TY - JOUR
T1 - Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries
T2 - an analysis of the PURE study
AU - PURE investigators
AU - Walli-Attaei, Marjan
AU - Rosengren, Annika
AU - Rangarajan, Sumathy
AU - Breet, Yolandi
AU - Abdul-Razak, Suraya
AU - Sharief, Wadeia Al
AU - Alhabib, Khalid F.
AU - Avezum, Alvaro
AU - Chifamba, Jephat
AU - Diaz, Rafael
AU - Gupta, Rajeev
AU - Hu, Bo
AU - Iqbal, Romaina
AU - Ismail, Rosnah
AU - Kelishadi, Roya
AU - Khatib, Rasha
AU - Lang, Xinyue
AU - Li, Sidong
AU - Lopez-Jaramillo, Patricio
AU - Mohan, Viswanathan
AU - Oguz, Aytekin
AU - Palileo-Villanueva, Lia M.
AU - Poltyn-Zaradna, Katarzyna
AU - R, Sreelakshmi P.
AU - Pinnaka, Lakshmi V.M.
AU - Serón, Pamela
AU - Teo, Koon
AU - Verghese, Sejil T.
AU - Wielgosz, Andreas
AU - Yeates, Karen
AU - Yusuf, Rita
AU - Anand, Sonia S.
AU - Yusuf, Salim
N1 - Funding Information:
The PURE study is funded by the Population Health Research Institute, Hamilton Health Sciences Research Institute, the Canadian Institutes of Health Research (including through the Strategy for Patient-Oriented Research via the Ontario SPOR Support Unit), the Heart and Stroke Foundation (ON, Canada), and the Ontario Ministry of Health and Long-Term Care. The study was also funded by unrestricted grants from the following pharmaceutical companies: AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma. And the study was also funded by several national and local organisations in participating countries as follows: Argentina: Fundacion ECLA (Estudios Clínicos Latino America); Bangladesh: Independent University and Mitra and Associates; Brazil: Hospital Alemão Oswaldo Cruz, São Paulo; Canada: an unrestricted grant from Dairy Farmers of Canada and the National Dairy Council (US), Public Health Agency of Canada, and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de La Frontera (EXD05-0003); China: National Center for Cardiovascular Diseases and ThinkTank Research Center for Health Development; Colombia: Colciencias (grant 6566-04-18062 and grant 6517-777-58228); India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia (grant number: 100-IRDC/BIOTEK 16/6/21 [13/2007], and 07-05-IFN-BPH 010), Ministry of Higher Education of Malaysia (grant number: 600-RMI/LRGS/5/3 [2/2011]), Universiti Teknologi MARA, Biostatistics & Data Repository Sector, National Institute of Health, Setia Alam, and National Registration Department (JPN), Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); the Middle East: the United Nations Relief and Works Agency for Palestine Refugees in the Near East and International Development Research Centre, Canada; The Philippines: Philippine Council for Health Research and Development; Poland: Polish Ministry of Science and Higher Education (grant number: 290/W-PURE/2008/0), Wroclaw Medical University; Saudi Arabia: Saudi Heart Association, Dr Mohammad Alfagih Hospital, The Deanship of Scientific Research at King Saud University (research group number: RG -1436-013), Saleh Hamza Serafi Chair for Research of Coronary Heart Disease, Umm AlQura University; South Africa: The North-West University, and Netherlands Programme for Alternative Development, National Research Foundation, Medical Research Council of South Africa, The South Africa Sugar Association, Faculty of Community and Health Sciences; Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors, the Swedish Heart and Lung Foundation, the Swedish Research Council (2018-02527), the Swedish Council for Health, Working Life and Welfare, King Gustaf V:s and Queen Victoria Freemason's Foundation, and AFA Insurance; Türkiye: Metabolic Syndrome Society, AstraZeneca, Sanofi Aventis; United Arab Emirates: Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences and Dubai Health Authority, Dubai. Further details on the funding and participating countries and institutions, and on collaborating staff, are shown in the appendix (pp 3–8).
