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PURE: The prevention gaps in 17 low, middle and high income countries involving over 150,000 people


Presenter | see Discussant report

Salim Yusuf(Canada)

Presentation webcast

Presentation slides

List of Authors:


Discussant | see Presenter abstract

Aldo Pietro Maggioni (Italy)

Presentation slides


Disclosures: none

The context

  • Cardiovascular diseases are not exclusive of well developed countries
  • On the contrary, the majority of them occurs in low- middle income countries
  • Several effective treatments for secondary prevention of CV are available (today also at low cost) and their application is associated with improved outcomes
  • No data are available on the strategies for secondary prevention of CV diseases which are adopted in low- middle income countries

Relevant strengths

  • Large very representative setting 
  • 154,000 individuals from 600 urban and rural communities in 17 high, middle and low income countries with any level of development and socio-cultural characteristics of 5 continents
  • Data collection in the community and not, as usual, in a hospital setting and just by cardiologists
  • Information on a large number of females (more than 50% of the population of the study)

 Most important findings of the PURE study

  • In all countries, at any economical level, medications for secondary prevention are underused, in particular long-term 
  • In this context, the rate of use of medications was higher in high income countries, and substantially lower in poorer countries 
  • Use of secondary prevention medications was higher in urban compared to rural areas. These differences in drug use were more evident in low income countries 
  • The rate of use of all drugs was higher in patients with hypertension compared to those without hypertension 
  • Risk factors seem to be more considered by doctors than the level of patient risk 
  • Rates of use of proven medications were substantially lower in women compared to men and in younger with respect to older patients 
  • In any case, the economic status of a country was more relevant (2/3 of the variations) than individual factors (only 1/3)


Few Limitations

  • An analysis comparing different health systems (i.e. drugs completely or partially reimbursed or no reimbursement at all) could explain differences, irrespective of the economical status 
  • Dosages of treatments are not available, but they could be important in different ethnicities


  • Very important, essential point of reference for further research
  • Need to improve the knowledge, with ad-hoc designed studies for specific countries on – reasons of under-treatment – relationships between rate of use of preventive drugs and occurrence of further CV events – impact of different NHS on secondary prevention strategies irrespective of country economical status
  • Need to improve the access to prevention – stronger collaborations between cardiologists/GPs and, specifically in low-income countries, also with nurses and non-physician health operators (i:e: HIV) – widespread diffusion of EB drugs, as generic drug but even better as essential WHO drugs which could be available at no cost if included in the national formularies of poor (and rich) countries (polypill ?)


  • PURE is a perfect example on how observational research can effectively contribute to the incorporation of EB treatments in clinical practice
  • A real improvement of global CV health could be likely obtained through – preventive strategies focused on the well known risk factors (INTERHEART, INTERSTROKE etc), including life-style changes – socio-political strategies focused to increase the use of preventive drugs more than through the identification of new sophisticated predictive biomarkers or modest refinements of the pharmacological properties of existing classes of drugs


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Hot Line I - Cardiovascular risk and complications

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.