Repositorio
Institucional

Yusuf, Salim

Islam, Shofiqul

Chow, Clara K.

Rangarajan, Sumathy

Dagenais, Gilles

Diaz, Rafael

Gupta, Rajeev

Kelishadi, Roya

Iqbal, Romaina

Avezum, Alvaro

Kruger, Annamarie

Kutty, Raman

Lanas, Fernando

Liu Lisheng

Wei, Li

Lopez-Jaramillo, Patricio

Oguz, Aytekin

Rahman, Omar

Swidan, Hany

Yusoff, Khalid

Zatonski, Witold

Rosengren, Annika

Teo, Koon K.

Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey

ELSEVIER SCIENCE INC

LANCET

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Background Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, beta blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke. Methods In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35-70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels. Findings We enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5.0 years previously [IQR 2.0-10.0]) and 2292 had stroke (4.0 years previously [2.0-8.0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25.3%), beta blockers (17.4%), ACE inhibitors or ARBs (19.5%), or statins (14.6%). Use was highest in high-income countries (antiplatelet drugs 62.0%, beta blockers 40.0%, ACE inhibitors or ARBs 49.8%, and statins 66.5%), lowest in low-income countries (8.8%, 9.7%, 5.2%, and 3.3%, respectively), and decreased in line with reduction of country economic status (p(trend)<0.0001 for every drug type). Fewest patients received no drugs in high-income countries (11.2%), compared with 45.1% in upper middle-income countries, 69.3% in lower middle-income countries, and 80.2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28.7% urban vs 21.3% rural, beta blockers 23.5% vs 15.6%, ACE inhibitors or ARBs 22.8% vs 15.5%, and statins 19.9% vs 11.6%; all p<0.0001), with greatest variation in poorest countries (p(interaction)<0.0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses). Interpretation Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas-systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.#Antecedentes Aunque la mayoría de las enfermedades cardiovasculares ocurren en países de ingresos bajos y medios, se sabe poco sobre el uso de medicamentos eficaces para la prevención secundaria en estas comunidades. Nuestro objetivo fue evaluar el uso de medicamentos de eficacia comprobada para la prevención secundaria (antiagregantes plaquetarios, betabloqueantes, inhibidores de la enzima convertidora de angiotensina [IECA] o bloqueadores de los receptores de angiotensina [ARA II] y estatinas) en personas con antecedentes de cardiopatía coronaria o accidente cerebrovascular. Métodos En el estudio epidemiológico prospectivo urbano-rural (PURE), reclutamos personas de 35 a 70 años de edad de comunidades rurales y urbanas en países en diferentes etapas de desarrollo económico. Evaluamos las tasas de enfermedades cardiovasculares previas (cardiopatía coronaria o accidente cerebrovascular) y el uso de medicamentos de eficacia comprobada para la prevención secundaria y medicamentos para reducir la presión arterial con cuestionarios estandarizados, que se completaron mediante entrevistas telefónicas, visitas domiciliarias o en la presentación del paciente en las clínicas. Presentamos estimaciones del uso de medicamentos a nivel nacional, comunitario e individual. Hallazgos Inscribimos a 153 996 adultos de 628 comunidades urbanas y rurales en países con ingresos clasificados como altos (tres países), medios-altos (siete), medios-bajos (tres) o bajos (cuatro) entre enero de 2003 y diciembre de 2009. 5650 participantes tuvieron un evento de enfermedad coronaria autoinformado (mediana 5,0 años antes [RIC 2,0-10,0]) y 2292 tuvieron un accidente cerebrovascular (4,0 años antes [2,0-8,0]). En general, pocas personas con enfermedad cardiovascular tomaban medicamentos antiplaquetarios (25,3%), betabloqueantes (17,4%), inhibidores de la ECA o ARA II (19,5%) o estatinas (14,6%). El uso fue mayor en los países de altos ingresos (antiagregantes plaquetarios 62,0%, betabloqueantes 40,0%, inhibidores de la ECA o ARA II 49,8% y estatinas 66,5%), menor en los países de bajos ingresos (8,8%, 9,7%, 5,2% y 3,3%, respectivamente) y disminuyó en consonancia con la reducción del nivel económico del país (p(tendencia)<0,0001 para cada tipo de fármaco). El menor número de pacientes que no recibieron fármacos se registró en los países de altos ingresos (11,2%), en comparación con el 45,1% en los países de ingresos medios altos, el 69,3% en los países de ingresos medios bajos y el 80,2% en los países de bajos ingresos. El uso de medicamentos fue mayor en las áreas urbanas que en las rurales (antiagregantes plaquetarios 28,7% urbano vs 21,3% rural, betabloqueantes 23,5% vs 15,6%, IECA o ARA II 22,8% vs 15,5%, y estatinas 19,9% vs 11,6%; todos p<0,0001), con la mayor variación en los países más pobres (p(interacción)<0,0001 para las diferencias urbano vs rural según el estatus económico del país). Los factores a nivel de país (p. ej., estatus económico) afectaron las tasas de uso de medicamentos más que los factores a nivel individual (p. ej., edad, sexo, educación, estado de tabaquismo, índice de masa corporal y estados de hipertensión y diabetes). Interpretación Debido a que el uso de medicamentos de prevención secundaria es bajo en todo el mundo, especialmente en países de bajos ingresos y áreas rurales, se necesitan enfoques sistemáticos para mejorar el uso a largo plazo de medicamentos básicos, económicos y efectivos.

