Atherosclerotic Cardiovascular Diseases in Type 2 Diabetes in the Middle East and Africa: Insights from the PACT-MEA Study

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among individuals with type 2 diabetes (T2D), particularly in regions with high diabetes prevalence, like the Middle East and Africa (MEA). However, contemporary data on ASCVD burden and management in these regions remain limited. The recent PACT-MEA study evaluated the prevalence of established ASCVD (eASCVD), cardiovascular risk profiles, and treatment practices in patients with T2D across seven countries. Several manuscripts and presentations on aspects of the study were published in several journals and conferences. This commentary consolidates a concise resume of the study. The PACT-MEA study is a multinational, cross-sectional, observational chart review and physician survey conducted across 55 centers in Bahrain, Egypt, Jordan, Kuwait, Qatar, South Africa, and the United Arab Emirates. Data were collected from 3,726 adults with T2D and approximately 400 physicians. The weighted prevalence of eASCVD was 20.9%, with substantial variation by age and country. Nearly all participants have high or very high cardiovascular risk. Only 30 to 37% met individual treatment targets for HbA1c, blood pressure, and low-density lipoprotein cholesterol. Utilization of cardioprotective therapies was suboptimal. No participant achieved all guideline targets. The PACT-MEA and DISCOVER-MEA studies shared some objectives but differed in scope, design, and primary outcomes. The burden of ASCVD and associated risk among patients with T2D in the MEA region is alarmingly high, but comprehensive risk factor control is insufficient. The PACT-MEA study findings underscored an urgent need for targeted regional strategies to improve cardiovascular outcomes.

 

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Keywords

type 2 diabetes - atherosclerotic cardiovascular disease - cardiovascular risk - Middle East - Africa - PACT-MEA - DISCOVER

Introduction

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality among individuals with type 2 diabetes (T2D).[1] In addition to microvascular complications, people with T2D face a significantly heightened risk of macrovascular diseases.[2] Recognizing and managing this risk is essential for reducing preventable cardiovascular outcomes.

The Middle East and Africa (MEA) have the highest prevalence rates of T2D globally, driven by rapid urbanization, lifestyle shifts, and limited access to health care in some areas.[3] [4] Despite the growing burden of diabetes, there is a lack of robust regional data on ASCVD prevalence, risk stratification, and adherence to evidence-based management.[5] [6] [7] These knowledge gaps hinder the development of targeted public health policies and clinical interventions. The PACT-MEA study was initiated to address the above knowledge gaps.[8] [9] This commentary presents a concise resume of the study findings for the MEA-based readership.

 

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Materials and Methods

The literature was identified through a search of two major scholarly databases, PubMed and Google Scholar. The retrieved records were examined for relevance and were narrated thematically. No statistical analysis was conducted on the original data, and numerical details were avoided. A noninferential comparison was made between the PACT-MEA and DISCOVER-MEA studies.[10] [11]

 

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PACT-MEA Study Design

This study examined the epidemiology and clinical management of patients with T2D. Established ASCVD (eASCVD) or high/very high ASCVD risks, defined by the 2021 European Society of Cardiology Guidelines, were evaluated and physicians' attitudes and their basis for decision-making in managing these patients were assessed.[8] [9] [12] The PACT-MEA included a cross-sectional, observational study based on a medical chart review of approximately 3,700 patients with T2D and a survey of approximately 400 physicians.[8] The characteristics of the study participants are presented in [Table 1].

Table 1 Baseline characteristics of the PACT-MEA study population (N = 3,726).

Characteristic	Total
Mean age, years ±SD	58 ± 12
Median BMI, kg/m2 (IQR)	30 (27–35)
Class 1 obesity (%)	29%
Class 2 obesity (%)	15%
Class 3 obesity (%)	9%
Duration of T2D, y (IQR)	10 (5–17)
HbA1c, % mean ±SD	8.0 ± 2.0
Hypertension (%)	71%
Dyslipidemia (%)	92%
Current smoking (%)	14%
eGFR <60 mL/min/1.73 m2 (%)	16%
Statin use (%)	77%
SGLT2i use (%)	36%
GLP-1 RA use (%)	13%

Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration rate; GLP1 RA, glucagon-like peptide-1; IQR, interquartile range; SGLT2i, sodium-glucose cotransporter 2 inhibitors; SD, standard deviation; T2D, type 2 diabetes.