Funding Information:
LMP-V received a grant from the Philippine Council for Health Research and Development to support this study. AW received funding support from the Population Health Research Institute for participation in the study as site principal investigator and is a member of the Board of Directors of the InterAmerican Heart Foundation. SSA received speaker and consulting fees from both Bayer AG and Janssen Pharma for work conducted outside the scope of this study. All other authors declare no competing interests.
Publisher Copyright:
© 2022 Elsevier Ltd
PY - 2022/9/10
Y1 - 2022/9/10
N2 - Background: There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared with men, especially from low-income and middle-income countries. Methods: In the Prospective Urban Rural Epidemiological (PURE) study, we enrolled participants from the general population from 21 high-income, middle-income, and low-income countries and followed them up for approximately 10 years. We recorded information on participants’ metabolic, behavioural, and psychosocial risk factors. For this analysis, we included participants aged 35–70 years at baseline without a history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population-attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. Findings: In this analysis, we included 155 724 participants enrolled and followed-up between Jan 5, 2005, and Sept 13, 2021, (90 934 [58·4%] women and 64 790 [41·6%] men), with a median follow-up of 10·1 years (IQR 8·5–12·0). At study entry, the mean age of women was 49·8 years (SD 9·7) compared with 50·8 years (9·8) in men. As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age-standardised incidence rate of 5·0 events [95% CI 4·9–5·2] per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). Compared with men, women presented with a more favourable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for major cardiovascular disease of 1·11 (95% CI 1·01–1·21) in women and 1·28 (1·19–1·39) in men, with a consistent pattern for higher risk among men than among women with other lipid markers. Symptoms of depression had a HR of 1·09 (0·98–1·21) in women and 1·42 (1·25–1·60) in men. By contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8), was more strongly associated with major cardiovascular disease in women (1·17 [1·08–1·26]) than in men (1·07 [0·99–1·15]). The total PAFs associated with behavioural and psychosocial risk factors were greater in men (15·7%) than in women (8·4%) predominantly due to the larger contribution of smoking to PAFs in men (ie, 1·3% [95% CI 0·5–2·1] in women vs 10·7% [8·8–12·6] in men). Interpretation: Lipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. Funding: Funding sources are listed at the end of the Article.
AB - Background: There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared with men, especially from low-income and middle-income countries. Methods: In the Prospective Urban Rural Epidemiological (PURE) study, we enrolled participants from the general population from 21 high-income, middle-income, and low-income countries and followed them up for approximately 10 years. We recorded information on participants’ metabolic, behavioural, and psychosocial risk factors. For this analysis, we included participants aged 35–70 years at baseline without a history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population-attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. Findings: In this analysis, we included 155 724 participants enrolled and followed-up between Jan 5, 2005, and Sept 13, 2021, (90 934 [58·4%] women and 64 790 [41·6%] men), with a median follow-up of 10·1 years (IQR 8·5–12·0). At study entry, the mean age of women was 49·8 years (SD 9·7) compared with 50·8 years (9·8) in men. As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age-standardised incidence rate of 5·0 events [95% CI 4·9–5·2] per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). Compared with men, women presented with a more favourable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for major cardiovascular disease of 1·11 (95% CI 1·01–1·21) in women and 1·28 (1·19–1·39) in men, with a consistent pattern for higher risk among men than among women with other lipid markers. Symptoms of depression had a HR of 1·09 (0·98–1·21) in women and 1·42 (1·25–1·60) in men. By contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8), was more strongly associated with major cardiovascular disease in women (1·17 [1·08–1·26]) than in men (1·07 [0·99–1·15]). The total PAFs associated with behavioural and psychosocial risk factors were greater in men (15·7%) than in women (8·4%) predominantly due to the larger contribution of smoking to PAFs in men (ie, 1·3% [95% CI 0·5–2·1] in women vs 10·7% [8·8–12·6] in men). Interpretation: Lipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. Funding: Funding sources are listed at the end of the Article.
UR - http://www.scopus.com/inward/record.url?scp=85137286917&partnerID=8YFLogxK
U2 - 10.1016/S0140-6736(22)01441-6
DO - 10.1016/S0140-6736(22)01441-6
M3 - Article
C2 - 36088949
AN - SCOPUS:85137286917
SN - 0140-6736
VL - 400
SP - 811
EP - 821
JO - The Lancet
JF - The Lancet
IS - 10355
ER -