1191017

research-article2023
JPCXXX10.1177/21501319231191017Journal of Primary Care & Community HealthBaharudin et al

Original Research
Journal of Primary Care & Community Health

Factors Associated With Achievement

Volume 14: 1–13
© The Author(s) 2023
Article reuse guidelines:
of Blood Pressure, Low-Density sagepub.com/journals-permissions
DOI: 10.1177/21501319231191017
https://doi.org/10.1177/21501319231191017

Lipoprotein Cholesterol (LDL-C), journals.sagepub.com/home/jpc

and Glycemic Targets for Primary

Prevention of Cardiovascular
Diseases Among High Cardiovascular
Risk Malaysians in Primary Care

Noorhida Baharudin1 , Anis Safura Ramli1 , Siti Syazwani Ramland2,

Nurul Izzaty Badlie-Hisham2, and Mohamed-Syarif Mohamed-Yassin1

Abstract
Introduction: Cardiovascular diseases (CVD) remain the world’s leading cause of death. About half of Malaysian adults
have at least 2 risk factors; thus, rigorous primary preventions are crucial to prevent the first cardiovascular (CV) event. This
study aimed to determine the achievement of treatment targets and factors associated with it among high CV risk individuals.
Methods: This cross-sectional study included 390 participants from a primary care clinic in Selangor, Malaysia, between
February and June 2022. The inclusion criteria were high-CV risk individuals, that is, Framingham risk score >20%, diabetes
without target organ damage, stage 3 kidney disease, and very high levels of low-density lipoprotein cholesterol (LDL-C)
>4.9 mmol/L or blood pressure (BP) >180/110 mmHg. Individuals with existing CVD were excluded. The treatment targets
were BP <140/90 mmHg (≤135/75 for diabetics), LDL-C <2.6 mmol/L, and HbA1c ≤6.5%. Multiple logistic regressions
determined the association between sociodemographic, clinical characteristics, health literacy, and medication adherence
with the achievements of each target. Results: About 7.2% achieved all treatment targets. Of these, 35.1% reached systolic
and diastolic (46.7%) BP targets. About 60.2% and 28.2% achieved optimal LDL-C and HbA1c, respectively. Working
participants had lower odds of having optimal systolic (aOR = 0.34, 95% CI: 0.13-0.90) and diastolic (aOR = 0.41, 95% CI:
0.17-0.96) BP. Those who adhered to treatments were more likely to achieve LDL-C and HbA1c targets; (aOR = 1.72, 95%
CI: 1.10-2.69) and (aOR = 2.46, 95% CI: 1.25-4.83), respectively. Conclusions: The control of risk factors among high CV
risk patients in this study was suboptimal. Urgent measures such as improving medication adherence are warranted.

Keywords
treatment targets, blood pressure, LDL-C, low-density lipoprotein cholesterol, HbA1c, primary prevention, primary care,
Malaysia

Dates received: 13 June 2023; revised: 12 July 2023; accepted: 13 July 2023.

Introduction
Cardiovascular diseases (CVD) remain the leading cause of
mortality, accounting for 32% of deaths globally.1 Ischemic
heart disease is responsible for 13.7% of deaths among
Malaysian adults.2 Almost half (43.2%) of Malaysians have
a combination of at least 2 cardiovascular (CV) risk factors,
such as smoking, obesity, hypercholesterolemia, hyperten-
sion, and diabetes.3
1
Universiti Teknologi MARA, Selangor, Malaysia
2
Hospital Ampang, Ministry of Health, Selangor, Malaysia
Corresponding Author:
Noorhida Baharudin, Department of Primary Care Medicine, Faculty
of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Jalan
Hospital, Sungai Buloh, Selangor 47000, Malaysia.
Email: noorhida8229@uitm.edu.my

