A Summary of Cardiometabolic Disorders in the Maghreb: Insights from the 2025 Saclay Cardiometabolic Summit.

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Learn more: PMC Disclaimer | PMC Copyright Notice Cardiol Ther . 2026 May 22;15(2):135–153. doi: 10.1007/s40119-026-00451-x A Summary of Cardiometabolic Disorders in the Maghreb: Insights from the 2025 Saclay Cardiometabolic Summit Faouzi Addad 1 , Walid Amara 2 , Ahmed Bennis 3 , Franck Boccara 4 , M Abed Bouraghda 5 , Mohammed Chettibi 6 , Hinde Iraqi 7 , Selma Siham El Khayat 8 , Inès Khochtali 9, 10 , Nadia Laredj 11 , Rachid Malek 12 , Habib Skhiri 13 , Aida Soufiani 7 , Marilucy Lopez-Sublet 14, 15, 16, ✉ Author information Article notes Copyright and License information 1 Heart Care Center, Medical Lake Tower, Berges du Lac 2, Tunis, Tunisia 2 GHI Le Raincy-Montfermeil, Montfermeil, France 3 Cardiology Department, Ibn Rochd CHU, Casablanca, Morocco 4 Clinical Research Group 22, C2MV-Cardiovascular and Metabolic Complications Among People Living with HIV, Inserm UMR_S 938, Saint Antoine Research Center, Cardio-Metabolism and Nutrition University Hospital Institute (ICAN), Department of Cardiology, Saint Antoine Hospital AP-HP, Sorbonne University, Paris, France 5 Cardiology Department, Omar Yacef Draa Ben Khedda Hospital, Tizi-Ouzou, Algeria 6 Cardiology Department, Hospital-University Centre (CHU) Beni Messous, Alger, Algeria 7 Faculty of Medicine and Pharmacy, Ibn Sina Hospital-University Centre (CHU), Rabat, Morocco 8 Nephrology Department, UHC Ibn Rochd, Faculty of Medicine and Pharmacy, Hassan II University, Casablanca, Morocco 9 Department of Endocrinology, Hospital University Monastir, Monastir, Tunisia 10 Department of Internal Medicine, Hospital University Monastir, Monastir, Tunisia 11 Cardiology Department, Hospital-University Centre (CHU) Oran, Oran, Algeria 12 Department of Internal Medicine, Hospital-University Centre (CHU) Sétif, Sétif, Algeria 13 Department of Nephrology and Dialysis, Hospital-University Monastir, Monastir, Tunisia 14 AP-HP, Hôpital Avicenne, Centre d’Excellence Européen en Hypertension Artérielle, Service de Médecine Interne, 125 Rue de Stalingrad, 93000 Bobigny, France 15 INSERM UMR942 MASCOT, Paris 13-Université Paris Nord, Villetaneuse, France 16 FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France ✉ Corresponding author. Received 2026 Feb 16; Accepted 2026 Apr 29; Issue date 2026 Jun. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13221515  PMID: 42171985 Abstract The inaugural 2025 Cardiometabolic Summit in Saclay, France, aimed to (i) disseminate the latest research on cardiometabolic diseases (CMDs) from the Maghreb and/or Middle East and North Africa region; (ii) discuss CMD management and provide clinical practice suggestions for improving adherence and reducing clinical inertia; and (iii) suggest policy and clinical practice initiatives to improve outcomes in patients with CMDs. Cardiovascular disease (CVD) is the leading cause of death worldwide, with 80% of CVD fatalities occurring in low- and middle-income countries. This trend is mirrored in Algeria, Morocco and Tunisia, three countries in the Maghreb region. In these countries, CMDs, such as type 2 diabetes mellitus (T2DM) and hypertension, have high prevalence and are undertreated. At the Cardiometabolic Summit, attended by 110 clinicians from Algeria, Morocco and Tunisia, regional CMD epidemiology and management data were presented, along with evidence on regional research initiatives to reduce the burden of CMDs and CVD and how Ramadan fasting affects adults with T2DM. Context-specific holistic strategies to improve the management of patients with multimorbidities were reviewed, including targeting modifiable risk factors to prevent T2DM and hypertension. Two barriers to optimal CMD management were addressed: (i) poor patient treatment adherence and (ii) clinician-related therapeutic inertia, noting the latter may be a greater contributor to poor outcomes. Prescription of single-pill combinations was recommended for initial blood pressure control, and a cost-effective sulfonylurea plus a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist (whenever feasible) was recommended for glycaemic control plus cardiorenal protection. Polypills may be appropriate where intervention for additional CMDs is required. Strategies for enhancing patient adherence and opportunities for reducing therapeutic inertia were presented. Finally, policy actions and clinical practice priorities were suggested. These steps provide a realistic path towards reducing CMD and CVD burden in the Maghreb. Keywords: Algeria, Cardiometabolic disorders, Cardiovascular disease, Diabetes, Hypertension, Maghreb, Morocco, Multimorbidity, North Africa, Therapeutic inertia, Tunisia Plain Language Summary Cardiovascular disease is a collection of disorders that affect the heart and blood vessels, and the leading cause of death worldwide. Cardiometabolic disorders refer to a group of interconnected conditions (type 2 diabetes mellitus, hypertension and dyslipidaemia) that are known to increase the risk of cardiovascular complications. Cardiometabolic disorders often remain underdiagnosed and undertreated, particularly in the Maghreb region, where there is a pressing need for enhanced patient care and outcomes. To address this critical issue, 110 clinicians from Algeria, Morocco and Tunisia convened at the inaugural Cardiometabolic Summit in Saclay, France, in April 2025. The Summit showcased the latest research findings on cardiometabolic disorders from the Maghreb and the broader Middle East and North Africa region. It also provided clinical practice recommendations