Secondary Prevention Medications for CVD Underutilized in Global Analysis

Medications for the secondary prevention of cardiovascular disease (CVD) are used sparingly worldwide, with minimal improvements over time, according to a new analysis of 17 high-, middle- and low-income countries.1

The Prospective Urban Rural Epidemiology (PURE) study described variations in secondary CVD prevention medication in ≥11,000 participants with diagnosed CVD between 30–70 years over 12 years, selecting communities in countries at different income levels based on criteria representing both urban and rural areas.

“After examining the progress of medication use for secondary CVD prevention, our research indicates that there continues to be a substantial underutilization of these medications with little improvement over time and that global targets are unlikely to be reached,” said lead study author Phillip Joseph, MD, Population Health Research Institute of McMaster University and Hamilton Health Sciences.2

Recent data reaffirmed CVD as the leading cause of death in the US, as well as globally, with its prevalence expected to increase in the coming decades. These high rates of CVD impact hospitalization, increase physical disability rates, and elevate costs of care, burdening the healthcare system. Primary prevention of CVD focuses on preventing the progression of atherosclerosis, with measures centering around the pursuit of ideal health behaviors, including diet and physical activity.3,4

Secondary CVD prevention focuses on eliminating further health problems in individuals who received a diagnosis of CVD, with the management of risk factors through lifestyle changes, as well as medication and treatments. Without these interventions, Joseph and colleagues noted these patients are at an elevated risk of death, myocardial infarction, stroke, and heart failure.1

Participating countries in the PURE study were separated by income level based on the World Bank classification at the beginning of the study. High-income countries included Canada, Sweden, and the United Arab Emirates, upper-middle-income countries included Argentina, Brazil, Chile, Malaysia, Poland, South Africa, and Turkey, and lower-middle-income countries included China, Colombia, and Iran. Low-income countries consisted of Bangladesh, India, Pakistan, and Zimbabwe.

Overall, the analysis included 7409 participants with CVD at the baseline visit, 8792 at the second visit, 9236 at the third visit, 11,082 at the fourth visit, and 11,677 at the last visit. Participants had a median age of 58 years and more than half (52.9%) were female. Upon analysis, medication use for secondary CVD prevention was dependent on country income level, with low use at the last study visit, compared with the first visit, in every income level but upper-middle-income countries.

Across the 12-year study period, the use of ≥1 class of medication for secondary CVD prevention was 41.3% (95% CI, 40.2–42.4) at baseline, with a peak at 43.1% (95% CI, 42.0–44.1) and a decrease to 31.3% (95% CI, 30.4–32.1) at the final study visit. High-income countries experienced a reduction in use from 88.8% (95% CI, 86.6–91.0) to 77.3% (95% CI, 74.9–79.6), while upper-middle-income countries increased use from 55.0% (95% CI, 52.8–57.3) to 61.1% (95% CI, 59.1–63.1).

For lower-middle-income countries, Joseph and colleagues found the use of ≥1 class of medication was 29.5% (95% CI, 28.1–30.9) at baseline, peaked at 31.7% (95% CI, 30.4–33.1), and decreased to 13.4% (95% CI, 12.5–14.2) by the final visit. Low-income countries reported the use of ≥1 medication class at 20.8% (95% CI, 18.1–23.5) at baseline, peaking at 47.3% (95% CI, 44.8–49.9) and decreasing to 27.5% (95% CI, 25.2–29.9) at the final visit.

“It is unacceptable that so many individuals worldwide who have already experienced heart disease are not receiving readily available and inexpensive treatments that could save lives and prevent further events,” said Harlan M. Krumholz, MD, Harold H. Hines Jr. Pressor at Yale School of Medicine and Editor-in-Chief of the Journal of the American College of Cardiology.2

References

1. Joseph P, Avezum Á, Ramasundarahettige C, et al. Secondary Prevention Medications in 17 Countries Grouped by Income Level (PURE): A Prospective Cohort Study. J Am Coll Cardiol. 2025;85(5):436-447. doi:10.1016/j.jacc.2024.10.121
2. ACCmediacenter. Cardiovascular disease medications underused globally. EurekAlert! February 3, 2025. Accessed February 7, 2025. https://www.eurekalert.org/news-releases/1071961.
3. Iapoce C. AHA report reaffirms cardiovascular disease as leading cause of US deaths. HCP Live. January 30, 2025. Accessed February 7, 2025. https://www.hcplive.com/view/aha-report-reaffirms-cardiovascular-disease-as-leading-cause-of-us-deaths.
4. Olvera Lopez E, Ballard BD, Jan A. Cardiovascular Disease. [Updated 2023 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535419/