Risk factors for incident cardiovascular events among adults in low- and middle-income countries: A systematic review and meta-analysis of prospective cohort studies

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The relative contributions of risk factors for cardiovascular events at a population level has received little attention in low- and middle-income countries (LMICs). We estimated the population attributable fraction (PAF) of risk factors associated with incident cardiovascular events in LMICs. We searched six databases for relevant articles, supplemented with a manual search of reference lists. Articles included in the meta-analyses were those based on prospective community-based cohorts and incorporating adjusted hazard ratios (HR) or relative risks with 95% confidence intervals (95% CI) for associations between risk factors and a composite cardiovascular and/or stroke endpoint. Pooled HRs and 95% CI were calculated using the random effects model. We assessed heterogeneity using the I2 test and study quality using the Newcastle-Ottawa Scale. We calculated the PAF of each associated risk factor. The protocol was registered in PROSPERO (CRD42019122741). We identified 18 cohorts from LMICs with 1,125,846 participants, 77,045 composite cardiovascular events and 42,216 strokes. Substantial proportions of incident cardiovascular events were attributable to hypertension (HR [95% CI], 2.23 [2.01–2.48], PAF = 28%); current smoking (1.44 [1.31–1.58], PAF = 10%); and diabetes mellitus (1.93 [1.67–2.23], PAF = 8%). Other risk factors identified included number of children, depression, bone mineral density, and air pollution. A substantial proportion of incident cardiovascular events were linked to traditional metabolic and behavioural modifiable risk factors. However, other novel risk factors also appear to contribute. Targeting of these established and novel risk factors has the potential to reduce the burden of CVD in LMICs.

Original languageEnglish
Article number107036
Number of pages9
JournalPreventive Medicine
Publication statusPublished - May 2022


  • Cardiovascular disease
  • Cardiovascular event
  • Cohort study
  • Epidemiology
  • Incidence
  • Low- and middle-income countries
  • Meta-analysis
  • Risk factors

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