Methods In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged

35-70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient’s presentation to clinics. We report estimates of drug use at national, community, and individual levels.

Findings We enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), SP600125 in vitro upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants ML323 molecular weight had a self-reported coronary heart disease event (median 5.0 years previously [IQR 2.0-10.0]) and 2292 had stroke (4.0 years previously [2.0-8.0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25.3%), beta blockers (17.4%), ACE inhibitors or ARBs (19.5%), or statins (14.6%). Use was highest in high-income countries

(antiplatelet drugs 62.0%, beta blockers 40.0%, ACE inhibitors or ARBs 49.8%, and statins 66.5%), lowest in low-income countries (8.8%, 9.7%, 5.2%, and 3.3%, respectively), and decreased in line with reduction of country economic status (p(trend)<0.0001 for every drug type). Fewest patients received no drugs in high-income

countries (11.2%), compared with 45.1% in upper middle-income countries, 69.3% in lower middle-income countries, and 80.2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28.7% urban vs check details 21.3% rural, beta blockers 23.5% vs 15.6%, ACE inhibitors or ARBs 22.8% vs 15.5%, and statins 19.9% vs 11.6%; all p<0.0001), with greatest variation in poorest countries (p(interaction)<0.0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses).

Interpretation Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas-systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.”
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