Secondary prevention medications for CVD in 628...

Secondary prevention

medications for CVD in 628

communities from 17 high,

middle and low income countries

The Prospective Urban Rural

Epidemiologic (PURE) study

Salim Yusuf on behalf of the PURE

investigators

Duality of Interests

None to declare with regards this presentation

Background

• Antiplatelet drugs, betablockers, ACE-I/ARBs and

statins reduce MI, stroke and death in CHD; and

these interventions and BP lowering reduces stroke

after a cerbro-vascular event.

• Most studies regarding the use of these drugs are

hospital based or among patients followed by

physicians, but not from the community.

• Little information from low and middle income

countries, where >80% of global CVD occurs.

Aims

• To document the rates of use of proven

secondary prevention medications in the

community in high, mid and low income

countries.

• To describe the variations in drug use by

societal ( economic level of countries and

urban vs rural) and individual ( gender, age,

SES, other conditions) factors.

Design of PURE

• Unbiased population sample from 628

urban and rural communities in 17 countries

involving >390,000 people (154,000 are >35

to 70 yrs; surveyed in 2003-2010.

• Documentation of the characteristics of the

community, the household and individual

(lifestyles, conditions, and drug use).

• Long term follow-up ongoing.

Countries in PURE

Classification of countries

Based on World Bank classifications at the

beginning of the study( 2003 – 2007):

HIC: Canada,Sweden & UAE.

• UMIC: Argentina,Brasil,Chile,Poland,Turkey,

S Africa,Malaysia.

• LMIC: Colombia,Iran,China .

• LIC: India,Bangladesh,Pakistan,Zimbabwe.

Key Characteristics of Eligible vs Enrolled

Eligible Enrolled

No. 197,332 153,662

Mean age (years) 50.2 50.7

% Females 53.0 55.6

% Current Smokers 22.1 21.2

% Low education 41.7 42.3

% H/O Hypertension 13.3 14.7

% H/O Diabetes 5.2 5.3

% H/O Stroke 1.2 1.3

% H/O CHD 3.5 3.9

% H/O Cancer 1.3 1.2

Use of Key Drugs in the Overall Study

among those with CHD vs Stroke

CHD Stroke

No. 5650 2292

%

Antiplatelets 25.8 24.3

Beta-blockers 20.4 9.4

ACE-I/ARB 20.0 18.6

Diuretics 13.6 15.2

CCB 13.3 14.4

BP lowering 43.0 40.0

Statins 16.7 9.0

%

Antiplatelet Agents

Drugs

Beta Blockers

ACE Inhibitors or ARBs Statins

BP Lowering Drugs

%

Drugs by Regions

%

Statins

% receiving proven medications in CAD

(154,000 people from 17 countries:PURE)

0

10

20

30

40

50

60

70

80

90

100

Overall HIC UMIC LMIC LIC

0 1 2 3 4

5593 671 1338 2879 705

Medications by the Number of Years since

Diagnosis

CHD: Antiplatelet

Year Since Diagnosis

Per

cent

0-2 2-4 4-6 6-8 8-10 10-12 >12

1015

2025

3035

P fo r tre n d 0 .0 0 0 3

CHD: Statin


Per

cent

0-2 2-4 4-6 6-8 8-10 10-12 >12

1015

2025

3035

P fo r tre n d = < 0 .0 0 0 1

CHD: ACE-I/ARB


Per

cent

0-2 2-4 4-6 6-8 8-10 10-12 >12

1015

2025

3035

P fo r tre n d = 0 .0 0 4 1

CHD: Beta Blocker


Per

cent

0-2 2-4 4-6 6-8 8-10 10-12 >12

1015

2025

3035

P fo r tre n d 0 .2 6 4 2P for trend 0.2642P for trend 0.0041

P for trend <0.0001P for trend 0.0003

Years Since Diagnosis Years Since Diagnosis

Years Since Diagnosis Years Since Diagnosis

Medication in those with CHD or Stroke* Age

and Sex

Antiplatelets B Blockers ACE-I/ARB Statin

01

02

03

04

0

Age<50Age50-60Age>=60

Age Group

Pe

rce

nt


01

02

03

04

0

FemaleMale

Sex

Pe

rce

nt

*Age, sex, mutual adjustment

Medication in those with CHD or Stroke

Education & Smoking*


01

02

03

04

0

None/PrimarySecondaryTrade/Coll/Univ

Education

Pe

rce

nt


01

02

03

04

0

NeverFormerCurrent

Smoking

Pe

rce

nt

*Age, sex adjusted

Medication in those with CHD or Stroke

BMI and Diabetes*


01

02

03

04

0

bmi<2525<=bmi<30bmi>=30

BMI Categories

Pe

rce

nt


01

02

03

04

0

NoYes

Diabetes

Pe

rce

nt

*Age, sex adjusted

Drug Use by Hypertension in people

with CVD

B B locker ACE-I/ARB Diuretic Calc Antag Any Hyp Med Antiplatelet S tatin

010

2030

4050

6070

No HypertensionHypertension

Figure 3: Rates of drug use by history of hypertension in people with CVDAdjusted for Age, sex, location, education and country economic status

Per

cent

BP Lowering Drugs Other Drugs

B Blocker ACE-I/ARB Diuretic Calc Antag Any Hyp Med Antiplatelet Statin

BP Lowering DrugsOther Drugs

Pe

rcen

t

Per-Capita Health Expenditure vs Percentage the

use of medications

CHD or Stroke: Antiplatelets

Per-Capita Health Expenditure

Per

cent

Ant

ipla

tele

t

0 1000 2000 3000 4000

020

4060

r = 0.81

CHD or Stroke: Statins


Per

cent

Sta

tin

0 1000 2000 3000 4000

020

4060

r = 0.88

CHD or Stroke: ACE-I/ARBs


Per

cent

AC

E-I/

AR

B

0 1000 2000 3000 4000

020

4060

r = 0.74

CHD or Stroke: Beta Blockers


Per

cent

Bet

a B

lock

er

0 1000 2000 3000 4000

020

4060

r = 0.70

Country (between country) & individual

level (within country) variances

Medication Between Country

Variance (%)

Within Country

Variance (%)

Antiplatelet 60.0 40.0

Beta-blocker 59.8 41.2

ACE-I/ARB 54.8 45.2

Statin 79.4 20.6

Any one of the above 68.4 31.6

Conclusions

• Substantial underutilization of proven,

inexpensive secondary prevention medications in

the community worldwide, but the gap is worse in

MIC & LIC.

• Less use of medications in rural compared to

urban communities, especially in LIC and MIC, in

young, females, less educated, smokers, non-

obese,& non-DM individuals.

Conclusions

• Marked differences in use of BB, ACE-I/ARB, diuretics &

CCB in those with hypertension + CVD vs those without

hypertension & CVD: Do physicians treat risk factors

rather than risk?

• Inter-country variability twice as large as between

subject variability: national policies & structured health

systems are more important.

The large global gap in use of proven, inexpensive

and safe strategies that could be readily dealt with

that can benefit millions of individuals each year.

Lancet, August 28, 2011

Secondary prevention medications for CVD in 628...

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