constant progression in national cardiology departments [5,6]. Finally, peripheral arterial disease (PAD) aggravates this clinical picture, particularly in diabetic patients, where it significantly increases the risk of amputations and functional disability [6].

Justification for the consensus: the direct application of international directives, notably those of the European Society of Cardiology (ESC) [1] or the American Heart Association (AHA) [11], faces the specific realities of the local context. Conventional risk algorithms do not integrate endemic variables that are nonetheless crucial, such as HIV infection, the impact of antiretroviral therapies, or the early onset of arterial hypertension. Furthermore, the most aggressive therapeutic targets and the use of expensive pharmacological innovations remain largely inaccessible due to the absence of universal health coverage and the prohibitive cost of treatments. Consequently, the development of this consensus responds to the imperative to decompartmentalize management by creating a synergy between cardiologists, endocrinologists, biologists, and general practitioners. The central objective of this document is to provide health professionals practicing in Cameroon with a national, harmonized, and pragmatic reference framework for the screening, diagnosis, and management of dyslipidemias, in order to reduce the incidence of major cardiovascular complications.

Methods

The development of the present consensus was based on the constitution of a multidisciplinary panel of 20 Cameroonian experts, whose selection was based on their recognized clinical expertise and their direct involvement in the management of metabolic diseases at the national level. This working group brought together cross-cutting skills, including clinical and interventional cardiologists, endocrinologists and diabetologists, internists, nephrologists, and neurologists. Participants were also selected based on their status as university faculty or active members of national scientific societies, notably the Cameroon Cardiac Society, the Cameroonian Society of Diabetology, the Cameroonian Society of Nephrology, and the Cameroonian Society of Neurology. The consensus process was articulated around three major methodological stages following a modified Delphi approach [12]. An initial analysis phase made it possible to identify international recommendations whose immediate applicability is constrained by local socio-economic realities or epidemiological particularities. The consensus process relied on a structured methodology combining scientific data review and collegiate deliberations. Proposals arising from the analysis of international recommendations were submitted to a formal vote of participants using an anonymous electronic voting system. A proposal was considered adopted when it obtained a simple majority of votes cast (>70%). In case of non-consensual results or significant divergences, a structured debate was organized to allow an argued discussion and, if necessary, a reformulation of the proposal before a new vote. This approach aimed to guarantee decisional transparency while promoting the balanced expression of multidisciplinary expertise. Finally, the writing and validation phase consisted of a synthesis of recommendations by a restricted committee, submitted to a critical re-reading by the entire panel until unanimous agreement on the final orientations was obtained. The consensus does not constitute an official recommendation formally endorsed by these learned societies, but reflects the opinion of experts from these bodies. The logistical organization of the consensus meeting was financially supported by a pharmaceutical firm marketing a statin. However, the sponsor participated neither in the scientific development of the recommendations, nor in the discussions, nor in the writing or final validation of the document. The sponsor had no influence on therapeutic choices, drug selection, or clinical recommendations. The experts worked in full intellectual independence.

Evaluation of a patient with dyslipidemia

Evaluation of global cardiovascular risk: the cornerstone of dyslipidemia management relies on rigorous stratification of global cardiovascular risk, allowing the classification of patients into four distinct categories: low, moderate, high, and very high risk. To refine this evaluation in the local context, the consensus relies on the reference work of the World Health Organization (WHO) Working Group on cardiovascular risk charts in 2019 [13] as illustrated in Figure 1. These updated predictive models have the major advantage of having been calibrated for 21 world regions, thus integrating the epidemiological specificities of sub-Saharan Africa. The adoption of these tools allows Cameroonian clinicians to surpass the limits of classic Western scores and to adjust the intensity of therapeutic interventions, both at the individual level and at that of national public health policies.

Biological diagnosis: in accordance with the consensus of Cameroonian experts of 2025, the diagnostic approach to dyslipidemias relies on targeted opportunistic screening towards vulnerable populations- notably patients suffering from hypertension, diabetes, obesity, HIV infection, or having a family history of premature disease-and now prioritizes non-HDL cholesterol as a frontline atherogenic marker. This strategic choice responds to local epidemiological specificities, characterized by a high prevalence of hypo-HDL-cholesterolemia and hypertriglyceridemia (30-35%), while offering an economically accessible and pragmatic solution not strictly requiring fasting. The biological diagnosis, harmonized between laboratories, must rely on a basic profile (TC, LDL-C, HDL-C, TG) systematically integrated into a stratification of global cardiovascular risk, including endogenous "risk multipliers". Finally, for complex profiles or those suspected of genetic origin, the consensus recommends the measurement, at least once in a lifetime, of apolipoprotein B and lipoprotein (a), thus guaranteeing a fine phenotypic evaluation adapted to the national technical platform.

