Journal
LANCET
Volume 378, Issue 9798, Pages 1231-1243Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/S0140-6736(11)61215-4
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Categories
Funding
- Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario, ON, Canada
- National Heart and Medical Research Council of Australia
- National Heart Foundation of Australia
- Sydney Medical School Foundation
- Population Health Research Institute
- Canadian Institutes of Health Research
- Heart and Stroke Foundation of Ontario
- AstraZeneca [Sweden]
- AstraZeneca [Canada]
- Sanofi-Aventis [France]
- Sanofi-Aventis [Canada]
- Boehringer Ingelheim [Germany]
- Boehringer Ingelheim [Canada]
- Servier
- GlaxoSmithKline
- Bangladesh Independent University
- Mitra and Associates in Bangladesh
- Unilever Health Institute in Brazil
- Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network in Canada
- Universidad de la Frontera in Chile
- National Center for Cardiovascular Diseases in China
- Colciencias in Colombia [6566-04-18062]
- Indian Council of Medical Research in India
- Ministry of Science, Technology and Innovation of Malaysia [07-05-IFN-MEB010]
- Universiti Teknologi MARA, Universiti Kebangsaan Malaysia in Malaysia [UKM-Hejim-Komuniti-15-2010]
- Polish Ministry of Science and Higher Education [290/W-PURE/2008/0]
- Wroclaw Medical University in Poland
- North-West University
- South Africa and Netherlands Programme for Alternative Development (SANPAD)
- National Research Foundation
- Medical Research Council of South Africa
- South Africa Sugar Association (SASA)
- Faculty of Community and Health Sciences (UWC) in South Africa
- Swedish Council for Working Life and Social Research
- Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning
- Swedish Heart and Lung Foundation
- Swedish Research Council
- Swedish State
- Vastra Gotaland Region (FOUU) in Sweden
- Metabolic Syndrome Society
- Astra Zeneca
- Sanofi-Aventis in Turkey
- Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences
- Dubai Health Authority, Dubai, in the United Arab Emirates
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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, beta 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%), beta blockers (17.4%), ACE inhibitors or ARBs (19.5%), or statins (14.6%). Use was highest in high-income countries (antiplatelet drugs 62.0%, beta 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, beta 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.
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