 

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Highlights of the Results

To date, eight full-text manuscripts[8] [9] [12] [13] [14] [15] [16] [17] and six abstracts of conference presentations[18] [19] [20] [21] [22] [23] have been published.

The Overall Results

The overall results of the study are presented in [Table 2], and both the overall and subanalyses are narratively summarized in [Table 3]. The study sample included patients from Bahrain (366), Egypt (550), Jordan (576), Kuwait (350), Qatar (346), South Africa (996), and the United Arab Emirates (UAE; 542).[8] [9] Nearly all patients (98%) had coronary risk factors, with 84% having at least two risk factors. The median duration of T2D was 10 years, and the mean glycated hemoglobin (HbA1c) was 8.0%. Hypertension and dyslipidemia were present in 71 and 92% of patients, respectively, and 14% were current smokers. Most patients (77%) were on statins ([Tables 1] and [2]).[9]

Table 2 Proportion of patients meeting ESC 2021 guideline targets

Treatment target	Proportion
HbA1c <7%	37%
Blood pressure <130/80 mm Hg	30%
LDL-C <70 mg/dL	30%
BMI <25 kg/m2	15%
≥5 physical activity sessions/week	16%
On SGLT2 inhibitor	36%
On GLP-1 RA	13%
All targets met	0%

Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration rate; ESC, European Society of Cardiology; GLP1 RA, glucagon-like peptide-1; LDL-C, low-density lipoprotein cholesterol; SGLT2, sodium-glucose cotransporter 2 inhibitors; SD, standard deviation; T2D, type 2 diabetes.

Table 3 Narrative summary of the findings and conclusions of the PACT-MEA study overall by region and selected variables

• One in five T2D patients had eASCVD; nearly all met ESC high/very high risk criteria. No participant met all recommended targets.

• Moderate-intensity statin use was common but insufficient for high-risk patients. High-intensity lipid-lowering therapy is underutilized.

• Women with T2D are significantly affected by eASCVD, emphasizing the need for equitable screening and treatment.

• Half of all patients had obesity; both obese and nonobese patients showed high ASCVD risk, warranting better obesity management strategies.

• Microvascular complications were common and linked to hypertension and dyslipidemia.

• Younger patients (aged 18–44) had lower eASCVD prevalence but high ASCVD risk. Treatment rates were also lower in this group.

• The use of GLP-1 RAs and SGLT2i remained suboptimal despite guideline support.

• In the Gulf region, over 20% had eASCVD. All patients were at high risk, signaling a need for prevention-focused policies.

• In Jordan, over one-quarter had eASCVD; comprehensive risk management strategies are needed across care settings.

• UAE showed higher eASCVD rates than the MEA average. No one met all guideline targets, indicating urgent regional needs.

• Egypt showed high ASCVD risk but low guideline adherence. GLP-1 RA usage was higher in lower-risk patients, a mismatch that needed systemic correction.

• Physician surveys showed broad awareness of guidelines, but target achievement remains poor.

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; e-ASVD, established atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate; ESC, European Society of Cardiology; GLP1 RA, glucagon-like peptide-1; IQR, interquartile range; MEA, Middle East and Africa; SGLT2i, sodium-glucose cotransporter 2 inhibitors; SD, standard deviation; T2D, type 2 diabetes; UAE, United Arab Emirates.

Microvascular complications of retinopathy, neuropathy, or nephropathy were present in 14, 25, and 15% of patients, respectively. Seven percent of patients had heart failure and 51% of study participants used inhibitors of the renin–angiotensin system (RAS). Regarding glucose-lowering therapies, 77% used biguanides, 38% used insulin, 36% used sodium-glucose cotransporter 2 inhibitor (SGLT2) inhibitors, and 13% used glucagon-like peptide-1 (GLP-1) RA ([Table 2]).[9] The weighted prevalence of eASCVD was 20.9%, higher for men than for women, and increasing with age.

