The Jordan results from the PACT-MEA study highlight a substantial burden of CVD among people with T2D. More than one-quarter of patients with T2D in Jordan had eASCVD, and nearly all (99.2%) individuals from Jordan met the definitions of high or very high cardiovascular risk, as outlined by the ESC 2021 guidelines [13]. Although prevalence was higher among patients receiving care in secondary care settings in Jordan, more than one in five individuals treated in primary care practices had eASCVD, and ASCVD risk was similar in primary and secondary care settings. However, the use of RAS inhibitors, statins, SGLT2is, and GLP-1 RAs was higher in secondary care settings, indicating that treatment of patients with T2D and eASCVD or ASCVD risk is variable based on the healthcare setting. Conversely, insulin use was higher in primary care settings. Achievement of guideline-recommended targets of HbA1c, BP, and LDL-C were met by, at most, one-third of patients with T2D in Jordan.

Some key differences exist between the main study results in Jordan and the regional PACT-MEA analysis. The prevalence of eASCVD was higher in Jordan than the regional PACT-MEA prevalence of 20.9% (which was weighted by the size of the population with diabetes in each of the seven participating countries) [11]. Although CAD was the most common type of eASCVD, more patients in Jordan had CeVD than the overall PACT-MEA study population (27.2% vs. 14.7%) [11]. Rates of eASCVD in Jordanian patients were higher in male patients than female patients, following the same pattern seen in the regional PACT-MEA analysis; however, the prevalence was higher in female patients in Jordan (20.5%), as compared with the regional average (16.0%) [11].

There are some important attributes of the Jordanian cohort warranting further consideration. The mean age of the population (59.7 years) was slightly lower than in contemporary diabetes and cardiovascular trials and in the CAPTURE study [7, 16,17,18,19], and nearly two-thirds of those studied were young (under the age of 65). Given that the median duration of T2D in our study was 10.0 years, this indicates that the diagnosis of T2D occurs at a young age in Jordan. The median BMI of the Jordan population was 29.8 kg/m2, indicative of the significant burden of obesity in the context of diabetes in the region. Nearly all of the Jordan cohort had coronary risk factors; 86.3% had at least two risk factors. More people in Jordan smoked than those in the overall regional sample (27.7% vs. 14.3%) [11]. Although the BP of the Jordanian patients was well controlled, HbA1c and LDL-C were not at target. Interestingly, LDL-C was higher in Jordan than in the regional analysis (2.5 mmol/l [98.0 mg/dl] vs. 2.2 mmol/l [85.1 mg/dl], respectively), but the use of statins was lower (69.4% vs. 77.0%) [11]. Use of high-intensity statins was low, even though international guidelines recommend their use in patients at high or very high ASCVD risk; this recommendation has been endorsed in a consensus statement by Jordanian physicians [20]. High LDL-C levels despite statin therapy have also been observed in a cross-sectional study of patients in Jordan and Lebanon, half of whom had diabetes [21]. Microvascular complications were present in 12.3–19.6% of the Jordanian population, similar to that seen in CAPTURE [7]. Although most patients had an eGFR ≥ 60 ml/min/1.73 m2, more than one-third had albuminuria.

Heart failure (HF) and PAD are important complications in T2D, and studies have shown that these may be the initial presenting cardiovascular event in many patients [22]. However, we found a low rate of these complications in the PACT-MEA population, including Jordan. This may be partly because of under-recognition or underdiagnosis by healthcare professionals or the availability or affordability of diagnostic testing (such as echocardiography or peripheral arterial dopplers). A recent consensus report recommends using biomarkers for identifying HF risk, such as abnormal natriuretic peptide (B-type natriuretic peptide; N-terminal pro-BNP) or high-sensitivity cardiac troponin [23], but these biomarkers were not collected in the current study. Thus, the prevalence of HF may be underreported in the PACT-MEA study.