The Cameroonian consensus adopts a pragmatic position regarding advanced biomarkers, reconciling international standards and local economic constraints. Although the theoretical superiority of apolipoprotein B (Apo B) is recognized to assess atherogenic load, its routine use is discarded in favor of non-HDL cholesterol, judged more accessible, free, and just as effective in the national context. As for lipoprotein (a), its assay is strictly reserved for risk stratification in secondary prevention (premature events), in case of marked family history, or suspicion of familial hypercholesterolemia. In the absence of specific targeted therapies, the identification of an elevated Lp(a) serves essentially as a clinical lever to intensify the lowering of LDL-cholesterol in high-risk patients. The lipid profile observed in clinical practice in Cameroon deviates from classic Western models and is characterized by mixed dyslipidemia with a strong atherogenic component, whose real prevalence is estimated between 30 and 35%. This predominant phenotype is marked by the "atherogenic triad" associating frequent hypo-HDL-cholesterolemia, moderate hypertriglyceridemia, and the presence of small dense LDL particles, particularly in diabetic, obese patients, or those living with HIV under antiretroviral treatment. This local specificity, where cardiovascular risk is often underestimated by total cholesterol assay alone, justifies the experts' recommendation to prioritize non-HDL cholesterol for a more precise evaluation. Finally, the consensus emphasizes the urgency of conducting longitudinal studies to define endogenous reference thresholds (cut-offs) adapted to sub-Saharan metabolism, genetics, and diet. The diagnostic approach in Cameroon is now part of a holistic approach that combines the systematic search for secondary etiologies- metabolic, endocrine, or renal and the evaluation of organic repercussions by imaging (carotid Doppler ultrasound, calcium score, or screening for metabolic hepatic steatosis).

Therapeutic target for the management of hypercholesterolemia: in coherence with international standards [1], the therapeutic strategy is dictated by rigorous stratification of global cardiovascular risk, setting LDL-cholesterol targets of <0.55 g/L for very high risk (with a minimal reduction of ≥ 50%), <0.70 g/L for high risk, and <1.00 g/L for moderate risk. Particular attention is paid to hypertriglyceridemias, frequent in the sub-Saharan context due to high-carbohydrate diets, where the use of fibrates is reserved for levels >5 g/L to prevent the risk of acute pancreatitis. Finally, the integration of local "risk modifiers," such as the early onset of hypertension and diabetes, as well as the systematic use of non-HDL cholesterol (target: LDL target + 0.30 g/L), allows adapting intervention thresholds to the phenotypic and socio-epidemiological specificities of the Cameroonian population.

Lifestyle modifications for improving the lipid profile: analysis of nutritional trends in Africa between 1990 and 2017 reveals a marked imbalance in the structure of total energy intake (TEI) on the continent [14]. The authors point out that the African diet remains largely dominated by carbohydrates, which often represent more than 70% of TEI in many countries, exceeding public health objectives set for the prevention of non-communicable diseases. In contrast, protein intake remains relatively low and stable, while the share of lipids increases progressively with urbanization but remains often below or at the lower limit of quality recommendations (notably due to a deficit in unsaturated fatty acids). This hyperglycemic profile is identified as a key driver of the prevalence of hypertriglyceridemias and low HDL-cholesterol levels observed in clinical practice, particularly in Cameroon. (Adopted reference typology of lifestyle interventions according to the type of dyslipidemia is presented in Table 1. Faced with this finding, the experts´ opinion for the Cameroonian consensus is to; i) reduce the share of carbohydrates in the global energy intake to bring it back to more balanced proportions (50-55%); ii) prioritize quality: encourage the consumption of carbohydrates with a low glycemic index and rich in fiber (whole grains, local vegetables like folong or ndole); iii) therapeutic education: sensitize patients to the fact that the "danger" for the heart comes not only from visible fats but also from excess starches.

Initiation of statin therapy

Therapeutic strategy: according to international recommendations, management is based on a rigorous "Treat-to-Target" strategy, where the intensity of treatment is dictated by the level of cardiovascular risk as shown in Table 2 [15]. In low-risk patients, priority is given to lifestyle and dietary measures during an observation period of 3 to 6 months. Statin therapy is envisaged only in case of failure of this phase and only if the LDL-C level remains ≥ 1.90 g/L (4.9 mmol/L) [1,11]. For patients at very high risk, the objective is to obtain a reduction of >50% of the initial LDL-C combined with an absolute target of <1.4 mmol/L (<0.55 g/L), while for high risk, the target is set at <1.8 mmol/L (<0.70 g/L). The algorithm prioritizes first a high-intensity statin at the maximum tolerated dose, followed, in case of failure after 8 to 12 weeks, by the addition of ezetimibe and then possibly a PCSK9 inhibitor in secondary prevention. Biological safety is simplified by a single control of alanine aminotransferase (ALAT) after initiation and a creatine phosphokinase (CPK) assay reserved for cases of myalgia, while emphasizing the importance of early and intensive initiation from the hospital phase in case of acute coronary syndrome [1,11].

