Cited by 983Cardiovascular Health and Risk FactorsHealth Promotion and Cardiovascular PreventionHealthcare Systems and Public Health

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Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries

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Yusuf, Salim, Rangarajan, Sumathy, Teo, Koon, Islam, Shofiqul, Li, Wei, Liu, Lisheng, Bo, Jian, Lou, Qinglin, Lu, Fanghong, Liu, Tianlu, Yu, Liu, Zhang, Shiying, Mony, Prem, Swaminathan, Sumathi, Mohan, Viswanathan, Gupta, Rajeev, Kumar, Rajesh, Vijayakumar, Krishnapillai, Lear, Scott, Anand, Sonia, Wielgosz, Andreas, Diaz, Rafael, Avezum, Alvaro, Lopez-Jaramillo, Patricio, Lanas, Fernando, Yusoff, Khalid, Ismail, Noorhassim, Iqbal, Romaina, Rahman, Omar, Rosengren, Annika, Yusufali, Afzalhussein, Kelishadi, Roya, Kruger, Annamarie, Puoane, Thandi, Szuba, Andrzej, Chifamba, Jephat, Oguz, Aytekin, McQueen, Matthew, McKee, Martin, Dagenais, Gilles·2014·New England Journal of Medicine

DOI 10.1056/nejmoa1311890

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Abstract

BACKGROUND: More than 80% of deaths from cardiovascular disease are estimated to occur in low-income and middle-income countries, but the reasons are unknown. METHODS: We enrolled 156,424 persons from 628 urban and rural communities in 17 countries (3 high-income, 10 middle-income, and 4 low-income countries) and assessed their cardiovascular risk using the INTERHEART Risk Score, a validated score for quantifying risk-factor burden without the use of laboratory testing (with higher scores indicating greater risk-factor burden). Participants were followed for incident cardiovascular disease and death for a mean of 4.1 years. RESULTS: The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 person-years vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3% in high-, middle-, and low-income countries, respectively; P=0.01). Urban communities had a higher risk-factor burden than rural communities but lower rates of cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) and case fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medications and revascularization procedures was significantly more common in high-income countries than in middle- or low-income countries (P<0.001). CONCLUSIONS: Although the risk-factor burden was lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries. The high burden of risk factors in high-income countries may have been mitigated by better control of risk factors and more frequent use of proven pharmacologic therapies and revascularization. (Funded by the Population Health Research Institute and others.).

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Authors: Yusuf, S., Rangarajan, S., Teo, K., Islam, S., Li, W., Liu, L., Bo, J., Lou, Q., Lu, F., Liu, T., Yu, L., Zhang, S., Mony, P., Swaminathan, S., Mohan, V., Gupta, R., Kumar, R., Vijayakumar, K., Lear, S., Anand, S., Wielgosz, A., Diaz, R., Avezum, A., Lopez-Jaramillo, P., Lanas, F., Yusoff, K., Ismail, N., Iqbal, R., Rahman, O., Rosengren, A., Yusufali, A., Kelishadi, R., Kruger, A., Puoane, T., Szuba, A., Chifamba, J., Oguz, A., McQueen, M., McKee, M., & Dagenais, G.
Affiliations: University of Ottawa (CA)
Population Health Research Institute (CA)
Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
Shandong First Medical University (CN)
St. John's Research Institute (IN)
Madras Diabetes Research Foundation (IN)
Fortis Escorts Hospital (IN)
Post Graduate Institute of Medical Education and Research (IN)
Health Action by People (IN)
Simon Fraser University (CA)
Universidad de La Frontera (CL)
UCSI University (MY)
Aga Khan University (PK)
Independent University, Bangladesh (BD)
University of Gothenburg (SE)
Dubai Health Authority (AE)
Isfahan University of Medical Sciences (IR)
North-West University (ZA)
University of the Western Cape (ZA)
Wroclaw Medical University (PL)
University of Zimbabwe (ZW)
London School of Hygiene & Tropical Medicine (GB)
Institut universitaire de cardiologie et de pneumologie de Québec (CA)
ORCID: Yusuf, Salim
Rangarajan, Sumathy
Teo, Koon
Islam, Shofiqul
Li, Wei
Liu, Lisheng
Liu, Tianlu
Mony, Prem
Swaminathan, Sumathi
Mohan, Viswanathan
Gupta, Rajeev
Kumar, Rajesh
Lear, Scott
Anand, Sonia
Wielgosz, Andreas
Lanas, Fernando
Yusoff, Khalid
Iqbal, Romaina
Rahman, Omar
Rosengren, Annika
Yusufali, Afzalhussein
Kelishadi, Roya
Puoane, Thandi
Szuba, Andrzej
Chifamba, Jephat
McKee, Martin
Dagenais, Gilles
Venue: New England Journal of Medicine
Publisher: Massachusetts Medical Society
Published: 2014-08-28
Volume: 371
Issue: 9
Pages: 818-827
ISSN: 0028-4793 (ISSN-L)
1533-4406
DOI: 10.1056/nejmoa1311890
OpenAlex: W2151739272
Cited by: 983
References: 17
Citations by year: 2026: 48 · 2025: 64 · 2024: 123 · 2023: 84 · 2022: 73 · 2021: 87 · 2020: 109 · 2019: 78 · 2018: 75 · 2017: 79 · 2016: 80 · 2015: 70 · 2014: 12
FWCI: 55.20
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: New England Journal of Medicine (publishedVersion)
PubMed (publishedVersion)
LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
Repositorio Universidad de Santander (submittedVersion, cc-by-nc)
Omeka S (Universidad de La Frontera) (submittedVersion, cc-by-nc-nd)
Boloka Institutional Repository (North-west University) (submittedVersion)
UWC Research Repository (University of the Western Cape) (submittedVersion)
Funders: Canadian Institutes of Health Research
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 › Epidemiology › Healthcare Systems and Public Health
Keywords: cardiovascular disease, cardiovascular risk, risk factor burden, low-income countries, middle-income countries, high-income countries, cardiovascular mortality, myocardial infarction, stroke, heart failure, case fatality, urban-rural differences, revascularization, global health disparities
MeSH terms: Cardiovascular Diseases, Female, Humans, Income, Male, Middle Aged, Risk Factors, Rural Health, Urban Health, Global Health, Risk Assessment

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Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries

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