Use of Secondary CVD Prevention Meds Still Meager Worldwide

An analysis of the PURE study shows some gains but “little to no improvement in most places over time,” says Philip Joseph.

Use of Secondary CVD Prevention Meds Still Meager Worldwide

Across the world, many patients with CVD still aren’t on the recommended medications for secondary prevention, according to more than a decade’s worth of data from the 17-country Prospective Urban Rural Epidemiology (PURE) study.

Use was particularly lackluster among those living in countries with low or lower-middle income, researchers reported online Monday in the Journal of the American College of Cardiology. But even in high-income countries, where most CVD patients started out on at least one preventive medication after receiving their diagnosis, use tapered off over time.

Philip Joseph, MD (Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Canada), lead author of the new study, told TCTMD these trends came as a disappointment. “We were expecting something quite different, I would admit,” Joseph said, noting that the researchers had hoped public health goals set by international groups—for instance, the World Health Organization in 2013 and the United Nations in 2015—would spur progress.

Instead, he continued, “we ended up seeing some mixed changes in different places, but overall the message was that there’s been little to no improvement in most places over time.”

This is, of course, not the first study to raise alarm over the scarcity of secondary prevention on an international scale. The question is: what comes next?

Abhishek Chaturvedi, MD (Georgetown University MedStar Washington Hospital Center, Washington, DC, and the Center for Chronic Disease Control, New Delhi, India) and Dorairaj Prabhakaran, MD (Center for Chronic Disease Control), in an accompanying editorial, agree there is an urgent need for better tactics.

“We dare say that tackling the burden of CVD requires not only the medical solutions, but political will,” they write, stressing that “strategies should be community-based, patient-centered, incorporate social determinants of health, and involve task-sharing with nonphysician healthcare workers.”

17 Countries, 12 Years

Joseph et al identified individuals in the PURE study who received a CVD diagnosis (either coronary artery disease or stroke) between approximately 2007 and 2019 across 17 countries. Study participants were tracked at five time points, approximately 3 to 4 years apart, over an average follow-up duration of 12 years.

In all, 7,409 people had a diagnosis of CVD at the baseline visit, 8,792 at the second visit, 9,236 at the third visit, 11,082 at the fourth visit, and 11,677 at the last visit. The median age at baseline was 58 years, 52.9% of participants were female, and 41.2% lived in rural areas.

The PURE investigators divided study participants based on whether they lived in countries classified by the World Bank as high income (Canada, Sweden, and United Arab Emirates), upper-middle income (Argentina, Brazil, Chile, Malaysia, Poland, South Africa, and Türkiye), lower-middle income (China, Colombia, and Iran), or lower income (Bangladesh, India, Pakistan, and Zimbabwe).

Most patients (52.7%) were located in lower-middle-income countries, with the rest in upper-middle- (24.8%), lower- (11.6%), and high-income countries (11.0%).

At the initial visit, 41.3% of the CVD patients were taking at least one class of secondary prevention medication. This included 23.6% on an antiplatelet, 15.5% on a statin, and 19.4% on a renin-angiotensin-system (RAS) inhibitor, 17.6% on a beta-blocker, 13.3% on a calcium channel blocker, and 13.5% on a diuretic.

Use of secondary prevention peaked at visit 2, when 43.1% of patients were on medication, then decreased to a low of 31.3% by the final visit. By this point, 19.0% were on an antiplatelet, 18.9% a statin, 17.9% a RAS inhibitor, 14.9% a beta-blocker, 10.5% a calcium channel blocker, and 6.9% a diuretic.

In the upper-income countries, which had the highest use of secondary prevention, the proportion of patients on medications was greatest at baseline and then decreased thereafter. In upper-middle-income countries, fewer patients started out on the drugs but midway through follow-up, use hit its peak and held steady at visit 5. Secondary prevention was least common in countries with lower-middle and low income, which saw the highest use of the medications midway through follow-up and a decrease by visit 5.

CVD Patients on ≥ 1 Secondary Prevention Drug Class by Country Income

 

Baseline

Peak

Visit 5

Upper

88.8%

77.3%

Upper Middle

55.0%

61.1%

Lower Middle

29.5%

31.7%

13.4%

Low

20%

47.3%

27.5%


Joseph pointed out that this analysis doesn’t address what factors are standing in the way of progress, though there are many possibilities. “It’s tough to know what the barriers are, because they can occur at different levels” related to the individual patient, the clinician providing care, or the country’s health system as a whole, he explained. “We weren’t quite able to delineate these specific barriers.”

Especially—though not exclusively—for countries at the lower end of the income spectrum, lack of access to healthcare providers and medications can be a problem, added Joseph.

As the editorialists highlight, even at the patient level there are numerous barriers, including “low health literacy, beliefs, out-of-pocket treatment costs, misinformation, difficulty making lifestyle changes, polypharmacy, poor access to healthcare, and poor socioeconomic status, which is linked to a higher prevalence of unhealthy behaviors, increased psychosocial stress, lack of health insurance, and poor awareness and control of CVDs.”

For clinicians, “knowledge, attitude, high patient volumes, burnout, and limited time and resources to follow secondary prevention guidelines” can stand in the way of providing optimal care, Chaturvedi and Prabhakaran specify.

Joseph and colleagues, in their paper, suggest two strategies that may help on a variety of levels: “the use of medications in a combination pill or ‘polypill,’ and shifting components of medication management from physicians to trained nonphysician health workers (ie, task-shifting or sharing).” These two possibilities could be applied quickly and across locales with differing healthcare resources, they say.

Future studies of additional datasets “will give some more information on where there are large barriers [to care] and then hopefully that can offer some solutions to what to target,” said Joseph.

Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…

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Disclosures
  • Joseph reports having received support from a McMaster Mid-Career Research Award.
  • Chaturvedi and Prabhakaran report no relevant conflicts of interest.

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