The most common type of eASCVD was coronary artery disease (87%), with 50% having a history of myocardial infarction and 78% having a history of coronary artery revascularization. Bahrain had the highest prevalence of eASCVD (36.6%), followed by the UAE, Jordan, Qatar, South Africa, and Egypt. Kuwait had the lowest prevalence among the participating countries (19.4%).[9]

The weighted distribution of cardiovascular risk categories revealed that 69.4% were classified as high risk and 29.9% as very high risk; 37% of patients at high/very high risk achieved HbA1c <7%, 30% met the blood pressure (BP) goal of <130/80 mm Hg, and 30% achieved low-density lipoprotein (LDL) cholesterol <70 mg/dL. Only 37% were on SGLT2 inhibitors; 13% were on GLP-1 RA; 16% exercised ≥5 times per week; and 15% had a body mass index (BMI) <25 kg/m². None achieved all the guideline recommendations ([Tables 2] and [3]).[9]

 

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Risk Factors and Comorbidities

A sub-analysis of the PACT-MEA study provided more detailed insights.[13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] These studies addressed certain complications, management, and the use of certain medications on one side, focusing on particular national, subregional data, or a combination of the two ([Table 3]).

Achievement of Guideline Targets

Bashier et al surveyed 385 physicians to explore factors influencing clinical decision-making.[13] They revealed factors influencing T2D management decisions, with most adhering to international guidelines. Among 542 UAE participants, 62.7% were at high risk for ASCVD, and 37.1% were at very high risk. Target HbA1c has achieved a 45% reduction in UAE, a 41% reduction in BP, a 36% reduction in LDL, a 63% increase in SGLT2 inhibitor use, and a 22% increase in GLP-1 RA use, respectively. All targets were higher than the regionwide rates.

 

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Microvascular Complications

The overall prevalence of one or more microvascular complications was 34.9%.[14] No differences between countries were observed: 35.0% in Bahrain, 32.6% in Kuwait, and 37.3% in Qatar. The prevalence was 38.9% in participants with eASCVD and 37.3% in those with ASCVD risk. Retinopathy and neuropathy were more common in participants with hypertension and dyslipidemia.[14]

Sex-based sub-analysis: females represented 47% with a median age of 59.0 years, and over one-third were <55 years old.[15] Across the seven countries, the prevalence of eASCVD was lower (16.0%) among females than among males (26.6%). Additionally, 0.6% of females were at moderate risk for ASCVD, 72.5% were at high risk, and 26.9% were at very high risk. Among males, 0.7, 65.9, and 33.4% were at moderate, high, and very high ASCVD risk, respectively.[15]

 

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Impact of Age

The prevalence of eASCVD and its associated risk were stratified by age.[16] The distribution was as follows: 14% were aged 18 to 44, 58% were 45 to 64, and 28% were 65 years or older. Mean diabetes duration was 6.1, 11.2, and 16.0 years, respectively. Also, the prevalence of eASCVD was 6.4, 20.1, and 33.2% in the three age groups, respectively. Furthermore, 87.4 and 10.8% of patients aged 18 to 44 were at high and very high risk, respectively. The high/very high risk was 70.8%/28.5% among patients aged 45 to 64 and 55.2%/44.8% among those aged 65 and above.[16] Use of SGLT2 inhibitors was similar across all age groups; however, use of GLP-1 RAs decreased with age. In line with risk levels, the use of statins, RAS inhibitors, antiplatelet therapy, β-blockers, calcium channel blockers, and diuretics was lower among patients aged 18 to 44 than among the older groups.[16]

 

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Impact of Obesity

Across obesity classes, the prevalence was similar for eASCVD, high ASCVD risk, and very high ASCVD risk.[17] Nearly half of the study sample who had eASCVD also had metabolic syndrome; of those at high and very high risk, 48 and 47% had metabolic syndrome, respectively. More patients with obesity than those without were on insulin, GLP-1 RA, RAS inhibitors, calcium channel blockers, or diuretics. However, statin intensity did not vary by obesity class.[17]

 

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Dyslipidemia

The status of dyslipidemia and its management in patients with T2D and eASCVD or high/very high ASCVD risk across the MEA was described by Sabbour et al.[18] In patients for whom data were available, the median LDL-C level was 2.2 mmol/L, the HDL-C level was 1.1 mmol/L, and the triglyceride level was 1.6 mmol/L. Of the patients with high/very high ASCVD risk, 30% met the recommended target for LDL-C of <1.8 mmol/L, and 16% met the <1.4 mmol/L target. Most patients were on statin therapy (77%, with a range across countries of 60–87%). The use increased with age and duration of diabetes. A similar pattern was observed in patients with HbA1c levels of 7% or higher. Most patients with nephropathy were on statins; their use increased with lower estimated glomerular filtration rate and higher microalbuminuria. Fewer patients were on other lipid-lowering medications.

