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

Mulugeta Molla Birhanu, Roger G. Evans, Ayse Zengin, Michaela Riddell, Kartik Kalyanram, Kamakshi Kartik, Oduru Suresh, Nihal Jacob Thomas, Velandai K. Srikanth, Amanda G. Thrift

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OBJECTIVES: 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. DESIGN: A cross-sectional study. SETTING: The study population comprised adult residents (aged ≥18 years) of the Rishi Valley region located in Chittoor District, south-western Andhra Pradesh, India. PARTICIPANTS: 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). RESULTS: 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. CONCLUSIONS: Cardiovascular risk prediction tools perform disparately in this setting of disadvantage. Few deemed at high risk were receiving the recommended treatment.

Original languageEnglish
Article numbere054617
Number of pages10
JournalBMJ Open
Issue number4
Publication statusPublished - Apr 2022


  • cardiac epidemiology
  • epidemiology
  • preventive medicine
  • public health

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