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

Epidemiology of CV diseaseEpidemiology of CV diseasein Central and Eastern Europein Central and Eastern Europe

Renata CRenata Cíífkovfkováá

Center for CV Prevention, Charles University Medical School Center for CV Prevention, Charles University Medical School && Thomayer University Hospital Thomayer University HospitalDepartment of Medicine II, Charles University Medical SchoolDepartment of Medicine II, Charles University Medical School

Department of Preventive CardiologyDepartment of Preventive Cardiology, IKEM, IKEMPrague, Czech RepublicPrague, Czech Republic

Death by causeDeath by causeEuropeEurope

Men WomenMen Women

All CVD deaths 43%All CVD deaths 43% All CVD deaths 54%All CVD deaths 54%

European CVD Statistics 2008European CVD Statistics 2008

Death by causeDeath by causeEuropean UnionEuropean Union

Men WomenMen Women

All CVD deaths 38%All CVD deaths 38% All CVD deaths 45%All CVD deaths 45%

European CVD Statistics 2008European CVD Statistics 2008

Russian Fed.Russian Fed.BulgariaBulgariaRomaniaRomaniaHungaryHungary

PolandPolandArgentinaArgentina

Czech RepublicCzech RepublicChina-RuralChina-Rural

ColombiaColombiaChina-UrbanChina-Urban

ScotlandScotlandIrelandIreland

FinlandFinlandN. IrelandN. Ireland

GreeceGreeceEngland/WalesEngland/Wales

BelgiumBelgiumUSAUSA

DenmarkDenmarkN. ZealandN. Zealand

MexicoMexicoGermanyGermanyPortugalPortugalSwedenSweden

KoreaKoreaAustriaAustria

NetherlandsNetherlandsItalyItaly

NorwayNorwayCanadaCanada

SpainSpainAustraliaAustralia

FranceFranceSwitzerlandSwitzerland

IsraelIsraelJapanJapan

Death Rates for CVD and StrokeDeath Rates for CVD and StrokeMen, 35-74 yrsMen, 35-74 yrs

Circulation 2009Circulation 2009;;119:e21-e181119:e21-e181

Russian Fed.Russian Fed.BulgariaBulgariaRomaniaRomaniaHungaryHungary

ColombiaColombiaChina-RuralChina-Rural

China-UrbanChina-UrbanArgentinaArgentina

PolandPolandCzech RepublicCzech Republic

MexicoMexicoPuerto RicoPuerto Rico

ScotlandScotlandN.IrelandN.Ireland

USAUSAEngland/WalesEngland/Wales

New ZealandNew ZealandGreeceGreeceKoreaKorea

IrelandIrelandDenmarkDenmarkBelgiumBelgiumPortugalPortugalGermanyGermanySwedenSwedenFinlandFinland

NetherlandsNetherlandsCanadaCanada

ItalyItalyAustriaAustriaNorwayNorway

AustraliaAustraliaIsraelIsraelSpainSpain

SwitzerlandSwitzerlandJapanJapan

FranceFrance

Death Rates for CVD and StrokeDeath Rates for CVD and StrokeWomen, 35-74 yrsWomen, 35-74 yrs

Circulation 2009Circulation 2009;;119:e21-e181119:e21-e181

0

100

200

300

400

500

600

700

800

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

Austria Czech Republic Finland Italy Poland Romania UK

Dea

rth

/100

000

(ag

e ad

j.)

Dea

rth

/100

000

(ag

e ad

j.)

yearyear

CV MortalityCV Mortality - - MalesMales

0

50

100

150

200

250

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

Austria Czech Republic Finland Italy Poland Romania UK

yearyear

Dea

th/1

000

000

(age

ad

j.D

eath

/100

0 00

0 (a

ge a

dj.