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2 Journal of Primary Care & Community Health 
Individuals who have not had CV events but have a
clustering of risk factors, such as hypertension, diabetes,
and dyslipidemia are considered high CV-risk individuals.
These individuals are vulnerable and require intensive pri-
mary prevention therapy to prevent their first CV event.
Various tools and algorithms, such as the Framingham Risk
Score (FRS), Revised Pooled Cohort Equations (RPCE),
and Systematic COronary Risk Evaluation 2 (SCORE 2)
incorporate CV risk factors to stratify individuals into
different risk categories.4-6 Recent literature discovered
that FRS and RPCE have good discrimination and are clin-
ically useful in predicting cardiovascular events among
Malaysians with clustering of CV risk factors.7 Malaysian
Clinical Practice Guidelines on the Management of Primary
and Secondary Prevention of Cardiovascular Diseases
2017 recommended utilizing FRS to stratify individuals
into CV risk categories. A high-risk individual includes
those who have more than 20% of 10-year CV risk calcu-
lated using FRS, diabetic patients without target organ
damage, patients with stage 3 chronic kidney disease, and
individuals with very high levels of an individual risk fac-
tor, that is, low-density lipoprotein (LDL-C) >4.9 mmol/L
or blood pressure (BP) >180/110 mmHg).8 The risk factors
in these patients need to be treated aggressively using phar-
macotherapy as well as incorporating therapeutic lifestyle
intervention to achieve their treatment targets.
Previous literature has shown various findings regarding
achieving treatment targets among patients with high CV
risk. Kotseva et al9 reported that about 47% and 46.9% of
high CV-risk individuals on treatment achieved BP and
LDL-C targets, respectively. The findings were worse in
Malaysia, where only 37.4% achieved the BP target, and
18.1% of diabetic patients achieved an HbA1c of less than
6.5%.10,11 As for LDL-C, only 16.1% of high CV-risk
patients achieved their LDL-C target.12
Several factors have been identified to be associated
with patients not achieving their treatment targets, includ-
ing patients’ sociodemographic characteristics, such as age
and gender, as well as clinical factors, such as obesity and
comorbidities.13-16 In addition, non-adherence to medica-
tions and low health literacy were also associated with poor
disease control and overall health outcomes.17,18
In Malaysia, there have been many studies concerning
the control of individual risk factors, such as hyperten-
sion and diabetes.10,11,13 However, they were conducted
without stratifying individual patients’ CV risk. The lit-
erature about the achievements of all treatment targets
(BP, glycemic control, and LDL-C) among individuals
with high CV risk remains limited. Thus, this study aimed
to determine the prevalence of treatment target achieve-
ment for BP, glycemic control, and LDL-C, and their
associated factors, among high CV risk patients in a pri-
mary care setting.
Methods
This cross-sectional study was conducted at a university
primary care clinic in Selangor, a central state in Malaysia.
This clinic provides acute medical care, chronic disease
follow-up, and preventative care to approximately
347,092 population in the Sungai Buloh district in
Malaysia.19 The sampling frame included patients attend-
ing the non-communicable disease (NCD) clinic follow-
ups at this primary care clinic between February 2022 and
June 2022. Convenience sampling method was used until
the target sample size was achieved. This method was
chosen due to the absence of an NCD registry, such as
diabetes or hypertension.
Inclusion and Exclusion Criteria
The inclusion criteria were patients aged more than 18 years
old, attended clinics at least twice in the last 12 months with
fasting blood test results (lipid profile, HbA1c) and had
high CV risk, as defined by at least one of these criteria:
(a) >20% of 10-year CV risk calculated using FRS,
(b) individuals with very high levels of individual risk fac-
tors (LDL-C >4.9 mmol/L and/or BP >180/110 mmHg),
(c) stage 3 chronic kidney disease (eGFR 30-59 mL/min per
1.73 m2), or (d) diabetic patients without documented pro-
teinuria or retinopathy.8 The exclusion criteria were those
with existing CVD and target organ damage (coronary
artery disease, stroke, peripheral vascular disease, and dia-
betes with proteinuria), who were pregnant or had cognitive
impairment or a mental health disorder which would impair
their ability to consent or answer the questionnaire reliably,
and those with an acute medical condition, such as a hyper-
tensive emergency.
Variable Definition
Hypertension, diabetes, and dyslipidemia were defined
based on their clinician’s diagnosis and/or if patients were
taking any antihypertensive, anti-diabetic treatment (oral
hypoglycemic agent, insulin), lipid-lowering medications,
respectively. A smoker is defined as those who currently
smokes any tobacco product. Previous smokers were
those who had stopped smoking for more than 5 years,
and non-smokers were defined as those who had never
smoked. Self-management booklet or mobile application
use was defined as participants’ self-reported utilization of
EMPOWER-SUSTAIN® booklet and mobile application as
self-empowerment tools to manage their CV risk factors.20
