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Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries

Chow CK 1 , Nguyen TN 2 , Marschner S 2 , Diaz R 3 , Rahman O 4 , Avezum A 5 Show all authors , Lear SA 6 , Teo K 7 , Yeates KE 8 , Lanas F 9 , Li W 10 , Hu B 10 , Lopez-Jaramillo P 11 , Gupta R 12 , Kumar R 13 , Mony PK 14 , Bahonar A 15 , Yusoff K 16 , Khatib R 17 , Kazmi K 18 , Dans AL 19 , Zatonska K 20 , Alhabib KF 21 , Kruger IM 22 , Rosengren A 23 , Gulec S 24 , Yusufali A 25 , Chifamba J 26 , Rangarajan S 7 , McKee M 27 , Yusuf S 7 , PURE Study

Affiliations 

  • 1 Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia clara.chow@sydney.edu.au
  • 2 Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  • 3 Estudios Clinicos Latino America, Rosario, Argentina
  • 4 Independent University, Dhaka, Dhaka District, Bangladesh
  • 5 International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil
  • 6 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  • 7 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
  • 8 Department of Medicine, Queen's University, Kingston, Ontario, Canada
  • 9 Universidad de La Frontera, Temuco, Chile
  • 10 Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Fuwai Hospital, Xicheng District, Beijing, China
  • 11 Masira Research Institute, Universidad de Santander, Bucaramanga, Colombia
  • 12 Eternal Heart Care Centre and Research Institute, Jaipur, India
  • 13 Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  • 14 St John's Medical College, Bangalore, Karnataka, India
  • 15 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (the Islamic Republic of)
  • 16 Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
  • 17 Institute for Community and Public Health, Birzeit University, Birzeit, Illinois, Palestine
  • 18 Department of Medicine, Aga Khan University, Karachi, Pakistan
  • 19 Section of Adult Medicine & Medical Research Unit, University of the Philippines, Manila, Philippines
  • 20 Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  • 21 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 22 Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
  • 23 Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
  • 24 Cardiology Department, Ankara University School of Medicine, Ankara, Turkey
  • 25 Dubai Medical University, Dubai, United Arab Emirates
  • 26 Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  • 27 Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK
BMJ Glob Health, 2020 11;5(11).
PMID: 33148540 DOI: 10.1136/bmjgh-2020-002640

Abstract

OBJECTIVES: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study.

METHODS: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types were available and affordable, group 2-all three drugs were available but not affordable and group 3-all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors.

RESULTS: Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50).

CONCLUSION: Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.

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

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