Experts´ opinion on the criteria for initiating statin therapy: the initiation of statin therapy relies on a multidimensional decisional approach prioritizing the assessment of global cardiovascular risk over an isolated biological parameter. Beyond systematic prescription in secondary prevention, the consensus defines major intervention criteria in primary prevention: a persisting LDL-cholesterol level ≥ 1.90 g/L (4.9 mmol/L), the presence of high-risk comorbidities such as type 2 diabetes, or the documentation of subclinical atherosclerosis (carotid plaques on imaging). The strategy also integrates local epidemiological specificities, notably HIV infection due to its pro-inflammatory and pro-atherogenic character and the atherogenic dyslipidemia profile (hypo-HDL-cholesterolemia and hypertriglyceridemia), frequent in the sub-Saharan context. For patients at low or moderate risk, pharmacological initiation remains conditioned by the failure of an observation period of three to six months dedicated to lifestyle and dietary measures, thus guaranteeing graduated and adapted management in the national socio-economic context.

Target LDL-C level

Experts´ opinion on LDL-C targets: aligning with the international directives of ESC 2019 [1], the Cameroonian consensus sets the therapeutic objective for patients at high cardiovascular risk at an LDL-cholesterol (LDL-C) level below 0.70 g/L (1.8 mmol/L), imperatively associated with a minimal reduction of 50% compared to the baseline value. This rigorous target applies to patients presenting severe risk factors, moderate renal insufficiency, or diabetes evolving for more than ten years. In case of analytical limits or complex diabetic profiles, the consensus advocates non-HDL-cholesterol as an alternative target with a threshold below 1.00 g/L (2.6 mmol/L). The therapeutic strategy relies on the use of high-intensity statins at the maximum tolerated dose, with early addition of ezetimibe after 8 to 12 weeks if objectives are not reached, an approach deemed feasible thanks to the adequacy of the local technical platform and necessary in view of the high prevalence of thromboembolic complications, notably strokes, in Cameroon.

Management of dyslipidemia in specific context

Dyslipidemias and cardiovascular disease

Experts´ opinion on the management of patients with established atherosclerotic vascular disease (ASCVD): in agreement with international recommendations [1,11] and in view of the Cameroonian clinical reality -marked notably by a high prevalence of ischemic strokes- the expert consensus emphasizes that patients presenting established atherosclerotic vascular disease (ASCVD) must be systematically classified in the "very high risk" cardiovascular category. For this population in secondary prevention, the experts recommend the immediate initiation of intensive lipid-lowering treatment, based on high-intensity statins, to achieve a strict therapeutic target of LDL-cholesterol below 0.55 g/L (1.4 mmol/L) or a reduction of at least 50% compared to the baseline value. This pharmacological strategy, pivotal for the stabilization of atheroma plaques, must be integrated into a multidimensional and perennial management including rigorous blood pressure control, the use of antiplatelet agents, and reinforced therapeutic education, aiming to drastically reduce an otherwise extremely high risk of recurrence.

Experts´ opinion on statin initiation in high-risk patients for primary prevention: the initiation of statin therapy in primary prevention in patients at high cardiovascular risk characterized by a 10-year risk ≥ 20% or long-standing diabetes is the subject of a robust consensus aligning international directives [1,11] and the position of Cameroonian experts. While international recommendations advocate immediate intervention with the highest level of evidence (class I, level A) to reduce LDL-cholesterol by ≥50%, the local consensus emphasizes the imperative of this proactive strategy to counter the high prevalence of atherogenic dyslipidemia in Cameroon and prevent precociously the occurrence of major accidents, such as strokes. Experts agree that the clinical benefit of this management largely outweighs the potential risks, especially since the national technical platform now allows adequate biological monitoring, making preventive pharmacological treatment an essential pillar of the strategy for reducing cardiovascular morbidity and mortality at the local level.

Experts´ opinion on statin initiation in patients with established atherosclerotic cardiovascular disease (ASCVD), in secondary prevention: the initiation of high-intensity statin therapy in patients with established atherosclerotic cardiovascular disease (ASCVD) is the subject of an absolute international consensus, positioning these patients in the "very high risk" category. The ESC/EAS and ACC/AHA recommendations advocate systematic intervention (Class I, Level A) aiming for a reduction of LDL-cholesterol ≥ 50% with a preferential target below 0.55 g/L (1.4 mmol/L). Aligning with these directives, Cameroonian experts emphasize the urgency of this management to stabilize atheroma plaques thanks to the pleiotropic effects of statins. In the local context, where recurrences of strokes are frequent and burdened with heavy mortality, the consensus establishes the early and systematic initiation of treatment as a major public health imperative to reduce cardiovascular morbidity and mortality in secondary prevention.