CV MortalityCV Mortality - - FemalesFemales

Standardized mortalityStandardized mortalityCzech Republic, 2009Czech Republic, 2009

MalesMales FemalesFemales

CVDCVDMalignanciesMalignanciesOtherOther

45.3 %45.3 %

27.9 %27.9 %

26.8 %26.8 % 51.4 %51.4 %

26.1 %26.1 %

22.5 %22.5 %

MalesMales- - TotalTotal- CVD- CVD- CHD- CHD- - StrokeStroke

FemalesFemales- Total- Total- CVD- CVD- CHD- CHD- Stroke- Stroke

15811581 844844 436436 250250

944944 548548 223223 202202

963963436436218218

8989

577577296296134134

7272

- 38.8- 38.8- 48.3- 48.3- 47.9- 47.9- 64.4- 64.4

- 38.9- 38.9- 46.0- 46.0- 39.9- 39.9-- 64.464.4

< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001

< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001

1985 2009 % p 1985 2009 % p

Age-adjusted death rates/100,000Age-adjusted death rates/100,000Czech Republic, 1985-200Czech Republic, 1985-20099

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 mortalityCVD mortalityIHD mortalityStroke mortality

Nu

mb

er o

f d

eath

s/10

0,00

0

Nu

mb

er o

f d

eath

s/10

0,00

0

Total mortality, age 35-74 yearsMales vs Females: p = 0,001

CVD mortality, age 35-74 yearsMales vs Females: p = 0,001

CAD mortality, age 35-74 yearsMales vs Females: p = 0,001

Stroke mortality, age 35-74 yearsMales vs Females: p = 0,0041

MalesFemales

year year

yearyear

Nu

mb

er o

f de

ath

s/10

0,00

0

Nu

mb

er o

f de

ath

s/10

0,00

0N

um

ber

of

deat

hs/

100,

000

Nu

mb

er o

f de

ath

s/10

0,00

0

J Hypertens 2010;28:2196-203

Factors affecting CHD mortalityFactors affecting CHD mortality

Risk factorsRisk factors

CHD incidenceCHD incidence

CHD mortalityCHD mortality

TreatmentTreatment

Case fatalityCase fatality

Pardubice

KroměřížChrudim

JindřichůvHradec

Benešov

Plzeň

Prahavýchod

Cheb

Litoměřice

WHO MONICA projekt

Nové okresy

Sample sizes and response ratesSample sizes and response rates

1985 1988 1992 1997/8 2000/1 2007/81985 1988 1992 1997/8 2000/1 2007/8

TotalTotal

MalesMalesResp.Resp.

FemalesFemalesResp.Resp.

25702570

1253125381.581.5

1317131785.085.0

27682768

1357135785.585.5

1411141188.488.4

23432343

1134113473.273.2

1209120976.776.7

19901990

96996963.263.2

1021102166.466.4

20552055

1003100362.062.0

1052105263.863.8

*** p < 0.001 *** p < 0.001 for trendfor trend

22462246

1102110262.762.7******

1144114463.163.1******

Systolic BPSystolic BP

Males FemalesMales Females

p < 0.001 p < 0.001

mmHgmmHg mmHgmmHg

Atherosclerosis 2010;211:676-81Atherosclerosis 2010;211:676-81

Diastolic BPDiastolic BP


p < 0.001 p < 0.001

mmHgmmHg mmHgmmHg


Prevalence of hypertensionPrevalence of hypertension


p for linear trend: ns p < 0.001

%% %%


BMIBMI


p < 0.001kg/mkg/m22 kg/mkg/m22

p pro trend: NS


Awareness of hypertensionAwareness of hypertension


p for linear trend: 0.001

%% %%



Antihypertensive medicationAntihypertensive medication


p for linear trend: 0.001%% %%



Hypertension controlHypertension controlBP < 140/90 mmHg of all hypertensivesBP < 140/90 mmHg of all hypertensives



%% %%



Total cholesterolTotal cholesterol


p < 0.001 p < 0.001

mmol/lmmol/l mmol/lmmol/l


Lipid-lowering drugsLipid-lowering drugs

81%81%

13%13% 3%3%3%3%

fibratesfibratesstatinsstatinsotherothercombinationscombinations

68.5%68.5%

27.5%27.5% 4%4%

1997/981997/98n = 130 n = 130 (3.95%)(3.95%)

2000/012000/01n = 171 n = 171 (5.1%)(5.1%)

78.0%78.0%

15.5%15.5%4.7%4.7%

2007/082007/08n = 386 n = 386 (10.7%)(10.7%)

1.6%1.6%


SmokingSmoking


p < 0.001 p for trend: n.s.

%% %%


ConclusionsConclusions

Total and CV mortality is decreasing in the Czech Republic.Total and CV mortality is decreasing in the Czech Republic.

The decrease is due to decreasing stroke and CHD mortality rates. The decrease is due to decreasing stroke and CHD mortality rates.

