EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

5. HEALTH IMPACTS OF NON COMMUNICABLE DISEASES AND RELATED TIME-TRENDS

5.2. Cardiovascular diseases

5.2.3. Data description and analysis

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5.2.3. Data description and analysis

 

5.2.3.1. Ischemic heart disease

 

Mortality

 

CVD is the main cause of death among old people, accounting for over 50% of deaths in people aged 80 and over; it is also the main cause of death in both genders and all ages, accounting for 42% of all causes of deaths in EU (Figure 5.1.1). Around half of the deaths are from IHD, accounting for over 741.000 deaths every year: one in six men and one in seven women die from IHD (Allender et al, 2008). Even below the age of 75 years, IHD mortality is higher in men than in women but still remains the most frequent cause of death in women, accounting for more deaths than breast cancer.

As explained in chapter 5.2.2Data sources’, it was decided to report standardized mortality rates only for 35-74 age range, as suggested by the EUROCISS project. However, mortality rates for the different age ranges (all ages, 45-64, 45-74) have already been published (Pisa and Uemura, 1982; Uemura and Pisa, 1988; Thom, 1989; Thom et al, 1985; Sans et al, 1997; Kesteloot et al, 2006).

In the 35-74 age-range, CVD accounts for 34% of total mortality and IHD for 15%. Mortality rates are higher in men than in women and percentages increase with age. IHD patterns showed a clear East-West gradient with the highest mortality rates in Baltic1, Central Eastern and Eastern Europe countries (Table 5.2.1). According to the most recent data (2001-2003), the rates vary from 42.7 deaths per 100.000 in France to 327.0 deaths per 100.000 in Latvia, being there almost eight times higher (in men 72 deaths per 100.000 in France and 555 in Latvia; in women 16 per 100.000 in France and 167 in Latvia).

 

Table 5.2.1. Ischemic heart diseases (codes ICD-9: 410-14) - Age-standardized (standard European population) mortality rates per 100.000.

 

Mortality trends for IHD in men are shown in Figure 5.2.1: in all countries from 1994 to 2003 mortality rates in the 35-74 age range fell by 38% in Northern countries2 (from 300 to 186 per 100.000), 45% in Central Eastern Europe countries3 (from 440 to 242 per 100.000), 27% in Eastern Europe countries4 (from 450 to 326 per 100.000), 37% in Central Europe countries5 (from 225 to 142 per 100.000), 34% in Southern Europe countries6 (from 139 to 91 per 100.000) and 27% in Baltic7 countries (from 696 to 505 per 100.000). Similar results can be found in women (Figure 5.2.2) for whom mortality rates fell by 40% in Central Europe countries (from 73 to 44 per 100.000), 51% in Central Eastern Europe countries (from 157 to 77 per 100.000), 23% in Eastern Europe countries (from 169 to 130 per 100.000), 41% in Northern Europe (from 102 to 61 per 100.000), 36% in Baltic Europe countries (from 231 to 148 per 100.000) and 41% in Southern Europe countries (from 40 to 23 per 100.000).

 

Figure 5.2.1. Age-standardized mortality rates per 100.000. Trends for ischemic heart diseases (codes ICD-9 410-14) Men aged 35-74 years

 

Figure 5.2.2. Age-standardized mortality rates per 100.000. Trends for ischemic heart diseases (codes ICD-9 410-14) Women aged 35-74 years

 

Morbidity

 

Table 5.2.2 shows IHD and AMI hospital discharge diagnoses for men and women of all ages combined for the last year available (http://www.euro.who.int/hfadb, 2007). Unfortunately these data are scarce and not validated, therefore the analysis of temporal trends was not possible and comparisons among countries are not totally reliable. Moreover, their interpretation is difficult due to various factors, such as different hospital admission policies, different coding practice and multiple hospital admissions for the same person. To facilitate comparison at least within the same country, data on IHD, AMI and stroke hospital discharges are reported together with the data on all CVD hospital discharges. There are great differences between hospitalization for all CVD and for IHD and stroke. Opposite to the common belief that most hospitalizations are for AMI and stroke, in almost all countries more than half of hospitalizations are due to other CVD. This means that in recent years there has been a notable increase in the number of hospitalizations for other CVD, such as heart failure and arrhythmias, which represent common complications of AMI and require frequent hospitalizations. Future availability of data on hospital discharges for these conditions could be crucial to understand the patterns of morbidity and future trends in medical care.

