Cardiovascular disease (CVD) is the leading cause of global mortality and morbidity, and the vast majority of the disease burden is in low-income countries (LICs) and low-income to middle-income countries (LMICs).1 CVD research, including clinical trials, is among the most productive in biomedical science, whether in terms of funding, publications or novel treatment strategies.2 However, the majority of this research does not represent the population where the highest proportion of CVD is concentrated, that is, LICs and LMICs.3 Therefore, research findings may not be applicable to most of the patients with CVD in the world, for example, risk prediction tools, projections of incidence and outcome, new drugs and devices and healthcare infrastructure. The so-called ‘10–90 gap’, where only 10% is allocated to poor countries that bear 90% of the world’s disease burden, describes the global inequity in research funding but underestimates the actual inequality in terms of research publications and research capacity.4

The associations between health, poverty and development are not in question.5 The role of poverty and development in cause and effect of CVD, and more broadly, non-communicable diseases, is crucial, yet under-recognised and underplayed in research, clinical practice and policy spheres. The paradox is that CVD, particularly coronary artery disease (CAD), is probably one of the most fertile grounds for research and trials worldwide compared with other disease areas. Increasing number of trials and registries are recruiting patients in lower-income countries.6^–8 A major motivation for this shift is the lower cost of recruitment and trial management in these settings; however, a potential positive spin-off is that results of trials may be more applicable to the global burden of disease.

Roy and colleagues report the associations between human development index and outcomes in the Targeted Platelet Inhibition to Clarify the Optimal …