Lebanon has achieved its epidemiologic transition during the last 2 decades. Noncommunicable diseases became the leading cause of illness and death in Lebanon, accounting for 84% of all deaths in 2010 (1). Cardiovascular diseases (CVDs) alone account for almost half of all annual deaths in the country (2). Multiple factors contribute to CVD pathogenesis. Although some factors, such as age, male sex, and genetic predisposition to atherosclerotic disease, are nonmodifiable, others, such as tobacco use, poor weight control, alcohol abuse, hypertension, diabetes, and dyslipidemia, are amenable to modification and control (3).

Lebanon has a high prevalence of modifiable cardiovascular risk factors. For example, 54.6% of the population aged 25 to 65 are smokers (4). Self-reported diabetes has been estimated at 11% in 2008 (4), and hypertension has increased almost threefold in 1 decade (4,5).

Cardiovascular events are the clinical expression of atherosclerotic disease in major end organs, such as the heart (myocardial infarction) and brain (stroke) (6). The likelihood that someone will develop a fatal or nonfatal cardiovascular event depends on a combination of risk factors rather than on the presence of any single risk factor (7). Risk factors for CVD can be compiled in algorithms able to predict an individual’s total cardiovascular risk (TCVR) in a given period (8). The World Health Organization (WHO) in partnership with the International Society of Hypertension (ISH) developed charts adapted to the Eastern Mediterranean Region populations. The simplified version of the WHO/ISH charts does not include dyslipidemia and permits the stratification of 3 risk factors: systolic blood pressure (SBP), glucose metabolism, and smoking status, in addition to age and sex, to quantify a total 10-year cardiovascular risk score (9,10). The advantage of using these charts is the simplicity of their use and their low cost (11).

The Ministry of Public Health (MOPH) in Lebanon subsidizes secondary and tertiary health care for uninsured citizens in an effort to provide universal health coverage (12), although budgets allocated for preventive measures remain scarce and irregular (13). This approach of health governance contributed to a culture of overuse of advanced medical care (14) while the early detection of risk factors remains insufficient (15). This situation is illustrated by the considerable proportion of adults who have never had any blood glucose or blood pressure measurements (4), a situation that MOPH is trying to modify.

A pilot project was subsidized in the second half of 2012 to implement a standardized screening protocol for Primary Health Care Network (PHC) users without CVD for 5 cardiovascular risk factors and to estimate their TCVR using simplified WHO/ISH charts (16). The goal was to reach presumably healthy individuals, empower them with knowledge of their cardiovascular risk, and motivate them to seek medical attention and to choose measures to reduce that risk. We present an epidemiological analysis of data produced during this pilot phase to assess the usefulness of integrating the protocol in the routine services provided by PHC and to present a preliminary cardiovascular risk profile in an average healthy population.

This pilot project used a simplified algorithm for the prediction of TCVR developed by WHO and ISH in 2009 and 2010 (9). WHO has encouraged individual countries to use this tool to identify patients who would benefit from medical attention to deal with their cardiovascular health (11). This injunction corresponded to a desire in Lebanon to implement a comprehensive CVD screening strategy focused on early detection of several cardiovascular risk factors in 1 procedure. The simplicity and the low-cost implementation of the charts were further incentives to use them as a mass screening tool. The running cost of the procedure did not exceed $0.50 per patient screened in the facility and $1 per patient screened in outreach. This inexpensive implementation was due to the voluntary contribution of nonphysician health workers employed at the centers of the PHC. The efficiency of this action in detecting a large number of potentially modifiable CVD risks in previously asymptomatic individuals was unequivocal, with 1 in 4 people detected for probable metabolic impairment and referred for further steps. The most important anticipated benefit from including such a protocol and implementing adequate follow-up for detected cases would be the decrease of CVD incidence, as demonstrated by the projection of the data using the Framingham algorithm.

PHC centers are more popular in rural areas than in urban areas. They attract beneficiaries from lower socioeconomic strata and are predominantly used by women. The sex distribution of the study population duplicates the sex distribution of PHC users in Lebanon (unpublished internal document of PHC, 2012). The greater use of centers by unemployed women may be partially caused by their availability during the morning hours when PHC centers are open. This observation calls for the modification of the hours that the PHC center is open to better accommodate working men (and women).

The proportion of people of lower socioeconomic status, as indicated by lower educational achievement (75%), was higher than the latest national figures for the same age groups (45%), reported in 2011 (22). The overrepresentation of less affluent people in the study’s population may have biased the findings, although it is not possible in the present phase of sociological transition in Lebanon to estimate whether the bias will be toward over- or under-estimating CVD risks for the entire population.

Men were more likely to be referred for metabolic impairment, which does not differ from global patterns of CVD (23). Women were more likely to have metabolically unimpaired obesity, reflecting the larger prevalence of obesity among women in the Middle East (24). The cutoff values for BMI and WC that were used may not be adapted for the Lebanese population, so the issue of defining optimal cutoff points and selecting the best obesity index to use should be addressed in forthcoming research.

The findings on RBS screening corroborate Lebanese national (25) and global (26) statistics, showing that diabetes is more likely to occur among men than women. However, the prevalence of hypertension among men and women is lower than that reported in national representative surveys conducted in 2005 (27) and 2008 (4) and the sex differential is larger. This particularity occurring over a short period is likely to be an artifact.

The proportion of patients with moderate and high TCVR was less than that projected by WHO for the same age groups in the geographic subregion in which Lebanon is classified (6). This discrepancy is probably due to the inclusion in WHO projections of previously diagnosed metabolically impaired patients, a category that was excluded from our analysis. A better benchmark would be a comparison of figures from a more limited area in the region, emanating from interventions on apparently healthy people and using a similar procedure. Colleagues from Oman undertook a similar screening project but used different cutoff points for raised fasting blood glucose (≥100 mg/dL) and hypertension (≥130 mm Hg/≥85 mm Hg) (28). To make the comparison valid, we reclassified our patients according to fasting blood glucose and hypertension by using the same criteria used by the Omani colleagues and found comparable rates of positive screening results for both measurements (Table 5). However, the equivalence of findings resulting from the screening interventions cannot guarantee equality in overall prevalence of diabetes and hypertension in those 2 countries, nor does it eliminate the need for population-based prevalence surveys or continuous surveillance in Lebanon.

Several countries in the region engaged in successful implementation of CVD prevention on the basis of early detection of multiple cardiovascular risk factors, for example in Kuwait (29) and in Oman (28). However, Lebanon is so far the first country in the region to test and report on the implementation of TCVR score estimation with mass screenings conducted by nonphysician health workers inside PHC facilities and through outreach to beneficiaries’ homes. The added value of such an approach is dual. First, it maximizes the predictive value of the CVD screening by optimizing several easily and economically measurable cardiovascular risk factors (30). Second, using the risk stratification approach as an indicator rather than emphasizing results of each individual cardiovascular risk factor will help improve the awareness of health workers and beneficiaries on the joint adverse effects of clustering cardiovascular risk factors on cardiovascular health, and the importance of addressing all of them as a package (6–8).