The Burden of Cardiovascular Events According to Cardiovascular Risk Profile in Adults from High-, Middle- and Low-Income Countries

Background Current strategies to prevent adverse cardiovascular outcomes focus on secondary prevention and primary prevention in high-risk groups. The proportion of events occurring in lower-risk groups globally is unknown. Methods We prospectively documented fatal or non-fatal myocardial infarction, stroke, heart failure, or any other fatal cardiovascular event stratified by history of cardiovascular disease (CVD), and by the INTERHEART and the Framingham risk score in those without prior CVD, in 189,097 adults from 26 high-, middle- and low-income countries. Results Participants’ mean±SD age was 51±10 years and 59% were women. We observed 14,829 outcome events affecting 8% of the cohort during a median 12.4 years’ follow-up. Overall, 44% of outcome events occurred in CVD-naïve participants at low or intermediate INTERHEART risk and 56% occurred in in CVD-naïve participants at non-high Framingham risk. The proportion of adverse cardiovascular outcomes occurring in these lower risk groups was inversely related to country income level and was higher in women (55%) than in men (35%). Conclusions To achieve a substantial population-level reduction in CVD, preventive strategies for CVD are essential in those considered low- or intermediate-risk. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Dr S Yusuf is supported by the Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario. The PURE study is an investigator-initiated study that is funded by the Population Health Research Institute, Hamilton Health Sciences Research Institute (HHSRI), the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Support from Canadian Institutes of Health Research?s Strategy for Patient Oriented Research, through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies [with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithKline], and additional contributions from Novartis and King Pharma and from various national or local organizations in participating countries. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The PURE study received approval from the ethics committees at each centre, and all participants provided written informed consent. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Individual-level data will not be made publicly available because further analyses are planned using the data and because consent has not been obtained from study participants to release these data to researchers who are not study investigators. On reasonable request, aggregate data will be made available. Study case report forms, the laboratory procedures manual and statistical code will also be shared on request.