Experts´ opinion for high-risk persons suffering from hypertriglyceridemia: international recommendations (ESC/EAS 2019, ACC/AHA 2018/2019) and the consensus of Cameroonian experts agree to establish statins as the first-line pharmacological treatment in high cardiovascular risk patients presenting hypertriglyceridemia. This strategy, validated with a high level of evidence (Class I, Level B), prioritizes reaching LDL-cholesterol targets as the absolute priority to reduce the incidence of major vascular events. Local experts emphasize that, faced with the lipid profile frequently observed in Cameroon characterized by hypertriglyceridemia associated with a low HDL-cholesterol level the statin constitutes the indispensable therapeutic base to treat the most atherogenic component of the assessment. The consensus thus advocates a rigorous sequential approach, where the optimization of statin treatment and lifestyle measures systematically precedes the addition of complementary molecules, such as fibrates, for the management of a possible residual risk or persisting hypertriglyceridemia.

Experts´ opinion on the prescription of a high-intensity statin in secondary prevention: international recommendations (ESC/EAS 2019, ACC/AHA 2018/2019) and the consensus of Cameroonian experts agree on the systematic use of high-intensity statins aiming for a reduction of LDL-cholesterol ≥ 50% in clinical situations where the risk of cardiovascular complications is major. This strategy is deemed imperative in secondary prevention for all patients presenting with established atherosclerotic cardiovascular disease (ASCVD), as well as in primary prevention for individuals with severe hypercholesterolemia (LDL-C ≥ 1.9 g/L) or calculated high cardiovascular risk. While aligning with these directives, local experts specify that, for the Cameroonian context, should be envisaged from a 10-year risk > 7.5% in order to prevent precociously high-intensity recurrences of strokes and infarctions. However, a nuance is brought regarding diabetes: contrary to sometimes more systematic international standards, Cameroonian experts advocate a graduated approach, prioritizing moderate intensity for diabetic patients without additional risk factors and reserving intensive doses for long-standing forms or those associated with other risk cofactors.

Experts´ opinion on the intensification of statin therapy before the introduction of a combined treatment: international guidelines (ESC/EAS, ACC/AHA) advocate a strict sequential approach where the intensification of statin monotherapy to the maximum tolerated dose constitutes an imperative step for all patients not having reached their LDL-cholesterol targets before any therapeutic adjunction. Aligning with this principle of pharmacological optimization, Cameroonian experts estimate, however, that in local clinical practice, this intensification specifically concerns 20 to 40% of patients. The consensus emphasizes that if therapeutic escalation is indispensable to bridge the often important gap between initial LDL-C levels and recommended objectives, it must imperatively be accompanied by increased surveillance of muscular and hepatic tolerance, as well as adherence. Thus, the introduction of a combined treatment, such as ezetimibe, is envisaged only after having exhausted the maximal benefit of tolerated monotherapy, thus guaranteeing cost-effective and safe management of dyslipidemia.

Statin in patients after percutaneous coronary intervention: international recommendations [1,11,16] and the consensus of Cameroonian experts agree on the systematic prescription of high-dose atorvastatin (40 to 80 mg) in patients who have benefited from a percutaneous coronary intervention (PCI). Classified immediately in the "very high risk" category, these patients require an aggressive strategy of LDL-cholesterol reduction of at least 50% to reach a preferential target below 0.55 g/L (1.4 mmol/L). Beyond the lipid-lowering effect, experts emphasize the capital importance of the pleiotropic effects of atorvastatin, notably its anti-inflammatory properties and its capacity to stabilize atheroma plaques immediately after stent placement. In the local clinical context, the early and systematic initiation of this high-intensity therapy is recognized as an essential pillar of secondary prevention to drastically reduce the risk of post-procedure ischemic recurrence.

Statin and heart failure: international recommendations [1,11,17] and the consensus of Cameroonian experts adopt a nuanced position regarding the use of atorvastatin in chronic heart failure (CHF), emphasizing the absence of demonstrated benefit on global mortality or hospitalizations in symptomatic forms of non-ischemic origin (CORONA and GISSI-HF studies). If systematic initiation is not advocated in isolated CHF, experts agree on the necessity to maintain or initiate treatment when the etiology is ischemic or in the presence of associated atheromatous pathology. In the local context, atorvastatin is considered an essential lever for stabilizing global cardiovascular risk factors and preventing incident heart failure in coronary patients, subject to attentive surveillance of hepatic and muscular tolerance in these fragile patients.

