Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study
Open accessAbstract
Background Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels.Methods In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs.Findings Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs.Interpretation Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.Funding Full funding sources are listed at the end of the paper (see Acknowledgments).
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Physical activity is a known protective factor for mortality and cardiovascular disease.
“Physical activity, a known protective risk factor for mortality and cardiovascular disease,10”
From Sex Differences in Physical Activity and Incident Stroke: A Systematic Review (2022) · cites this paper as [10]
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- Authors
- Yusuf, S., Joseph, P., Rangarajan, S., Islam, S., Mente, A., Hystad, P., Brauer, M., Kutty, V. R., Gupta, R., Wielgosz, A., AlHabib, K. F., Dans, A., Lopez-Jaramillo, P., Avezum, A., Lanas, F., Oguz, A., Kruger, I. M., Diaz, R., Yusoff, K., Mony, P., Chifamba, J., Yeates, K., Kelishadi, R., Yusufali, A., Khatib, R., Rahman, O., Zatonska, K., Iqbal, R., Wei, L., Bo, H., Rosengren, A., Kaur, M., Mohan, V., Lear, S. A., Teo, K. K., Leong, D., O'Donnell, M., McKee, M., & Dagenais, G.
- Affiliations
- Population Health Research Institute (CA)
- Oregon State University (US)
- University of British Columbia (CA)
- Health Action by People (IN)
- Eternal Hospital (IN)
- University of Ottawa (CA)
- King Saud University (SA)
- University of the Philippines Manila (PH)
- Universidad de La Frontera (CL)
- Universiti Teknologi MARA System (MY)
- St.John's Medical College Hospital (IN)
- University of Zimbabwe (ZW)
- Queen's University (CA)
- Isfahan University of Medical Sciences (IR)
- Dubai Health Authority (AE)
- Advocate Health Care (US)
- Independent University, Bangladesh (BD)
- Aga Khan University (PK)
- Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
- Sahlgrenska University Hospital (SE)
- Post Graduate Institute of Medical Education and Research (IN)
- Madras Diabetes Research Foundation (IN)
- Simon Fraser University (CA)
- Ollscoil na Gaillimhe – University of Galway (IE)
- London School of Hygiene & Tropical Medicine (GB)
- Institut universitaire de cardiologie et de pneumologie de Québec (CA)
- Corresponding author
- Yusuf, Salim
- ORCID
- Yusuf, Salim
- Joseph, Philip
- Rangarajan, Sumathy
- Islam, Shofiqul
- Mente, Andrew
- Hystad, Perry
- Brauer, Michael
- Kutty, Vellappillil Raman
- Gupta, Rajeev
- Wielgosz, Andreas
- AlHabib, Khalid F
- Lanas, Fernando
- Yusoff, Khalid
- Mony, Prem
- Chifamba, Jephat
- Yeates, Karen
- Kelishadi, Roya
- Yusufali, Afzalhussein
- Khatib, Rasha
- Rahman, Omar
- Iqbal, Romaina
- Rosengren, Annika
- Kaur, Manmeet
- Mohan, Viswanathan
- Lear, Scott A
- Teo, Koon K
- Leong, Darryl
- O'Donnell, Martin
- McKee, Martin
- Dagenais, Gilles
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2020-03
- Volume
- 395
- Issue
- 10226
- Pages
- 795-808
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC8006904
- OpenAlex
- W2971576504
- Cited by
- 2,017
- References
- 23
- Citations by year
- 2026: 268 · 2025: 365 · 2024: 382 · 2023: 360 · 2022: 279 · 2021: 222 · 2020: 123 · 2019: 15 · 2018: 2
- FWCI
- 115.52
- Type
- journal article
- Language
- en
- Update notices
- erratum (2020-03-07)
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- eCommons - AKU (Aga Khan University) (submittedVersion)
- Omeka S (Universidad de La Frontera) (submittedVersion)
- Boloka Institutional Repository (North-west University) (submittedVersion)
- Funders
- Sanofi
- Ontario Ministry of Health and Long-Term Care
- Heart and Stroke Foundation of Canada
- Servier
- AstraZeneca Canada
- Boehringer Ingelheim
- GlaxoSmithKline
- National Institutes of Health (DP5OD019850)
- Office of the Director
- Canadian Institutes of Health Research (136893)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- modifiable risk factors, cardiovascular disease, mortality, population attributable fraction, hypertension, hypercholesterolemia, diabetes mellitus, obesity, tobacco use, alcohol consumption, dietary intake, physical activity, sodium intake, depression, grip strength, household air pollution, ambient air pollution, socioeconomic factors, cardiovascular mortality, myocardial infarction, stroke, heart failure, PURE study
- MeSH terms
- Adult, Aged, Cardiovascular Diseases, Developing Countries, Educational Status, Environmental Exposure, Female, Health Policy, Humans, Hypertension, Income, Male, Middle Aged, Poverty, Prospective Studies, Risk Factors, Socioeconomic Factors, Cohort Studies, Health Behavior, Developed Countries
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