It is well established that the presence of multiple risk factors increases vascular risk in people with diabetes; it is also recognized that multifactorial approaches to reducing risk factors can markedly mitigate cardiovascular risk in these patients [24,25,26]. However, none of the Jordanian patients in this study achieved all guideline-recommended goals of glycemic control, BP, cholesterol, exercise, BMI, and cardioprotective antihyperglycemic therapy. Despite the availability of cardioprotective antihyperglycemic treatments in Jordan, in patients at high or very high risk, the rate of SGLT2i use was low (31.7%); however, this was higher than rates seen in the CVD group in CAPTURE (15.1%) [7] and in a health system–level cohort of patients with T2D and eASCVD in the US in 2018 [27]. Use of GLP-1 RAs among Jordanian patients at high or very high risk was only 4.0%, considerably lower than observed in the overall PACT-MEA and CAPTURE studies (13.1% and 8.3%, respectively) [7, 11], possibly due to cost or lack of access to these medications.

Managing T2D with the goal of avoiding or reducing the risk of CVD can be challenging, necessitating greater awareness, increased multidisciplinary collaboration, and the implementation of a patient-centered healthcare approach. Men with T2D participating in a small qualitative study in Jordan indicated that the treatment goals for their T2D were generally limited to glycemic control rather than to avoid CVD complications, which study participants did not identify as a likely complication of T2D [28]. Additionally, although the patients in the qualitative study were prescribed lipid-lowering medications, they reported that their healthcare provider did not clearly explain the purpose of these treatments [28]. Lack of understanding of medications and the reasons for taking them is one of the many factors that can lead to low adherence levels [29]. Suboptimal medication adherence was observed in a study of older adults (mean age of 68.1) who had both T2D and CVD [30]. Further, a large, global survey conducted by the International Federation of Diabetes in 2017–2018 among people with T2D revealed that one-third of participants from the MENA region considered themselves to not be at risk for CVD or thought their risk was low; only about one in five thought they were at high risk [31]. Concerningly, one in three people with T2D in MENA had not discussed CVD risk with their healthcare provider and thought they were too young to worry about CVD, despite more than half of the participants being aged 50 or older [31]. However, nearly two-thirds said they needed more information on how to self-manage their diabetes; just over half reported relying on information about CVD from diabetes clinics [31], suggesting referrals to secondary care settings could be valuable in the successful management of diabetes and potentially avoiding or delaying complications.

A survey study in Jordan found discordance between patients and healthcare professionals regarding communication skills and patient-centered care [32], which could be a focus for further research and improvement in this country. Further, elements of individualized patient care have been identified as potentially valuable in the management of T2D, including interdisciplinary care collaboration and considering patient preferences when developing treatment plans [33]. Collaboration of care between primary care physicians and specialists is particularly critical for patients with T2D, especially as they age, due to polypharmacy and potential drug interactions [34, 35], potentially improving T2D care.

The MENA region has a high burden of T2D and associated cardiovascular complications, with rates expected to rise over the next decade [1, 36]. Reasons for these disparities are likely multifactorial, including various socioeconomic, cultural, and ethnic factors; these are also likely to be factors in the high prevalence of ASDVD/ASCVD risk and low achievement rates of guideline-recommended treatment goals revealed in our study. Additionally, a study of healthy adults in Jordan found that half had metabolic syndrome, defined as a cluster of symptoms, including insulin resistance or glucose intolerance, central/abdominal obesity, hypertension, and dyslipidemia [37]. Rates of metabolic syndrome have increased over time in Jordan [38], likely due in part to changes in dietary and physical activity over the past several decades [39, 40]. Our study demonstrates the high burden of T2D and CVD in Jordan, which will continue to increase if not addressed by clinicians and policymakers. Our findings highlight the need for greater awareness of the high level of unmet treatment goals in patients with T2D and ASCVD and integrating guideline-recommended cardioprotective antidiabetic therapies such as SGLT2is and GLP-1 RAs into routine care to improve patient outcomes; greater access to and affordability of antidiabetic medications may be necessary to increase usage.

This study has limitations. Despite aiming to obtain a sample of patients with T2D representative of the target population, the prevalence estimates may not truly represent the entire country due to the small sample size, selection methods, and cross-sectional design. The study sample may be over-represented with patients who have more comorbidities or who have high cardiovascular risk because the patients in PACT-MEA attended clinics; these patients may use healthcare at a higher rate than patients with fewer comorbidities. Additionally, there was a small proportion of patients in primary care compared with secondary care participating in the PACT-MEA study in Jordan, limiting understanding of the management of T2D in the two settings. Data collection in PACT-MEA reflects real-world routine clinical practice, which may have impacted the amount of data and potentially limited its interpretation.