Epidemiology of CV disease in Central and Eastern Europe Renata Cífková Center for CV Prevention, Charles University Medical School & Thomayer University Hospital Department of Medicine II, Charles University Medical School Department of Preventive Cardiology, IKEM Prague, Czech Republic

Death by cause Europe Men Women All CVD deaths 43% All CVD deaths 54% European CVD Statistics 2008

Death by cause European Union Men Women All CVD deaths 38% All CVD deaths 45% European CVD Statistics 2008

Russian Fed. BulgariaRomaniaHungaryPolandArgentina Czech Republic China-RuralColombiaChina-UrbanScotlandIrelandFinland N. Ireland GreeceEngland/WalesBelgiumUSADenmark N. Zealand MexicoGermanyPortugalSwedenKoreaAustriaNetherlandsItalyNorwayCanadaSpainAustraliaFranceSwitzerlandIsraelJapan Death Rates for CVD and Stroke Men, yrs Circulation 2009;119:e21-e181

Russian Fed. BulgariaRomaniaHungaryColombiaChina-RuralChina-UrbanArgentinaPoland Czech Republic Mexico Puerto Rico ScotlandN.IrelandUSAEngland/Wales New Zealand GreeceKoreaIrelandDenmarkBelgiumPortugalGermanySwedenFinlandNetherlandsCanadaItalyAustriaNorwayAustraliaIsraelSpainSwitzerlandJapanFrance Death Rates for CVD and Stroke Women, yrs Circulation 2009;119:e21-e181

Dearth/ (age adj.) year CV Mortality - Males

year Death/ (age adj. CV Mortality - Females

Standardized mortality Czech Republic, 2009 Males Females CVDMalignanciesOther 45.3 % 27.9 % 26.8 % 51.4 % 26.1 % 22.5 %

Males - Total - CVD - CHD - Stroke Females - Total - CVD - CHD - Stroke < % p Age-adjusted death rates/100,000 Czech Republic,

Age-stand. total, CVD, IHD, and stroke mortality (age group yrs) Czech Republic J Hypertens 2010;28: Males Females Total mortality CVD mortality IHD mortality Stroke mortality Number of deaths/100,000

Total mortality, age years Males vs Females: p = 0,001 CVD mortality, age years Males vs Females: p = 0,001 CAD mortality, age years Males vs Females: p = 0,001 Stroke mortality, age years Males vs Females: p = 0,0041 Males Females year Number of deaths/100,000 J Hypertens 2010;28:

Factors affecting CHD mortality Risk factors CHD incidence CHD mortality Treatment Case fatality

Pardubice Kroměříž Chrudim Jindřichův Hradec Benešov Plzeň Praha východ Cheb Litoměřice WHO MONICA projekt Nové okresy

Sample sizes and response rates /8 2000/1 2007/8 TotalMalesResp.FemalesResp *** p < for trend *** ***

Methods Physician-completed questionnaire (CVD history) Body weight, height, BP Total cholesterol, HDL-cholesterol Physician-completed questionnaire (CVD history incl. family history) Body weight, height, BP, waist/hip ratio Total cholesterol, HDL-cholesterol Triglycerides Fasting glycemia /982000/012007/08

Systolic BP Males Females p < mmHg mmHg Atherosclerosis 2010;211:676-81

Diastolic BP Males Females p < mmHg mmHg Atherosclerosis 2010;211:676-81

Prevalence of hypertension Males Females p for linear trend: ns p < % % Atherosclerosis 2010;211:676-81

BMI Males Females p < kg/m 2 p pro trend: NS Atherosclerosis 2010;211:676-81

Awareness of hypertension Males Females p for linear trend: % % Atherosclerosis 2010;211:676-81

Antihypertensive medication Males Females p for linear trend: % % Atherosclerosis 2010;211:676-81

Hypertension control BP < 140/90 mmHg of all hypertensives Males Females p for linear trend: % % Atherosclerosis 2010;211:676-81

Hypertension control BP< 140/90 mmHg of all drug-treated hypertensives Males Females p for linear trend: < % % Atherosclerosis 2010;211:676-81

