The burden of cardiovascular events according to cardiovascular risk profile in adults from high-income, middle-income, and low-income countries (PURE): a cohort study
Leong D.P. Yusuf R. Iqbal R. Avezum Á. Yusufali A. Rosengren A. Chifamba J. Lanas F. Diaz M.L. Miranda J.J. Davletov K. Mirrakhimov E. Yeates K. Khatib R. Alhabib K.F. Gulec S. Paucar M.J. Lopez-Lopez J.P. Mohan V. Gupta R. Soman B. Lakshmi P.V.M. Poirier P. Teo K. Zatonska K. Mat-Nasir N. Artamonova G. Hu B. Liu Z. Liu X. Dans A. Rangarajan S. Yusuf S.
August 2025Elsevier Ltd
The Lancet Global Health
2025#13Issue 8e1406 - e1414 pp.
Background: Current strategies to prevent adverse cardiovascular outcomes focus primary prevention in high-risk groups and secondary prevention in people with known cardiovascular disease. We aimed to determine the proportion of events occurring in lower-risk groups globally. Methods: We included people aged 40 years to younger than 75 years who were enrolled in the Prospective Urban Rural Epidemiology (PURE) study, which is an ongoing, international, prospective, population-based cohort study that started recruiting adults from households selected to be broadly representative of the sociodemographic composition of their communities. We prospectively documented fatal or non-fatal myocardial infarction, stroke, heart failure, or any other fatal cardiovascular event stratified by history of cardiovascular disease and by the 10-year predicted disease risk scores based on WHO 2019 laboratory risk tables (<10% [low], 10% to <20% [intermediate], and ≥20% [high]) in people without previous cardiovascular disease from 26 high-income, middle-income, and low-income countries. Outcome event rates were standardised for the cohorts age and sex distribution. Findings: Between July 11, 2000, and May 6, 2019, 128 973 participants were included from 26 countries (mean age 53·6 years [SD 8·2]; 75 858 [58·8%] were female and 53 115 [41·2%] were male). We observed 11 483 outcome events affecting 8·9% of the cohort during a median follow-up of 12·3 years (IQR 9·8–14·6). Among participants, 89 508 (69·4%) had a low cardiovascular disease risk, 22 363 (17·3%) had an intermediate cardiovascular disease risk, and 5529 (4·3%) had a high cardiovascular disease risk, while 11 573 (9·0%) had known cardiovascular disease. The age-standardised and sex-standardised cardiovascular disease incidence rates per 1000 person-years was 4·1 (95% CI 4·0–4·2) in the low-risk group, 17·7 (15·2–20·2) in the intermediate-risk group, and 40·8 (25·1–56·4) in the high-risk group. Overall, 41% of outcome events occurred in cardiovascular disease-naive participants at low risk. The proportion of adverse cardiovascular outcomes occurring in this low-risk group was inversely related to country income level (32% in high-income, 38% in middle-income, and 54% in low-income countries) and was higher in women (51%) than in men (32%). Interpretation: To achieve a substantial population-level reduction in cardiovascular disease, a fundamental change is needed, so that preventive strategies for cardiovascular disease extend beyond those at high or even intermediate predicted risk to include those at considered to be at low risk. Funding: The funding bodies are listed in the appendix (p 29).
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Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
International Research Center, Hospital Alemão Oswaldo Cruz, São Paolo, Brazil
Dubai Health Authority, Dubai, United Arab Emirates
Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe
Universidad de la Frontera, Temuco, Chile
Estudios Clinicos Latinoamerica, Instituto Cardiovascular de Rosario, Rosario, Argentina
CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
Asfendiarov Kazakh National Medical University and Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan and College of Medicine, Korea University, Seoul, South Korea
Department of Medicine, Queens University, Kingston, ON, Canada
Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI, United States
Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
Cardiology Department, Ankara University School of Medicine, Ankara, Turkey
Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
Masira Research Institute, Universidad de Santander, Bucaramanga, Colombia
Madras Diabetes Research Foundation and Dr Mohans Diabetes Specialities Centre, Chennai, India
Eternal Heart Care Centre & Research Institute, Jaipur, India
Health Action by People, Medical College PO, Trivandrum and Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, Trivandrum, India
Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
Faculté de Pharmacie and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, QC, Canada
Division of Population Studies and Prevention of Noncommunicable Diseases, Wroclaw Medical University, Wroclaw, Poland
Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia
Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russian Federation
Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
Department of Phase I Clinical Trail Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
UP College of Medicine, University of the Philippines Manila, Manila, Philippines
Population Health Research Institute
BRAC James P Grant School of Public Health
Department of Community Health Sciences
International Research Center
Dubai Health Authority
Sahlgrenska Academy
Department of Biomedical Sciences
Universidad de la Frontera
Estudios Clinicos Latinoamerica
CRONICAS Center of Excellence in Chronic Diseases
Asfendiarov Kazakh National Medical University and Research Institute of Cardiology and Internal Diseases
Kyrgyz State Medical Academy
Department of Medicine
Advocate Aurora Research Institute
Department of Cardiac Sciences
Cardiology Department
Facultad de Ciencias de la Salud Eugenio Espejo
Masira Research Institute
Madras Diabetes Research Foundation and Dr Mohans Diabetes Specialities Centre
Eternal Heart Care Centre & Research Institute
Health Action by People
Department of Community Medicine & School of Public Health
Faculté de Pharmacie and Institut Universitaire de Cardiologie et de Pneumologie de Québec
Division of Population Studies and Prevention of Noncommunicable Diseases
Department of Primary Care Medicine
Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”
Medical Research & Biometrics Center
Department of Pharmacy
Department of Phase I Clinical Trail Center
UP College of Medicine
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