Explaining the CHD mortality fall in Explaining the CHD mortality fall in the the

Czech Czech RRepublic epublic 1985-2007: 1985-2007: RESULTSRESULTS

- 50000

- 30000

- 10000

10000

12,080 fewer deaths in 2007

Risk Factors worse Risk Factors worse ++ 6 6%%

Risk Factors better -Risk Factors better - 6611%%

Treatments Treatments -- 4411%%

Unexplained - 4%200

71985

- 50000

- 30000

- 10000

10000

12,080 fewer deaths in 2007

Risk Factors worse Risk Factors worse ++66%% Obesity (increase) +1% Diabetes (increase) +5%

Risk Factors better -6Risk Factors better -611%%Population BP fall -15%Smoking - 8%Cholesterol (diet) -38%

Treatments Treatments - -4141%%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%20071985

Explaining the CHD mortality fall in Explaining the CHD mortality fall in the the

Czech Czech RRepublic epublic 1985-2007: 1985-2007: RESULTS RESULTS

Percentage of the Decrease in Death from CHD Atributed Percentage of the Decrease in Death from CHD Atributed to Treatment and Risk-Factors Changesto Treatment and Risk-Factors Changes

NEJM 2007;356:2388-98NEJM 2007;356:2388-98

134.7 135.6 135.3

120122124126128130132134136138140

1985 1988 1990

128.8 131.3 131.1

120122124126128130132134136138140

1985 1988 1990

Systolic BPSystolic BPGerman CV Prevention StudyGerman CV Prevention Study

mm

Hg

mm

Hg


Preventive Medicine 1994Preventive Medicine 1994;;23:197-20523:197-205

ns

** **

84.0 83.1 83.4

76

78

80

82

84

86

88

1985 1988 1990

FemalesFemales

Diastolic BPDiastolic BPGerman CV Prevention StudyGerman CV Prevention Study

79.8 79.8 80.3

76

78

80

82

84

86

88

1985 1988 1990

MalesMales

mm

Hg

mm

Hg


**

BMIBMIGerman CV Prevention StudyGerman CV Prevention Study


25.8 25.8 26.2

24

25

26

27

28

1985 1988 1990

26.5 26.5 26.8

24

25

26

27

28

1985 1988 1990

kg/m

kg/m

22


****

SmokingSmokingGerman CV Prevention StudyGerman CV Prevention Study

41.6 43.7 39.0

0

10

20

30

40

50

1985 1988 1990


26.7 27.4 28.0

0

10

20

30

40

50

1985 1988 1990

%% %%


Total CholesterolTotal CholesterolGerman CV Prevention StudyGerman CV Prevention Study


6.00 6.06 6.09

0

1

2

3

4

5

6

7

8

1985 1988 1990

6.08 6.12 6.16

0

1

2

3

4

5

6

7

8

1985 1988 1990

mmol/Lmmol/L mmol/Lmmol/L


** ** **

HDL-cholesterolHDL-cholesterolGerman CV Prevention StudyGerman CV Prevention Study

1.67 1.63 1.74

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

1985 1988 1992

mmol/Lmmol/L

FemalesFemales

1.31 1.28 1.36

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

1985 1988 1990

MalesMalesmmol/Lmmol/L


Kaunas Population, LithuaniaKaunas Population, LithuaniaAge range, 35-64 yrsAge range, 35-64 yrs

1983/84 1986/87 1992/93 2001/02 1983/84 1986/87 1992/93 2001/02

TotalTotalResp.Resp.