 

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GLP-1 RA and SGLT2 Inhibitor Utilization

The usage of GLP-1 RAs and SGLT2 inhibitors among individuals with T2D in Bahrain, Kuwait, and Qatar who either had eASCVD or were at high risk of developing ASCVD was studied by Al-Dahi et al.[19] Among 1,062 T2D participants with eASCVD, a significantly higher proportion (41.3%) received SGLT2 inhibitors than GLP-1 RAs (10.5%). There were notable variations in the utilization of GLP-1 RAs and SGLT2i across countries (being lowest in Bahrain). The use of both medications was significantly higher in individuals with a BMI of 30 kg/m² or greater.[14] Low rates of use of these evidence-based therapeutic options were also reported from Egypt (20).

 

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Regional Sub-analysis

Arabian Gulf

Two separate reports were from the Arabian Gulf. In the first study, Alkandari et al reported the prevalence and risk of ASCVD in patients with T2D in three countries: Bahrain, Kuwait, and Qatar.[21] Bahrain had the highest prevalence at 36.6%, followed by Qatar and Kuwait at 23.4 and 19.4%, respectively. The unweighted prevalence was significantly higher in men and increased with age. Coronary artery disease was the most common type of ASCVD, followed by cerebrovascular and peripheral artery disease. Furthermore, participants in all three countries were classified as having a high or very high risk of ASCVD. In the second report, the UAE data subset was described by Awadi et al.[22] The 542 participants from the UAE, from secondary care, had a median age of 55.7 years. The estimated 10-year cardiovascular disease risk was 99.8% in the UAE. The eASCVD was 29.7% in the UAE; coronary artery disease was the most common ASCVD type.

 

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Jordan

The Jordan cohort included 576 individuals (27.8% primary care, 72.2% secondary care settings). There was an equal sex distribution, a mean age of 59.7 years, and a median duration of diabetes of 10.0 years.[23] The prevalence of ASCVD was 26.2% overall and 21.9 and 27.9% in primary care and secondary care settings, respectively. Also, 66.0% were classified as high risk and 33.3% as very high risk (which included eASCVD). The use of RAS inhibitors, statins, and cardioprotective antidiabetic medication was higher in secondary care settings. None of the participants achieved all guideline recommendations.

 

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Egypt

Assaad-Khalil et al reported on 550 participants.[24] The mean age was 54.5 years, with a mean duration of T2D of 9.3 years and a mean HbA1c level of 8.3%. The prevalence of established ASCVD was 19.6%, with a prevalence of 15.1% for coronary artery disease, 3.1% for cerebrovascular disease, and 2.9% for peripheral artery disease. In people without eASCVD, the prevalence of high ASCVD risk was high at 85.5%. The weighted distribution of cardiovascular risk categories revealed that 27% had a very high risk, 72.1% had a high risk, and only 0.9% had a moderate risk. Only 20% received SGLT2 inhibitors, and remarkably low number (3%) received GLP-1 RAs.[24]

 

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PRACT-MEA Limitations

The authors acknowledged several study limitations. The sample size and convenience sampling approach may yield prevalence estimates that do not accurately reflect the entire country.[9] Although population size differences are mitigated by weighting the mean ASCVD prevalence and risk estimates by each country's diabetes population size and the respective prevalence rates, missing laboratory data may limit the interpretation of the clinical findings. Screening for heart failure using natriuretic peptides and echocardiography was low in the region and was not captured; this may have contributed to the lower prevalence of heart failure observed. Additionally, the study recruited a biased sample that did not fully represent the regions it claimed to cover. For instance, the study does not include Saudi Arabia and Iraq, the two largest countries in the Arabian Gulf region. Furthermore, there is no representation of the Maghreb and sub-Saharan belt countries. Personal interest in participants and logistics may have contributed to these issues. Concerning the dissemination plan, the primary results article was published as a letter which could have limited important details to be included. The secondary articles suffer from overlaps and duplications that could have been avoided. Notably, none of the articles were published in any regional journal. Better planning for future studies should mitigate these shortcomings in future studies.

