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
ty p
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
ty p
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
Mor
tali
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er 1
00,0
00
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
ty p
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
tali
ty p
er 1
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