for Maghreb-based healthcare professionals, with an emphasis on strategies to improve treatment adherence (i.e. how well the patient follows their prescribed treatment) and reduce clinical inertia (i.e. clinician-based delays in start or intensifying treatment). Key initiatives proposed to enhance cardiometabolic disorder outcomes included the strengthening of public healthcare policies, the adaptation of global guidelines to local contexts, increased investment in professional training and patient engagement, and the expansion of both regional and global collaborations. This strategic call-to-action aims to catalyse a significant transformation of cardiometabolic care, ultimately leading to improved outcomes for patients with cardiometabolic disorders in the Maghreb region, and remains the main objective of this manuscript. Key Summary Points Type 2 diabetes mellitus, hypertension and dyslipidaemia are cardiometabolic disorders (CMDs), which are interconnected conditions that increase cardiovascular disease risk. In the North African region of the Maghreb, CMDs are underdiagnosed and undertreated, related in part to poor patient treatment adherence and clinician-related therapeutic inertia. Strategies to improve patient treatment adherence include (i) optimising the ease of use of prescribed therapies (such as single-pill combination therapy [SPC] or polypills) and (ii) strengthening patient health literacy and doctor–patient communication. Use of SPC or polypills may also assist in overcoming therapeutic inertia when there is a tendency to focus on monotherapy and delay treatment intensification. Four policy priorities to improve care in patients with CMD were identified: (1) strengthen public health policies for equitable access; (2) adapt global guidelines to local realities; (3) invest in professional training and patient engagement; and (4) leverage regional and international collaboration. Open in a new tab Introduction The purpose of the inaugural Cardiometabolic Summit, conducted in Saclay, France, in April 2025, was to (i) disseminate the latest research on cardiometabolic diseases (CMDs) from the Maghreb and/or Middle East and North Africa (MENA) region; (ii) present studies on CMD management and provide clinical practice suggestions for Maghreb-based clinicians, focusing on improving adherence and reducing clinical inertia; and (iii) suggest policy and clinical practice initiatives to improve outcomes in patients with CMDs. Cardiovascular diseases (CVDs) are the leading cause of death globally, with Global Burden of Disease data revealing that CVD was responsible for 18.6 million deaths in 2019 [ 1 , 2 ]. In 2021, CVD-related deaths had risen to 20.5 million worldwide, with 80% occurring in low- and middle-income countries (LMICs), highlighting the disproportionate impact of CVD in LMICs versus high-income countries [ 3 ]. In the MENA region, CVD mortality has increased, although age-standardised rates decreased between 1990 and 2021 (Fig. 1 ). Despite this, CVD remains a significant cause of mortality in the Maghreb region within MENA, being associated with 34% of deaths in Algeria [ 4 ], 38% in Morocco [ 5 ] and 26% in Tunisia [ 6 ]. Fig. 1. Open in a new tab Time trend of ASR versus all-age numbers for mortality, DALYs, incidence and prevalence caused by CVDs in NAME region, both sexes, 1990–2021 [ 103 ]. This licensed material is not part of the governing Open Access license (CC BY-NC) but has been reproduced with permission from Soleimani et al. [ 103 ], Springer Nature. ASR age-standardized rate, CVD cardiovascular disease, DALYs disability-adjusted life years, NAME North Africa and Middle East CMDs are a cluster of interrelated conditions, including type 2 diabetes mellitus (T2DM) or insulin resistance, hypertension and dyslipidaemia, that significantly increase the risk of CVD complications [ 7 , 8 ]. The link between CMDs and CVD is complex, with multiple components and risk factors interacting (Fig. 2 ). The increased CVD mortality seen in LMICs is associated with an increase in the prevalence of CMDs [ 9 ]. In particular, an increased prevalence of T2DM and hypertension has been observed in MENA, attributable at least in part to rapid urbanisation in the region and accompanying increases in the rates of obesity, physical inactivity and smoking [ 10 – 12 ]. However, T2DM and hypertension are underdiagnosed and undertreated, with glycated haemoglobin (HbA1c; < 7%) [ 13 ] and blood pressure (BP; < 140/90 mmHg) targets infrequently met [ 10 , 14 , 15 ]. Undertreatment is mainly attributed to patient non-adherence and clinical inertia [ 16 ]. Confronted with similar shortfalls, clinicians from countries in the Maghreb region are seeking context-specific solutions to improve patient outcomes. Fig. 2. Open in a new tab From cardiometabolic disorders to cardiovascular disease [ 104 ]. Common metabolic and genetic risk factors, such as insulin resistance, dyslipidaemia and obesity, drive the development of diabetes and hypertension, which in turn promote atherosclerosis, endothelial dysfunction, vascular inflammation, fibrosis and arterial remodelling. These processes give rise to both macrovascular and microvascular disease and culminate in cardiovascular disease. Figure reproduced from Petrie et al. [ 104 ], under a Creative Commons (CC BY 4.0) license, with changes made only to the figure caption and explanatory text To address this unmet need, the Cardiometabolic Summit was attended by 110 clinicians from Algeria, Morocco and Tunisia. The contents of this narrative commentary are based on presentations made at the Summit by the authors, with a particular focus on three Maghreb