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.,The Lancet

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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.
The Lancet ( IF 98.4 ) Pub Date : 2020-05-20 , DOI: 10.1016/s0140-6736(20)30543-2
Marjan Walli-Attaei ₁ , Philip Joseph ₁ , Annika Rosengren ₂ , Clara K Chow ₃ , Sumathy Rangarajan ₁ , Scott A Lear ₄ , Khalid F AlHabib ₅ , Kairat Davletov ₆ , Antonio Dans ₇ , Fernando Lanas ₈ , Karen Yeates ₉ , Paul Poirier ₁₀ , Koon K Teo ₁ , Ahmad Bahonar ₁₁ , Felix Camilo ₁₂ , Jephat Chifamba ₁₃ , Rafael Diaz ₁₄ , Joanna A Didkowska ₁₅ , Vilma Irazola ₁₆ , Rosnah Ismail ₁₇ , Manmeet Kaur ₁₈ , Rasha Khatib ₁₉ , Xiaoyun Liu ₂₀ , Marta Mańczuk ₁₅ , J Jaime Miranda ₂₁ , Aytekin Oguz ₂₂ , Maritza Perez-Mayorga ₂₃ , Andrzej Szuba ₂₄ , Lungiswa P Tsolekile ₂₅ , Ravi Prasad Varma ₂₆ , Afzalhussein Yusufali ₂₇ , Rita Yusuf ₂₈ , Li Wei ₂₉ , Sonia S Anand ₁ , Salim Yusuf ₁

Affiliation

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia.
Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.
Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
The Faculty of Medicine, Health Research Institute, Kazakh National University, Almaty, Kazakhstan.
Department of Medicine, University of Philippines, Manila, Philippines.
Department of Medicine, Universidad de La Frontera, Temuco, Chile.
Department of Medicine, Queen's University, Kingston, ON, Canada.
Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, QC, Canada.
Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
Facultad de Ciencias Medicas Eugenio Espejo, Universidad Universidad Tecnológica Equinoccial, Quito, Ecuador.
Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
Estudios Clinicos Latinoamerica, Rosario, Argentina.
Department of Epidemiology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute, Warsaw, Poland.
Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; South American Center of Excellence for Cardiovascular Health, Buenos Aires, Argentina.
Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Medical Center, Kuala Lumpur, Malaysia.
School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
Institute for Community and Public Health, Birzeit University, Birzeit, Palestine.
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
Facultad de Medicina, Universidad Nueva Granada and Clinica de Marly, Bogota, Colombia.
Wroclaw Medical University, Department of Angiology, Diabetology and Hypertension, Wroclaw, Poland.
University of the Western Cape, School of Public Health, Cape Town, South Africa.
Health Action by People, Thiruvananthapuram, India; Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
School of Life Sciences, Independent University, Dhaka, Bangladesh.
National Centre for Cardiovascular Diseases, Cardiovascular Institute & Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.

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).

中文翻译：

在27个高收入，中等收入和低收入国家（PURE）中，男女在危险因素，治疗，心血管疾病的发生率和死亡方面的差异：一项前瞻性队列研究。

背景

一些主要来自高收入国家（HICs）的研究报告说，妇女对心血管疾病的护理（调查和治疗）少于男性，并且可能有更高的死亡风险。但是，很少有研究系统地报告危险因素，一级或二级预防药物的使用，心血管疾病的发生率或社区居民的死亡。鉴于大多数心血管疾病都发生在低收入和中等收入国家（LMIC），因此有必要提供综合信息，以比较HIC，中等收入国家和社区中来自低收入国家的男女在治疗和结果方面的差异。基于人口的研究。

方法

在前瞻性城市农村流行病学研究（PURE）中，来自27个国家的城市和农村社区的年龄在35-70岁之间的个人被考虑纳入研究。我们记录了有关参与者的社会人口统计学特征，危险因素，药物使用，心脏检查和干预措施的信息。参加了PURE的三个阶段的前两个阶段的168490名参与者进行了前瞻性的心血管疾病和死亡事件随访。

发现

从2005年1月6日到2019年5月6日，共招募了202072名个体。研究中女性的平均年龄为50·8（SD 9·9）岁，男性为51·7（10）岁。参加者的随访中位数为9·5（IQR 8·5-10·9）年。使用两种不同的危险评分（INTERHEART和Framingham），女性的心血管疾病危险因素负担较低。与男性相比，女性更倾向于采取一级预防策略，例如采取几种健康的生活方式和使用经证实的药物。心血管疾病的发病率（女性每4 000人年有4·1 [95％CI 4·0-4·2]，男性为6·4 [6·2-6·6]；调整后的危险比[aHR] 0女性vs ·75 [95％CI 0·72-0·79]和全因死亡（4·5 [95％CI 4·4-4·7] vs每1000人年为7·4 [7·2-7·7]；女性的aHR 0·62 [95％CI 0·60-0·65]也较低。相比之下，在所有国家中，女性的二级预防治疗，心脏检查和冠状动脉血运重建的发生率均低于男性。尽管如此，女性发生心血管疾病的风险较低（2000年每千人年20·0 [95％CI 18·2–21·7]比27·7 [95％CI 25·6–29·8]男性，调整后的危险比0·73 [95％CI 0·64-0·83]，女性在发生新的心血管疾病后的30天死亡率比男性低（女性为22％，男性为28％； p <0·0001）。LMIC中男女在治疗和预后方面的差异更为明显，而有或没有心血管疾病的人中HIC差异很小。