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Causes of death and cardiovascular risk factors by income level: latest data from PURE

ESC Congress News 2019 - Paris, France

Yesterday, two Hot Line presentations provided us with the latest data from the Prospective Urban Rural Epidemiology (PURE) study.

Initiated in 2001, PURE is one of the most extensive prospective studies examining the effects of societal, environmental, behavioural, metabolic and genetic risk factors that influence the development of cardiovascular (CVD) and other non-communicable diseases. The latest analysis included over 150,000 community-dwelling adults (aged 35–70 years) from four high-income, 12 middle-income and five low-income countries across five continents, making it the only study to date that involves standardised data collection from so many different income-level countries. Indeed, the proportions of participants from high-, middle-, and low-income countries (around 11%, 66% and 23%, respectively) reasonably approximate to the distribution among global populations.

Risk Factors and Prevention

esc_presentation_Causes_of_death_and_cardiovascular_esc_congress_news_2019_wednesday.jpgFirstly, Doctor Darryl Leong (Population Health Research Institute, McMaster University, Hamilton, Canada) presented an analysis on the primary cause of death. “Although CVD remains the leading cause of death worldwide,” says Dr. Leong, “it may be overtaken by cancer in some higher-income countries.” The ratio of CVD deaths to cancer deaths in high-, middle- and low-income countries was 0.4, 1.3 and 3.0, respectively.

Dr. Leong continues, “Understanding the what and why of trends in death and disease rates is key to improving global heath. This shifting pattern in high-income countries reflects how effective we are becoming at preventing and treating CVD. The high rates of CVD and related mortality in low-income countries are likely related to gaps in access to healthcare, with lower use of preventive medications and less frequent hospitalisation for CVD. Improving access to quality healthcare is key to reducing deaths from cardiovascular and other diseases in low- and middle-income countries. Importantly, wider implementation of proven CVD prevention and treatment strategies in all countries, regardless of income level, could lead to further substantial reductions in CVD deaths.”

To be effective, CVD prevention strategies rely on a clear understanding of the modifiable risk factors. This was the focus of a second analysis from PURE, presented in the same Hot Line Session by Professor Salim Yusuf (Population Health Research Institute, McMaster University, Hamilton, Canada), which was simultaneously published in The Lancet.1 The impact of 14 commonly known, potentially modifiable risk factors on CVD and death was assessed globally and according to country income-level. The risk factors were environmental (e.g. air pollution), socioeconomic (e.g. education, depression), behavioural (e.g. tobacco smoking, diet, physical activity, alcohol, sodium consumption) and metabolic (e.g. lipid profile, blood pressure, obesity). The risk factor analysis involved 155,137 participants who did not have a prior history of vascular disease. During 9.5 years’ follow-up, 10,234 deaths and 7,980 major CVD events occurred (approximately 50% each for strokes and heart attacks), most commonly in the poorest countries.

Globally, the greatest contributors to CVD were hypertension and high cholesterol. However, the relative importance of the major risk factors differed depending on income region. In high-income countries, the primary risk factors were elevated cholesterol followed by tobacco smoking, whereas they were hypertension and low education in middle-income countries, and hypertension and high cholesterol in low-income countries. Household air pollution was the third largest contributor to CVD globally. “Air pollution, both indoor and outdoor, is associated with CVD, especially strokes, and overall mortality. Air pollution is a big problem in low-income countries, but much less so in high-income countries,” says Prof. Yusuf.

The main contributor to all-cause mortality differed from CVD. The primary causes of mortality globally were low education, followed by tobacco smoking and poor grip strength.

“The impact of low physical strength is a previously under-appreciated mortality risk factor.”

“Being physically active is still important to maintain health, but less so than improving muscle strength,” says Prof. Yusuf.

The main cause of death in high-income countries was tobacco smoking, whereas in low-income countries it was poor diet. However, there were some surprising insights as to what ‘poor diet’ entails, “Traditionally, we have thought of poor diets as those containing high levels of fat; however, our study showed that it is diets comprising inadequate amounts of fats and proteins, as well as low levels of fruits and vegetables, that are associated with increased mortality risk,” explained Prof. Yusuf. “These findings suggest we need to rethink messaging around what constitutes healthy and unhealthy diets.”

He finishes, “What we can conclude from our analysis is that the order and relevance of major risk factors for CVD and death vary in different parts of the world. As such, prevention strategies need to be tailored to the risk factors that are most important within each region.”




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1. Yusuf S, et al. Lancet 2019. doi/10.1016/S0140-6736(19)32008-2

Notes to editor

About the European Society of Cardiology

The European Society of Cardiology brings together healthcare professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

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ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2019 takes place 31 August to 4 September at the Paris Expo Porte de Versailles, Paris - France. Explore the scientific programme