Dyslipidemia and diabetes: international recommendations agree to classify the large majority of diabetic patients in high or very high cardiovascular risk categories, imposing increasingly strict LDL-cholesterol (LDL-C) targets. According to ESC/EAS (2019), diabetic patients with target organ damage or at least three major risk factors are at "very high risk", with an LDL-C target of < 55 mg/dL (1.4 mmol/L). The ADA joins this position by recommending, for diabetic patients with established atherosclerotic cardiovascular disease (ASCVD) or at very high risk, an intensive approach also aiming for an LDL-C target of < 55 mg/dL, emphasizing that a reduction of 50% or more compared to the initial value is necessary. For patients at "high risk" (diabetes without target organ damage but with a duration > 10 years), the objective remains generally < 70 mg/dL (1.8 mmol/L) [18-20]. Therapeutically, the ADA and ACC/AHA (2018) advocate the systematic initiation of a moderate-intensity statin for all diabetic adults aged 40 to 75, independently of calculated risk. Intensification towards a high-intensity statin is recommended by the ADA for diabetic patients aged 40 to 75 presenting additional cardiovascular risk factors or a 10-year risk > 20%. In case of non-achievement of objectives under the maximum tolerated dose of statin, the consensus between ESC/EAS, ACC/AHA, and ADA is to add ezetimibe as the first line of combined treatment. If targets are still not reached, the use of PCSK9 inhibitors is recommended, particularly for patients in secondary prevention. Finally, regarding the management of triglycerides, the three societies emphasize the importance of lifestyle modifications. However, for patients under statin therapy having persistent triglycerides (between 135 and 499 mg/dL), the ADA and ESC/EAS now recommend the addition of icosapent ethyl (a purified EPA ester) to reduce the residual risk of cardiovascular events, based on the results of the REDUCE-IT study. Fibrates are generally envisaged only in case of severe hypertriglyceridemia (> 500 mg/dL) to prevent the risk of pancreatitis, although their cardiovascular benefit in combination with statins remains less documented than that of icosapent ethyl in recent guidelines.

Experts´ opinion for the initiation of a statin in diabetic patients (aged 20 to 29 years) presenting a risk of atherosclerotic cardiovascular disease: regarding young diabetic patients (aged 20 to 39 years), Cameroonian experts advocate the initiation of statin therapy as soon as diabetes is associated with target organ lesions or cardiovascular risk cofactors such as arterial hypertension, obesity, or smoking. The consensus emphasizes that diabetes acts as a premature accelerator of the atherosclerotic process, justifying a "primordial prevention" strategy to limit the deleterious impact of prolonged exposure to dyslipidemia. Although lifestyle modifications remain the cornerstone of management in this age group, experts recommend not delaying pharmacological treatment if the risk of atherosclerotic cardiovascular disease (ASCVD) is deemed significant. This vigilance is all the more crucial in the Cameroonian context, where the lipid profile of young diabetics is frequently marked by hypertriglyceridemia associated with a low HDL-cholesterol level, constituting a particularly atherogenic phenotype.

Experts´ opinion for the prescription of a high-intensity statin in diabetic patients presenting several risk factors: Cameroonian experts unanimously agree on the relevance of initiating a high-intensity statin therapy in patients presenting several cardiovascular risk factors. This position relies on the recognition of the synergistic effect of comorbidities such as arterial hypertension, smoking, and sedentarity behavior which exponentially increase global cardiovascular risk. In the local clinical context, where patients frequently present a complex multifactorial profile from diagnosis, the use of high-intensity statins (atorvastatin 40-80 mg) is advocated as the most reliable strategy to rapidly achieve increasingly strict LDL-cholesterol targets. While advocating this robust primary prevention approach to limit entry into vascular disease (stroke, infarction), the consensus emphasizes the imperative of attentive clinical surveillance to guarantee tolerance and therapeutic adherence in the face of the challenges of polymedication often encountered in Cameroon.

Experts´ opinion in diabetic patients (aged 40 to 75 years) without atherosclerotic cardiovascular disease: Cameroonian experts unanimously agree on the systematic initiation of moderate-dose statin therapy in all diabetic patients aged 40 to 75 years, even in the absence of established atherosclerotic cardiovascular disease (ASCVD). This recommendation relies on the recognition of diabetes in this age group as a major risk factor, justifying pharmacological protection as soon as the LDL-cholesterol level is > 0.70 g/L (70 mg/dL). Considered a minimal standard of care in Cameroon, this strategy aims to prevent precocious atherosclerotic complications before vascular damage becomes irreversible. However, the consensus specifies that the intensity of treatment must be reevaluated on a case-by-case basis: the switch to a high-intensity statin is advocated if the patient presents additional risk cofactors, such as arterial hypertension, smoking, or chronic renal insufficiency.

Experts´ opinion for the prescription of atorvastatin to diabetic patients suffering from dyslipidemia: the use of atorvastatin in dyslipidemic diabetic patients relies on a documented balance between lipid-lowering efficacy and organ protection. If the international literature, notably the study by Barakat et al. [19], demonstrates a superiority of rosuvastatin in the raw reduction of LDL-cholesterol, it highlights the superiority of atorvastatin in terms of nephroprotection, with a significantly lower incidence rate of microalbuminuria. Aligning with these data, the consensus of Cameroonian experts massively validates atorvastatin as a therapeutic pillar, emphasizing its particular efficacy on mixed lipid profiles (elevated LDL-C, hypertriglyceridemia, and low HDL-C) frequently encountered in Cameroon. Experts insist that, through its pleiotropic effects and its capacity to reduce the residual risk of macrovascular complications (infarction, stroke), atorvastatin constitutes a strategy of choice to slow vessel damage and protect target organs, while presenting a satisfactory clinical tolerance profile for the local population.

