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Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

Journal article
Authors Salim Yusuf
Philip Joseph
Sumathy Rangarajan
Shofiqul Islam
Andrew Mente
Perry Hystad
Michael Brauer
Vellappillil Raman Kutty
Rajeev Gupta
Andreas Wielgosz
Khalid F AlHabib
Antonio Dans
Patricio Lopez-Jaramillo
Alvaro Avezum
Fernando Lanas
Aytekin Oguz
Iolanthe M Kruger
Rafael Diaz
Khalid Yusoff
Prem Mony
Jephat Chifamba
Karen Yeates
Roya Kelishadi
Afzalhussein Yusufali
Rasha Khatib
Omar Rahman
Katarzyna Zatonska
Romaina Iqbal
Li Wei
Hu Bo
Annika Rosengren
Manmeet Kaur
Viswanathan Mohan
Scott A Lear
Koon K Teo
Darryl Leong
Martin O'Donnell
Martin McKee
Gilles Dagenais
Published in Lancet (London, England)
ISSN 1474-547X
Publication year 2019
Published at Institute of Medicine, Department of Molecular and Clinical Medicine
Language en
Links dx.doi.org/10.1016/S0140-6736(19)32...
www.ncbi.nlm.nih.gov/entrez/query.f...
Subject categories Clinical Medicine

Abstract

Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels.In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs.Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs.Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.Full funding sources are listed at the end of the paper (see Acknowledgments).

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