artículo original

SY is supported by the Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario, ON, Canada. CKC is supported by a fellowship co-funded by the National Heart and Medical Research Council of Australia, National Heart Foundation of Australia and Sydney Medical School Foundation. The main PURE study and its components are funded by the Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, and through unrestricted grants from several pharmaceutical companies (major contributions from AstraZeneca [Sweden and 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 organisations in participating countries. These contributions were from the Bangladesh Independent University and Mitra and Associates in Bangladesh

Unilever Health Institute in Brazil

Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network in Canada

Universidad de la Frontera in Chile

National Center for Cardiovascular Diseases in China

Colciencias in Colombia (grant number 6566-04-18062)

Indian Council of Medical Research in India

Ministry of Science, Technology and Innovation of Malaysia (grant number 07-05-IFN-MEB010) and Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010) in Malaysia

Polish Ministry of Science and Higher Education (grant number 290/W-PURE/2008/0) and Wroclaw Medical University in Poland

The North-West University, South Africa and Netherlands Programme for Alternative Development (SANPAD), National Research Foundation, Medical Research Council of South Africa, The South Africa Sugar Association (SASA), and Faculty of Community and Health Sciences (UWC) in South Africa

Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, Swedish Heart and Lung Foundation, Swedish Research Council, Grant from the Swedish State under LUA (LakarUtbildningsAvtalet) agreement, and grant from the Vastra Gotaland Region (FOUU) in Sweden

Metabolic Syndrome Society, Astra Zeneca, and Sanofi-Aventis in Turkey

Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences, Dubai Health Authority, Dubai, in the United Arab Emirates.

SY cuenta con el apoyo de la cátedra Marion W Burke de la Heart and Stroke Foundation of Ontario, ON, Canadá. CKC cuenta con el apoyo de una beca cofinanciada por el National Heart and Medical Research Council of Australia, la National Heart Foundation of Australia y la Sydney Medical School Foundation. El estudio principal PURE y sus componentes están financiados por el Population Health Research Institute, los Canadian Institutes of Health Research, la Heart and Stroke Foundation of Ontario y a través de subvenciones sin restricciones de varias compañías farmacéuticas (contribuciones importantes de AstraZeneca [Suecia y Canadá], Sanofi-Aventis [Francia y Canadá], Boehringer Ingelheim [Alemania y Canadá], Servier y GlaxoSmithKline), y contribuciones adicionales de Novartis y King Pharma y de varias organizaciones nacionales o locales en los países participantes. Estas contribuciones fueron de la Bangladesh Independent University y Mitra and Associates en Bangladesh

Unilever Health Institute en Brasil

Public Health Agency of Canada y Champlain Cardiovascular Disease Prevention Network en Canadá

Universidad de la Frontera en Chile

National Center for Cardiovascular Diseases en China

Colciencias en Colombia (número de subvención 6566-04-18062)

Consejo Indio de Investigación Médica en India

Ministerio de Ciencia, Tecnología e Innovación de Malasia (número de subvención 07-05-IFN-MEB010) y Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010) en Malasia

Ministerio de Ciencia y Educación Superior de Polonia (número de subvención 290/W-PURE/2008/0) y Universidad Médica de Breslavia en Polonia

The North-West University, Programa de Sudáfrica y Países Bajos para el Desarrollo Alternativo (SANPAD), Fundación Nacional de Investigación, Consejo de Investigación Médica de Sudáfrica, The South Africa Sugar Association (SASA) y Facultad de Ciencias Comunitarias y de la Salud (UWC) en Sudáfrica

Consejo Sueco para la Vida Laboral y la Investigación Social, Consejo Sueco de Investigación para el Medio Ambiente, las Ciencias Agrícolas y la Planificación Espacial, Fundación Sueca del Corazón y los Pulmones, Consejo Sueco de Investigación, Subvención del Estado sueco en virtud del acuerdo LUA (LakarUtbildningsAvtalet) y subvención de la Región de Vastra Gotaland (FOUU) en Suecia

Sociedad del Síndrome Metabólico, Astra Zeneca y Sanofi-Aventis en Turquía

Premio Sheikh Hamdan Bin Rashid Al Maktoum para las Ciencias Médicas, Autoridad Sanitaria de Dubái, Dubái, en los Emiratos Árabes Unidos.

