Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study


Salim Yusuf, Hamilton Health Sciences
Philip Joseph, Hamilton Health Sciences
Sumathy Rangarajan, Hamilton Health Sciences
Shofiqul Islam, Hamilton Health Sciences
Andrew Mente, Hamilton Health Sciences
Perry Hystad, Oregon State University
Michael Brauer, The University of British Columbia
Vellappillil Raman Kutty, Health Action by People
Rajeev Gupta, Eternal Heart Care Centre and Research Institute
Andreas Wielgosz, University of Ottawa, Canada
Khalid F. AlHabib, King Khalid University Hospital
Antonio Dans, University of the Philippines Manila
Patricio Lopez-Jaramillo, Fundación Oftalmológica de Santander
Alvaro Avezum, Universidade de Santo Amaro
Fernando Lanas, Universidad de la Frontera
Aytekin Oguz, Istanbul Medeniyet University
Iolanthe M. Kruger, North-West University
Rafael Diaz, Estudios Clínicos Latinoamérica, Argentina
Khalid Yusoff, Universiti Teknologi MARA
Prem Mony, St. John's Research Institute
Jephat Chifamba, University of Zimbabwe
Karen Yeates, Queen's University, Kingston
Roya Kelishadi, Isfahan Cardiovascular Research Center, Isfahan UMS
Afzalhussein Yusufali, Dubai Health Authority
Rasha Khatib, Advocate Aurora Health
Omar Rahman, Independent University, Bangladesh
Katarzyna Zatonska, Wroclaw Medical University
Romaina Iqbal, The Aga Khan University
Li Wei, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
Hu Bo, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
Annika Rosengren, Sahlgrenska Universitetssjukhuset
Manmeet Kaur, Postgraduate Institute of Medical Education & Research, Chandigarh


Advocate Health Care


Background: 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.

Methods: 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.

Findings: 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.

Interpretation: 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.

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

Document Type


PubMed ID


Link to Full Text