ArticlesUse of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey
Introduction
About 35 million people have an acute coronary or cerebrovascular event every year and about half of these events occur in individuals with pre-existing vascular disease.1 The number of people with known prevalent cardiovascular disease worldwide probably exceeds 100 million. β blockers,2 angiotensin-converting-enzyme (ACE) inhibitors,3, 4 statins,5 and antiplatelet drugs6 each reduce death, reinfarction, or stroke in patients with coronary heart disease.7, 8 Similarly, use of antiplatelet drugs, ACE inhibitors, or statins, coupled with reduction of blood pressure with diuretics, β blockers, ACE inhibitors, or angiotensin-receptor blockers (ARBs), is beneficial in patients with stroke.9 Such drugs are widely recommended for the management of patients with cardiovascular disease or their risk factors. Some studies of hospital registries or surveys of patients recruited in out-patient or general practice clinics (mainly in high-income countries) report moderate to high rates of drug use.10, 11, 12 However, treatment rates for individuals with prevalent coronary heart disease or stroke in the community are unknown, because many people might not be in medical care years after their acute event. Most available data are from high-income countries or from centres that participate in multicentre studies (generally trials) and whether their findings reflect the actual situation in communities is debateable. Because about 75% of the burden of cardiovascular disease falls on low-income and middle-income countries, relevant data for secondary prevention practices are needed in countries at various stages of economic development and in different regions.13 Furthermore, many individuals live in rural areas where access to medical care can be restricted, and few data exist for differences in the use of secondary prevention medications between people in urban or rural settings. We designed the Prospective Urban Rural Epidemiology (PURE) study to assess rates of use of key drugs for secondary prevention in populations with prevalent cardiovascular disease from urban and rural communities in such countries.
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Study design and participants
In our prospective epidemiological survey, we recruited individuals from communities in low-income, middle-income, and high-income countries with wide variation in economic development and sociocultural diversity. We selected the number and location of countries on the basis of a need to balance between having a large number of communities in countries with substantial heterogeneity in socioeconomic circumstances and policies, and the feasibility of centres to successfully achieve long-term
Results
We recruited 382 341 individuals from 107 599 households in 628 communities (348 urban and 280 rural) in 17 countries on five continents. Recruitment started in Karnataka, India in January, 2003; however, most communities were recruited between January, 2005, and December, 2009. 197 332 (52%) individuals were eligible for the main study, and 153 996 adults participated (78%; 151 966 were aged 35–70 years, 1444 were aged <35 years, and 586 were aged >70 years; figure 1 and table 1). Of these, 36
Discussion
Effective preventive drugs for coronary heart disease and stroke are underused globally, with striking variation between countries at different stages of economic development. Even the use of accessible and inexpensive treatments such as aspirin (the most commonly used antiplatelet drug) varied seven-fold between low-income and high-income countries but the use of statins varied 20-fold. For every group of countries, classified by economic development, rates of drug use were consistently lower
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