For this study, the treatment targets for these high-risk
participants were defined according to the Malaysian
Clinical Practice Guidelines on Management of Primary
and Secondary Prevention of Cardiovascular Diseases, as
Baharudin et al
per the following: BP of <140/90 mmHg (≤135/75 mmHg
for diabetics), LDL-c target of <2.6 mmol/L, and HbA1c
≤6.5%).8 The outcomes of this study were documented
using parameters from their current clinic visit. The best BP
on the day, and the latest LDL-C and HbA1c readings from
the EMR were used as outcomes for this study.
Study Tool
Health literacy (HL) was assessed using the Short-Form
Health Literacy Instrument (HLS-SF-12).21 The HSL-SF-12
has 12 items, and each item was scored using a Likert
scale from 1 to 4 (1: very difficult, 2: moderately difficult,
3: fairly difficult, and 4: very easy). The HL score range
from 0 to 50 and was determined by the formula:
(mean –1) × (50/3), where the mean is the mean of all par-
ticipating items for each individual. The score determines
the HL level: Inadequate (0-25), Problematic (>25-33),
Sufficient (>33-42), and Excellent (>42-50). The “inade-
quate” and “problematic” categories were combined to
form a “limited” HL level (score 0-33), while “sufficient”
and “excellent” were combined to form an “adequate” HL
level (score >33-50). It is valid and reliable for Malaysians
with Cronbach’s alpha of .85.21
Medication adherence was assessed using the 12-item
Malaysian Medication Adherence Assessment Tool
(MyMAAT).22 This tool has good internal consistency
(Cronbach’s α = .91). The items were scored on a 5-point
Likert scale, ranging from “strongly disagree” (5) to
“strongly agree” (1). The minimum score was 12, and the
maximum score was 60. A score from 12 to 53 is considered
non-adherence, while a score from 54 to 60 is considered
adherence.22 The original authors have granted permission
to use these questionnaires in this study.
Study Conduct: Recruitment and Data
Collection Procedures
Patients attending NCD follow-ups were screened for eligi-
bility through face-to-face interviews at the clinic waiting
area. Their eligibility was confirmed through an EMR
review. They were stratified according to FRS via reviews
of electronic medical record, using parameters (blood pres-
sure and lipids profile) from their previous clinic visit.
Patients who were eligible and agreed to participate were
given a study information sheet, and written consent was
obtained. Each patient was allocated a blinded research
identification number to preserve confidentiality. Demo­
graphic and medical history were gathered through a self-
administered questionnaire and the review of EMR. The
questionnaire was checked for completeness before the par-
ticipants left the clinic. Their clinical information, such as
blood test results, was retrieved from the EMR.
3
Anthropometry measurement was performed by trained
staff. Height in meters (m) and weight in kilograms (kg)
were measured using a standardized stadiometer (seca
787). The body mass index (BMI) was calculated manu-
ally. BP measurements were done twice, 2 minutes apart,
on the right arm supported at the level of the heart, in a
sitting position using Omron automatic digital BP monitor
(Omron HBP-1100). The best measurement from the 2
readings was used.
Sample Size Calculation
Based on a study by Kotseva et al,9 among high-risk and
treated patients, 47% achieved the BP target, 46.9%
achieved the LDL-C target, and 65.2% achieved the HbA1c
target. Based on this, using the single proportion formula,
taking an α value of .05 with absolute precision of 5%, the
minimum calculated sample sizes were 383, 383, and 349,
respectively.
Statistical Analysis
The normally distributed descriptive data were expressed as
mean with standard deviation (SD), and the non-normally
distributed data as median with interquartile range (IQR).
Categorical variables were described in numbers and per-
centages. Simple logistic regression was initially perfor­
med to determine the factors associated with achieving the
treatment target. Variables with a P-value of <0.25 were
included in the multiple logistic regressions to determine
the associated factors after adjusting for the confounders.
P-values of <0.05 was considered significant. Achievements
of BP, LDL-C, or HbA1c targets were the dependent vari-
ables. The factors associated with the achievements of these
treatment targets were the independent variables. Multiple
logistic regression analyses were conducted for each of the
dependent variables (BP, LDL-C, and HbA1c).
Results
390 participants were eligible and agreed to enrol in this
study. The median (IQR) age was 63 (9) years old. There
was almost equal distribution between males (50.8%) and
females (49.2%). As for clinical characteristics, more than
half were obese (55.6%), had diabetes (78.5%), hyperten-
sion (81.5%), and dyslipidemia (96.2%). The median (IQR)
HbA1c was 7.0 (1) %, the mean (SD) systolic BP was 141.8
(14.6) mmHg, and the median (IQR) LDL-C was 2.3 (1.0)
mmol/L. The sociodemographic and clinical characteristics
of participants are shown in Tables 1 and 2.
In terms of treatment targets, only 28 participants (7.2%)
achieved all treatment targets. Achievements of individual
treatment targets are shown in Figure 1.
4 Journal of Primary Care & Community Health 