 

Table 5.2.2. Crude hospital discharge rates (x100.000) from all CVD, IHD,AMI, and stroke Last year available, all ages

 

Revascularization rates represent another important source of information for CVD morbidity. Three treatments are recommended for IHD in acute care setting: thrombolytic drugs, PTCA and CABG. Given the difficulties in identifying thrombolytic therapy use from hospital in-patient database, coronary revascularization procedures (PTCA, CABG) were considered and reported in Table 5.2.3 (Allender et al, 2008). The data vary widely across Europe and all countries have seen significant rate increase since the 90s. Central Eastern and Eastern Europe countries have lower rates than Northern and Southern countries. The only data available are those collected by the European Society of Cardiology (ESC) in 2004 (Allender et al, 2008). Most AMI patients who receive a CABG do not undergo this procedure during their initial admission. The patient is usually stabilized and then referred for a follow-up admission for CABG. As it was not possible to identify the patient when he/she is re-admitted in hospital for surgery, the data refer to two separate cases of AMI or one case of AMI and one case of IHD. In addition, there is a recent tendency to perform PTCA in high-risk patients with vessel obstruction: when this occurs, it is not possible to know if the patient may have experienced an AMI. Therefore, it would be useful for the future to distinguish between direct PCI (coronary angioplasty performed in AMI within hours after it has started) and elective PCI (made in angina pectoris or in post AMI).

The best source of valid data on surgical procedures is the hospital-based register, which allows to identify the patient when he/she is re-admitted in hospital for surgery and distinguish between the surgery performed on patients with AMI and that performed on patients with IHD.

 

Table 5.2.3. Crude rates per 1 million population of revascularization procedures – All ages. Men and women combined (year 2000)

 

The only available and comparable data on morbidity of acute coronary events - although collected till late 1990’s, but not always representative of the country in which they were collected - are those of the WHO MONICA Project, reported in Table 5.2.4; here we can see mean attack rates of 10-year surveillance for coronary events and 28-day case fatality for men and women aged 35-64 years. Trends for age-adjusted event rates are also reported (Tunstall-Pedoe et al, 1999). Attack rate, which includes fatal and non-fatal, in and out of hospital, first and recurrent coronary events represent the most valid and reliable indicator. According to the MONICA data, this was higher in populations in Northern, Southern, Central Eastern and Eastern Europe than in Southern Europe countries; for men living in Warsaw it was three times higher than it was in Catalonia, while it was four times higher in women. The results of the WHO MONICA Project also show that incidence was falling rapidly in most people living in Northern countries, but not falling as fast in the populations in Baltic, Central Eastern and Eastern countries. Case fatality from coronary heart disease (CHD) was higher in many populations in Southern, Central Eastern and Eastern Europe countries than in Northern and Southern Europe countries (Tunstall-Pedoe et al, 1999). Following the MONICA experience, some countries continued to collect data every year while others did it periodically. The existing population based registers in Europe adopt different data collection procedures cover different age groups, while the degree of validation of the diagnostic information varies and in most registers it is much less intensive than in the MONICA project (Eurociss Working Group, 2003).

 

Table 5.2.4. WHO-MONICA 13 EU population. Mean annual coronary events rates (fatal and non fatal in and out of hospital first and recurrent events) per 100.000 during 10-year registration in men and women aged 35-64 years; 28-day case fatality (including patients dying before reaching hospital); annual change in coronary event rate in 10 years.