countries (Algeria, Morocco and Tunisia). Each expert author independently prepared their own presentation after conducting a separate literature search. The presentation structure and choice of references were based on the author’s clinical experience and the latest international guidelines, particularly the European recommendations. Authors were responsible for identifying and reviewing published articles in the scientific literature using standard searches on major databases (e.g. PubMed), without solicitation of pharmaceutical requests or target audiences. Finally, presentations underwent a regulatory process prior to meeting to emphasise the authors’ independence and neutrality. Diabetes and Hypertension in Maghreb Countries CMDs constitute a growing public health challenge in North Africa, yet reliable epidemiological data from individual Maghreb countries are limited. All Maghreb countries are considered LMICs [ 17 ]; therefore, their CVD risk statistics are expected to be similar to that of other LMICs [ 9 ]. This section examines epidemiological data on diabetes and hypertension from Algeria, Morocco and Tunisia (Table 1 ). Table 1. Cardiometabolic disorder-related statistics for Algeria, Morocco and Tunisia Country Prevalence (%) Control rate (%) Diabetes Hypertension HbA1c < 7% BP < 140/90 mmHg Algeria [ 21 , 106 , 107 ] 14.4 22 43.1 – Morocco [ 19 , 22 ] 10.6 29.3 26.8 10.1 Tunisia [ 20 , 23 , 27 , 29 ] 23 44.2 24.7 51.8 Open in a new tab BP blood pressure, HbA1c glycated haemoglobin In 2024, an estimated 84.7 million adults in the MENA region had diabetes; this prevalence is projected to reach 162.6 million by 2050 [ 10 ]. According to World Health Organization (WHO) STEP wise approach to Surveillance (STEPS) surveys conducted in Algeria (adult population 47.4 million) in 2016–2017 [ 18 ] and Morocco (population 36.8 million) in 2017–2018 [ 19 ], the estimated prevalence of diabetes was 14.4% and 10.6%, respectively. In Tunisia (population 12.1 million), the prevalence is higher, with the 2024 Tunisian Association on Study and Research on Atherosclerosis (ATERA) survey reporting a diabetes prevalence of 23% among adults aged > 25 years [ 20 ]. Across Algeria, Morocco and Tunisia, the 2025 International Diabetes Federation (IDF) age-adjusted prevalence of diabetes among adults (aged 20–75 years) was 17.5%, 11.9% and 16.0%, respectively [ 10 ]. Glycaemic control remains poor, with only 43.1%, 26.8% and 24.7% of patients with T2DM achieving an HbA1c < 7% in Algeria [ 21 ], Morocco [ 22 ] and Tunisia [ 23 ], respectively. Beyond reported prevalence, T2DM in the Maghreb represents a hidden burden, characterised by underdiagnosis, delayed treatment intensification and suboptimal long-term glycaemic control. The prevalence of hypertension in MENA has risen steadily since 1990, mirroring global trends [ 24 ]. In the 2013 Epidemiological Trial of Hypertension in North Africa (ETHNA) study, conducted in Algeria, Morocco and Tunisia ( N = 28,500), the overall prevalence of hypertension was 45.4% and the age- and sex-adjusted prevalence was 26.9% [ 25 ]. While most patients (86%) were receiving antihypertensive treatment, only 35.7% of these reached the target BP (< 140/90 mmHg) [ 25 ]. In the 2023 WHO global report on hypertension, the 2019 age-standardised prevalence of hypertension among adults (aged 30–79 years) was 36% in Algeria, 35% in Morocco and 35% in Tunisia [ 26 ]. Between 2016 and 2019, an ATERA survey of 10,576 individuals across seven regions of Tunisia estimated a hypertension prevalence of 44.2% among individuals aged 25–75 years [ 27 ]. Notably, 52.7% of individuals with hypertension were previously undiagnosed (incidental detection during the survey), and 23% of the population had high-normal BP (also known as pre-hypertension, defined as systolic BP [SBP] 120–139 mmHg or diastolic BP [DBP] 80–89 mmHg) [ 28 ]. According to the NaTuRe HTN observational registry study ( N = 25,826), BP control was observed in 51.8% of Tunisian adults with hypertension had BP control when this was defined as SBP/DBP < 140/90 mmHg, but only 18.6% met the more stringent < 130/80 mmHg target [ 29 ]. Hypertension ranks first for cost among the 24 medical conditions covered by the Tunisian health insurance fund (‘CNAM’) and accounts for 40% of the total expenditure by CNAM on fully covered conditions [ 30 ]. The Moroccan 2017 WHO STEPS survey reported that the prevalence of high BP (< 140/90 mmHg) or treatment with antihypertensive medications was 29.3%, with 13.0% achieving BP control while receiving treatment and 15.6% having persistent high BP despite treatment [ 19 ]. Less than half (46.3%) of the individuals with previously diagnosed hypertension were receiving treatment; after exclusion of these individuals, the prevalence of hypertension was 22.8% [ 19 ]. New Regional Evidence Shaping Practice Several regional research initiatives have been undertaken to reduce the burden of CMDs and CVD in Algeria, Morocco and Tunisia. ACE Inhibitor Plus CCB Therapy On the basis of clinical evidence, a panel of 12 Algerian hypertension specialists concluded that combination therapy with an angiotensin-converting enzyme (ACE) inhibitor (perindopril) plus calcium channel blocker (CCB; amlodipine) provides effective 24-h BP control (< 140/90 mmHg), reduces visit-to-visit variability in BP, is well tolerated and reduces the incidence of cardiovascular events [ 31 – 33 ]. These conclusions were based on data from the pivotal ASCOT-BPLA trial in patients with hypertension plus other cardiovascular risk factors [ 34 ] and the EUROPA-CCB trial in patients with stable coronary artery disease (CAD) [ 35 ]. Both ASCOT-BPLA