Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study


Marjan Walli-Attaei, Hamilton Health Sciences
Philip Joseph, Hamilton Health Sciences
Annika Rosengren, Sahlgrenska Universitetssjukhuset
Clara K. Chow, The University of Sydney
Sumathy Rangarajan, Hamilton Health Sciences
Scott A. Lear, Simon Fraser University
Khalid F. AlHabib, King Khalid University Hospital
Kairat Davletov, Al Farabi Kazakh National University
Antonio Dans, University of the Philippines Manila
Fernando Lanas, Universidad de la Frontera
Karen Yeates, Queen's University, Kingston
Paul Poirier, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval
Koon K. Teo, Hamilton Health Sciences
Ahmad Bahonar, Hypertension Research Center, Isfahan UMS
Felix Camilo, Universidad UTE
Jephat Chifamba, University of Zimbabwe
Rafael Diaz, Estudios Clínicos Latino América
Joanna A. Didkowska, Maria Sklodowska-Curie Institute – Oncology Center
Vilma Irazola, Institute for Clinical Effectiveness and Health Policy, Ciudad Autonoma de Buenos Aires
Rosnah Ismail, Universiti Kebangsaan Malaysia
Manmeet Kaur, Postgraduate Institute of Medical Education & Research, Chandigarh
Rasha Khatib, Advocate Aurora Health
Xiaoyun Liu, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
Marta Mańczuk, Maria Sklodowska-Curie Institute – Oncology Center
J. Jaime Miranda, Universidad Peruana Cayetano Heredia
Aytekin Oguz, Istanbul Medeniyet University
Maritza Perez-Mayorga, Universidad Militar Nueva Granada
Andrzej Szuba, Wroclaw Medical University
Lungiswa P. Tsolekile, University of the Western Cape
Ravi Prasad Varma, Health Action by People
Afzalhussein Yusufali, Dubai Health Authority
Rita Yusuf, Independent University, Bangladesh


Background: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

Methods: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

Findings: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

Interpretation: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).

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