 

To summarize, IHD, the leading cause of death in the twentieth century, began to decline in the mid 1970s in Western European countries. IHD continued to fall through the 1990s, although it changed more modestly, but still remains the largest single cause of death and disability. A continuous increase was noticed in Eastern European countries up to the 1990s. Since then, cardiovascular mortality started to decrease also in Eastern European countries (approximately 20 years later than Western European countries). The decline in IHD mortality rates has been greater for countries with the highest mortality rates. Not surprisingly, mortality rates are much higher for men than for women; mortality rates have been falling faster for men than for women. Faster declining mortality rates for men have narrowed the gap with women over the last ten years, but have not eliminated it. The patterns for IHD are associated with changes in the environment exposures, health behaviours, diagnosis and treatment.

The decline in mortality in the different populations could be explained by changes in the average level of risk factors, such as serum cholesterol and blood pressure, and by the reduction in the prevalence of smokers. The first two could be ascribed to improvements in dietary habits (decrease in consumption of saturated and trans-unsaturated fatty acidschanging from butter and “hardmargarine to mono- and poly-unsaturated oils and to “softmargarine, from whole fat to low fat milk, increasing fruit and vegetables and reducing salt intake). The more recent decline is also due to improvements in modern therapies for acute phase of myocardial infarction, such as thrombolytic therapies, PCI and CABG, and in more efficient therapies for chronic conditions and the management of risk factors.

Comparable data on morbidity are more difficult to collect and validate. Their interpretation is difficult due to various factors such as different hospital admission policies, different coding practice and multiple hospital admissions for the same person. At present, there is no routinely updated sources of CVD morbidity data in EU.

 

5.2.3.2. Stroke

Data on morbidity and mortality are available only for the cerebrovascular disease aggregate group, including sequelae of stroke, therefore it is not possible to distinguish between haemorrhagic and ischemic stroke, which are characterized by different prevalence, age distribution and risk factors.

In addition, the recent availability of new and more sophisticated diagnostic technologies, such as MRI and CT-Scan, may have led to an increase in the number of diagnosed events, thus making the interpretation of temporal trends in the various countries more difficult. Stroke units have been shown to improve significantly both the functional outcome and the case fatality after stroke.

 

Mortality

Stroke alone is the second single most common cause of death in EU, accounting for over 508.000 deaths each year. Around one in ten men and one in eight women die from this disease (Allender et al, 2008). Stroke mortality is higher in men than in women in most countries but the differences narrow considerably above the age of 75. As explained in chapter 4.2.2Data sources’, it was decided to report standardized mortality rates only for the 35-84 age range, as suggested by the EUROCISS project.

Among people aged 35-84, stroke accounts for 10% of all-cause mortality. Analyses of mortality highlighted substantial differences among countries.

 

Table 5.2.5. Age-standardized (standard European Population) cerebrovascular mortality rates per 100.000 men and women aged 35-74 and 35-84 - 3 years average

 

In men, mortality rate varies from 60 deaths per 100.000 in France to 399 deaths per 100.000 in Romania, being there almost seven times higher. In women it varies from 36 deaths per 100.000 in France to 297 deaths in Bulgaria, being there almost eight times higher. As shown in table 5.2.5, in the age range 75-84 years stroke events double in both men and women: this demonstrates that stroke is a disease that mainly affects the elderly.

Mortality trends for stroke in men are shown in Figure 5.2.3; from 1994 to 2003 mortality rates in the age range 35-84 fell by 63% in Central Europe (from 133 to 49 per 100.000), 40% in Southern Europe countries (from 136 to 82 per 100.000), 21% in Northern countries (from 110 to 87 per 100.000), 34% in Central Eastern Europe (from 273 to 180 per 100.000) and 6% in Baltic Europe countries (from 298 to 279 per 100.000). Mortality increased by 10% in Eastern Europe (from 324 to 357 per 100.000). In 2003, mortality rates in Central Europe countries were more than seven times lower than in Eastern Europe countries. Temporal trends from 1993 to 2002 in stroke mortality were more favourable in Central and Southern Europe and showed a clear East-West gradient with the highest mortality rates in Baltic Europe and Eastern Europe.

