Mortality and cardiovascular and respiratory morbidity in individuals with impaired FEV1 (PURE): an international, community-based cohort study
The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown. In this international, community-based cohort st...
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| Vydané v: | The Lancet global health Ročník 7; číslo 5; s. e613 - e623 |
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| Hlavní autori: | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |
| Médium: | Journal Article |
| Jazyk: | English |
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Elsevier Ltd
01.05.2019
Elsevier |
| ISSN: | 2214-109X, 2214-109X |
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| Abstract | The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown.
In this international, community-based cohort study, we prospectively enrolled adults aged 35–70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to −1 SD), moderate impairment (FEV1% <–1 SD to −2 SDs), and severe impairment (FEV1% <–2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression.
Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6–9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18–1·36] for mild, 1·74 [1·60–1·90] for moderate, and 2·54 [2·26–2·86] for severe impairment), cardiovascular disease (1·18 [1·10–1·26], 1·39 [1·28–1·51], 2·02 [1·75–2·32]), and respiratory hospitalisation (1·39 [1·24–1·56], 2·02 [1·75–2·32], 2·97 [2·45–3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2–27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1–5·2]) and from tobacco use (19·7% [17·2–22·3]), previous cardiovascular disease (5·5% [4·5–6·5]), and hypertension (17·1% [14·6–19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8–19·7), second only to the contribution of hypertension (30·1% [27·6–32·5]).
FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment).
Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix. |
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| AbstractList | The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown.
In this international, community-based cohort study, we prospectively enrolled adults aged 35–70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to −1 SD), moderate impairment (FEV1% <–1 SD to −2 SDs), and severe impairment (FEV1% <–2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression.
Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6–9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18–1·36] for mild, 1·74 [1·60–1·90] for moderate, and 2·54 [2·26–2·86] for severe impairment), cardiovascular disease (1·18 [1·10–1·26], 1·39 [1·28–1·51], 2·02 [1·75–2·32]), and respiratory hospitalisation (1·39 [1·24–1·56], 2·02 [1·75–2·32], 2·97 [2·45–3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2–27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1–5·2]) and from tobacco use (19·7% [17·2–22·3]), previous cardiovascular disease (5·5% [4·5–6·5]), and hypertension (17·1% [14·6–19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8–19·7), second only to the contribution of hypertension (30·1% [27·6–32·5]).
FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment).
Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix. Background: The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown. Methods: In this international, community-based cohort study, we prospectively enrolled adults aged 35–70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to −1 SD), moderate impairment (FEV1% <–1 SD to −2 SDs), and severe impairment (FEV1% <–2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression. Findings: Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6–9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18–1·36] for mild, 1·74 [1·60–1·90] for moderate, and 2·54 [2·26–2·86] for severe impairment), cardiovascular disease (1·18 [1·10–1·26], 1·39 [1·28–1·51], 2·02 [1·75–2·32]), and respiratory hospitalisation (1·39 [1·24–1·56], 2·02 [1·75–2·32], 2·97 [2·45–3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2–27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1–5·2]) and from tobacco use (19·7% [17·2–22·3]), previous cardiovascular disease (5·5% [4·5–6·5]), and hypertension (17·1% [14·6–19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8–19·7), second only to the contribution of hypertension (30·1% [27·6–32·5]). Interpretation: FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment). Funding: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix. The associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown.BACKGROUNDThe associations between the extent of forced expiratory volume in 1 s (FEV1) impairment and mortality, incident cardiovascular disease, and respiratory hospitalisations are unclear, and how these associations might vary across populations is unknown.In this international, community-based cohort study, we prospectively enrolled adults aged 35-70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to -1 SD), moderate impairment (FEV1% <-1 SD to -2 SDs), and severe impairment (FEV1% <-2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression.METHODSIn