and EUROPA-CCB showed greater reductions in the incidence of cardiovascular events, cardiovascular mortality and all-cause mortality in patients receiving perindopril plus amlodipine versus controls [ 34 , 35 ]. A randomized, double-blind, comparative phase 3 study [ 36 ] and two prospective observational studies [ 37 , 38 ] have confirmed a rapid, sustained reduction in BP, high target-achievement rates and marked renal-cardiovascular event reductions in patients receiving perindopril-amlodipine treatment. Fixed-dose dual combinations (e.g. ACE inhibitor–diuretic, angiotensin-receptor blocker [ARB]–diuretic, CCB–diuretic, beta-blocker–diuretic, ACE inhibitor–CCB, beta-blocker–CCB or ARB–CCB) may also be beneficial in this setting [ 39 ]. The ongoing SYNERGIA-Morocco study is a prospective, multicentre, observational 90-day trial that is evaluating the effectiveness and safety of add-on perindopril for adult patients with BP previously uncontrolled on amlodipine monotherapy [ 40 ]. The results of this study are awaited with interest. AFEX: ACT on Angina Worldwide, CAD is one of the most common CVDs, occurring in 135 million individuals [ 41 ], with angina its most common symptom [ 42 ]. In Morocco’s national ST-elevation myocardial infarction (STEMI) registry, history of untreated chronic angina was reported in 74.2% of patients presenting with STEMI [ 43 ]. Persistent or severe angina predicts an increased 12-month risk of cardiovascular events [ 44 ]. Angina is also associated with a three-fold greater risk of disability and a 1.5-fold higher job-loss rate, and four-fold greater the risk of depression [ 45 , 46 ]. In 2025, the pan-African group of leading cardiologists ‘African Experts: Advanced Cardiovascular Training on Angina’ (AFEX: ACT on Angina) developed a roadmap and guidance for the management of chronic coronary syndrome (CCS) [ 47 ]. African countries face unique challenges in managing patients with stable CCS. Firstly, the burden of CCS may be under-recognised, in part due to the predominantly younger age of African populations, especially in sub-Saharan Africa. Additionally, CCS may be underdiagnosed or not detected early (resulting in therapeutic delays) due to limited healthcare resources. Furthermore, once diagnosed, access to care may be impeded by the limited number of specialised treatment centres and trained healthcare professionals, as well as restricted access to high-efficacy antianginal medications because of inadequate reimbursement and/or a lack of universal healthcare coverage. Finally, there may be an uneven geographic distribution of specialised healthcare services within each country. For example, in Morocco, there are insufficient specialised resources (e.g. 92 catheterisation centres for an average total population size of 37 million people), and these centres are mostly only located in larger cities, which excludes a substantial proportion of the Moroccan population from necessary revascularisation services [ 47 ]. In our opinion, the AFEX: ACT on Angina programme aligns with the 2024 European Society of Cardiology (ESC) CCS guidelines in recognising that no single antianginal drug class is universally superior to other classes [ 47 , 48 ]. AFEX: ACT on Angina advocates for a personalised, patient-centred treatment approach, using combination therapy with agents from drug classes with different mechanisms of action [ 47 ]. If optimal pharmacological therapy is used to target underlying mechanisms and cardiovascular risk factors, then revascularisation by angioplasty in patients with CCS could be avoided. This alternative, more tailored, approach to managing patients, their comorbidities and the underlying mechanisms of chronic stable angina has previously been named the ‘diamond’ approach [ 49 ]. The ‘diamond’ approach enables clinicians to select and combine the most appropriate antianginal therapies (e.g. β-blockers, ivabradine, CCBs, diltiazem/verapamil, nitrates/nicorandil, trimetazidine, ranolazine), guided by both patient-specific needs and evidence-based drug compatibility [ 49 ]. Along with guidance on treatment individualisation, the AFEX: ACT on Angina authors also highlighted the need for pragmatic considerations in LMICs in Africa, such as drug availability, reimbursement barriers and counterfeit drug risk [ 47 ]. TUN-CKDD Tunisian Study The multicentre, cross-sectional observational Tunisian Chronic Kidney Disease among Diabetics (TUN-CKDD) study was sponsored by the Tunisian Society of Nephrology, Dialysis and Renal Transplantation (Société Tunisienne de Néphrologie, Dialyse & Transplantation Rénale) to estimate the prevalence of chronic kidney disease (CKD) in adults with diabetes ( N = 10,145) [ 50 ]. Conducted between January and February 2023, TUN-CKDD estimated that 38.7% of individuals with diabetes had CKD [ 50 ]. This finding underscores the need for a coordinated strategy for the early detection, guideline-driven management and ongoing monitoring of diabetic kidney disease (DKD) in Tunisia. Diabetes and Ramadan Fasting Ramadan has profound religious and social importance in MENA countries. Up to 90% of Muslim adults with T2DM worldwide choose to fast during Ramadan, often for more than 15 days, despite receiving a medical exemption from fasting in some cases [ 51 , 52 ]. Ramadan fasting can potentially lead to poor blood glucose control and an increased risk of hypoglycaemia, hyperglycaemia and diabetic ketoacidosis [ 53 ]. These risks should be appropriately managed through changes to glycaemia self-monitoring schedules, medication dose adjustments and potentially the type(s) of antidiabetic medication used during fasting [ 53 ]. The decision