Physicians' Academy for Cardiovascular Education

CV mortality more common in low-income than in high-income countries

News - Sep. 3, 2019

PURE: Contrasting patterns of cardiovascular disease, cancers and related mortality between high- versus low-middle income countries in 21 countries

PURE: Impact of modifiable risk factors on cardiovascular disease and mortality

Presented at ESC Congress 2019 in Paris, France by Salim Yusuf (Hamilton, ON, Canada)

During the press conference dr. Yusuf also presented the data on modifiable risk factors, which would be presented by dr. Darryl P Leong in the main session.

Introduction and methods

The Prospective Urban Rural Epidemiology (PURE) Study collects data from a total of 202,000 participants, in 27 countries, with ongoing follow-up. 21 Countries have follow-up, and 6 countries have recently joined, so follow-up is awaited. All parts of the world, except Australia, are represented in this cohort.

These analyses of the PURE data looked into the distribution cause-specific deaths in low-income countries (LIC), middle income countries (MIC) and high income countries (HIC). Moreover, the impact of modifiable risk factors on CVD and mortality was explored for the different types of countries.

Main results


Based on these results, Yusuf concluded that CVD is more common in poorer countries and CVD accounts for about 40% of deaths globally (23% HIC, 42% MIC, 43% LIC). Cancer deaths are more frequent than CVD deaths in several HIC and some upper MIC. The differences in CVD rates are not primarily due to differences in metabolic risk factors, but may be due to differences in smoking, diet, air pollution and access to care.

The data are applicable to the countries involved and may not necessarily translate to other countries. It is, however, relevant to note that the cohort consists of non-selected participants.


During the press conference, the question was raised what should be focused on in LIC and MIC in terms of CVD prevention. Greatest benefit may be expected from reducing smoking, controlling hypertension and appropriate investments in healthcare. As an example, Yusuf mentioned that some provinces in India are now investing more in healthcare, and an effect of this measure can be seen. Thus, having healthcare systems set up, low-cost drugs available, smoking cessation and control of BP and lipids helps. Moreover, it helps to train non-physician healthcare workers to focus on prevention, because they likely are more dedicated and effective at helping control risk factors than physicians.

The finding that grip strength impact mortality may be explained by that is could be a marker of frailty. That is currently being investigated in more detail. Yusuf suggested it may also be related to childhood nutrition, and protein consumption. Genomic and proteomic research to look into this is ongoing.

During the discussion it came up that the etiology of cancer is more complicated to understand than of CVD. Effects of smoking generally show a delay of 20 years. Some signs are now appearing that air pollution may also relate to cancer, and preliminary data suggest that insecticides and pesticides may also be linked to cancer. Thus, Yusuf said, we need new lines of thinking about that. Many cancers are now also related to HIV, HPV and other viruses. We begin to understand it more, but a lot remains to be elucidated.

- Our reporting is based on the information provided at the ESC congress -

Watch our video about the PURE trial

The PURE morbidity and mortality data have simultaneously been published in The Lancet The PURE risk factor data have simultaneously been published in The Lancet

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