Table 1. Socio-demographic Characteristics of Participants, Table 2. (continued)

n = 390.
Clinical characteristics
Sociodemographic characteristics
Treatment with sodium-glucose 27 (6.9)
Age (years) [median (IQR)] 63 (9) cotransporter-2 (SGLT2) inhibitors (n, %)
Age groups (years) (n, %) Treatment with insulin (n, %) 54 (13.8)
≤50 33 (8.5) Comorbidities: hypertension (n, %) 318 (81.5)
51-60 101 (25.9) Systolic blood pressure (mmHg) 141.8 (14.6)
>60 256 (65.6) [mean (SD)]
Gender (n, %) Diastolic blood pressure (mmHg) [mean 78.9 (10.3)
Male 198 (50.8) (SD)]
Female 192 (49.2) Treatment with antihypertensive (n, %)
Ethnicity (n, %)   No medication 78 (20.0)
Malay 331 (85.1)   1 medication 119 (30.5)
Chinese 24 (6.2)   2 medications 134 (34.4)
Indian 28 (7.2)   ≥ 3 medications 59 (15.1)
Others/Indigenous 6 (1.5) Treatment with angiotensin receptor 241 (61.8)
Education attainment (n, %) blockers (ARBs) or angiotensin-converting
No formal education/primary school 26 (6.7) enzyme (ACE) inhibitors (n, %)
Secondary school 199 (51) Comorbidities: dyslipidemia (n, %) 375 (96.2)
Tertiary education 165 (42.3) Low-density lipoprotein cholesterol 2.3 (1.0)
(LDL-C; mmol/L) [median (IQR)]
Marital status (n, %)
Treatment with lipid-lowering medications (n, %)
Married 357 (91.5)
  No medication 25 (6.4)
Single/widowed/divorced 33 (8.5)
  1 medication 343 (87.9)
Occupation (n, %)
  2 medications 22 (5.6)
Pensioner/homemaker/unemployed 291 (74.6)
Treatment with statin (n, %) 360 (92.3)
Technician/armed forces/self- 51 (13.1)
employed/elementary Polypharmacy (n, %)
Managerial and professional 48 (12.3) No (<5 total medications) 281 (72.1)
Yes (≥ 5 total medications) 109 (27.9)
Family history (n, %)
Premature cardiovascular disease 19 (4.9)
Table 2. Clinical Characteristics of Participants, n = 390. (age < 45 years old)
Diabetes 244 (62.6)
Clinical characteristics
Hypertension 241 (61.8)
Smoking status (n, %) Dyslipidemia 132 (33.8)
Non-smoker 293 (75.1) Self-management booklet/mobile application 225 (57.7)
Previous smoker 67 (17.2) use (n, %)
Current smoker 30 (7.7) Health literacy (n, %)
Body mass index (n, %) Limited 133 (34.1)
Underweight (<18.5 kg/m2) 4 (1.0) Adequate 257 (65.9)
Normal (18.5-22.9 kg/m2) 23 (6.0) Medication adherence (n, %)
Overweight (23-27.4 kg/m2) 143 (37.3) Non-adherent 143 (36.7)
Obese (≥27.5 kg/m2) 213 (55.6) Adherent 247 (63.3)
Comorbidities: diabetes (n, %) 306 (78.5)
HbA1c (%) [median (IQR)] 7.0 (1.0)
Treatment with oral hypoglycemic agent (n, %) After adjusting for confounders, current smokers were
  No medication 105 (26.9) more likely to achieve the systolic BP target (aOR = 3.39,
  1 medication 141 (36.2) 95% CI: 1.30-8.85). Participants taking 1 or 2 antihyperten-
  2 medications 112 (28.7) sives also had lower odds of achieving systolic BP targets
  ≥ 3 medications 32 (8.2) (Table 3).
Treatment with metformin (n, %) 280 (71.8) Those who worked as a technician, arm-forces, self-
Treatment with sulfonylureas (n, %) 112 (28.7) employed, or in an elementary role were less likely to
Treatment with dipeptidyl peptidase 4 46 (11.8)
achieve both systolic (aOR = 0.34, 95% CI: 0.13-0.90) and
(DPP-4) inhibitors (n, %)
diastolic (aOR = 0.41, 95% CI: 0.17-0.96) BP targets,
(continued) compared to those who were pensioner, homemaker, or
Baharudin et al
Figure 1. Achievements of treatment targets.
unemployed (Tables 3 and 4). Furthermore, obese partici-
pants also had lower odds of achieving their diastolic BP
target (aOR = 0.42, 95% CI: 0.19-0.91).
Those who were previous smokers had lower odds of
achieving LDL of <2.6 mmol/L (aOR = 0.54, 95% CI: 0.31-
0.94; Table 5). Participants who adhered to their medica-
tions were more likely to achieve their LDL-C and HbA1c
targets; (aOR = 1.72, 95% CI: 1.10-2.69) and (aOR = 2.46,
95% CI: 1.25-4.83), respectively (Tables 5 and 6).
Participants aged between 51 and 60 years old were more
likely to achieve HbA1c of ≤6.5% (aOR=6.29, 95% CI:
1.17-34.00), compared to those who were 50 years or
younger. Other factors associated with less odds of achiev-
ing glycemic target were taking 2 (aOR = 0.10, 95% CI:
0.03-0.36), 3 or more (aOR = 0.09, 95% CI: 0.02-0.48)
OHA and being treated with insulin (aOR = 0.03, 95% CI:
0.004-0.25; Table 6).
Discussion
International and local clinical practice guidelines outline
strict BP, LDL-C, and glycemic control among patients
with high-CV risk based on findings from convincing and
strong levels of evidence.8,23 This study discovered that
only a small proportion (7.2%) of these high-CV risk par-
ticipants from primary care achieved all their targets.
Another study in Norway, although it had different cut-off
points and study outcomes, discovered slightly better results
5
where 9.8% achieved all targets, which comprised of BP
<140/90 (<135/85 for diabetics) mmHg, total cholesterol
<5mmol/L, LDL-C <3 mmol/L, and smoking cessation.24
Other existing literature reported on the achievement of
individual treatment targets, such as BP, lipid, and glycemic
targets, and findings on the achievements of all these treat-
ment targets remain scarce locally and internationally.9-12,25
Yusuf et al26 discovered that smoking, hypertension, diabe-
tes, and dyslipidemia attributed to about 75.8% risk of acute
myocardial infarction among their study population. Thus,
optimizing management of all these risk factors is para-
mount to prevent patient’s first CV event.
The local Malaysian guideline advocated target BP of
<140/90 for most patients and ≤135/75 mmHg for those
with diabetes.8 Approximately a third of the participants
from this study achieved their systolic BP (35.1%) and dia-
stolic BP (46.7%) targets. Compared to other Asian coun-
tries, BP control ranged widely across Asia, from 5.5% in
Pakistan to 70% in Taiwan.27 Focusing on high-CV risk
populations, a European study reported that about 63.4%
achieved their BP target.25 Chung et al28 studied the time
spent at BP target among primary prevention patients and
discovered that those who maintained their target BP for the
duration of 6 to 8.9 months per year had 78% lower odds of
myocardial infarction, stroke, and cardiovascular death,
compared to those who never reached their targets. These
findings confirm the need to treat BP to target to minimize
adverse CVD outcomes among patients.
6 Journal of Primary Care & Community Health 

Table 3. Factors Associated With Achieving Systolic Blood Pressure Targeta.

