secondary prevention medications for cvd in 628...
TRANSCRIPT
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
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 1
CHD: ACE-I/ARB
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 4 1
CHD: Beta Blocker
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 .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
Antiplatelets B Blockers ACE-I/ARB Statin
01
02
03
04
0
FemaleMale
Sex
Pe
rce
nt
*Age, sex, mutual adjustment
Medication in those with CHD or Stroke
Education & Smoking*
Antiplatelets B Blockers ACE-I/ARB Statin
01
02
03
04
0
None/PrimarySecondaryTrade/Coll/Univ
Education
Pe
rce
nt
Antiplatelets B Blockers ACE-I/ARB Statin
01
02
03
04
0
NeverFormerCurrent
Smoking
Pe
rce
nt
*Age, sex adjusted
Medication in those with CHD or Stroke
BMI and Diabetes*
Antiplatelets B Blockers ACE-I/ARB Statin
01
02
03
04
0
bmi<2525<=bmi<30bmi>=30
BMI Categories
Pe
rce
nt
Antiplatelets B Blockers ACE-I/ARB Statin
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-Capita Health Expenditure
Per
cent
Sta
tin
0 1000 2000 3000 4000
020
4060
r = 0.88
CHD or Stroke: ACE-I/ARBs
Per-Capita Health Expenditure
Per
cent
AC
E-I/
AR
B
0 1000 2000 3000 4000
020
4060
r = 0.74
CHD or Stroke: Beta Blockers
Per-Capita Health Expenditure
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