Experts´ opinion on the prescription of a statin in women and elderly diabetic persons: international scientific literature, supported by the works of Saku et al. Fulcher et al. and Welty et al. [20-22], confirms the efficacy and safety of statins in various specific populations, emphasizing their crucial role in the stabilization of atheroma plaques and the reduction of coronary events. These studies demonstrate notably that the clinical benefits of treatment are proportionally identical in women, pleading for a paritarian therapeutic intensification, and that they remain major in elderly subjects, for whom chronological age must no longer constitute a barrier to the initiation of treatment in view of the benefit on morbidity and mortality. Aligning with these conclusions, Cameroonian experts reaffirm that the optimization of dyslipidemia management with statins must be transversal, including without distinction of sex or age, high-risk patients, to durably reduce the burden of cardiovascular diseases at the national level.

Experts´ opinion on the choice of statin in diabetics for lowering the LDL-C rate: for the lowering of LDL-cholesterol (LDL-C), the consensus of Cameroonian experts privileges atorvastatin as the reference molecule. This choice relies on the pharmacological power of this statin, deemed indispensable to reach the rigorous therapeutic targets required in high-risk patients and in secondary prevention. Beyond its efficacy, experts emphasize the clinical versatility of atorvastatin on complex metabolic profiles, notably in diabetic patients or those with metabolic syndrome, frequent in Cameroon, as well as its excellent safety profile. Finally, its wide availability and local accessibility make it the preferred option to harmonize dyslipidemia management practices and optimize therapeutic adherence at the national scale.

Experts´ opinion on the choice of statin in elderly diabetics for lowering the LDL-C rate: for the management of dyslipidemias in the elderly subject, the consensus of Cameroonian experts designates atorvastatin as the first-intention treatment. This choice is motivated by its well-established efficacy and safety profile in the reduction of major cardiovascular events, notably ischemic strokes, whose prevalence is particularly high among seniors in Cameroon. Experts advocate, however, a prudent approach, consisting of initiating treatment at moderate doses followed by progressive titration to limit the risk of adverse effects, notably muscular. The consensus emphasizes that the therapeutic decision must integrate a global assessment of the patient's frailty, comorbidities, and risk of drug interactions in order to guarantee an optimal cardiovascular benefit while preserving clinical tolerance.

Experts´ opinion on the prescription of statins in patients with hepatic insufficiency: although international literature, illustrated by the works of Chan et al. [23] highlights the excellent hepatic innocuity of atorvastatin with a rare incidence of enzymatic elevations (< 1%) and often reversible, Cameroonian experts adopt a much more reserved position, expressing a disagreement regarding its systematic recommendation in case of hepatic insufficiency. While data suggest safety of use even in the presence of non-alcoholic hepatic steatosis, the local consensus recalls that the molecule remains formally contraindicated in case of evolutive hepatic disease or persistent elevation of transaminases superior to three times the normal limit. This prudence is explained by the essentially hepatic metabolism of atorvastatin, whose alteration can lead to systemic accumulation and increase the risk of muscular toxicity. Consequently, experts advocate rigorous pre-therapeutic assessment and restrict the use of statins to mild hepatic impairments under close surveillance, privileging therapeutic alternatives for clinically significant insufficiencies.

Dyslipidemia and stroke: the stroke prevention by aggressive reduction in cholesterol levels (SPARCL) study, published in the New England Journal of Medicine (2006) [24], demonstrated that daily administration of 80 mg of atorvastatin reduces by 16% the relative risk of recurrence of fatal or non-fatal stroke in patients having recently suffered an ischemic accident (stroke or TIA) without known ischemic heart disease. Besides a major 35% reduction in the risk of global cardiovascular events, these works emphasize that, despite a slight increase in the incidence of hemorrhagic strokes, the net clinical benefit remains largely in favor of high-intensity therapy. These results were thus fundamental to establish the systematic use of statins as a pillar of cerebrovascular secondary prevention, proving their efficacy even in patients whose risk profile did not initially include ischemic heart disease [24].

Experts' opinion for recommending atorvastatin in patients with a history of stroke or transient ischemic attack: Cameroonian experts express unanimous agreement regarding the systematic prescription of atorvastatin in patients with a history of cerebrovascular accident (stroke) or transient ischemic attack (TIA), classifying these patients immediately in the "very high risk" category. This recommendation, erected as an absolute public health priority in Cameroon due to the high prevalence of strokes, aims to prevent recurrences often more disabling or fatal than the initial episode. Beyond the proven reduction in recurrence risk, the consensus emphasizes the major interest of atorvastatin in the stabilization of carotid atheroma plaques, thus limiting the risk of cerebral embolism. For this population, experts advocate increased rigor in achieving therapeutic targets, with an LDL-cholesterol objective systematically below 0.70 g/L (1.8 mmol/L), or even 0.55 g/L (1.4 mmol/L) depending on the severity of associated vascular lesions.