2413241370.270.2

1762176269.669.6

1231123158.658.6

Medicina 2003Medicina 2003;;39:1193-119939:1193-1199

1403140362.462.4

139.7 135.3 135.9 133.2

120

125

130

135

140

145

150

1983/84 1986/87 1992/93 2001/02

Systolic BP Systolic BP Kaunas, LithuaniaKaunas, Lithuania

mm

Hg

mm

Hg

138.9 136.2 138.3 136.4

120

125

130

135

140

145

150

1983/84 1986/87 1992/93 2001/2002


p < 0.001

**** ****


87.9 87.0 88.9 87.1

76

78

80

82

84

86

88

90

1983/84 1986/87 1992/93 2001/02

FemalesFemales

86.5 84.2 86.6 82.7

76

78

80

82

84

86

88

90

1983/84 1986/87 1992/93 2001/02

MalesMales

mm

Hg

mm

Hg

************


Diastolic BP Diastolic BP Kaunas, LithuaniaKaunas, Lithuania


30.0 29.8 28.2 28.9

26

27

28

29

30

31

32

1983/84 1986/87 1992/93 2001/02

27.5 27.5 27.1 27.4

26

27

28

29

1983/84 1986/87 1992/93 2001/02

kg/m

kg/m

22

** ************

BMIBMIKaunas, LithuaniaKaunas, Lithuania



5.95 5.99 5.94 6.11

0

1

2

3

4

5

6

7

8

1983/84 1986/87 1992/93 2001/02

6.09 6.32 6.27 6.31

0

1

2

3

4

5

6

7

8

1983/84 1986/87 1992/93 2001/02

mmol/Lmmol/L mmol/Lmmol/L

p < 0.001p < 0.001

** ****** ** ******

Total CholesterolTotal CholesterolKaunas, LithuaniaKaunas, Lithuania


WHO MONICA ProjectWHO MONICA ProjectMultinational Multinational MONIMONItoring of Trends and Determinants in toring of Trends and Determinants in CACArdiovascular Diseaserdiovascular Disease

38 populations in 21 countries38 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 yearsaged 35-64 years

• cross-sectional population surveys of major RFcross-sectional population surveys of major RF

WHO MONICAWHO MONICAAge-standardized SBP Age-standardized SBP

Men, 35-64 yearsMen, 35-64 years

133

136129

133135135

132133

130132

134126

131141

132137

136137

130129

100 110 120 130 140 150

BEL-GHEBEL-GHECAN-HALCAN-HALCZE-CZECZE-CZEGER-AURGER-AURGER-AUUGER-AUUGER-BREGER-BREGER-EGEGER-EGE

ITA-BRIITA-BRINEZ-AUCNEZ-AUCPOL-TARPOL-TAR

POL-WARPOL-WARRUS-MOCRUS-MOCRUS-MOIRUS-MOIRUS-NOCRUS-NOCRUS-NOIRUS-NOI

UNK-BELUNK-BELUNK-GLAUNK-GLAUSA-STAUSA-STA

YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICAAge-standardized SBP Age-standardized SBP

Women, 35-64 yearsWomen, 35-64 years

129

137119

126129

137131

133133

128134

122127

137128

131129

134126

122

100 110 120 130 140 150

Lancet 2000Lancet 2000; ; 355:675-87355:675-87





YUG-NOSYUG-NOS

MEANMEAN

WHO MONICAWHO MONICASmokersSmokers


36

4923

4129

5860

4247

5254

1734

2645

3524

3932

43

10 15 20 25 30 35 40 45 50 55 60





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICASmokersSmokers


21

3019

4125

86

1414

3421

1423

1130

2516

2325

27

0 5 10 15 20 25 30 35 40 45





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICATotal cholesterolTotal cholesterol


5,8

6,45,4

6,15,9

5,45

5,45,3

5,75,65,7

5,95,8

6,26,2

6,16,2

5,66,2

0 1 2 3 4 5 6 7





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICATotal cholesterolTotal cholesterolWomen, 35-64 yearsWomen, 35-64 years

5,8

6,25,3

6,15,9

5,45,3

5,55,65,6

5,55,6

5,95,8

6,25,95,9

6,15,8

6

0 1 2 3 4 5 6 7





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICABMIBMI


26,6

27,326,9

26,826,3

26,125,9

25,625,2

27,125,9

26,726,4

26,926,8

27,127,8

27,627,5

27,1

25 25,5 26 26,5 27 27,5 28





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

WHO MONICAWHO MONICABMIBMI


26,5

27,826,6

26,925,6

29,328,5

26,326,5

27,528,5

25,625,5

26,426,3

26,526,8

27,827,6

26,1

25 25,5 26 26,5 27 27,5 28 28,5 29 29,5 30





YUG-NOSYUG-NOS

MEANMEAN

Lancet 2000Lancet 2000; ; 355:675-87355:675-87

ConclusionsConclusions

CVD mortality in all European post-Communist CVD mortality in all European post-Communist

countries is the highest in Europecountries is the highest in Europe..