to fast should therefore hinge on three intertwined factors: personal preference, religious practice and the clinician’s medical advice [ 54 ]. Clinicians should stratify the risk of complications from Ramadan fasting by taking into account disease characteristics (e.g. duration and type of diabetes) and personal risk elements (e.g. age, comorbidities and previous experience of Ramadan fasting) [ 55 ]. Risk stratification using the IDF-Diabetes and Ramadan International Alliance (DAR) risk-scoring tool identifies whether a patient’s risk category is low (it is probably safe to fast), moderate (the safety of fasting is uncertain) or high (fasting is probably unsafe and should be advised against) [ 56 ]. In a prospective multicentre observational study in Algeria ( N = 1647), glycaemic response to fasting varied by IDF-DAR risk category, with greater increases in mean blood glucose observed in the low-risk group (+ 33.6 mg/dL) compared with the moderate- and high-risk groups (+ 19.3 and + 10.8 mg/dL, respectively). There were also greater mean HbA1c reductions in the high- versus moderate-risk group (− 0.4% vs − 0.3%), while HbA1c increased in the low-risk group (+ 0.3%) [ 57 ]. However, in our clinical experience, the effects of fasting still differ between individuals even with risk stratification, underscoring the importance of personalised care. With regard to antidiabetic medication use during Ramadan fasting, agents with a low hypoglycaemia risk are metformin, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists (GLP-1 RAs), sodium–glucose cotransporter 2 (SGLT2) inhibitors, acarbose and pioglitazone, while basal insulin and glinides carry an intermediate risk. Sulfonylureas, rapid-acting insulin analogues and human insulins have a high risk of hypoglycaemia; however, third-generation sulfonylureas (gliclazide, glimepiride) have a lower associated risk during Ramadan fasting than older sulfonylureas (glibenclamide) [ 55 ]. Holistic Approach to Managing Patients with Multimorbidity The global prevalence of multimorbidity is 37.2%, although this prevalence varies across regions, from 28.2% in Africa to 45.7% in South America (Fig. 3 ) [ 58 ]. Cardiometabolic multimorbidity prevalence ranges from 5.9% to 14.4% depending on the region and how it is defined [ 59 – 61 ]. The coexistence of poorly controlled CMDs increases the risk of cardiovascular, metabolic and renal complications, referred to by the American Heart Association as ‘cardiovascular-kidney-metabolic syndrome’ [ 62 ]. Fig. 3. Open in a new tab Global prevalence of multimorbidity by a WHO region [ 58 ] and b cardiometabolic multimorbidity patterns (reproduced with permission from Burch et al. [ 105 ]). In a , the prevalence of multimorbidity was determined in a meta-analysis of 126 peer-reviewed studies that included approximately 15.4 million individuals [ 58 ]. WHO World Health Organization To our knowledge, no specific studies on cardiometabolic multimorbidity have been conducted in Algeria, Morocco, Tunisia or the MENA region. However, the aforementioned ETHNA study [ 25 ] may be interpreted as being an indirect indicator of the prevalence at least two CMDs across Algeria, Morocco and Tunisia, although it did not report the prevalence of cardiometabolic multimorbidities per se. In ETHNA, hypertension had significantly higher prevalence among individuals with diabetes (type 1 diabetes mellitus, 59.4%; T2DM 61.3% vs 25.6% without diabetes), hypercholesterolaemia (68.3% vs 24.5% without hypercholesterolaemia), obesity (36.4% vs 22.7% with a normal body mass index) or kidney failure (82.3% vs 31.7% with no kidney failure; all p < 0.00001) [ 25 ]. Cardiometabolic multimorbidity has a profound effect on the absolute risk of cardiovascular events due to synergistic effects between CMDs [ 63 ], with CVD risk increasing with each added cardiovascular risk factor (i.e. total cholesterol > 7 mmol/L, smoking, high-density lipoprotein cholesterol < 1 mmol/L, male sex, diabetes and increased SBP) [ 64 , 65 ]. As diabetes and hypertension are both key drivers of CVD [ 10 , 66 ] and persistently poorly controlled in Maghreb countries, their combined effect on CMDs is of particular cause for concern. The 2023 European Society of Hypertension (ESH) guidelines recommend an integrated cardiorenal-metabolic approach to the management hypertension and T2DM [ 39 ]. First-line treatment should target a BP of < 130/80 mmHg and consist of renin–angiotensin–aldosterone system (RAAS) inhibitor-based dual combination therapy to prevent or slow progression of DKD complications. The goals of treatment are to prevent the onset of microalbuminuria, reduce protein excretion in patients who also have proteinuria, slow glomerular filtration rate decline in patients with nephropathy and prevent end-stage kidney disease [ 39 ]. For patients in Maghreb countries, we similarly suggest the early use of combination therapy that includes a RAAS inhibitor (ACE inhibitor or ARB) plus a CCB or thiazide/thiazide-like diuretic, consistent with ESH guidelines [ 39 ]. Meta-analyses show ACE inhibitors reduce the incidence of all-cause mortality, cardiovascular deaths, myocardial infarction (MI), heart failure (HF) hospitalisations and major cardiovascular events by 13–30% in patients with diabetes and hypertension, whereas ARBs do not produce significant benefits on most of these endpoints [ 67 , 68 ]. For glycaemic control, the 2025 IDF guidelines recommend background metformin therapy in patients with T2DM, with addition of a RAAS inhibitor in those with concurrent hypertension plus an SGLT2 inhibitor or GLP-1 RA in those with or are at risk of cardiorenal complications (SGLT2 