Rethinking cardiovascular prevention beyond short term risk scores in low and middle income countries

Cardiovascular disease remains the leading cause of death worldwide, accounting for more than 20 million deaths each year, over 75% of which occur in low- and middle-income countries (LMICs). Despite this burden, contemporary cardiovascular prevention continues to rely largely on short-term risk scores developed in high-income settings, prioritising a relatively small proportion of individuals at high predicted risk. According to the PURE study, more than 40% of cardiovascular events, and over 50% in LMICs, occur among individuals classified as low or intermediate risk (calculated using the World Health Organization 10-year cardiovascular risk score), highlighting a critical gap in current prevention paradigms. Cardiovascular risk in LMICs accumulates across the life course through sustained exposure to biological, social, and environmental determinants that are insufficiently captured by conventional risk models. In parallel, the geographic concentration of cardiovascular evidence generation in high-income countries has shaped prevention frameworks that are poorly calibrated to the populations bearing the greatest disease burden. The aim of this Perspective is to argue for a more inclusive and anticipatory framework for cardiovascular prevention, integrating social determinants of health, cumulative and lifespan-based risk assessment, and scalable population-level strategies alongside traditional high-risk approaches. Aligning clinical prevention with public policy and health system capacity may enable earlier, more equitable, and more effective cardiovascular prevention in settings where the global cardiovascular burden is highest.