Pharmacogenomics-guided cardiovascular therapy in low- and middle-income countries: A systematic review of barriers, equity gaps, and pathways to personalized medicine
- 1Department of Pharmacy, University of Asia Pacific, Dhaka, Bangladesh
- 2Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Dhaka, Dhaka, Bangladesh
Abstract
Cardiovascular disease causes more deaths than any other condition worldwide, and four in five of these deaths occur in low- and middle-income countries (LMICs). Pharmacogenomics (PGx) uses genetic testing to guide drug selection and administration, which can reduce adverse drug reactions and enhance treatment response; however, LMIC groups are significantly underrepresented in the evidence base, limiting equitable clinical translation. A systematic review was conducted, following PRISMA 2020 guidance, mapping PGx-guided cardiovascular therapy, implementation barriers, and equity gaps in LMICs. PubMed and Scopus were searched for studies published between January 2020 and December 2025 and included 24 studies (one randomized controlled trial, 19 observational studies, and four economic models); because of substantial clinical and methodological heterogeneity, findings were combined through SWIM guidelines, and certainty of evidence was assessed using GRADE. Genotype-guided warfarin dosing nearly quintupled the time patients spent in the therapeutic INR range compared with standard care, and decision-analytic models supported the cost-effectiveness of genotype-guided antiplatelet therapy. Ancestry-specific genetic variants relevant to heart-failure drug response, statin-induced myotoxicity, and resistant hypertension were identified, yet African-ancestry individuals made up less than 1% of global PGx study participants. The certainty of evidence varied from very low to moderate across outcomes, indicating a near-total dependence on observational designs and small sample sizes. High testing prices, workforce shortages, low physician genetic knowledge, and the lack of locally appropriate prescribing recommendations all remain obstacles to implementation. Based on these findings, a four-tiered, health-system-focused implementation approach is proposed that spans primary care to national policy. To create regionally calibrated prescribing guidelines in LMICs, multi-site randomized trials, ancestry-informed genomic data, and coordinated policy investment are required.
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BibTeX
@article{mashfi2026pharmacogenomicsguided,
title = {{Pharmacogenomics-guided cardiovascular therapy in low- and middle-income countries: A systematic review of barriers, equity gaps, and pathways to personalized medicine}},
author = {Md. Farid Reza Mashfi and Sumiya Sharmin Mou and Monalisa Riya and Nasiba Binte Bahar and Tasnuha Islam and Fayek Rafi Ahmad and Fabliha Fatima and Md. Elias Al-Mamun},
journal = {PLOS Global Public Health},
year = {2026},
month = nov,
doi = {10.1371/journal.pgph.0006591},
url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006591},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Pharmacogenomics-guided cardiovascular therapy in low- and middle-income countries: A systematic review of barriers, equity gaps, and pathways to personalized medicine
AU - Md. Farid Reza Mashfi
AU - Sumiya Sharmin Mou
AU - Monalisa Riya
AU - Nasiba Binte Bahar
AU - Tasnuha Islam
AU - Fayek Rafi Ahmad
AU - Fabliha Fatima
AU - Md. Elias Al-Mamun
PY - 2026
DA - 2026/11/04
JO - PLOS Global Public Health
DO - 10.1371/journal.pgph.0006591
UR - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006591
AB - Cardiovascular disease causes more deaths than any other condition worldwide, and four in five of these deaths occur in low- and middle-income countries (LMICs). Pharmacogenomics (PGx) uses genetic testing to guide drug selection and administration, which can reduce adverse drug reactions and enhance treatment response; however, LMIC groups are significantly underrepresented in the evidence base, limiting equitable clinical translation. A systematic review was conducted, following PRISMA 2020 guidance, mapping PGx-guided cardiovascular therapy, implementation barriers, and equity gaps in LMICs. PubMed and Scopus were searched for studies published between January 2020 and December 2025 and included 24 studies (one randomized controlled trial, 19 observational studies, and four economic models); because of substantial clinical and methodological heterogeneity, findings were combined through SWIM guidelines, and certainty of evidence was assessed using GRADE. Genotype-guided warfarin dosing nearly quintupled the time patients spent in the therapeutic INR range compared with standard care, and decision-analytic models supported the cost-effectiveness of genotype-guided antiplatelet therapy. Ancestry-specific genetic variants relevant to heart-failure drug response, statin-induced myotoxicity, and resistant hypertension were identified, yet African-ancestry individuals made up less than 1% of global PGx study participants. The certainty of evidence varied from very low to moderate across outcomes, indicating a near-total dependence on observational designs and small sample sizes. High testing prices, workforce shortages, low physician genetic knowledge, and the lack of locally appropriate prescribing recommendations all remain obstacles to implementation. Based on these findings, a four-tiered, health-system-focused implementation approach is proposed that spans primary care to national policy. To create regionally calibrated prescribing guidelines in LMICs, multi-site randomized trials, ancestry-informed genomic data, and coordinated policy investment are required.
SN - 2767-3375
ER -