inhibitors preferred in those with HF) [ 13 ]. SGLT2 inhibitors and GLP-1 RAs have shown cardiorenal protection in patients with CMD complications. SGLT2 inhibitors reduce the risks of CKD progression, HF hospitalisations and cardiovascular death among patients with T2DM, while GLP-1 RAs reduce the risks of major adverse cardiovascular events, composite kidney outcomes and all-cause mortality [ 13 ]. However, as there is no significant relationship between BP reduction with SGLT2 inhibitors and the risk of adverse cardiovascular events [ 69 ], SGLT2 inhibitors are not yet considered to be antihypertensive drugs. GLP-1 RAs also offer modest BP-lowering effects, and may give cardiorenal protection [ 39 ]. For patients with hypertension and diabetes in Maghreb countries, we suggest antidiabetic therapy with oral sulfonylureas (e.g. gliclazide) due to their relatively low cost compared with other antidiabetic drugs, effective HbA1c reduction and acceptable safety profile during Ramadan fasting (e.g. lower hypoglycaemia risk with gliclazide vs glimepiride) [ 70 – 73 ]. Although cost data are limited, we expect that access to SGLT2 inhibitors may be limited in LMICs (e.g. Algeria, Morocco and Tunisia) because of their high cost; however, given their well-established cardiovascular and renal benefits, their use in combination with gliclazide should be considered where possible. To reduce CVD risk, the main goal for healthcare providers is preventing the onset of diabetes and hypertension through the reduction in associated risk factors (e.g. insulin resistance, dyslipidaemia, obesity). A Swedish National Diabetes Registry study demonstrated that adults with T2DM who achieved targets for five modifiable risk factors (HbA1c, low density-lipoprotein cholesterol [LDL-C], albuminuria, smoking status, BP) had minimal or no excess risk of all-cause mortality, MI or stroke compared with the general population [ 74 ]. Similarly, a 2025 Global Cardiovascular Risk Consortium study showed that the absence of five key risk factors (i.e. hypertension, dyslipidaemia, obesity, diabetes and smoking at 50 years of age) was associated with an increase in the estimated duration of life-years free from CVD [ 75 ]. In contrast, individuals with fewer controlled risk factors exhibited a progressively higher risk of cardiovascular mortality [ 74 ]. A US study reported that individuals with poorly controlled diabetes and hypertension during the COVID-19 pandemic had an increased risk of severe COVID-19 outcomes, including a higher likelihood of hospitalisation, critical care and mechanical ventilation, compared with those with well-controlled BP and HbA1c [ 76 ]. This highlights the importance of comprehensive, multifactorial risk factor management to reduce cardiovascular morbidity and mortality. We suggest a holistic approach to multifactorial risk factor management that includes combining lifestyle changes and patient education with four treatment pillars: (1) tight glycaemic control to prevent vascular damage; (2) strict BP management to reduce haemodynamic stress; (3) aggressive lipid-lowering to stabilise plaques; and (4) the use of pharmacotherapy with proven cardiorenal benefits (e.g. SGLT2 inhibitors, GLP-1 RAs). CMD Management: Treatment Adherence and Clinical Inertia Poor adherence to medications and recommended lifestyle changes is a key factor in failing to achieve treatment targets in patients with CMDs and is associated with an increased risk of CVD-related morbidity and mortality [ 77 , 78 ]. CVD medication adherence is expected to be lower in LMICs than in high-income countries given the reduced availability of healthcare resources in LMICs [ 77 , 79 ]. The WHO propose five ‘dimensions’ (or factors) that affect treatment adherence: (1) the healthcare system; (2) socioeconomic factors; (3) condition-related factors; (4) therapy-related factors; and (5) patient-related factors [ 79 ]. Treating clinicians and policymakers in Algeria, Morocco and Tunisia should be aware of these five dimensions and understand the influence of socioeconomics (being LMICs) and cultural factors (e.g. Ramadan fasting) on treatment adherence. Two key strategies for enhancing patient adherence are (i) optimising the ease-of-use of prescribed therapies and (ii) strengthening patient health literacy and doctor–patient communication. Since polypharmacy is unavoidable in the context of cardiometabolic multimorbidity, simplification of treatment is expected to be particularly advantageous. An SPC incorporates two or more agents that target either a single CMD, while a polypill incorporates two or more agents to target several CMDs for a multifactorial approach [ 80 – 82 ]. A systematic review indicated that treatment adherence may be improved when complex treatment regimens are simplified through the use of polypills [ 83 ]. In this analysis, adherence was higher with SPCs or polypills versus free-combinations regimens [ 83 ]. When chronic treatment is required, such as for CMDs, there is a clinical imperative to improve patient engagement, address patient health literacy (i.e. the ability to understand and use health information to make informed decisions [ 84 ]) and strengthen clinician–patient communication. In our opinion, the Process Communication Model® (PCM) helps to meet this need [ 85 , 86 ]. By observing and understanding the five cues (words, tone, gestures, posture and facial expression), clinicians can quickly identify the principal PCM personality archetype of the patient, and adapt their communication style accordingly to prevent ‘entry’ under stress and the resulting non-adherence to treatment. Although data on the use of PCM in