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Epidemiology of CV disease in Central and Eastern Europe Renata Cífková Center for CV Prevention, Charles University Medical School & Thomayer University.

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Presentation on theme: "Epidemiology of CV disease in Central and Eastern Europe Renata Cífková Center for CV Prevention, Charles University Medical School & Thomayer University."— Presentation transcript:

1 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

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

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

4 Russian Fed. BulgariaRomaniaHungaryPolandArgentina Czech Republic China-RuralColombiaChina-UrbanScotlandIrelandFinland N. Ireland GreeceEngland/WalesBelgiumUSADenmark N. Zealand MexicoGermanyPortugalSwedenKoreaAustriaNetherlandsItalyNorwayCanadaSpainAustraliaFranceSwitzerlandIsraelJapan Death Rates for CVD and Stroke Men, 35-74 yrs Circulation 2009;119:e21-e181

5 Russian Fed. BulgariaRomaniaHungaryColombiaChina-RuralChina-UrbanArgentinaPoland Czech Republic Mexico Puerto Rico ScotlandN.IrelandUSAEngland/Wales New Zealand GreeceKoreaIrelandDenmarkBelgiumPortugalGermanySwedenFinlandNetherlandsCanadaItalyAustriaNorwayAustraliaIsraelSpainSwitzerlandJapanFrance Death Rates for CVD and Stroke Women, 35-74 yrs Circulation 2009;119:e21-e181

6 Dearth/100 000 (age adj.) year CV Mortality - Males

7 year Death/1000 000 (age adj. CV Mortality - Females

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

9 Males - Total - CVD - CHD - Stroke Females - Total - CVD - CHD - Stroke 1581 844 844 436 436 250 250 944 944 548 548 223 223 202 202 9634362188957729613472 - 38.8 - 48.3 - 47.9 - 64.4 - 38.9 - 46.0 - 39.9 - 64.4 < 0.001 1985 2009 % p Age-adjusted death rates/100,000 Czech Republic, 1985-2009

10 Age-stand. total, CVD, IHD, and stroke mortality (age group 35-74 yrs) Czech Republic 1970-2008 J Hypertens 2010;28:2196-203 Males Females Total mortality CVD mortality IHD mortality Stroke mortality Number of deaths/100,000

11 Total mortality, age 35-74 years Males vs Females: p = 0,001 CVD mortality, age 35-74 years Males vs Females: p = 0,001 CAD mortality, age 35-74 years Males vs Females: p = 0,001 Stroke mortality, age 35-74 years Males vs Females: p = 0,0041 Males Females year Number of deaths/100,000 J Hypertens 2010;28:2196-203

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

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

14 Sample sizes and response rates 1985 1988 1992 1997/8 2000/1 2007/8 TotalMalesResp.FemalesResp. 2570125381.5131785.0 2768135785.5141188.4 2343113473.2120976.7 199096963.2102166.4 2055100362.0105263.8 *** p < 0.001 for trend 22461102 62.7 *** 1144 63.1 ***

15 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 1985198819921997/982000/012007/08

16 Systolic BP Males Females p < 0.001 mmHg mmHg Atherosclerosis 2010;211:676-81

17 Diastolic BP Males Females p < 0.001 mmHg mmHg Atherosclerosis 2010;211:676-81

18 Prevalence of hypertension Males Females p for linear trend: ns p < 0.001 % % Atherosclerosis 2010;211:676-81

19 BMI Males Females p < 0.001 kg/m 2 p pro trend: NS Atherosclerosis 2010;211:676-81

20 Awareness of hypertension Males Females p for linear trend: 0.001 % % Atherosclerosis 2010;211:676-81

21 Antihypertensive medication Males Females p for linear trend: 0.001 % % Atherosclerosis 2010;211:676-81

22 Hypertension control BP < 140/90 mmHg of all hypertensives Males Females p for linear trend: 0.001 % % Atherosclerosis 2010;211:676-81

23 Hypertension control BP< 140/90 mmHg of all drug-treated hypertensives Males Females p for linear trend: < 0.001 % % Atherosclerosis 2010;211:676-81

24 Antihypertensive medication Czech Republic 51.2% 33.6% 17.3% 46.7% 35.4% 17.6% 1997/98 2000/01 2007/08* monotherapy combination of 2 drugs combination of > 3 drugs n = 512 n = 615 40.6% 27.1% 33.3% n = 573 * Only 6 districts

