Secondary prevention medications for cardiovascular diseases (CVD) are underused globally and additional strategies to increase their use are needed to improve CVD management and reduce premature mortality rates, according to a study published today in JACC, the flagship journal of the American College of Cardiology. The study observed participants with CVD from 17 countries over 12 years and found that medication use remains low with little improvement.

Secondary prevention of CVD focuses on preventing further health problems in people already diagnosed with CVD. This includes managing risk factors through lifestyle changes, medications and treatments. Without intervention, these patients are at a higher risk of death, future heart attacks, strokes and heart failure. Leading international organisations, such as the World Health Organization (WHO) and the United Nations (UN), have issued targets over the last decade to reduce premature mortality from CVD through improved treatments and medications.

"After examining the progress of medication use for secondary cardiovascular (CVD) prevention, our research indicates that there continues to be substantial under-utilisation of these medications with little improvement over time, and that global targets are unlikely to be reached," said Dr. Philip Joseph, lead author of the study and scientist at the Population Health Research Institute (PHRI) - a joint institute of McMaster University and Hamilton Health Sciences, Canada.

The PHRI Prospective Urban Rural Epidemiology (PURE) study, a multi-national, community-based, prospective cohort study, analysed over 11,000 participants with diagnosed CVD between 30-70 years of age over 12 years. Participants were from communities in countries at different income levels and were selected based on criteria representing urban and rural areas.

Participating countries include: (income level based on their World Bank classification at the time of starting the study)

Research results showed that medication use for secondary CVD prevention varied by country income level and was lower at the last study visit compared to the first visit in every income level except for upper-middle-income countries.

Overall, the use of at least one medication for secondary prevention started at 41.3% at the baseline study visit, peaked at 43.1%, and dropped to 31.3% at the last study visit. In high-income countries, use declined from 88.8% to 77.3%. In upper-middle-income countries, it rose from 55% to 61.1%. In lower-middle-income countries, it began at 29.5%, peaked at 31.7%, and fell to 13.4%. In low-income countries, it increased from 20.8% to a peak of 47.3%, then declined to 27.5%. Use of three or more proven medication classes for secondary prevention was substantially lower in all country income levels.

"Our findings suggest that current secondary prevention strategies continue to leave the majority of people with CVD either untreated or undertreated and highlight the general lack of progress being made to increase the use of secondary CVD prevention medications in most parts of the world," Joseph said.

"This landmark study underscores an immense opportunity to improve global cardiovascular health," said Harlan M. Krumholz, MD, SM, Harold H. Hines Jr. Professor at Yale School of Medicine and Editor-in-Chief of JACC. "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. We have the tools to bridge this gap in care now - and we must act urgently."

Limitations of the study include the analysis of only seventeen countries, although they were from a broad range of geographical areas as well as levels of economic development. The potential for participants to have underestimated their medication use may have caused limitations, including the unknown extent to which changes in cohort demographics, CVD duration or severity impacted variations in medication use over time. Lastly, the COVID-19 pandemic restricted the ability to conduct research in some countries during part of the last follow-up visit cycle.

Joseph P, Avezum Á, Ramasundarahettige C, Mony PK, Yusuf R, Kazmi K, Szuba A, Lopez-Jaramillo P, Diaz ML, Yusufali AH, Gulec S, Kelishadi R, Wei L, Chifamba J, Lanas F, Puoane T, Krishnapillai A, Rangarajan S, Yusuf S; PURE Investigators. Secondary Prevention Medications in 17 Countries Grouped by Income Level (PURE): A Prospective Cohort Study. J Am Coll Cardiol. 2025 Feb 11;85(5):436-447. doi: 10.1016/j.jacc.2024.10.121