Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study

Walli-Attaei M 1 , Joseph P 2 , Rosengren A 3 , Chow CK 4 , Rangarajan S 2 , Lear SA 5 Show all authors , AlHabib KF 6 , Davletov K 7 , Dans A 8 , Lanas F 9 , Yeates K 10 , Poirier P 11 , Teo KK 2 , Bahonar A 12 , Camilo F 13 , Chifamba J 14 , Diaz R 15 , Didkowska JA 16 , Irazola V 17 , Ismail R 18 , Kaur M 19 , Khatib R 20 , Liu X 21 , Mańczuk M 16 , Miranda JJ 22 , Oguz A 23 , Perez-Mayorga M 24 , Szuba A 25 , Tsolekile LP 26 , Prasad Varma R 27 , Yusufali A 28 , Yusuf R 29 , Wei L 30 , Anand SS 2 , Yusuf S 2

Affiliations 

  • 1 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address: walliam@mcmaster.ca
  • 2 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
  • 3 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
  • 4 The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
  • 5 Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
  • 6 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 7 The Faculty of Medicine, Health Research Institute, Kazakh National University, Almaty, Kazakhstan
  • 8 Department of Medicine, University of Philippines, Manila, Philippines
  • 9 Department of Medicine, Universidad de La Frontera, Temuco, Chile
  • 10 Department of Medicine, Queen's University, Kingston, ON, Canada
  • 11 Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, QC, Canada
  • 12 Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 13 Facultad de Ciencias Medicas Eugenio Espejo, Universidad Universidad Tecnológica Equinoccial, Quito, Ecuador
  • 14 Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
  • 15 Estudios Clinicos Latinoamerica, Rosario, Argentina
  • 16 Department of Epidemiology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute, Warsaw, Poland
  • 17 Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; South American Center of Excellence for Cardiovascular Health, Buenos Aires, Argentina
  • 18 Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Medical Center, Kuala Lumpur, Malaysia
  • 19 School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
  • 20 Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
  • 21 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
  • 22 Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
  • 23 Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
  • 24 Facultad de Medicina, Universidad Nueva Granada and Clinica de Marly, Bogota, Colombia
  • 25 Wroclaw Medical University, Department of Angiology, Diabetology and Hypertension, Wroclaw, Poland
  • 26 University of the Western Cape, School of Public Health, Cape Town, South Africa
  • 27 Health Action by People, Thiruvananthapuram, India; Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
  • 28 Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 29 School of Life Sciences, Independent University, Dhaka, Bangladesh
  • 30 National Centre for Cardiovascular Diseases, Cardiovascular Institute & Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
Lancet, 2020 07 11;396(10244):97-109.
PMID: 32445693 DOI: 10.1016/S0140-6736(20)30543-2

Abstract

BACKGROUND: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

METHODS: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

FINDINGS: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

INTERPRETATION: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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