 

Figure 5.2.3. Age-standardized (standard European population) mortality rates per 100.000 Cerebrovascular disease (codes ICD-9 430-38) - Men aged 35-84 years

 

Similar results can be found in women (Figure 5.2.4) for which mortality rates fell by 39% in Central Europe (from 89 to 54 per 100.000), 46% in Southern Europe countries (from 99 to 54 per 100.000), 21% in Northern countries (from 87 to 68 per 100.000), 13% in Baltic Europe countries (from 218 to 189 per 100.000) and 37% in Central Eastern Europe (from 193 to 121 per 100.000). Mortality rates increased by 21% in Eastern Europe (from 203 to 246 per 100.000). In 2003, mortality rates in Southern Europe were more than four times lower than in Eastern Europe countries.

 

Figure 5.2.4. Age-standardized (standard European population) mortality rates per 100.000 Cerebrovascular disease (codes ICD-9 430-38) - Women aged 35-84 years

 

Morbidity

 

Table 5.2.2 also shows stroke hospital discharge rates for men and women of all ages combined for the last year available (http://www.euro.who.int/hfadb, 2007). Unfortunately, these data are not validated and cannot be compared among countries. Their interpretation is difficult due to various factors such as multiple hospital admissions for the same person, in particular sequelae of the original event, different hospital admission policies and coding practices. The use of diagnostic technologies, such as CT-Scan and MRI, has greatly improved the accuracy of diagnoses of hospitalized cerebrovascular events allowing delineation of the location and type of lesion. Data on hospital discharges separated for ischemic and haemorrhagic stroke are not available.

 

The only available and comparable data, although seldom representative of the whole country, are those collected more than 10 years ago through the same standardized methodology within the WHO MONICA Project. These data are reported in Table 5.2.6: here mean attack rates of the last 3 years of surveillance for stroke events and 28-day case fatality for men and women aged 35-64 are shown. However, only one third of all non-fatal stroke events and one tenth of all fatal stroke events occur in this age range, excluding therefore the large number of patients suffering from strokes.

Attack rate (which include fatal and non-fatal, in- and out-of-hospital, first and recurrent events) is higher in populations in Northern Europe (Lithuania, Finland, Northern Sweden); for those living in Lithuania is three times higher than it is in Italy. A comparison of changes in attack and case fatality rates with changes in mortality rates revealed that two thirds of the decreasing mortality was attributable to reduced case fatality and one third to reduced incidence. However, it was not possible to establish whether this decrease of case fatality was due to changes in the management of stroke or changes in disease severity (Sarti et al, 2003).

 

Table 5.2.6. WHO-MONICA Project 6 EU population. Age-standardized average attack rate per stroke events (fatal and non fatal) per 100.000 mean of the last 3 years of the 10- year surveillance in men and women aged 35-64; 28-day case fatality; average annual trend in 10 years of stroke events .

 

In brief, the declining trends of stroke mortality during the last 10 years suggest that acute stroke events have become milder and that the prevalence of stroke survivors is increasing. The decline in mortality has been greater in countries with higher rates. The decline would be only partly attributed to an improvement in the control of hypertension; there is evidence suggesting that a decrease in the prevalence of some environmental factors (intake of dietary salt and saturated fat, smoking habit) has contributed to this favourable trend.

In contrast, the 1990s have seen a dramatically increase in stroke mortality for men and women in Eastern Europe. The political, social and economic transition in the former communist countries has greatly affected people’s lives, many of whom have experienced rising levels of poverty and economic hardship. The east-West gap might be mostly explained by increased levels of traditional risk factors, such as diet rich in saturated fats but low in antioxidants due to a low intake of fruit and vegetables, along with smoking habit and excessive alcohol consumption. Thus, overall poor nutrition and high level of psycho-social stress may explain the increase in mortality.