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

Background Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of eff ective secondary prevention medications in these communities. We aimed to assess use of proven eff ective 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. Methods In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35–70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven eff ective 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. We report estimates of drug use at national, community, and individual levels. Findings We enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classifi ed 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 (ptrend<0・0001 for every drug type). Fewest patients received no drugs in high-income countries (