Variables Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value

Age groups (years)
≤50 1 1
51–60 0.76 (0.34-1.67) .487 0.66 (0.25-1.72) .397
<60 0.58 (0.28-1.20) .140 0.51 (0.17-1.53) .233
Gender
Male 1 1
Female 0.43 (0.28-0.66) <.001 0.61 (0.34-1.09) .094
Ethnicity
Non-Malay 1
Malay 0.87 (0.49-1.55) .639 — —
Education attainment
No formal education/primary school 1 1
Secondary school 1.58 (0.61-4.13) .350 1.23 (0.45-3.39) .683
Tertiary education 2.28 (0.87-5.97) .094 1.49 (0.53-4.20) .450
Marital status
Single/widowed/divorced 1
Married 1.49 (0.67-3.30) .326 — —
Occupation
Pensioner/homemaker/unemployed 1 1
Technician/arm-forces/self-employed/elementary 0.75 (0.39-1.44) .383 0.34 (0.13-0.90) .029
Managerial and professional 2.14 (1.16-3.96) .015 1.55 (0.66-3.62) .316
Family history premature cardiovascular disease (age < 45 years old)
No 1 —
Yes 0.85 (0.31-2.28) .740 —
Family history hypertension
No 1 1
Yes 0.63 (0.42-0.97) .036 0.62 (0.38-1.01) .54
Smoking status
Non-smoker 1 1
Previous smoker 1.89 (1.10-3.25) .022 1.50 (0.77-2.95) .237
Current smoker 4.02 (1.84-8.81) <.001 3.39 (1.30-8.85) .013
Body mass index (kg/m2)
Underweight (<18.5)/normal (18.5-22.9) 1 1
Overweight (23-27.4) 2.03 (0.86-4.81) .107 1.85 (0.72-4.74) .202
Obese (≥27.5) 1.73 (0.75-4.01) .201 1.65 (0.66-4.12) .281
Self-management booklet/mobile application use
No 1 1
Yes 0.72 (0.48-1.10) .131 0.83 (0.52-1.33) .437
Treatment with antihypertensive
No medication 1 1
1 medication 0.40 (0.22-0.73) .002 0.39 (0.20-0.76) .005
2 medications 0.32 (0.18-0.57) <.001 0.32 (0.16-0.65) .002
≥3 medications 0.47 (0.24-0.95) .035 0.59 (0.22-1.58) .290
Polypharmacy
No (<5 total medications) 1 1
Yes (≥5 total medications) 0.66 (0.41-1.06) .086 1.17 (0.58-2.35) .657
Health literacy
Limited 1
Adequate 0.99 (0.64-1.53) .95 — —
Medication adherence
Non-adherent 1
Adherent 1.01 (0.66-1.56) .96 — —

1 = Reference group. Emboldened: Significant at P < .05.

a
Systolic Blood Pressure ≤135 mmHg for diabetes, <140 mmHg for non-diabetes.
Variable with P < .25 were included in multiple logistic regression: age, gender, education level, occupation, family history of hypertension, smoking
status, body mass index, using self-management app/booklet, and treatment with antihypertensive and polypharmacy. Model fits the data well (Hosmer
Lemeshow goodness of fit test P = .178). Cox & Snell R2 = 12.8%, Nagelkerke R2 = 17.8%. All assumptions (interaction, multicollinearity) were met.
Baharudin et al 7

Table 4. Factors Associated With Achieving Diastolic Blood Pressure Targeta.

Variables Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value

Age groups (years)
≤50 1 1
51-60 1.22 (0.52-2.85) .646 0.92 (0.36-2.35) .868
< 60 2.65 (1.21-5.79) .015 1.56 (0.55-4.37) .401
Gender
Male 1
Female 0.86 (0.58-1.28) .465 — —
Ethnicity
Non-Malay 1
Malay 0.93 (0.53-1.63) .805 — —
Education attainment
No formal education/primary school 1
Secondary school 0.82 (0.36-1.85) .625 — —
Tertiary education 0.65 (0.28-1.49) .305 — —
Marital status
Single/widowed/divorced 1
Married 0.92 (0.45-1.89) .827 — —
Occupation
Pensioner/homemaker/unemployed 1 1
Technician/arm-forces/self-employed/ elementary 0.26 (0.13-0.52) <.001 0.41 (0.17-0.96) .041
Managerial and professional 0.73 (0.40-1.35) .318 1.22 (0.56-2.66) .612
Family history: premature cardiovascular disease (age < 45 years old)
No 1
Yes 1.61 (0.63-4.09) .318 — —
Family history: hypertension
No 1 1
Yes 0.75 (0.50-1.14) .177 0.75 (0.48-1.18) .214
Smoking status
Non-smoker 1
Previous smoker 1.12 (0.66-1.91) .675 — —
Current smoker 0.88 (0.41-1.88) .747 — —
Body mass index (kg/m2)
Underweight (<18.5)/normal (18.5-22.9) 1 1
Overweight (23-27.4) 0.42 (0.19-0.93) .032 0.46 (0.20-1.03) .060
Obese (≥ 27.5) 0.36 (0.17-0.78) .010 0.42 (0.19-0.91) .029
Self-management booklet/mobile application use
No 1
Yes 1.14 (0.76-1.70) .538 — —
Treatment with antihypertensive
No medication 1 1
1 medication 1.28 (0.72-2.28) .405 1.16 (0.62-2.18) .634
2 medications 1.44 (0.82-2.53) .207 1.42 (0.76-2.66) .277
≥3 medications 1.21 (0.61-2.40) .579 1.24 (0.58-2.64) .585
Polypharmacy
No (<5 total medications) 1
Yes (≥5 total medications) 0.82 (0.53-1.28) .382 — —
Health literacy
Limited 1 1
Adequate 0.73 (0.48-1.11) .138 0.75 (0.48-1.17) .200
Medication adherence
Non-adherent 1
Adherent 1.08 (0.72-1.63) .715 — —

1 = Reference group. Emboldened: Significant at P < .05.

a
Diastolic nlood pressure ≤75 mmHg for diabetes and <90 mmHg for non-diabetes.
Variable with P < .25 were included in multiple logistic regression: age, occupation, family history of hypertension, body mass index, treatment with
antihypertensive, and health literacy. Model fits the data well (Hosmer Lemeshow goodness of fit test P = .442). Cox & Snell R2 = 7.4%, Nagelkerke
R2 = 9.9%. All assumptions (interaction, multicollinearity) were met.
8 Journal of Primary Care & Community Health 

Table 5. Factors Associated With Achieving Low-Density Lipoprotein Cholesterol (LDL-C) <2.6 mmol/L.