the clinical practice setting are limited [ 87 ], in our experience, PCM offers a rapid, evidence-based method to improve clinician–patient communication and trust, which may ultimately enhance treatment adherence. Health literacy may be further extended with the use of social media. In our opinion, clinicians may use social media to present complex information (e.g. from clinical guidelines) as shareable narratives and correct clinical misinformation in real time [ 88 ]. For example, cardiologists used social media during the COVID-19 pandemic to raise awareness of cardiovascular risks. We propose that digital engagement used in conjunction with the PCM principles has the potential to reinforce the clinician–patient bond and promote health literacy across communities. Clinical inertia remains a pervasive barrier to effective management of CMDs [ 78 , 89 ]. It typically manifests as (1) failure to promptly recognise disease; (2) slow initiation of treatment; and (3) reluctance to intensify therapy when targets are not achieved [ 90 ]. In our experience, this last source of delay is particularly evident in the Maghreb, where monotherapy continues to dominate prescribing practices for patients with CMDs. Clinical inertia may be caused by clinician-related, patient-related and healthcare system-related factors. Clinician-related factors (which contribute to approximately 60% of clinical inertia [ 91 ]) are failure to set treatment goals, initiate or intensify treatment if goals are not met; failure to identify and manage comorbidities and adverse effects; poor patient–clinician communication skills; insufficient consultation time and work overload; underestimation of patient needs; a reactive rather than proactive approach; and inadequate knowledge of new therapies, guidelines and current scientific evidence [ 90 ]. Patient-related factors (20–30% of clinical inertia [ 91 ]) include denial of the diagnosis and/or of its seriousness, absence of overt clinical symptoms, low health literacy, poor clinician–patient communication, adverse effects, polypharmacy and complex treatment regimens, depression and substance abuse [ 90 ]. Healthcare system-related factors (10–20% of clinical inertia [ 91 ]) include a lack of treatment guideline, decision support and disease registries, poor communication with healthcare colleagues and a lack of multidisciplinary management, patient education and healthcare resources [ 90 ]. Suboptimal control from clinical inertia is associated with negative clinical outcomes in patients with CMDs. For example, delayed treatment intensification has been associated with an increased risk of MI, HF and stroke in newly diagnosed patients with T2DM with persistent poor glycaemic control compared with those who achieved target glycaemic control [ 92 ]. Suboptimal control of glycaemia, BP and LDL-C also prolongs symptom burden, potentially eroding patient quality of life, may inflate long-term healthcare costs and increase reliance on rescue interventions, and result in diminished trust in the clinician, further undermining patient engagement. Future Directions Opportunities to improve patient care and health outcomes in the Maghreb region include focusing on integrated care pathways, shared decision-making that incorporates patient preferences, personalised patient-centred care plans, using digital health technologies, and simplifying treatment regimens. Fortunately, progress is being made. Several countries in the Maghreb region have initiated proactive strategies to increase SPC use and have begun to build a foundation of regional evidence through aforementioned programmes, reflecting a growing commitment to improving CMD care. Moreover, there is improved alignment between clinical decision-making and international hypertension guidelines, consistent with a 2024 expert clinician opinion statement from the wider MENA region, which proposed that SPCs are among a range of tools available to address non-adherence and clinical inertia and reduce cardiovascular risk in patients in the Middle East [ 89 ]. Their recommendations included routine early use of SPCs [ 32 , 33 ], combined with educational programmes for patients and clinicians and multidisciplinary team-based care [ 89 ]. Digital health innovation is also gaining traction, with many notable examples in diabetes management [ 93 ]. Studies have investigated artificial intelligence for diagnostics and/or screening in diabetes [ 94 – 96 ], as well as personalised diabetes management using mobile smart phone applications paired with smart watches equipped with non-invasive detection technology for interstitial continuous blood glucose monitoring [ 97 ]. Other wearable devices have been developed to predict hypoglycaemia and hyperglycaemia based on non-invasive electrocardiogram monitoring [ 98 , 99 ], as well as handheld devices that provide automated insulin titration instructions [ 100 ]. Deep-learning models have been investigated to detect and predict CKD and T2DM from retinal fundus images [ 101 ]. Real-time chatbot systems are already in use in Switzerland for generalised primary care health questions on 30 chronic diseases [ 102 ]. All of these developments point to a readiness to embrace technology-driven solutions that could meaningfully improve adherence and outcomes in CMD care. In our opinion, to achieve lasting improvements in CMD care in the Maghreb countries, national health authorities, professional medical societies and industry partners must act decisively on four interlinked priorities (Table 2 ). Strengthen public health policies for equitable access: Access to care should be expanded through government subsidised