10.1016/S0140-6736(11)61215-4

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acute coronary syndromes

myocardial-infarction

risk-factors

heart-failure

self-report

stroke

availability

medicines

validity

impact

síndromes coronarios agudos

infarto de miocardio

factores de riesgo

insuficiencia cardíaca

autoinforme

accidente cerebrovascular

disponibilidad

medicamentos

validez

impacto

acute coronary syndromes

myocardial-infarction

risk-factors

heart-failure

self-report

stroke

availability

medicines

validity

impact

síndromes coronarios agudos

infarto de miocardio

factores de riesgo

insuficiencia cardíaca

autoinforme

accidente cerebrovascular

disponibilidad

medicamentos

validez

impacto

Sistema Cardiovascular y Cardiaco # Epidemiología # Política de Salud y Servicios

Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey

LANCET

hibrido

restringido

restringido

PMID 21872920

en

artículo original

versión publicada

Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario, ON, Canada

National Heart and Medical Research Council of Australia

National Heart Foundation of Australia

Sydney Medical School Foundation

Population Health Research Institute

Canadian Institutes of Health Research

Heart and Stroke Foundation of Ontario

AstraZeneca Sweden

AstraZeneca Canada

Sanofi-Aventis France

Sanofi-Aventis Canada

Boehringer Ingelheim Germany

Boehringer Ingelheim Canada

Servier

GlaxoSmithKline

Bangladesh Independent University

Mitra and Associates in Bangladesh

Unilever Health Institute in Brazil

Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network in Canada

Universidad de la Frontera in Chile

National Center for Cardiovascular Diseases in China

Colciencias in Colombia 6566-04-18062

Indian Council of Medical Research in India

Ministry of Science, Technology and Innovation of Malaysia 07-05-IFN-MEB010

Universiti Teknologi MARA, Universiti Kebangsaan Malaysia in Malaysia UKM-Hejim-Komuniti-15-2010

Polish Ministry of Science and Higher Education 290/W-PURE/2008/0

Wroclaw Medical University in Poland

North-West University

South Africa and Netherlands Programme for Alternative Development (SANPAD)

National Research Foundation

Medical Research Council of South Africa

South Africa Sugar Association (SASA)

Faculty of Community and Health Sciences (UWC) in South Africa

Swedish Council for Working Life and Social Research

Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning

Swedish Heart and Lung Foundation

Swedish Research Council

Swedish State

Vastra Gotaland Region (FOUU) in Sweden

Metabolic Syndrome Society

Astra Zeneca

Sanofi-Aventis in Turkey

Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences

Dubai Health Authority, Dubai, in the United Arab Emirates

Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario, ON, Canada

National Heart and Medical Research Council of Australia

National Heart Foundation of Australia

Sydney Medical School Foundation

Population Health Research Institute

Canadian Institutes of Health Research

Heart and Stroke Foundation of Ontario

AstraZeneca Sweden

AstraZeneca Canada

Sanofi-Aventis France

Sanofi-Aventis Canada

Boehringer Ingelheim Germany

Boehringer Ingelheim Canada

Servier

GlaxoSmithKline

Bangladesh Independent University

Mitra and Associates in Bangladesh

Unilever Health Institute in Brazil

Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network in Canada

Universidad de la Frontera in Chile

National Center for Cardiovascular Diseases in China

Colciencias in Colombia 6566-04-18062

Indian Council of Medical Research in India

Ministry of Science, Technology and Innovation of Malaysia 07-05-IFN-MEB010

Universiti Teknologi MARA, Universiti Kebangsaan Malaysia in Malaysia UKM-Hejim-Komuniti-15-2010

Polish Ministry of Science and Higher Education 290/W-PURE/2008/0

Wroclaw Medical University in Poland

North-West University

South Africa and Netherlands Programme for Alternative Development (SANPAD)

National Research Foundation

Medical Research Council of South Africa

South Africa Sugar Association (SASA)

Faculty of Community and Health Sciences (UWC) in South Africa

Swedish Council for Working Life and Social Research

Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning

Swedish Heart and Lung Foundation

Swedish Research Council

Swedish State

Vastra Gotaland Region (FOUU) in Sweden

Metabolic Syndrome Society

Astra Zeneca

Sanofi-Aventis in Turkey

Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences

Dubai Health Authority, Dubai, in the United Arab Emirates

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Medicine, General & Internal

Medicina general e interna

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