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Lancet. 2019 Sep 3. pii: S0140-6736(19)32008-2. doi: 10.1016/S0140-6736(19)32008-2. [Epub ahead of print]

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.

Author information

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address:
Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA.
School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
Health Action by People, Trivandrum, India.
Eternal Heart Care Centre & Research Institute, Jaipur, India.
Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Department of Cardiac Sciences, University of Philippines, Manila, Philippines.
Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia; Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia.
Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
Department of Medicine, Universidad de La Frontera, Temuco, Chile.
Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa.
Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina.
Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia.
St John's Research Institute, St John's Medical College, Bangalore, India.
Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
Department of Medicine, Queen's University, Kingston, ON, Canada.
Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Health Care, Chicago, IL, USA.
Independent University, Dhaka, Bangladesh.
Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland.
Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan.
National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India.
Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.
Department of Medicine, National University of Ireland Galway, London, UK.
Department of Public Health, London School of Hygiene & Tropical Medicine, London, UK.
Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada.

Erratum in



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.


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.


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.


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.


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

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