Cardiovascular diseases in Eastern Europe

Martin Bobak

University College London

0 100 200 300 400 500 600 700 800 900

2006Ukraine2006Russian Federation2006CIS2005Uzbekistan2008Kazakhstan2006Kyrgyzstan2008Republic of Moldova2006Bulgaria2003TFYR Macedonia2007Belarus2007Latvia2008Romania2007Azerbaijan2008Serbia2008Lithuania2005Slovakia2008Estonia2008EU members since 2004 or 20072008Hungary2008European Region2004Albania2008Croatia2007Poland2008Czech Republic2007Slovenia2008Greece2008EU 2006Germany2004Portugal2008Finland2008Austria2004Belgium2007Sweden2006Denmark2007EU members before May 2004 2008Ireland2007United Kingdom2007Italy2007Norway2008Iceland2005Spain2007Switzerland2008Netherlands2007France

SDR, diseases of circulatory system, all ages per 100000, Last available

Mortality from CVD in Russia and the “old” EU in 2006(both genders, age standardised, per 100,000).

Trends in male mortality from CHD in Central and Eastern Europe between the mid 1950s and 2000, age group 45-54 years (data from the WHO Health for All database).

0

100

200

300

400

500

600

700

800

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Mor

tali

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er 1

00,0

00

BulgariaCzech RHungaryPolandSweden

Trends in female mortality from CHD in Central and Eastern Europe between the mid 1950s and 2000, age group 45-54 years (data from the WHO Health for All database).

020406080

100

120140160180200

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Mor

tali

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er 1

00,0

00

BulgariaCZHungaryPolandSweden

Trends in male mortality from CHD in the former Soviet Union between the mid 1950s and 2000, age group 45-54 years (data from the WHO Health for All database).

0

100

200

300

400

500

600

700

800

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

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LatviaPolandRussia(1)Russia(2)Sweden

Trends in female mortality from CHD in the former Soviet Union between the mid 1950s and 2000, age group 45-54 years (data from the WHO Health for All database).

020406080

100

120140160180200

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Mor

tali

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er 1

00,0

00

LatviaRussia(1)Russia(2)SwedenPoland

Death rates in Russia 1980-2007both genders, per 100,000

800

1000

1200

1400

1600

180019

8019

8219

8419

8619

8819

9019

9219

9419

9619

9820

0020

0220

0420

0620

08

SDR Crude DR

Gorbatchevelected

Coup againstGorbatchev, breakup of USSR

Roublecrisis

3M extra deaths(Men et al, 2003)

Proposed explanations

• Medical care

• Risk factors

• Societal factors

Mortality rates in MONICA centres in CEE/FSU and western countries, East/West mortality rate ratios after controlling for

medical care score, age band 35-64

Data from the MONICA Project (www.ktl.fi/monica).

CEE/FSU western countries

East/West rate ratio

Men(No. of centres)Age-adjusted ratesAdj. for care

(10)274257

(26)162167

1.811.54

Women(No. of centres)Age-adjustedAdj. for care

(10)7567

(24)4446

1.701.46

PARF associated with 9 risk factors for MI in Western and Eastern Europe (INTERHEART Study, Yusuf et al 2004)

0%

50%

100%

150%

200%

250%

300%

Western Europe Eastern Europe

Lipids

PS factors

Abd.obesity

Diabetes

Hypert.

Alcohol (-)

Low PA

Low F&V

Smoking

Adjusted total: 94% 73%

Proportion of variance in mortality explained

by risk factors* in the MONICA study

Men Women

All causes 40% 34%

All CVD 21% 35%

IHD 23% 14%

Stroke 39% 35%

* smoking, BP, cholesterol Int J Epidemiol 1994

The HAPIEE study (Health, Alcohol and Psychosocial factors In Eastern Europe)

• Multi-centre study of determinants of CVD in Eastern Europe.

• Baseline survey in 2002-05• Random population samples in

– Novosibirsk (Russia) – Krakow (Poland) – 7 towns of the Czech Republic (Havirov, Hradec

Kralove, Jihlava, Karvina, Kromeriz, Liberec, Usti n.L.)– Kaunas (Lithuania), joined in 2006

• Random samples of men and women aged 45-69 years old at baseline, stratified by gender and 5 year age groups

• Almost 36,000 subjects (response rate 59%).

CZ

PL

RU

The HAPIEE study

LT

Availability of enzymes and T&T for non-fatal CHD events (follow up)

CZ RU

MI

N

At least one troponin

2+ troponin

52

98%

98%

139

0.4%

20%

Tests and treatment

N

Positive

CABG

PCI

131

95

19 (20%)

60 (63%)

44

33

11 (33%)

17 (52%)

Male participants and deaths in HAPIEE (follow up until end of 2008)

N All deaths

CVD deaths

Czech R

Poland

Russia

3833

4797

3741

289

431

528

99

118

201

Total 12371 1248 418

Survival of men in HAPIEE0

.75

1.0

0

0 500 1000 1500 2000analysis time

country = Czech country = Russiacountry = Poland

Kaplan-Meier survival estimates

Hazard ratio of CVD death by country (CZ=1)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Age-adj. . .

Czech

Poland

Russia

Hazard ratio of CVD death by country (CZ=1)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Age-adj. + RF .

