Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Lancet. 2011 Oct 1;378(9798):1231-43. doi: 10.1016/S0140-6736(11)61215-4. Epub 2011 Aug 26.
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, β blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.
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.
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%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β 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, β 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).
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.
Full funding sources listed at end of paper (see Acknowledgments).
尽管大多数心血管疾病发生在低收入和中等收入国家，但对这些社区中有效二级预防药物的使用情况知之甚少。我们旨在评估有冠心病或中风病史的个体使用已证实有效的二级预防药物（抗血小板药物、β受体阻滞剂、血管紧张素转换酶[ACE]抑制剂或血管紧张素受体阻滞剂[ARB]和他汀类药物）的情况。
在前瞻性城乡流行病学（PURE）研究中，我们从处于不同经济发展阶段的国家的农村和城市社区招募了 35-70 岁的个体。我们使用标准化问卷评估先前的心血管疾病（冠心病或中风）的发生率以及已证实有效的二级预防药物和降压药物的使用情况，这些问卷通过电话访谈、家访或患者就诊诊所完成。我们报告了国家、社区和个体层面的药物使用估计数。
我们从收入分类为高（三个国家）、中上（七个国家）、中下（三个国家）或低（四个国家）的国家的 628 个城乡社区招募了 153996 名成年人。5650 名参与者有自我报告的冠心病事件（中位数为 5.0 年前[IQR 2.0-10.0]），2292 名参与者有中风（4.0 年前[2.0-8.0]）。总体而言，患有心血管疾病的个体服用抗血小板药物（25.3%）、β受体阻滞剂（17.4%）、ACE 抑制剂或 ARB（19.5%）或他汀类药物（14.6%）的人数较少。在高收入国家（抗血小板药物 62.0%、β受体阻滞剂 40.0%、ACE 抑制剂或 ARB 49.8%和他汀类药物 66.5%）中使用量最高，在低收入国家（分别为 8.8%、9.7%、5.2%和 3.3%）中最低，并且随着国家经济状况的降低而减少（每种药物类型的趋势检验 p<0.0001）。在高收入国家，接受药物治疗的患者最少（11.2%），而上中收入国家为 45.1%，中下收入国家为 69.3%，低收入国家为 80.2%。城市地区的药物使用率高于农村地区（抗血小板药物 28.7%城市 vs 21.3%农村，β受体阻滞剂 23.5%vs 15.6%，ACE 抑制剂或 ARB 22.8%vs 15.5%，他汀类药物 19.9%vs 11.6%；所有 p<0.0001），在最贫穷的国家中差异最大（按国家经济地位划分的城乡差异的交互检验 p<0.0001）。国家层面的因素（例如经济状况）比个体层面的因素（例如年龄、性别、教育程度、吸烟状况、体重指数以及高血压和糖尿病状况）更能影响药物使用率。
由于全世界特别是在低收入国家和农村地区二级预防药物的使用都很低，因此需要采取系统的方法来改善基本、廉价和有效的药物的长期使用。
文末列出了全部资助来源（见致谢）。