healthcare, national registries and primary and secondary prevention programmes, standardised CVD risk stratification, and ensured availability of guideline-endorsed therapies. Adapt global guidelines to local realities: International recommendations must be adapted for local healthcare settings, taking into account epidemiology, prescribing practices, reimbursement structures, cultural components and population health literacy. These clinical practice pathways should be co-developed by local and regional stakeholders. Invest in professional training and patient engagement: Clinician training on treatment intensification, CVD risk-based prescribing and effective patient communication is urgently needed. Clinical tools and behavioural techniques should be used to support long-term treatment adherence. Patient-centred counselling and culturally sensitive education are central to building therapeutic alliances. Digital technologies and social media may further elevate care standards, reinforce clinician and patient education and increase patient engagement. Leverage regional and international collaboration: Building on established programmes, Maghreb-wide and global partnerships may serve as valuable platforms for sharing geographically relevant epidemiological data and harmonising healthcare strategies. There is an urgent need to establish national registries and coordinated policies to translate regional evidence into actions that improve CMD management in the Maghreb region. Ideally, these initiatives should be launched, maintained, expanded and linked to policy change. Table 2. Call-to-action: summary of policy and practice priorities Priority area Proposed action Strengthen public health policies for equitable access Healthcare subsidies; national primary and secondary prevention programmes; standardised CVD risk stratification; ensure availability of SPCs Adapt global guidelines to local realities Local tailoring of global recommendations and stakeholder co-development of practical implementation of the recommendations Invest in professional training and patient engagement Training on how to adapt treatment regimens based on response, how to prescribe based on cardiovascular risk, and how to engage and communicate with the patient (e.g. culturally sensitive, patient-centred counselling, use of digital/social media) Leverage regional and international collaboration Launched, maintained, expanded Maghreb-wide and global partnerships to promote epidemiological data collection and sharing and best practice sharing, and linked to policy change Open in a new tab CVD cardiovascular disease, SPCs single-pill combinations Conclusion The Cardiometabolic Summit highlighted the urgent need to transform cardiometabolic care in Maghreb countries, and it is hoped that our call-to-action results in the implementation of policy and practice changes to improve outcomes in patients with CMDs. Acknowledgments Medical Writing/Editorial Assistance We would like to thank Marc Pirson who assisted in preparing the first draft of this manuscript on behalf of Springer Health+, and Tracy Harrison, CMPP, and Sarah Greig, PhD, CMPP, of Springer Health+, who provided editorial assistance on subsequent drafts and post-submission revisions, respectively. This medical writing and editorial assistance was funded by Servier. Author Contributions Faouzi Addad, Walid Amara, Ahmed Bennis, Franck Boccara, M. Abed Bouraghda, Mohammed Chettibi, Hinde Iraqi, Selma Siham El Khayat, Inès Khochtali, Nadia Laredj, Rachid Malek, Habib Skhiri, Aida Soufiani and Marilucy Lopez-Sublet were speakers at the summit, read, revised, and approved the drafts of the manuscript and the final manuscript for submission. Funding Sponsorship for the Cardiometabolic Summit and medical writing assistance were provided by Servier. This work, including the journal’s Rapid Service Fee, was supported by Servier, whose only involvement was to invite the clinicians to participate in the Cardiometabolic Summit meeting and provide them with third-party medical writing support. Servier did not participate in the meeting, nor in the development of the subsequent publication. Data Availability Data sharing is not applicable to this article as no datasets were generated from this symposium. Declarations Conflict of Interest Faouzi Addad, Walid Amara, Ahmed Bennis, Franck Boccara, M. Abed Bouraghda, Mohammed Chettibi, Hinde Iraqi, Selma Siham El Khayat, Inès Khochtali, Nadia Laredj, Rachid Malek, Habib Skhiri, Aida Soufiani and Marilucy Lopez-Sublet have received research fees, speaker fees or honoraria from Servier. Hinde Iraqi has additionally received speaker fees or honoraria from Servier, AstraZeneca, Viatris, Novo Nordisk, Sanofi and Sothema; and consultancy fees from CooperPharma and the World Health Organization. Each author participates in expert assessments or continuing education or receives research funding, speaker fees or honoraria from other industry partners. Further information regarding the author disclosures is available on https://www.transparence.sante.gouv.fr/pages/accueil . Ethical Approval This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. Footnotes Prior Presentation: This article is based on presentations given at a Cardiometabolic Summit held in Saclay, France, on 25–26 April 2025, which was sponsored by Servier. References 1. Kocarnik JM, Compton K, Dean FE, et al. Cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life years for 29 cancer groups from 2010 to 2019: a systematic analysis for the Global Burden of Disease study 2019. JAMA Oncol. 2022;8(3):420–44. 10.1001/jamaoncol.2021.6987. 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