Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
Lancet. 2020 Mar 7;395(10226):795-808. doi: 10.1016/S0140-6736(19)32008-2. Epub 2019 Sep 3.
Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels.
In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs.
Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs.
Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.
Full funding sources are listed at the end of the paper (see Acknowledgments).
全球关于常见可修正风险因素对心血管疾病和死亡率影响的估计，主要基于来自不同研究的数据，这些研究使用不同的方法。前瞻性城市农村流行病学（PURE）研究通过使用类似的方法，前瞻性地测量 21 个国家（跨越五个大陆）的可修正风险因素对心血管疾病和死亡率的影响，克服了这些限制。这些国家按不同的经济水平分组。
在这项多国家、前瞻性队列研究中，我们在来自 21 个高收入、中等收入或低收入国家（高收入国家、中等收入国家或低收入国家）的 155722 名无心血管疾病既往史的参与者中，检查了 14 种潜在可修正风险因素与心血管疾病和死亡率之间的关系。本文的主要结果是心血管疾病事件（定义为心血管死亡、心肌梗死、中风和心力衰竭）和死亡率的综合结果。我们描述了与行为因素（即烟草使用、酒精、饮食、身体活动和钠摄入）、代谢因素（即血脂、血压、糖尿病、肥胖）、社会经济和心理社会因素（即教育、抑郁症状）、握力以及家庭和环境污染相关的心血管疾病和死亡率的流行情况、危险比（HR）和人群归因分数（PAF）。使用多变量 Cox 脆弱模型和整个队列的 PAF 以及按收入水平分组的国家，确定风险因素与结局之间的关系。结果以 HR 和 95%CI 表示。
在 2005 年 1 月 6 日至 2016 年 12 月 4 日期间，6 名参与者被纳入并接受风险因素测量。17249 名（11.1%）参与者来自高收入国家，102680 名（65.9%）来自中等收入国家，35793 名（23.0%）来自低收入国家。整个研究人群中约 70%的心血管疾病病例和死亡归因于可修正的风险因素。代谢因素是心血管疾病的主要风险因素（PAF 的 41.2%），高血压是最大的风险因素（PAF 的 22.3%）。作为一个集群，行为风险因素对死亡的影响最大（PAF 的 26.3%），尽管最大的单一风险因素是教育水平低（PAF 的 12.5%）。环境空气污染与心血管疾病 PAF 的 13.9%有关，尽管对这一分析使用了不同的统计方法。在中等收入国家和低收入国家，家庭空气污染、不良饮食、低教育程度和低握力对心血管疾病或死亡率的影响大于高收入国家。
大多数心血管疾病病例和死亡可以归因于少数常见的、可修正的风险因素。虽然有些因素具有广泛的全球影响（如高血压和教育），但其他因素（如家庭空气污染和不良饮食）在各国的经济水平上存在差异。卫生政策应侧重于对全球范围内预防心血管疾病和死亡影响最大的风险因素，同时对特定国家群体中最重要的风险因素给予更多关注。
全文的完整资助来源列在文末（见致谢）。