Experts' opinion on the chronology of the lipid assessment in a patient victim of stroke: regarding the chronology of biological assessment in patients victims of a cerebrovascular accident (stroke), the expert consensus advocates a lipid profile sample at admission, or imperatively within the first 24 hours following the event. This recommendation aims to prevent interpretation biases induced by the acute-phase metabolic response, the systemic inflammatory reaction, which potentially artificially lowers total cholesterol and LDL-C levels beyond 24 to 48 hours. Early sampling thus allows faithfully documenting the patient's basal profile before the rapid initiation of high-intensity statin therapy in secondary prevention. In the absence of sampling within this critical timeframe, experts recommend deferring the biological evaluation for 6 to 8 weeks to obtain stable results representative of the patient's usual metabolic state, thus guaranteeing optimal therapeutic orientation.

Experts' opinion on the LDL cholesterol objective after a first ischemic stroke: following a first ischemic stroke, the consensus of Cameroonian experts imposes systematic classification of the patient in the "very high risk" cardiovascular category, justifying rigorous therapeutic objectives. The retained LDL-cholesterol target is an absolute value below 0.70 g/L (70 mg/dL), doubled by an exigency of relative reduction of at least 50% compared to the basal rate. To reach these thresholds, experts advocate the precocious use, from the post-acute phase, of a high-intensity statin such as atorvastatin (40 mg or 80 mg). This aggressive strategy aims not only at biological normalization, but especially at the stabilization of carotid and intracranial atheroma plaques, a measure deemed crucial in the Cameroonian context to prevent neurological recurrences often more severe than the initial episode.

Experts' opinion on the expected LDL cholesterol-lowering threshold after the instauration of lifestyle modifications associated with a statin in a patient with a history of ischemic stroke: for patients having suffered an ischemic stroke, the consensus of Cameroonian experts sets an LDL-cholesterol-lowering threshold of at least 50% compared to the initial basal value. This relative reduction objective must be pursued jointly with the achievement of a strict absolute target (< 0.70 g/L, or even < 0.55 g/L), thanks to the synergistic effect of lifestyle measures and intensive pharmacological treatment. Aiming essentially at the stabilization of atherosclerotic plaque to prevent recurrences, this strategy imposes an intensification or a therapeutic combination if statin monotherapy does not allow us to reach this double objective.

Dyslipidemia and chronic kidney disease (CKD): specific management at pre-dialysis and dialysis stages: local data from the study by Halle et al. [25], concerning Cameroonian patients with non-dialyzed chronic kidney disease (CKD) (stages 3 to 5), underscore the magnitude of cardiovascular risk in this vulnerable population. The prevalence of dyslipidemia is particularly high there (69.8%), frequently integrating into a multifactorial risk profile dominated by arterial hypertension (90.3%), abdominal obesity (79.5%), and hyperuricemia (69.8%). Despite this metabolic burden, only 53.4% of dyslipidemic patients were receiving specific treatment, with a rate of achievement of LDL-cholesterol targets limited to 51.6% in treated subjects. These results highlight the necessity of more proactive and systematic management of lipid disorders in patients with renal insufficiency in Cameroon, to reduce cardiovascular morbidity and mortality otherwise exacerbated by comorbidities such as anemia.

Experts´ opinion on the frequency of dyslipidemia in patients with non-dialyzed chronic kidney disease: Cameroonian experts emphasize that dyslipidemia is a quasi-systematic complication of non-dialyzed chronic kidney disease (CKD), with an estimated prevalence between 80% and 90% from the early stages of the pathology. This lipid profile is distinguished by marked hypertriglyceridemia, a low HDL-cholesterol level, and a predominance of small, dense LDL particles that are particularly atherogenic, the severity of which intensifies with the importance of proteinuria and the decline in glomerular filtration rate. The consensus recalls that, for this population, the risk of cardiovascular mortality often surpasses that of progression to the end stage of renal disease, making the management of lipid disorders a fundamental pillar of nephroprotection and global survival.

Recommendation of experts for the treatment of dyslipidemia in patients with non-dialyzed chronic kidney disease: for the management of dyslipidemia in patients with non-dialyzed chronic kidney disease (CKD), Cameroonian experts advocate a strategy of systematic initiation of a statin (or a statin/ezetimibe combination) in adults aged 50 and over, regardless of the initial LDL-cholesterol level. In younger patients (18-49 years), treatment is recommended in the presence of comorbidities such as diabetes, coronary artery disease, a history of ischemic stroke, or a 10-year cardiovascular risk greater than 10%. Atorvastatin is the preferred molecule due to its primarily non-renal metabolism, thus limiting accumulation risks, with a dosage that should be adjusted according to the glomerular filtration rate. Although aligning with the absence of strict numerical targets advocated by certain international standards, the local consensus insists on obtaining a significant reduction in LDL-C to slow the accelerated atherosclerosis specific to CKD, while imposing rigorous surveillance of muscular tolerance given the increased risk of rhabdomyolysis in this context of renal fragility.