 

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Comparison of the Pact-MEA versus DISCOVER-MEA

Both the PACT-MEA and MEA cohorts of the DISCOVER study (DISCOVER-MEA) addressed the burden of cardiovascular and vascular complications among patients with T2D in the MEA.[8] [9] [10] [11] Still, they differed in scope, design, and primary outcomes ([Table 4]).

Table 4 A qualitative noninferential comparison between the design, characteristics, and findings of the two modern MEA-cardiovascular risk studies in people with diabetes: PACT-MEA versus DISCOVER (MEA Cohort)

Characteristic	PACT-MEA[a]	DISCOVER (MEA cohort)[b]
Study design	Cross-sectional, observational	Prospective, longitudinal
Sample size	3,726 patients	3,525 patients.
Coverage	7 (Kuwait, Qatar, Bahrain, Egypt, Jordan, South Africa, and UAE)	12 (Algeria, Egypt, Jordan, Lebanon, Tunisia, Turkey, Bahrain, Kuwait, Oman, Saudi Arabia, South Africa, and UAE).
Patient age (mean)	58 y	54.3 y
T2D duration (median)	10 y	6.2 y
Main focus	Prevalence of eASCVD and ESC risk classification	Microvascular, macrovascular complications.
Key outcomes	eASCVD: 20.9%; 99.3% at high/very high risk	Microvascular: 17.7% Macrovascular: 10.7%
Statin use	77% (mostly high intensity)	42.3% (low to moderate intensity mainly)
Mean HbA1c	8.0%	8.7%.
Guideline targets achieved	None met all ESC targets	Suboptimal glycemic and BP control
Risk factors identified	ESC classification, comorbidities, demographics	Age, male sex, hyperlipidemia, and hypertension.

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; BP, blood pressure; e-ASVD, established atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate; ESC: European Society of Cardiology; GLP1 RA, glucagon-like peptide-1; LDL-C, low-density lipoprotein cholesterol; MEA, Middle East and Africa; SGLT2i, sodium-glucose cotransporter 2 inhibitors; SD, standard deviation; T2D, type 2 diabetes; UAE, United Arab Emirates.

^a Verma et al (2023).[8] [9]

^b Hafidh et al (2022)[10] and Al-Rubean et al (2022)[11].

The sample sizes of the two studies are comparable, but the coverage varies. For instance, PACT-MEA covered seven countries, including South Africa and the Gulf states, while DISCOVER-MEA spanned a broader geographic scope, encompassing 12 countries, including North Africa and the Levant. Whereas PACT-MEA was a cross-sectional study, DISCOVER was part of a 3-year, prospective, longitudinal study among patients initiating second-line glucose-lowering therapy. Patients in both studies had similar age profiles ([Table 4]). However, DISCOVER-MEA patients were slightly earlier in the disease progression than PACT-MEA. PACT-MEA found a 20.9% prevalence of eASCVD, with 99.3% of patients at high or very high cardiovascular risk, but none achieved all guideline-recommended targets. DISCOVER-MEA reported a crude prevalence of 17.7% for microvascular and 10.7% for macrovascular complications, with significant risk factors ([Table 4]). Concerning risk management, PACT-MEA participants were more often treated with statins (77%) and had better documentation of risk stratification. DISCOVER-MEA provided detailed analyses on medication patterns and baseline treatment regimens. Both studies highlighted inadequate glycemic control with average values over 8% ([Table 4]).

 

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Conclusions

These two recent studies from the MEA region provide complementary information on the cardiovascular burden and risk factors in individuals with T2D in the region. When read together, they provided adequate coverage of the African, Gulf, and Levant regions. Most patients in the PACT-MEA study with T2D were under the age of 65. Nearly all people with T2D aged 45 to 64 had eASCVD or were at high risk. Although eASCVD was low in those aged 18 to 44, almost 9 in 10 were at high risk for developing ASCVD. Younger patients with T2D were less likely to be treated for hypertension and dyslipidemia. Regular screening for ASCVD risk as part of the management strategy for T2D, including in younger patients, is crucial to ensure that patients receive effective treatment to reduce their ASCVD risk.

 

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Conflict of Interest

None declared.

Compliance with Ethical Principles

No ethical approval is required for a narrative review article type of study.

Data Availability Statement

Not applicable.

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Publication History

Article published online:
05 September 2025