Metabolic, behavioral, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-, middle-, and low-income countries: an analysis of the PURE study
Background
There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared to men, especially in low- and middle-income countries.
Methods
In the Prospective Urban Rural Epidemiology (PURE) study, we enrolled participants from the general population from 21 high-, middle-, and low-income countries and followed them for approximately 10 years . We recorded information on participants’ metabolic, behavioral, and psychosocial risk factors. For this analysis, we included participants aged 35 to 70 years at baseline with no history of cardiovascular disease, with at least one follow-up visit.
The primary outcome was a composite of major cardiovascular events (deaths from cardiovascular disease, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586.
Results
In this analysis, we included 155,724 participants enrolled and followed between January 5, 2005 and September 13, 2021 (90,934 [58·4%] women and 64,790 [41·6%] men), with a median follow-up of 10.1 years (IQR 8.5-12.0).
At baseline, the mean age of women was 49.8 years (SD 9.7) compared to 50.8 years (9.8) for men. As of data cutoff (September 13, 2021), there had been 4,280 major cardiovascular disease events in women (age-standardized incidence rate of 5.0 events [95% CI, 4.9–5.2]). per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years).
Compared with men, women presented a more favorable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for cardiovascular disease greater than 1·11 (95% CI 1·01 –1·21) in women and 1·28 (1·19–1·39) in men, with a consistent pattern of higher risk among men than among women with other lipid markers. Depression symptoms had an HR of 1·09 (0·98–1·21) in women and 1·42 (1·25–1·60) in men.
In contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8) was more strongly associated with major cardiovascular disease in women (1·17 [1·08–1·26]). than in women. men (1·07 [0·99–1·15]). Total PAFs associated with behavioral and psychosocial risk factors were higher in men (15.7%) than in women (8.4%), predominantly due to the greater contribution of smoking to PAFs in men (i.e., 1, 3% [95% CI 0·5–2·1] in women vs 10·7% [8·8–12·6] in men).
Interpretation
Lipid markers and depression are more strongly associated with cardiovascular disease risk in men than in women, while diet is more strongly associated with cardiovascular disease risk in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasize the importance of a similar strategy for the prevention of cardiovascular disease in men and women.
Comments
Women and men share most of the same risk factors for cardiovascular disease (CVD), a large international study has found, the first of its kind to include people not only from high-income countries, but also from countries low and middle income where the burden of CVD is the greatest. The study was published in The Lancet .
The global study assessed risk factors, including metabolic (such as high blood pressure, obesity and diabetes), behavioral (smoking and diet) and psychosocial (economic status and depression) in approximately 156,000 people with no history of CVD between the ages of 35 and 70. Living in 21 low-, middle-, and high-income countries on five continents, they were followed for an average of 10 years .
"Women and men have similar CVD risk factors, which emphasizes the importance of a similar strategy for CVD prevention in men and women," said the paper’s first author, Marjan Walli-Attaei, a researcher at the Institute. Health Research Institute (PHRI). ) from McMaster University and Hamilton Health Sciences (HHS).
In general, women had a lower risk of developing CVD than men, especially at younger ages. However, diet was more strongly associated with CV risk in women than in men, "something that has not been described previously and requires independent confirmation," said Salim Yusuf, the study’s lead investigator, senior author, chief executive officer. of PHRI, professor of medicine at McMaster University and cardiologist at HHS.
High levels of bad cholesterol (LDL) and symptoms of depression were more strongly associated with CVD risk in men than in women.
The patterns of these findings were generally similar in high-income countries and upper-middle-income countries, and in low-income and lower-middle-income countries.
