Cardiovascular disease (CVD) remains the leading cause of death in the Philippines, driven largely by atherosclerosis and delayed treatment. Health experts are now urging earlier and more aggressive intervention to prevent thousands of avoidable heart attacks and strokes.
Atherosclerosis is the buildup of plaque, composed of cholesterol, fat, and cellular waste, inside artery walls due to high levels of LDL (bad) cholesterol. This common condition narrows the arteries and restricts blood flow, often remaining asymptomatic until it triggers a life-threatening complication. Complications arising from plaque buildup, including heart attacks and strokes, remain the leading cause of death worldwide.
The current challenge, experts say, is not the lack of medicine but delays in treatment. Many patients receive aggressive intervention only after a cardiovascular event has already occurred. Specialists argue that a more proactive and patient-centered approach, focused on early risk detection and sustained prevention, is essential to slowing disease progression.
‘In the Philippine setting, ischemic heart disease, which includes heart attacks, remains the leading cause of mortality. One of the major risk factors contributing to heart attacks is poor control of cholesterol levels, particularly LDL or bad cholesterol,’ said Dr. Lourdes Ella Gonzales-Santos, President of the Asian-Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD).
Dr. Santos noted that Filipinos’ fondness for meat products increases the risk of elevated LDL cholesterol. She added that lifestyle changes following the pandemic-including more sedentary lifestyles, smoking, alcohol intake, stress, and poor sleep-all contribute to cholesterol buildup in the arteries.
‘Unless we identify all of these risk factors together and address them, ischemic heart disease will continue to be the leading cause of mortality in the Philippines,’ she said.
Early intervention in dyslipidemia
A primary strategy highlighted by experts is the early use of combination therapy involving statins and ezetimibe.
To reduce the burden of CVD in the Philippines, clinical practice must move beyond standard monotherapy and embrace early combination treatment with statins and ezetimibe to save lives and prevent thousands of avoidable cardiac events. ‘When we look at data in the Philippines, we are not doing such a great job getting patients to the LDL targets we want. Whether it’s physicians not prescribing aggressively enough or patients not complying with their medications, there is clearly a treatment gap. We have the tools, but they are not being fully utilized,’ said Dr. Santos.
Globally, growing attention toward dyslipidemia-elevated total or LDL cholesterol levels, or low HDL cholesterol-is driving record rates of diagnosis. However, experts stressed that diagnosis alone is not enough. Clinical evidence shows that reducing heart attacks and strokes depends on prompt and intensive treatment.
‘Clinical trial evidence shows that when you treat dyslipidemia early and sustain low LDL levels over time, it translates into a reduction in heart attacks and strokes. The longer you keep patients on therapy and maintain low LDL cholesterol, the greater the cumulative benefit,’ Dr. Santos explained.
Dr. Brian Tomlinson, a globally recognized expert in lipid management and Professor at the Faculty of Medicine at Macau University of Science and Technology, said treatment traditionally followed a stepwise approach.
Under the older model, doctors would first recommend dietary changes and wait six months to assess progress before prescribing a statin. Another six months would then pass before adjusting the dosage if needed.
‘But now we realize that this delay is dangerous. Especially for patients who have already had a cardiovascular event, we need to reduce cholesterol as quickly as possible. Guidelines now recommend starting combination therapy straight away. No more waiting six months because in that time, a patient could already have another event,’ said Dr. Tomlinson. ‘Real-world registries like SwedeHeart show that patients who receive treatment earlier have better outcomes compared to those who receive delayed or no treatment. That lag in treatment translates into more events,’ added Dr. Santos.
The power of combination therapy
Dr. Santos explained that ezetimibe is a cholesterol absorption inhibitor that works in the small intestine to block cholesterol absorption, reducing LDL cholesterol by around 18 to 20 percent.
‘If you double the dose of a statin, you only get about six percent additional reduction. So adding ezetimibe is like tripling the effect of the statin without increasing the dose,’ she said.
While statins reduce cholesterol production, they do not remove cholesterol from the body. Adding ezetimibe to statin therapy safely mimics the effect of tripling the statin dose. Meta-analyses have shown that this combination achieves greater LDL reduction with lower rates of liver and muscle enzyme elevation, new-onset diabetes, and treatment discontinuation compared to high-dose statin monotherapy.
‘Statins reduce cholesterol production, but they don’t remove cholesterol from the body. Ezetimibe helps eliminate cholesterol by blocking reabsorption in the intestine. That’s why the combination is so effective,’ said Dr. Tomlinson.
Due to increased cholesterol absorption and lower excretion at the intestinal level, individuals with diabetes are biologically more responsive to ezetimibe. Multiple studies, including IMPROVE-IT and MRS ROSE, confirm that ezetimibe reduces cardiovascular events more significantly in diabetic patients than in non-diabetic patients.
Benefits for high-risk patients
The statin-ezetimibe combination offers distinct clinical advantages for high-risk populations. Patients with diabetes, obesity, or insulin resistance often have higher levels of harmful fats in the blood that accelerate plaque buildup in the arteries. While statins target cholesterol production, ezetimibe helps address these dangerous particles, creating a complementary effect that stabilizes the patient’s metabolic profile.
Experts also emphasized the urgency of aggressive lipid management following a heart attack or acute coronary syndrome. In the critical days and weeks after an event, the heart remains highly vulnerable to arrhythmias or recurrent attacks. Early intensive combination therapy can help stabilize the cardiovascular system and prevent further damage.
‘The chance of dying or having another heart attack is highest within the first 30 days. That’s why this period is a critical opportunity for intervention,’ said Dr. Tomlinson.
18th APSAVD Congress
Dr. Santos and Dr. Tomlinson were among the speakers during the 18th Asian-Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) Congress held recently in Manila. The symposium gathered experts to discuss evolving strategies in cardiovascular prevention and management.
Discussions underscored a shared concern: while effective treatments are widely available, they are often not applied early enough, aggressively enough, or consistently enough to prevent disease progression and complications. Across sessions, experts called for a more proactive, patient-centered, and evidence-based approach that emphasizes early risk recognition, tailored therapies, and sustained prevention.
‘The key takeaway from the symposium is aggressive, early, intensive, and sustained lowering of LDL cholesterol,’ said Dr. Santos. ‘We need stronger awareness campaigns, better implementation of local guidelines, and more proactive community interventions-such as promoting physical activity, reducing sugar intake, and discouraging smoking. It’s not just about the healthcare system-it’s about both physicians and patients working together.’