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Absolute cardiovascular risk scores and medication use in rural India: a cross-sectional study.

  • Birhanu, Mulugeta Molla1
  • Evans, Roger G2
  • Zengin, Ayse1
  • Riddell, Michaela1
  • Kalyanram, Kartik3
  • Kartik, Kamakshi3
  • Suresh, Oduru1, 3
  • Thomas, Nihal Jacob4
  • Srikanth, Velandai K1, 5
  • Thrift, Amanda G6
  • 1 Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Victoria, Australia. , (Australia)
  • 2 Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Victoria, Australia. , (Australia)
  • 3 Rishi Valley Rural Health Centre, Chittoor District, Andhra Pradesh, India. , (India)
  • 4 Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India. , (India)
  • 5 Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia. , (Australia)
  • 6 Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Victoria, Australia [email protected] , (Australia)
Published Article
BMJ Open
Publication Date
Apr 22, 2022
DOI: 10.1136/bmjopen-2021-054617
PMID: 35459666


We compared the performance of laboratory-based cardiovascular risk prediction tools in a low-income and middle-income country setting, and estimated the use of antihypertensive and lipid-lowering medications in those deemed at high risk of a cardiovascular event. A cross-sectional study. The study population comprised adult residents (aged ≥18 years) of the Rishi Valley region located in Chittoor District, south-western Andhra Pradesh, India. 7935 participants were surveyed between 2012 and 2015. We computed the 10-year cardiovascular risk and undertook pair-to-pair analyses between various risk tools used to predict a fatal or non-fatal cardiovascular event (Framingham Risk Score (FRS), World Health Organization Risk Score (WHO-RS) and Australian Risk Score (ARS)), or a fatal cardiovascular event (Systematic COronary Risk Evaluation (SCORE-high and SCORE-low)). Concordance was assessed by ordinary least-products (OLP) regression (for risk score) and quadratic weighted kappa (κw, for risk category). Of participants aged 35-74 years, 3.5% had prior cardiovascular disease. The relationships between risk scores were quasi-linear with good agreement between the FRS and ARS (OLP slope=0.96, κw=0.89). However, the WHO-RS underestimated cardiovascular risk compared with all other tools. Twenty per cent of participants had ≥20% risk of an event using the ARS; 5% greater than the FRS and nearly threefold greater than the WHO-RS. Similarly, 16% of participants had a risk score ≥5% using SCORE-high which was 6% greater than for SCORE-low. Overall, absolute cardiovascular risk increased with age and was greater in men than women. Only 9%-12% of those deemed 'high risk' were taking lipid-lowering or antihypertensive medication. Cardiovascular risk prediction tools perform disparately in this setting of disadvantage. Few deemed at high risk were receiving the recommended treatment. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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