Variables Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value

Age groups (years)
≤ 50 1 1
51-60 1.66 (0.75-3.69) .215 1.79 (0.73-4.38) .200
<60 1.86 (0.89-3.89) .100 1.90 (0.70-5.14) .205
Gender
Male 1
Female 0.94 (0.63-1.41) .757 — —
Ethnicity
Non-Malay 1
Malay 1.07 (0.61-1.89) .809 — —
Education attainment
No formal education/primary school 1
Secondary school 0.73 (0.31-1.71) .461 — —
Tertiary education 0.87 (0.37-2.07) .755 — —
Marital status
Single/widowed/divorced 1 1
Married 1.92 (0.94-3.93) .075 1.85 (0.87-3.92) .111
Occupation
Pensioner/homemaker/unemployed 1 1
Technician/arm-forces/self-employed/elementary 0.64 (0.35-1.16) .139 0.84 (0.37-1.93) .688
Managerial and professional 1.16 (0.61-2.19) .652 1.43 (0.64-3.23) .386
Family history of premature cardiovascular disease (age < 45 years old)
No 1 1
Yes 0.58 (0.23-1.46) .248 0.49 (0.19-1.30) .152
Family history of dyslipidemia
No 1
Yes 0.92 (0.60-1.41) .69 —
Smoking status
Non-smoker 1 1
Previous smoker 0.51 (0.30-0.87) .014 0.54 (0.31-0.94) .029
Current smoker 1.13 (0.51-2.51) .772 1.23 (0.50-3.02) .649
Body mass index (kg/m2)
Underweight (<18.5)/normal (18.5-22.9) 1
Overweight (23-27.4) 0.92 (0.43-1.95) .817 — —
Obese (≥ 27.5) 1.18 (0.56-2.46) .663 — —
Self-management booklet/mobile application use
No 1 1
Yes 1.46 (0.97-2.20) .070 1.50 (0.97-2.30) .068
Treatment with lipid-lowering medication
No medication 1 1
1 medication 2.95 (1.27-6.87) .012 1.02 (0.13-7.84) .983
2 medications 1.96 (0.60-6.39) .267 0.82 (0.09-7.58) .858
Treatment with statin
No 1 1
Yes 2.83 (1.31-6.13) .008 2.76 (0.43-17.81) .287
Polypharmacy
No (<5 total medications) 1
Yes (≥5 total medications) 1.24 (0.79-1.97) .351 — —
Health literacy
Limited 1
Adequate 0.95 (0.62-1.46) .828 — —
Medication adherence
Non-adherent 1 1
Adherent 1.77 (1.16-2.69) .008 1.72 (1.10-2.69) .017

1 = Reference group. Emboldened: Significant at P < .05.

Variable with P < .25 were included in multiple logistic regression: age, marital status, occupation, family history of premature cardiovascular disease,
smoking status, using self-management app/booklet, treatment with lipid-lowering medication, treatment with statin, and medication adherence.
Model fits the data well (Hosmer Lemeshow goodness of fit test P = .321). Cox & Snell R2 = 7.9%, Nagelkerke R2 = 10.7%. All assumptions (interaction,
multicollinearity) were met.
Baharudin et al 9

Table 6. Factors Associated With Achieving HbA1c ≤ 6.5%a.

Variables Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value

Age groups (years)

≤50 1 1
51-60 4.88 (1.07-22.13) .040 6.29 (1.17-34.00) .033
<60 5.34 (1.22-23.38) .026 3.69 (0.64-21.40) .145
Gender
Male 1
Female 1.13 (0.67-1.88) .652 — —
Ethnicity
Non-Malay 1
Malay 1.27 (0.62-2.56) .515 — —
Education attainment
No formal education/primary school 1
Secondary school 1.16 (0.40-3.35) .781 — —
Tertiary education 1.66 (0.57-4.82) .352 — —
Marital status
Single/widowed/divorced 1
Married 0.64 (0.28-1.46) .290 — —
Occupation
Pensioner/homemaker/unemployed 1 1
Technician/arm-forces/self-employed/elementary 0.45 (0.19-1.07) .071 0.46 (0.15-1.46) .187
Managerial and professional 0.63 (0.27-1.45) .276 0.82 (0.28-2.45) .725
Family history premature of cardiovascular disease (age < 45 years old)
No 1 1
Yes 0.38 (0.08-1.70) .205 0.44 (0.08-2.44) .351
Family history of diabetes
No 1 1
Yes 0.69 (0.40-1.19) .183 0.81 (0.42-1.56) .522
Smoking status
Non-smoker 1
Previous smoker 1.48 (0.71-3.07) .296 — —
Current smoker 1.36 (0.49-3.78) .551 — —
Body mass index (kg/m2)
Underweight (<18.5)/normal (18.5-22.9) 1
Overweight (23-27.4) 1.03 (0.41-2.61) .948 — —
Obese (≥ 27.5) 0.79 (0.32-1.93) .600 — —
Self-management booklet/mobile application use
No 1
Yes 0.90 (0.54-1.50) .686 —
Treatment with oral hypoglycemic agent
No medication 1 1
1 medication 0.52 (0.20-1.30) .161 0.46 (0.15-1.36) .159
2 medications 0.10 (0.04-0.29) <.001 0.10 (0.03-0.36) <.001
≥3 medications 0.08 (0.02-0.34) <.001 0.09 (0.02-0.48) .005
Treatment with insulin
No 1 1
Yes 0.04 (0.01-0.27) .001 0.03 (0.004-0.25) <.001
Polypharmacy
No (<5 total medications) 1 1
Yes (≥5 total medications) 0.31 (0.17-0.58) <.001 0.67 (0.32-1.42) .297
Health literacy
Limited 1 1
Adequate 0.60 (0.36-1.01) .053 0.57 (0.29-1.12) .102
Medication adherence
Non-adherent 1 1
Adherent 1.68 (0.98-2.90) .062 2.46 (1.25-4.83) .009

