Physicians' Academy for Cardiovascular Education

the PURE Study:

Literature -

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


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. The study 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.


The Prospective Urban Rural Epidemiological (PURE) study, recruited individuals aged 35–70 years from rural and urban communities in countries at various stages of economic development. The study 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. Estimates of drug use at national, community, and individual levels are reported.



The study 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).


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.


About 35 million people have an acute coronary or cerebrovascular event every year and about half of these events occur in individuals with pre-existing vascular disease.1 The number of people with known prevalent cardiovascular disease worldwide probably exceeds 100 million. β blockers,2 angiotensin-converting-enzyme (ACE) inhibitors,3,4 statins,5 and antiplatelet drugs6 each reduce death, reinfarction, or stroke in patients with coronary heart disease.7,8 Similarly, use of antiplatelet drugs, ACE inhibitors, or statins, coupled with reduction of blood pressure with diuretics, β blockers, ACE inhibitors, or angiotensin-receptor blockers (ARBs), is beneficial in patients with stroke.9 Such drugs are widely recommended for the management of patients with cardiovascular disease or their risk factors. Some studies of hospital registries or surveys of patients recruited in out-patient or general practice clinics (mainly in high-income countries) report moderate to high rates of drug use.10–12 Because about 75% of the burden of cardiovascular disease falls on low-income and middle-income countries, relevant data for secondary prevention practices are needed in countries at various stages of economic development and in different regions.13 Furthermore, many individuals live in rural areas where access to medical care can be restricted, and few data exist for differences in the use of secondary prevention medications between people in urban or rural settings. The Prospective Urban Rural Epidemiology (PURE) study was designed to assess rates of use of key drugs for secondary prevention in populations with prevalent cardiovascular disease from urban and rural communities in such countries.


The study recruited 382 341 individuals from 107 599 households in 628 communities (348 urban and 280 rural) in 17 countries on five continents. Patients with coronary heart disease or stroke in high-income countries had the highest rates of drug use, which decreased with declining country economic wealth. Strong correlations between overall rates of drug use and per head health expenditure by country (figure 3) and gross domestic product were noted. Striking variations in the use of effective drugs (ie, antiplatelet drugs, β blockers, ACE inhibitors or ARBs, and statins) existed between regions with the highest rates of drug use (North America and Europe) and those with the lowest rates of use (Africa), where such drugs were used in less than 10% of patients with previous coronary heart disease or stroke. Use of statins was especially low in south Asia (3.5% [34 of 970 patients]), China (1.7% [53 of 3070]), and Africa (1.1% [3 of 283]).


Effective preventive drugs for coronary heart disease and stroke are underused globally, with striking variation between countries at different stages of economic development. Even the use of accessible and inexpensive treatments such as aspirin varied seven-fold between low-income and high-income countries but the use of statins varied 20-fold. Such non-community studies tend to provide an overestimate of the rates of drug use in a population, because they do not include individuals who have no access to medical care, those who are not longterm drug users, or those who have discontinued active follow-up by a doctor. Consequently, data from hospital registries or general practices tend to substantially overestimate the rates of actual use of secondary prevention drugs in a population.

The authors plan therefore to systematically obtain information about the barriers to optimum care in communities participating in PURE, and in various types of individuals to inform national and community policies for improving availability, access, and affordability of essential drugs for chronic conditions. Such information will also assist in development and implementation of structured longterm programmes that could involve non-physician health workers, low cost and affordable combination therapies (eg, the polypill),14,15 and better educate patients and health-care providers about the benefits, safety, and lifelong need for basic secondary prevention strategies. This study shows the large gap that exists in secondary prevention worldwide, with extremely low rates of use of effective therapies in middle-income and low-income countries. Systematic efforts are needed to understand why even inexpensive drugs are substantially underused globally. Efforts to increase the use of effective and inexpensive drugs for prevention of cardiovascular disease are urgently needed, and would substantially reduce disease burden within a few years.


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