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PURE study: risk factors cardiovascular disease in low- and high-income countries

Dr Salim Yusuf
ESC 2019
Approximately 70% of the risk of cardiovascular disease (CVD) and death can be explained by modifiable risk factors [1]. Globally, the largest contributing risk factor for CVD are metabolic risk factors (41.2%) of which hypertension (22%) was the leading risk factor in that category. Yet, a large variation was observed between countries with different levels of income with regard to the relative impact of the CVD risk factors.

The PURE study assessed data from 21 countries spreading 5 continents, and aimed to describe the incidence of various diseases and related deaths in countries at different economic levels (high-, middle- and low-income) and to document the relative importance of risk factors for CVD and mortality overall and in these countries. A total number of 152,722 subjects without CVD from high-, middle- and low-income countries were included. Fourteen risk factors were assessed, consisting of behavioural risk factors (i.e. tobacco use, diet, alcohol use, physical activity, and sodium intake), metabolic risk factors (i.e. hypertension, diabetes, obesity, and lipids), psychosocial risk factors (i.e. education and depression), grip strength, and air pollution (in the household [solid fuel use], and PM 2.5 ambient air pollution).

Results showed that the largest group of population attributable factors were behavioural risk factors (26.3%). However, the importance of household air pollution, poor diet, low education, and low grip strength were substantially larger in low- and middle-income countries than in high-income countries. Contrarily, metabolic risk factors, such as high cholesterol, abdominal obesity or diabetes, had a larger impact in high-income countries than in low-income countries on the development of CVD.

According to Dr Salim Yusuf, who presented the results on behalf of the Prospective Urban Rural Epidemiology (PURE) Study Investigators, the implications of these findings are that reducing CVD and mortality require a two-way approach. “Modifying risk factors which have larger effects in specific contexts, with continuing emphasis on low-cost proven treatments, control of hypertension, and tobacco control, as well as improving health care and reducing indoor and outdoor air pollution, particularly in poorer countries.”

1. Yusuf S. PURE - Impact of modifiable risk factors on cardiovascular disease and mortality. FP Number 5069. ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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