1 = Reference group. Emboldened: Significant at P < .05.

Variable with P < .25 were included in multiple logistic regression: age, occupation, family history of premature cardiovascular disease, family history of
diabetes, treatment with oral hypoglycemic agents, treatment with insulin, polypharmacy, health literacy, and medication adherence. Model fits the data
well (Hosmer Lemeshow goodness of fit test P = .278). Cox & Snell R2 = 25.8%, Nagelkerke R2 = 37.1%. All assumptions (interaction, multicollinearity)
were met.
a
For diabetes only.
10
As for factors associated with the achievement of sys-
tolic BP targets, this study discovered an association
between occupation and the achievement of BP targets.
Research from the United States showed that protective ser-
vice workers, such as police officers, had higher rates of
hypertension and were less likely to achieve control29; find-
ings shared with our study showed that the middle-occupa-
tion category, including armed forces, had lesser odds of
achieving systolic and diastolic BP target. Various hypoth-
eses, including job stress, have been attributed to poor BP
control among them.29 This study also found that current
smokers had higher odds of achieving systolic BP targets,
parallel with previous findings, which showed current
smokers having lower BP.30 Nevertheless, smoking is a
strong risk factor for CVD8; therefore, it should not be
advocated as a measure to achieve BP control among
patients. Another finding from this study was the significant
association between obesity and achievement of diastolic
BP target. The participants who were obese had lower odds
of achieving diastolic BP target. This finding is supported
by previous literature which showed various mechanism in
which obesity can contribute to hypertension, including
compression of the kidney by the surrounding fat, leading
to the activation of the renin-angiotensin-aldosterone sys-
tem, as well as an increased in the activity of sympathetic
nervous system.31 Thus, weight management counseling
should be actively implemented by the primary care provid-
ers as part of the holistic management of hypertension.
This research discovered that 60.2% of its participants
attained LDL-C of <2.6 mmol/L, while another Malaysian
community-based study reported that a smaller proportions
(16.1%) of its high-risk participants achieved the target.12
International studies focusing on the LDL-C target achieve-
ments among high-risk individuals discovered varying find-
ings, where only 16.8% of high-risk individuals in Hungary
achieved LDL-C.25 In contrast, the EUROSPIRE V study
discovered that 46.9% of high-risk participants treated with
lipid-lowering medications achieved their LDL-C target.9
Bruckert et al,32 in their systematic review of European
populations, found that approximately 46% of high-risk
individuals attained their LDL-C target. The 2019 European
Society of Cardiology and European Atherosclerosis
Society Guideline recommend an even lower LDL-C target
of <1.4 mmol/L for those with very high CV risk and
<1.8 mmol/L for high-risk individuals.23 Recent literature,
however, debated whether individuals with lower LDL-C
had better CV outcomes, where some showed continued
effectiveness, even with LDL-C <1 mmol/L (40 mg/dL) for
patients with high CV risk.33 At the same time, Rong et al34
found the contrary, in which those with LDL-C lower than
1.8 mmol/L (70 mg/dL) had higher odds of developing CVD
mortality with a hazard ratio (HR) of 1.60 (95% CI, 1.01-
2.54), compared to those with LDL-C of 2.59 mmol/L
(100 mg/dL) to 3.36 mmol/L (129.9 mg/dL). In the same
Journal of Primary Care & Community Health 
study, Rong et al34 also concluded that those with very high
LDL-C of more than 4.91 mmol/L (190 mg/dL) had a higher
risk of CVD death. Thus, the Malaysian guideline on dys-
lipidemia management’s recommendation for an LDL-C
target of less than 2.6 mmol/L is appropriate for primary
prevention among patients with high CV risk until further
research can elucidate the optimal LDL-C levels among the
various risk categories. In terms of factors associated with
the achievement of the LDL-C target, a positive association
between medication adherence and achievement of LDL-C
was discovered in this study, consistent with previous litera-
ture, which showed that those who adhered to medications
had a higher likelihood of reaching their optimal LDL-C.35
Lastly, previous smokers were also found to have lower
odds of achieving LDL-c target, in line with findings from
previous literature which showed that former smokers,
along with active smokers, were more likely to have dyslip-
idemia compared to non-smokers.36 This knowledge further
affirms existing evidence on the magnitude of negative
effects that smoking has on individuals.
Diabetes has been recognized as a strong CVD risk fac-
tor, in which those with diabetes have a high risk of devel-
oping CVD.8 The risk becomes more prominent if they
develop any signs of target organ damage, such as retinopa-
thy or proteinuria. These individuals will be considered to
be in the very high-risk group, even without coronary heart
disease or stroke.8 The glycemic control for each individu-
als with diabetes is set according to his or her comorbidities
and risk of developing hypoglycemia.8 A strict HbA1c tar-
get of less than 6.5% is appropriate for participants in this
study as they have yet to develop any CVD. The glycemic
control among the participants with diabetes in this study
