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Cited by 964Cardiovascular Health and Risk FactorsLipoproteins and Cardiovascular HealthAntiplatelet Therapy and Cardiovascular Diseases

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

Open access
Yusuf, Salim, Islam, Shofiqul, Chow, Clara K, Rangarajan, Sumathy, Dagenais, Gilles, Diaz, Rafael, Gupta, Rajeev, Kelishadi, Roya +15 more·2011·The Lancet
DOI 10.1016/s0140-6736(11)61215-4
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Abstract

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 (p(trend)<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 (p(interaction)<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).

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Authors
Yusuf, S., Islam, S., Chow, C. K., Rangarajan, S., Dagenais, G., Diaz, R., Gupta, R., Kelishadi, R., Iqbal, R., Avezum, A., Kruger, A., Kutty, R., Lanas, F., Lisheng, L., Wei, L., Lopez-Jaramillo, P., Oguz, A., Rahman, O., Swidan, H., Yusoff, K., Zatonski, W., Rosengren, A., & Teo, K. K.
Affiliations
  • Population Health Research Institute (CA)
  • Fortis Escorts Hospital (IN)
  • Isfahan University of Medical Sciences (IR)
  • Aga Khan University (PK)
  • North-West University (ZA)
  • Health Action by People (IN)
  • Universidad de La Frontera (CL)
  • Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
  • Independent University, Bangladesh (BD)
  • Dubai Health Authority (AE)
  • Universiti Teknologi MARA System (MY)
  • University of Gothenburg (SE)
Corresponding author
Yusuf, Salim
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2011-10
Volume
378
Issue
9798
Pages
1231-1243
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(11)61215-4
OpenAlex
W2098194481
Cited by
964
References
37
Citations by year
2026: 15 · 2025: 53 · 2024: 48 · 2023: 60 · 2022: 55 · 2021: 49 · 2020: 56 · 2019: 57 · 2018: 67 · 2017: 85 · 2016: 73 · 2015: 87 · 2014: 102 · 2013: 84 · 2012: 63
FWCI
56.97
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet (publishedVersion)
  • PubMed (publishedVersion)
  • eCommons - AKU (Aga Khan University) (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Omeka S (Universidad de La Frontera) (submittedVersion, cc-by-nc-nd)
  • Boloka Institutional Repository (North-west University) (submittedVersion)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
  • Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
Keywords
secondary prevention, cardiovascular disease, antiplatelet agents, beta-blockers, ACE inhibitors, angiotensin receptor blockers, statins, coronary artery disease, stroke, drug use, economic development, low-income countries, middle-income countries, high-income countries, PURE study, blood pressure medication, rural and urban communities, medication adherence, cardiovascular risk reduction
MeSH terms
Adrenergic beta-Antagonists, Adult, Aged, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Cardiovascular Agents, Cardiovascular Diseases, Coronary Disease, Data Collection, Developing Countries, Drug Utilization, Female, Humans, Male, Middle Aged, Platelet Aggregation Inhibitors, Rural Population, Urban Population, Developed Countries, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Stroke, Secondary Prevention

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