Czech

Poland

Russia

RF: adj. for age, smoking, HT, diabetes, physical act, vit C intake, WHR, control

If not risk factors, then what?

Alcohol?

Risk of CHD by alcohol consumption in 28 high quality cohort studies (Corrao et al 2000)

RR of CVD death by drinking frequency and mean dose per occasion in Novosibirsk men

0

0.5

1

1.5

2

2.5

3

Rare Occas. Weekly Frequent

Drinking frequency

Rel

ativ

e ri

sk <80g80-119g120g+

Malyutina et al, Lancet 2003

5% of all men

Alcohol drinking pattern and all-cause mortality in Izhevsk study

Cases(n=1633)

Controls(n=1587)

OR (95% CI)

Abstains 132 186 1.3 (1.0-1.7)

Beverage alcohols only, no problem drinking

585 1118 1.0 [ref]

Beverages alcohol only, problem drinking

152 85 3.0 (2.2-4.0)

Surrogates, no problem drinking

99 25 6.3 (4.0-10.0)

Surrogates, problem drinking

500 82 9.7 (7.5-12.6)

Difficult to answer 165 91 3.0 (2.3-4.0)

(Leon et al, Lancet 2007)

Relative risks of death from selected diseases for drinking 3+ bottles of vodka per week

Men Women

Accidents / violence 5.9 9.3

Alcohol poisoning 21.7 75.2

CHD 3.0 2.6

Respir. Cancers 3.5 2.2

TB 4.1 5.3

Zaridze et al Lancet 2009

Odds ratio of death for hazardous drinking in the Izhevsk case-control study

0

2

4

6

8

10

12

14

16

All CHD MI Other CHD AlcoholicCMP

Other CMP

Leon et al. Int J Epidemiol 2010

Hazard ratio of CVD death for problem drinking (CAGE 2+) in HAPIEE

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

All HAPIEE Russia Russia other HD

No

Yes

Hazard ratio of CVD death for binge drinking in HAPIEE (>150 g of ethanol at one occasion at least once a month)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

All HAPIEE Russia Russia other HD

No

Yes

Hazard ratio of CVD death by drinking frequency in HAPIEE

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

All HAPIEE Russia Russia other CHD

Never

<1/mo

1-3/mo

1-4/w

5+/w

Hazard ratio of CVD death by country (CZ=1)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Age-adj. + RF .

Czech

Poland

Russia

RF: adj. for age, smoking, HT, diabetes, physical act, vit C intake, WHR, control

Hazard ratio of CVD death by country (CZ=1)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Age-adj. + RF + alcohol

Czech

Poland

Russia

RF: adj. for age, smoking, HT, diabetes, physical act, WHR, vit C intake, controlAlcohol: binge drinking, problem drinking (CAGE) and drinking frequency

If not risk factors and alcohol, then what?

Societal disruption?

Central and Eastern Europe in 1990

0

0.1

0.2

0.3

0.4

0.5

0.6

0 20 40 60 80 100 120

GDP per capita (PPP), West=100%

Gin

i coe

ffici

ent

??

CEE

West

LA

From Unicef

Poland and Czech Rep. 1989-2000 (Data from UNICEF)

0

0.1

0.2

0.3

0.4

0.5

0.6

0 20 40 60 80 100 120

GDP per capita (PPP), West=100%

Gin

i co

effi

cien

t

West

LA

Poland1989

Poland2000

Czech1989

Czech 2000

Russia 1989-2000 (Data from UNICEF)

0

0.1

0.2

0.3

0.4

0.5

0.6

0 20 40 60 80 100 120

GDP per capita (PPP), West=100%

Gin

i co

effi

cien

t

West

LA

Russia1989

Russia2000

Increase in educational differentials in mortality between 1980s and 1990s in St Petersburg men (based on data from Plavinski et al 2003)

0

10

20

30

40

50

60

1980s 1990s

Mor

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000

PrimaryHigh schoolUniversity

Mortality (per 1000) by weekly alcohol intake in St Petersburg men in 1980s and 1990s

10

100

1980s 1990s

Mo

rta

lity

per

10

00

>150g/w<150g/w

% drinking >150g/w: 19% 15%

From Plavinski et al 2003

Survival in Russian men by education:

0.4

0.45

0.5

0.55

0.6

0.65

0.7

Calendar year

45 p

20

university elementary

45p20 = probability of living to 65 yrs when aged 20 yrs Murphy et al, AJPH 2006

Survival in Russian men by education: Trends remained unchanged after

controlling for smoking and alcohol

0.4

0.45

0.5

0.55

0.6

0.65

0.7

Calendar year

45 p

20

university elementary

45p20 = probability of living to 65 yrs when aged 20 yrs Murphy et al, AJPH 2006

Recent trends: 5-year mortality rate ratios by education in Czech men and women aged 45-64, 1980s and 2000s

0

0.2

0.4

0.6

0.8

1

1.2

1980s 2000s . 1980s 2000s

Primary

Secondary

Univerity

Men Women

Unpublished data

Conclusions

• Huge differences in CVD mortality between Eastern and Western Europe

• Dramatic fluctuations in FSU after 1990• Conventional risk factors and acute care explain

some but not all of the differences between populations

• High rates in FSU may be related to alcohol but results remain inconsistent

• Social changes after 1990 seems to have played a major role in mortality rates but biological mechanisms not clear