Elsevier

The Lancet

Volume 378, Issue 9798, 1–7 October 2011, Pages 1231-1243
The Lancet

Articles
Use 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

https://doi.org/10.1016/S0140-6736(11)61215-4Get rights and content

Summary

Background

Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, β blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.

Methods

In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35–70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels.

Findings

We enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously [IQR 2·0–10·0]) and 2292 had stroke (4·0 years previously [2·0–8·0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (ptrend<0·0001 for every drug type). Fewest patients received no drugs in high-income countries (11·2%), compared with 45·1% in upper middle-income countries, 69·3% in lower middle-income countries, and 80·2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28·7% urban vs 21·3% rural, β blockers 23·5% vs 15·6%, ACE inhibitors or ARBs 22·8% vs 15·5%, and statins 19·9% vs 11·6%; all p<0·0001), with greatest variation in poorest countries (pinteraction<0·0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses).

Interpretation

Because use of secondary prevention medications is low worldwide—especially in low-income countries and rural areas—systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.

Funding

Full funding sources listed at end of paper (see Acknowledgments).

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.

Section snippets

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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