Clara Kayei Chow
Tu Ngoc Nguyen
Simone Marschner
Rafael Diaz
Omar Rahman
Alvaro Avezum
Scott A Lear
Koon Teo
Karen E Yeates
Fernando Lanas
Wei Li
Bo Hu
Patricio Lopez-Jaramillo
Rajeev Gupta
Rajesh Kumar
Prem K Mony
Ahmad Bahonar
Khalid Yusoff
Rasha Khatib
Khawar Kazmi
Antonio L Dans
Katarzyna Zatonska
Khalid F Alhabib
Iolanthe Marike Kruger
Annika Rosengren
Sadi Gulec
Afzalhussein Yusufali
Jephat Chifamba
Sumathy Rangarajan
Martin McKee
Salim Yusuf

OBJECTIVES: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study.
METHODS: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types were available and affordable, group 2-all three drugs were available but not affordable and group 3-all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors.
RESULTS: Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50).
CONCLUSION: Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.

Chow CK, Nguyen TN, Marschner S, Diaz R, Rahman O, Avezum A, Lear SA, Teo K, Yeates KE, Lanas F, Li W, Hu B, Lopez-Jaramillo P, Gupta R, Kumar R, Mony PK, Bahonar A, Yusoff K, Khatib R, Kazmi K, Dans AL, Zatonska K, Alhabib KF, Kruger IM, Rosengren A, Gulec S, Yusufali A, Chifamba J, Rangarajan S, McKee M, Yusuf S; PURE Study. Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries. BMJ Glob Health. 2020 Nov;5(11):e002640. doi: 10.1136/bmjgh-2020-002640. PMID: 33148540; PMCID: PMC7640501