this international, community-based cohort study, we prospectively enrolled adults aged 35-70 years who had no intention of moving residences for 4 years from rural and urban communities across 17 countries. A portable spirometer was used to assess FEV1. FEV1 values were standardised within countries for height, age, and sex, and expressed as a percentage of the country-specific predicted FEV1 value (FEV1%). FEV1% was categorised as no impairment (FEV1% ≥0 SD from country-specific mean), mild impairment (FEV1% <0 SD to -1 SD), moderate impairment (FEV1% <-1 SD to -2 SDs), and severe impairment (FEV1% <-2 SDs [ie, clinically abnormal range]). Follow-up was done every 3 years to collect information on mortality, cardiovascular disease outcomes (including myocardial infarction, stroke, sudden death, or congestive heart failure), and respiratory hospitalisations (from chronic obstructive pulmonary disease, asthma, pneumonia, tuberculosis, or other pulmonary conditions). Fully adjusted hazard ratios (HRs) were calculated by multilevel Cox regression.Among 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6-9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18-1·36] for mild, 1·74 [1·60-1·90] for moderate, and 2·54 [2·26-2·86] for severe impairment), cardiovascular disease (1·18 [1·10-1·26], 1·39 [1·28-1·51], 2·02 [1·75-2·32]), and respiratory hospitalisation (1·39 [1·24-1·56], 2·02 [1·75-2·32], 2·97 [2·45-3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2-27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1-5·2]) and from tobacco use (19·7% [17·2-22·3]), previous cardiovascular disease (5·5% [4·5-6·5]), and hypertension (17·1% [14·6-19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8-19·7), second only to the contribution of hypertension (30·1% [27·6-32·5]).FINDINGSAmong 126 359 adults with acceptable spirometry data available, during a median 7·8 years (IQR 5·6-9·5) of follow-up, 5488 (4·3%) deaths, 5734 (4·5%) cardiovascular disease events, and 1948 (1·5%) respiratory hospitalisation events occurred. Relative to the no impairment group, mild to severe FEV1% impairments were associated with graded increases in mortality (HR 1·27 [95% CI 1·18-1·36] for mild, 1·74 [1·60-1·90] for moderate, and 2·54 [2·26-2·86] for severe impairment), cardiovascular disease (1·18 [1·10-1·26], 1·39 [1·28-1·51], 2·02 [1·75-2·32]), and respiratory hospitalisation (1·39 [1·24-1·56], 2·02 [1·75-2·32], 2·97 [2·45-3·60]), and this pattern persisted in subgroup analyses considering country income level and various baseline risk factors. Population-attributable risk for mortality (adjusted for age, sex, and country income) from mildly to moderately reduced FEV1% (24·7% [22·2-27·2]) was larger than that from severely reduced FEV1% (3·7% [2·1-5·2]) and from tobacco use (19·7% [17·2-22·3]), previous cardiovascular disease (5·5% [4·5-6·5]), and hypertension (17·1% [14·6-19·6]). Population-attributable risk for cardiovascular disease from mildly to moderately reduced FEV1 was 17·3% (14·8-19·7), second only to the contribution of hypertension (30·1% [27·6-32·5]).FEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment).INTERPRETATIONFEV1 is an independent and generalisable predictor of mortality, cardiovascular disease, and respiratory hospitalisation, even across the clinically normal range (mild to moderate impairment).Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix.FUNDINGPopulation Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline, Novartis, and King Pharma. Additional funders are listed in the appendix. |
| Author | Bahonar, Ahmad Lear, Scott Duong, MyLinh Gupta, Rajeev du Plessis, Johannes Lodewykus Avezum, Alvaro Li, Wei Yan, Ruohua Ismail, Noorhassim Karsidag, Kubilay Igumbor, Ehimario U Iqbal, Romaina Killian, Kieran Teo, Koon Yusufali, Afazalhussein O'Byrne, Paul M Islam, Shofiqul Kumar, Rajesh Yusoff, Khalid Yusuf, Salim Lopez-Jaramillo, Patricio Leong, Darryl Lamelas, Pablo M Mony, Prem Rahman, Omar Zatonska, Katarzyna Rosengren, Annika Mohan, Viswanathan Zhi, Fumin Lanas, Fernando Nair, Sanjeev Kurmi, Om Wielgosz, Andreas Rangarajan, Sumathy Chifamba, Jephat Dagenais, Gilles Lu, Yin |
| Author_xml | – sequence: 1 givenname: MyLinh surname: Duong fullname: Duong, MyLinh email: duongmy@mcmaster.ca organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 2 givenname: Shofiqul surname: Islam fullname: Islam, Shofiqul organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 3 givenname: Sumathy surname: Rangarajan fullname: Rangarajan, Sumathy organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 4 givenname: Darryl surname: Leong fullname: Leong, Darryl organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 5 givenname: Om surname: Kurmi fullname: Kurmi, Om organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 6 givenname: Koon surname: Teo fullname: Teo, Koon organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 7 givenname: Kieran surname: Killian fullname: Killian, Kieran organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 8 givenname: Gilles surname: Dagenais fullname: