Berlin, Germany - New figures show a changing pattern of cardiovascular mortality within Europe, which should be taken into account when defining high- and low-risk countries for the primary prevention of cardiovascular disease, say Dr Jacqueline Müller-Nordhorn (Charité University Medical Center, Berlin, Germany) and colleagues in a study published online February 5, 2008 in the European Heart Journal [1].

"Cardiovascular mortality rates are decreasing overall, but there is a clear East-West gradient, with the Eastern and Middle European countries having a far higher mortality," Müller-Nordhorn told heartwire. "And there does appears to be some change in the pattern," she notes.

For practical purposes, this change now means that "all Western European countries should be classified as low risk and all Central and Eastern European countries as high risk," she says. This has important implications when it comes to guidelines, she adds. "I think they need to be revised to take into account this changing pattern; otherwise, you risk overtreating (or undertreating) many people because you have classified them wrongly. Regular updates on the complex pattern of regional variation within Europe are needed to make efficient prevention possible," she says.

Müller-Nordhorn and her colleagues calculated age-standardized mortality rates for ischemic heart disease (IHD) and cerebrovascular disease (CVD) from data provided by the statistical office of the European Communities (Eurostat) and the national statistics offices of all the countries. They focused on those aged 45 to 74, as mortality in younger age groups is very low. They divided the rates per 100 000 of the population into quintiles of lowest to highest mortality—on their maps of Europe, the lowest quintile is indicated by dark green, the second-lowest by light green, the middle quintile by yellow, the second-highest by orange, and the highest by red.

"With regard to IHD, there is a clear Northeast-to-Southwest gradient in mortality. In particular, countries from Central and Eastern Europe have high mortality rates compared with other European countries. The lowest mortality rates are found in France, Portugal, Italy, and Spain," Müller-Nordhorn says. She pointed out, however, that there is considerable within-country variation in IHD in Germany, the UK, and Poland.

Age-standardized mortality rates from cardiovascular disease (ie, ischemic heart disease and cerebrovascular disease combined, in European regions (women, age group 45-74 years; year 2000). Female CVD mortality rates per 100 000: Dark green 0<67; light green 67<100; yellow 100<139; orange 139<230; red 230<580. [Source: Müller-Nordhorn J et al. Eur Heart Journal 2008; DOI:10.1093/eurheartj/ehm604, Figure 6]

With regard to CVD, the pattern is "less clear," she says. There appears to be a "green circle" of reduced mortality in the center of Western Europe, with the lowest rates in Switzerland and France. But there are now higher stroke rates than before in Portugal, southern Spain, Greece, and southern Italy, which were previously considered low risk for stroke. There is also substantial within-country variation in the UK, she notes.

In most Central and Eastern European countries, however, the picture is bleaker, say the researchers. CVD mortality increased during the 1970s and 1980s and started to decline only during the 1990s. Despite this recent decrease, mortality rates are still considerably higher in these countries compared with Western European countries. Some countries, such as Ukraine, reach almost top levels in a worldwide comparison.

"Although most Central and Eastern European counties appear to have reached their peak in cardiovascular mortality, the majority of them can clearly still be classified as high-risk countries," says Müller-Nordhorn.

There have been some small successes, however. "For example, in Poland, changes in dietary-fat intake during the 1990s, leading to a more favorable ratio of polyunsaturated to saturated fat, were associated with a drop in mortality from IHD by approximately one-quarter."

Müller-Nordhorn told heartwire that research indicates that "about 50% of the decrease in cardiovascular mortality" is due to better control of classic risk factors and improved lifestyles.

Specific explanations for in-country variations often differed depending on the location. "For example, regional differences in Israel, Bavaria (Germany), and the Czech Republic were found to be associated particularly with . . . blood-pressure levels. Within England, on the other hand, the regional variation was associated to a large extent with differences in smoking prevalence," Müller-Nordhorn said.

In general, mortality from both IHD and CVD has decreased continually in most Western European countries over the past decades, with public-health interventions on a population level in countries such as Finland making an enormous difference to the mortality rates.

And in Central and Eastern European counties, more work is needed to achieve similar results, she says.

"However, we still don't know about 50% of the reasons why the rates are decreasing," she admits.

Source
1) Müller-Nordhorn J, Binting S, Roll S, et al. An update on regional variation in cardiovascular mortality within Europe. Eur Heart Journal 2008; DOI: 10.1093/eurheartj/ehm604.