was poor, where only 28.2% achieved HbA1c of less than
6.5%, and their median (IQR) HbA1c was 7.0 (1.0) %. Like
LDL-C, medication adherence was also positively associ-
ated with achieving glycemic targets among participants in
this study, consistent with previous literature.37 Furthermore,
it was also proven to reduce hospitalization and visits to the
emergency department.38 Thus, improving medication
adherence should be prioritized to achieve optimal glyce-
mic control among these populations. Additionally, middle-
aged participants (51-60 years old) were more like to have
HbA1c of less than 6.5%, compared to those aged 50 years
and younger. This finding was consistent with the outcome
from a previous study, which concluded that younger age
was associated with worse glycemia control.39 Thus, it is
imperative to treat diabetes more aggressively in younger
patients to prevent adverse CV outcomes among them. This
study also discovered that participants prescribed with 2 or
more OHA, or insulin had lower odds of having HbA1c less
than 6.5%. The escalation of pharmacotherapy in these
patients is needed to achieve optimal glycemic control, in
line with the recommendation from clinical practice guide-
lines to utilize OHA or insulins as a single therapy or in
Baharudin et al
combination to achieve glycemic targets for individual
patient.8
Strength, Limitations, and Implications
for Clinical Practice and Future
Research
The main strength of this research is the discovery of
achievement of all treatment targets among high-CV risk
individuals in Malaysia, which has important clinical impli-
cations. The findings showed that further treatment optimi-
zation is required to achieve their BP, LDL-C, and glycemic
targets. This alarming finding should alert the primary care
providers to treat these risk factors aggressively, using
appropriate measures to reach the targets. Efforts should be
targeted to factors found to be significant in achieving these
targets. For example, high job stress and demand among
armed forces may contribute to poor BP control. Thus,
providing proactive employer-led onsite check-ups and
treatment of BP may assist them in reaching their optimal
BP target. Measures to improve medication adherence such
as educational programs to improve health awareness,
knowledge, and self-efficacy should also be implemented.40
Treatment-related factors, such as simplifying the treatment
regime with a single-pill combination, should also be used,
as it has been shown to improve treatment adherence.41
This study has some limitations. The convenience sam-
pling methods may introduce selection bias. However, this
was minimized as each consecutive patient was approached
and screened for eligibility on data collection days, which
occurred daily during the study period. Also, the study was
conducted at 1 center. While the results may still be general-
izable to primary care clinics with similar sociodemographic
characteristics, the findings may not be generalizable to other
healthcare facilities in Malaysia. Nevertheless, this research
provides a valuable glimpse into the state of risk factor con-
trol among high-CV risk patients in a Malaysian primary care
setting. Future research using more robust sampling methods
representing broader populations should be conducted to
improve the generalizability of the findings and subsequently
improve the care provided to these high-CV risk populations.
This study did not include some essential variables, such as
dietary habits and physical activities, due to limited human
and financial resources. The results should thus be interpreted
in this context. Future studies should consider these factors in
their multiple logistic regression.
Conclusion
Management of CVD risk factors among patients at high
CV risk is still suboptimal. Immediate actions, such as
measures to improve medication adherence, are needed to
improve cardiovascular outcomes among these high-risk
individuals.
11
Acknowledgments
The authors would like to thank the staff at the Primary Care
Clinic, Universiti Teknologi MARA, Sungai Buloh Campus, and
the participants for their willingness to participate in this study.
Author Contributions
NB, ASR, and MSMY conceptualized and designed the study. NB
acquired the funding and coordinated the study. SSR and NIBH
acquired the data. NB analyzed, interpreted the data, and drafted
the manuscript. ASR, SSR, NIBH, and MSMY critically revised
the manuscript for intellectual content. All authors have no com-
peting interest and read and approved the final version for submis-
sion. All authors contributed substantially to the intellectual
contents, fulfilled the requirements for authorship of this manu-
script, and agreed to be accountable for all aspects of the work
including its accuracy and integrity.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was funded by the Clinical Excellent Grant (DCEG),
Hospital Al-Sultan Abdullah, Universiti Teknologi MARA;
[Research Grant Reference No: 600-TNCPI 5/3/DDJ (HUITM)
(002/2021)].
Ethical Statement
This research was conducted according to the Declaration of
Helsinki. The research team obtained ethical approval from the
Research Ethics Committee of Universiti Teknologi MARA
[REC/12/2021 (MR/906)] before the study commenced.
ORCID iDs
Noorhida Baharudin https://orcid.org/0000-0002-8188-4148
Anis Safura Ramli https://orcid.org/0000-0002-9517-1413
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