IIn fact, CVD mortality rates continue to rise in most n 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, Conclusions, cont’dcont’d

In most of the countries, there is a In most of the countries, there is a lack oflack of recent CVD risk recent CVD risk

factor factor datadata on representative populations. Longitudinal on representative populations. Longitudinal

trends are available only for the Czech Republic, Germany trends are available only for the Czech Republic, Germany

and Lithuania. and Lithuania. Improvement in the CV risk profileImprovement in the CV risk profile was was

seen in the seen in the Czech RepublicCzech Republic (BP, lipids, smoking in males); (BP, lipids, smoking in males);

a smaller improvementa smaller improvement was found was found in Kaunasin Kaunas, mostly , mostly

in females (BP, BMI). Most of the in females (BP, BMI). Most of the major risk factors major risk factors

increased increased slightly slightly in Germanyin Germany over the study period. over the study period.

Conclusions, Conclusions, cont’dcont’d

Therefore, the best comparable data are still provided Therefore, the best comparable data are still provided

by the WHO-coordinated by the WHO-coordinated MONICA studyMONICA study confirming confirming

a a poor CV risk profilepoor CV risk profile in most of the Europeanin most of the European

post-Communist countriespost-Communist countries (particularly for smoking, (particularly for smoking,

BP, and BMI).BP, and BMI).

304 territorial clusters, three-stage stratified sampling procedure304 territorial clusters, three-stage stratified sampling procedure

CV RISK ASSESSMENT CV RISK ASSESSMENT IN POLAND IN 2002IN POLAND IN 2002

DESIGN AND METHODS:DESIGN AND METHODS:

The diagnosis of hypertension was based on three separate visits The diagnosis of hypertension was based on three separate visits (BP>=140/90 mmHg or medication) (BP>=140/90 mmHg or medication)

Response rate for BP and anthropometric measurements 78%,Response rate for BP and anthropometric measurements 78%,for laboratory tests 62% for laboratory tests 62%

BP, BMI, laboratory tests BP, BMI, laboratory tests RepRepresentative sample of 3051 adults in Polandresentative sample of 3051 adults in Poland AAge range18-94 yearsge range18-94 years

95% confidence interval ± 95% confidence interval ± 2%2%

T. Zdrojewski et al.,J Hum Hypertens 2004T. Zdrojewski et al.,J Hum Hypertens 2004;;18:557-6218:557-62

18%

31%

33%

19%

OptimalNormalHigh normalHypertension

Prevalence and control of arterial Prevalence and control of arterial hypertension in Poland (age range 30-70)hypertension in Poland (age range 30-70)

31%

11%

44%

14%

Treated sufficientlyTreated insufficiently Detected, not treatedNot detected

T. Zdrojewski et al., J Hum Hypertens 2004T. Zdrojewski et al., J Hum Hypertens 2004;;18:557-6218:557-62

Gypsies Non-GypsiesGypsies Non-Gypsies ppNumber 156 501 Number 156 501 Response, % 28 53Response, % 28 53

Hypertension 49 43 nsHypertension 49 43 nsUndiagnosedUndiagnosed hypertension 16 23 nshypertension 16 23 nsObesity 65 30 0.0001Obesity 65 30 0.0001Central obesity 38 20 0.04Central obesity 38 20 0.04Metabolic syndrome 20 4 0.0001Metabolic syndrome 20 4 0.0001CVD 35 26 0.04 CVD 35 26 0.04

Age- and sex-adjusted prevalenceAge- and sex-adjusted prevalence

““Manage it well!“ program:Manage it well!“ program:blood pressure control ratesblood pressure control rates

0

20

40

60

80

100

120

overall control systoliccontrol

diastoliccontrol

responders

baseline end of follow-upP

atie

nts

wit

h c

ontr

olle

d B

P (

%)

Pat

ien

ts w

ith

con

trol

led

BP

(%

)

overall control: <140/90 mmHg, systolic control: <140 mmHg, diastolic control: <90 mmHgoverall control: <140/90 mmHg, systolic control: <140 mmHg, diastolic control: <90 mmHgresponders: responders: <<140 or 140 or <<90 mmHg90 mmHg

L. Szirmai, J Hypertens 2005L. Szirmai, J Hypertens 2005;;23:203-21123:203-211

n = 4568n = 4568

Limitations of hypertension studies Limitations of hypertension studies in primary carein 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 populationpopulationss

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 databy GPs with no review of source data

No review of patient selection according to the protocolNo review of patient selection according to the protocol

Documents

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