Antihypertensive medication Czech Republic 51.2% 33.6% 17.3% 46.7% 35.4% 17.6% 1997/ / /08* monotherapy combination of 2 drugs combination of > 3 drugs n = 512 n = % 27.1% 33.3% n = 573 * Only 6 districts

Total cholesterol Males Females p < mmol/l mmol/l Atherosclerosis 2010;211:676-81

HDL-cholesterol Males Females p < 0.001p for linear trend: n.s mmol/l mmol/l Atherosclerosis 2010;211:676-81

Non-HDL-cholesterol 1985 – 2007/ /982000/012007/08 p for trend 4.85 ± ± ± ± ± ± 1.10 < < ± ± ± ± ± ± 1.12 < < Males Females Atherosclerosis 2010;211:676-81

Lipid-lowering drugs 81% 13% 3% 3% fibratesstatinsothercombinations 68.5% 27.5% 4% 1997/98 n = 130 (3.95%) 2000/01 n = 171 (5.1%) 78.0% 15.5% 4.7% 2007/08 n = 386 (10.7%) 1.6% Atherosclerosis 2010;211:676-81

Smoking Males Females p < p for trend: n.s. % % Atherosclerosis 2010;211:676-81

BMI Males Females p < kg/m 2 p for trend: NS Atherosclerosis 2010;211:676-81

MalesFemales BMI in the Czech Republic BMI > 30.0 kg/m 2 BMI 25.0–29.9 kg/m 2 BMI < 25.0 kg/m 2 p for trend in obesity: < p for trend in obesity: n.s. Atherosclerosis 2010;211:676-81

Conclusions Conclusions Total and CV mortality is decreasing in the Czech Republic. The decrease is due to decreasing stroke and CHD mortality rates.

Conclusions (2) Conclusions (2) In a random Czech population sample mean SBP and DBP decreased mean SBP and DBP decreased the prevalence of hypertension in females decreased the prevalence of hypertension in females decreased the number of individuals using antihypertensive agents the number of individuals using antihypertensive agents increased increased hypertension control improved over a period of years hypertension control improved over a period of years

Conclusions (3) Conclusions (3) In a random Czech population sample the proportion of male smokers decreased (by a third), the proportion of male smokers decreased (by a third), with no change in the prevalence of female smokers (25%) with no change in the prevalence of female smokers (25%) total and non-HDL-cholesterol decreased in both genders; total and non-HDL-cholesterol decreased in both genders; there was a rise in individuals using lipid-lowering drugs there was a rise in individuals using lipid-lowering drugs there was an increase in male BMI over a period of years there was an increase in male BMI over a period of years

Explaining the CHD mortality fall in the Czech R epublic : RESULTS Explaining the CHD mortality fall in the Czech R epublic : RESULTS 12,080 fewer deaths in 2007  Risk Factors worse + 6 % Risk Factors better % Treatments % Treatments % Unexplained - 4 %

12,080 fewer deaths in 2007  Risk Factors worse + 6 % Obesity (increase) +1% Diabetes (increase) + 5 % Risk Factors better -61% Population BP fall -15% Smoking - 8% Cholesterol (diet) -38% Treatments -41% Treatments -41% AMI treatments -7% Unstable angina -1% Secondary prevention post MI and post revasc. -11% Heart failure -13% Angina: CABG surgery -1.5% Angina ASA -1% Hypertension therapies -3% Statins (primary prevention) -4% Unexplained -4% Explaining the CHD mortality fall in the Czech R epublic : RESULTS

Percentage of the Decrease in Death from CHD Atributed to Treatment and Risk-Factors Changes NEJM 2007;356:

10-year risk of death from CVD in the Czech population

Systolic BP German CV Prevention Study mmHg Males Females Preventive Medicine 1994;23: ns * *

Females Diastolic BP German CV Prevention Study Males mmHg Preventive Medicine 1994;23: *

BMI German CV Prevention Study Males Females kg/m 2 Preventive Medicine 1994;23: * *

Smoking German CV Prevention Study Males Females % % Preventive Medicine 1994;23:

Total Cholesterol German CV Prevention Study Males Females mmol/L mmol/L Preventive Medicine 1994;23: ** *

HDL-cholesterol German CV Prevention Study mmol/L Females Males mmol/L Preventive Medicine 1994;23:

Kaunas Population, Lithuania Age range, yrs 1983/ / / /02 TotalResp Medicina 2003;39:

Systolic BP Kaunas, Lithuania mmHg Males Females p < ** ** Medicina 2003;39:

Females Males mmHg *** *** Diastolic BP Kaunas, Lithuania

Males Females kg/m 2 * *** *** BMI Kaunas, Lithuania Medicina 2003;39:

Males Females mmol/L mmol/L p < * *** * *** Total Cholesterol Kaunas, Lithuania Medicina 2003;39:

WHO MONICA Project Multinational MONItoring of Trends and Determinants in CArdiovascular Disease 38 populations in 21 countries monitoring of nonfatal MI and CHD deaths in males and females monitoring of nonfatal MI and CHD deaths in males and females aged years aged years cross-sectional population surveys of major RF cross-sectional population surveys of major RF

WHO MONICA Age-standardized SBP Men, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA Age-standardized SBP Women, years Lancet 2000; 355: BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN

WHO MONICA Smokers Men, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA Smokers Women, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA Total cholesterol Men, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA Total cholesterol Women, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA BMI Men, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

WHO MONICA BMI Women, years BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN Lancet 2000; 355:675-87

Conclusions Conclusions CVD mortality in all European post-Communist CVD mortality in all European post-Communist countries is the highest in Europe. countries is the highest in Europe. In fact, CVD mortality rates continue to rise in most In fact, CVD mortality rates continue to rise in most post-Communist countries in Europe except for the post-Communist countries in Europe except for the Czech Republic, Poland, and Slovenia. Czech Republic, Poland, and Slovenia.

Conclusions, cont’d Conclusions, cont’d In most of the countries, there is a lack of recent CVD risk factor data on representative populations. Longitudinal trends are available only for the Czech Republic, Germany and Lithuania. Improvement in the CV risk profile was seen in the Czech Republic (BP, lipids, smoking in males); a smaller improvement was found in Kaunas, mostly in females (BP, BMI). Most of the major risk factors increased slightly in Germany over the study period.

Conclusions, cont’d Conclusions, cont’d Therefore, the best comparable data are still provided by the WHO-coordinated MONICA study confirming a poor CV risk profile in most of the European post-Communist countries (particularly for smoking, BP, and BMI).

304 territorial clusters, three-stage stratified sampling procedure CV RISK ASSESSMENT IN POLAND IN 2002 DESIGN AND METHODS: The diagnosis of hypertension was based on three separate visits (BP>=140/90 mmHg or medication) Response rate for BP and anthropometric measurements 78%, for laboratory tests 62% BP, BMI, laboratory tests Representative sample of 3051 adults in Poland Age range18-94 years 95% confidence interval ± 2% T. Zdrojewski et al.,J Hum Hypertens 2004;18:557-62

Prevalence and control of arterial hypertension in Poland (age range 30-70) T. Zdrojewski et al., J Hum Hypertens 2004;18:557-62

Gypsies Non-Gypsies p Gypsies Non-Gypsies p Number Response, % Hypertension ns Undiagnosed hypertension ns hypertension ns Obesity Central obesity Metabolic syndrome CVD Age- and sex-adjusted prevalence

“Manage it well!“ program: blood pressure control rates Patients with controlled BP (%) overall control: <140/90 mmHg, systolic control: <140 mmHg, diastolic control: <90 mmHg responders: <140 or <90 mmHg L. Szirmai, J Hypertens 2005;23: n = 4568

Limitations of hypertension studies Limitations of hypertension studies in primary care in primary care Not dealing with population random samples (involving Not dealing with population random samples (involving mostly individuals with a disease), predominantly elderly mostly individuals with a disease), predominantly elderly populations populations Most of the studies are based on a questionnaire completed Most of the studies are based on a questionnaire completed by GPs with no review of source data by GPs with no review of source data No review of patient selection according to the protocol No review of patient selection according to the protocol