Dagenais, Gilles organization: Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada – sequence: 9 givenname: Scott surname: Lear fullname: Lear, Scott organization: Faculty of Health Sciences and Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Vancouver, BC, Canada – sequence: 10 givenname: Andreas surname: Wielgosz fullname: Wielgosz, Andreas organization: Department of Medicine, University of Ottawa, Ottawa, ON, Canada – sequence: 11 givenname: Sanjeev surname: Nair fullname: Nair, Sanjeev organization: Department of Pulmonary Medicine, Medical College, Thiruvananthapuram, Kerala, India – sequence: 12 givenname: Viswanathan surname: Mohan fullname: Mohan, Viswanathan organization: Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India – sequence: 13 givenname: Prem surname: Mony fullname: Mony, Prem organization: Community Health & Epidemiology, St John's Research Institute, Bangalore, Karnataka, India – sequence: 14 givenname: Rajeev surname: Gupta fullname: Gupta, Rajeev organization: Eternal Heart Care Centre and Research Institute, Jaipur, Rajasthan, India – sequence: 15 givenname: Rajesh surname: Kumar fullname: Kumar, Rajesh organization: Post Graduate Institute of Medical Education and Research (PGIMER), School of Public Health, Chandigarh, India – sequence: 16 givenname: Omar surname: Rahman fullname: Rahman, Omar organization: Department of Community Medicine and School of Public Health, Independent University, Dhaka, Bangladesh – sequence: 17 givenname: Khalid surname: Yusoff fullname: Yusoff, Khalid organization: Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia – sequence: 18 givenname: Johannes Lodewykus surname: du Plessis fullname: du Plessis, Johannes Lodewykus organization: Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, North West Province, South Africa – sequence: 19 givenname: Ehimario U surname: Igumbor fullname: Igumbor, Ehimario U organization: School of Public Health, University of the Western Cape, Cape Town, South Africa – sequence: 20 givenname: Jephat surname: Chifamba fullname: Chifamba, Jephat organization: Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe – sequence: 21 givenname: Wei surname: Li fullname: Li, Wei organization: State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China – sequence: 22 givenname: Yin surname: Lu fullname: Lu, Yin organization: State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China – sequence: 23 givenname: Fumin surname: Zhi fullname: Zhi, Fumin organization: State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China – sequence: 24 givenname: Ruohua surname: Yan fullname: Yan, Ruohua organization: State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China – sequence: 25 givenname: Romaina surname: Iqbal fullname: Iqbal, Romaina organization: Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Sindh, Pakistan – sequence: 26 givenname: Noorhassim surname: Ismail fullname: Ismail, Noorhassim organization: Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia – sequence: 27 givenname: Katarzyna surname: Zatonska fullname: Zatonska, Katarzyna organization: Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland – sequence: 28 givenname: Kubilay surname: Karsidag fullname: Karsidag, Kubilay organization: Division of Endocrinology, Department of Internal Medicine, Medical Faculty of Istanbul University, Istanbul, Turkey – sequence: 29 givenname: Annika surname: Rosengren fullname: Rosengren, Annika organization: Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Östra, Göteborg, Sweden – sequence: 30 givenname: Ahmad surname: Bahonar fullname: Bahonar, Ahmad organization: Hypertension Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran – sequence: 31 givenname: Afazalhussein surname: Yusufali fullname: Yusufali, Afazalhussein organization: Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates – sequence: 32 givenname: Pablo M surname: Lamelas fullname: Lamelas, Pablo M organization: Estudios Clinicos Latinoamerica (ECLA), Rosario, Santa Fe, Argentina – sequence: 33 givenname: Alvaro surname: Avezum fullname: Avezum, Alvaro organization: Dante Pazzanese Institute of Cardiology, São Paulo, São Paulo, Brazil – sequence: 34 givenname: Patricio surname: Lopez-Jaramillo fullname: Lopez-Jaramillo, Patricio organization: Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca, Santander, Colombia – sequence: 35 givenname: Fernando surname: Lanas fullname: Lanas, Fernando organization: University of La Frontera, Temuco, Chile – sequence: 36 givenname: Paul M surname: O'Byrne fullname: O'Byrne, Paul M organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada – sequence: 37 givenname: Salim surname: Yusuf fullname: Yusuf, Salim organization: Population Health Research Institute, Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada |
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| PublicationDate_xml | – month: 05 year: 2019 text: May 2019 |
| PublicationDecade | 2010 |
| PublicationTitle | The Lancet global health |
| PublicationYear | 2019 |
| Publisher | Elsevier Ltd Elsevier |
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