25 Total cholesterol Males Females p < 0.001 mmol/l mmol/l Atherosclerosis 2010;211:676-81

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

27 Non-HDL-cholesterol 1985 – 2007/2008 1985198819921997/982000/012007/08 p for trend 4.85 ± 1.35 4.96 ± 1.26 4.65 ± 1.33 4.36 ± 1.16 4.63 ± 1.11 3.97 ± 1.10 < 0.001 < 0.001 4.61 ± 1.29 4.66 ± 1.25 4.44 ± 1.32 4.03 ± 1.24 4.33 ± 1.18 3.65 ± 1.12 < 0.001 < 0.001 Males Females Atherosclerosis 2010;211:676-81

28 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

29 Smoking Males Females p < 0.001 p for trend: n.s. % % Atherosclerosis 2010;211:676-81

30 BMI Males Females p < 0.001 kg/m 2 p for trend: NS Atherosclerosis 2010;211:676-81

31 MalesFemales 19.7 25.3 19.9 25.2 29.5 33.6 28.030.0 25.5 26.5 27.8 30.1 BMI in the Czech Republic 1985 1988 1992 1997 2000 2007 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: < 0.001 p for trend in obesity: n.s. Atherosclerosis 2010;211:676-81

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

33 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 22-23 years hypertension control improved over a period of 22-23 years

34 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 22-23 years there was an increase in male BMI over a period of 22-23 years

35 Explaining the CHD mortality fall in the Czech R epublic 1985-2007: RESULTS Explaining the CHD mortality fall in the Czech R epublic 1985-2007: RESULTS 12,080 fewer deaths in 2007  Risk Factors worse + 6 % Risk Factors better - 6 1 % Treatments - 4 1 % Treatments - 4 1 % Unexplained - 4 % 2007 1985

36 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% 2007 1985 Explaining the CHD mortality fall in the Czech R epublic 1985-2007: RESULTS

37 Percentage of the Decrease in Death from CHD Atributed to Treatment and Risk-Factors Changes NEJM 2007;356:2388-98

38 10-year risk of death from CVD in the Czech population

39

40 Systolic BP German CV Prevention Study mmHg Males Females Preventive Medicine 1994;23:197-205 ns * *

41 Females Diastolic BP German CV Prevention Study Males mmHg Preventive Medicine 1994;23:197-205 *

42 BMI German CV Prevention Study Males Females kg/m 2 Preventive Medicine 1994;23:197-205 * *

43 Smoking German CV Prevention Study Males Females % % Preventive Medicine 1994;23:197-205

44 Total Cholesterol German CV Prevention Study Males Females mmol/L mmol/L Preventive Medicine 1994;23:197-205 ** *

45 HDL-cholesterol German CV Prevention Study mmol/L Females Males mmol/L Preventive Medicine 1994;23:197-205

46 Kaunas Population, Lithuania Age range, 35-64 yrs 1983/84 1986/87 1992/93 2001/02 TotalResp. 241370.2 176269.6 123158.6 Medicina 2003;39:1193-1199 140362.4

47 Systolic BP Kaunas, Lithuania mmHg Males Females p < 0.001 ** ** Medicina 2003;39:1193-1199

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

49 Males Females kg/m 2 * *** *** BMI Kaunas, Lithuania Medicina 2003;39:1193-1199

50 Males Females mmol/L mmol/L p < 0.001 * *** * *** Total Cholesterol Kaunas, Lithuania Medicina 2003;39:1193-1199

51

52 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 35-64 years aged 35-64 years cross-sectional population surveys of major RF cross-sectional population surveys of major RF

53 WHO MONICA Age-standardized SBP Men, 35-64 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

54 WHO MONICA Age-standardized SBP Women, 35-64 years Lancet 2000; 355:675-87 BEL-GHECAN-HALCZE-CZEGER-AURGER-AUUGER-BREGER-EGEITA-BRINEZ-AUCPOL-TARPOL-WARRUS-MOCRUS-MOIRUS-NOCRUS-NOIUNK-BELUNK-GLAUSA-STAYUG-NOSMEAN

55 WHO MONICA Smokers Men, 35-64 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

56 WHO MONICA Smokers Women, 35-64 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

57 WHO MONICA Total cholesterol Men, 35-64 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

58 WHO MONICA Total cholesterol Women, 35-64 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

59 WHO MONICA BMI Men, 35-64 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

60 WHO MONICA BMI Women, 35-64 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

61 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.

62 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.

63 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).

64

65 304 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

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

67

68 Gypsies Non-Gypsies p Gypsies Non-Gypsies p Number 156 501 Response, % 28 53 Hypertension 49 43 ns Undiagnosed hypertension 16 23 ns hypertension 16 23 ns Obesity 65 30 0.0001 Central obesity 38 20 0.04 Metabolic syndrome 20 4 0.0001 CVD 35 26 0.04 Age- and sex-adjusted prevalence

69 “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;23:203-211 n = 4568

70 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

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