Recommendation of experts for the choice of statins during chronic kidney disease: concerning dosage adjustment of statins during chronic kidney disease (CKD), the consensus of Cameroonian experts designates atorvastatin as the reference molecule requiring no dose adjustment, whatever the stage of renal impairment. This major clinical manageability is explained by quasi-exclusively hepatic elimination, with less than 2% renal excretion, guaranteeing the absence of plasma accumulation linked to the decline in glomerular function. Fluvastatin also shares this safety profile due to its predominant metabolism by the liver. Conversely, experts recommend increased caution and a systematic reduction of doses for rosuvastatin, pravastatin, and simvastatin in case of severe renal insufficiency (GFR < 30 mL/min), as their more significant renal clearance exposes patients to an increased risk of muscular toxicity and rhabdomyolysis. Ultimately, atorvastatin is favored in local practice as the safest and simplest option to maintain therapeutic efficacy without compromising the safety of the patient with renal insufficiency [26,27].

Recommendation of experts for the continuation of statins in dyslipidemic patients with chronic kidney disease on dialysis: regarding patients with chronic kidney disease (CKD) at the dialysis stage, the consensus of Cameroonian experts makes a crucial distinction between the initiation and continuation of statin treatment. Experts advocate maintaining treatment if it was already established before the dialysis stage, considering that no clinical benefit justifies stopping a therapy initially indicated by the cardiovascular risk profile. However, in agreement with international trials (4D, AURORA) and KDIGO recommendations, the *de novo* initiation of a statin in a patient already on dialysis is not recommended, as it has not demonstrated a significant reduction in mortality or major cardiovascular events. Atorvastatin is preferred for patients maintained on treatment thanks to its hepatic elimination, which dispenses with dosage adjustment. This approach aims to limit cardiovascular morbidity and mortality, the leading cause of death among dialysis patients in Cameroon, by stabilizing atheromatous risk profiles.

Recommendation of experts for the initiation of statins in dialyzed patients with CKD presenting dyslipidemia: regarding the initiation of statin treatment in patients with chronic kidney disease (CKD) at the dialysis stage, Cameroonian experts express disagreement with a systematic recommendation. This position is based on the absence of clinical benefit demonstrated by major international studies (4D and AURORA), which did not show a significant reduction in cardiovascular deaths, infarctions, or strokes upon initiation at this stage. The consensus emphasizes that the risk profile in dialysis patients evolves towards arrhythmic or congestive pathologies on which statins have little impact, unlike pure atherosclerosis. An exception may, however, be discussed on a case-by-case basis for secondary prevention if an acute ischemic event occurs during dialysis, to promote plaque stabilization. Ultimately, experts advocate avoiding unjustified polypharmacy in dialysis patients in Cameroon when the benefit on survival is not solidly established.

Strengths and limitations of this consensus: this consensus on dyslipidemias in Cameroon stands out for its inclusive multidisciplinary approach (cardiologists, endocrinologists, nephrologists, etc.) its adaptation to local epidemiological realities such as hypo-HDL-cholesterolemia, hypertriglyceridemia, and early hypertension, using WHO charts for sub-Saharan Africa; it prioritizes pragmatic and accessible recommendations (non-HDL cholesterol, atorvastatin), aligned with international guidelines (ESC/EAS 2019, ACC/AHA 2018, ADA 2024) while integrating endogenous Cameroonian data (Shisong) and exhaustively covering various clinical situations (diabetes, stroke, CKD). However, it presents notable limitations: absence of high-quality local evidence-based data, non-formalized methodology, lack of cost-effectiveness analysis, and of a dissemination/evaluation strategy. To improve it, an update every 3-5 years with a monitoring committee including healthcare and public health providers is advocated, promoting effective harmonization of local cardiovascular practices.

Conclusion     

Dyslipidemias constitute a major cardiovascular risk factor in Cameroon. This consensus proposes a pragmatic and contextualized approach based on risk stratification, the optimization of lifestyle measures, and the priority use of statins. It harmonizes practices by taking into account local diagnostic and therapeutic constraints. Its effective implementation could contribute to significantly reducing cardiovascular morbidity and mortality. Prospective national studies remain necessary to evaluate its impact.

Competing interests     

The author declares no competing interests.

Authors' contributions     

All authors interpreted guidelines in the Cameroonian context, approved the recommendations, and took responsibility for the document. All authors have read and agreed to the final manuscript.

Acknowledgments     

This expert consensus was supported by a research grant from Ajanta Pharma Ltd, Mumbai, India. The sponsor had no role in the scientific discussions, data interpretation, manuscript drafting, or approval of the final manuscript.

Tables and figure     

Table 1: typology of lifestyle interventions according to the type of dyslipidemia

Table 2: intervention strategies as a function of total cardiovascular risk and untreated low-density lipoprotein cholesterol levels

Figure 1: cardiovascular risk assessment according to World Health Organization; Western sub-Saharan Africa (Benin, Burkina Faso, Cote d'Ivoire, Cameroon, Cabo Verde, Ghana, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra leone, Sao Tome and principe, Chad, Togo)

References