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Review
. 2015 Sep;12(9):508-30.
doi: 10.1038/nrcardio.2015.82. Epub 2015 Jun 16.

Contributions of risk factors and medical care to cardiovascular mortality trends

Majid Ezzati  1 , Ziad Obermeyer  2 , Ioanna Tzoulaki  1 , Bongani M Mayosi  3 , Paul Elliott  1 , David A Leon  4
Affiliations
Review

Contributions of risk factors and medical care to cardiovascular mortality trends

Majid Ezzati et al. Nat Rev Cardiol. 2015 Sep.

Abstract

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

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Conflict of interest statement

Competing interest

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Figures

Figure 1
Figure 1
Trends in age-standardised death rates from cardiovascular diseases for adults aged 30 years and older, by region and sex between 2000 and 2012. Death rates are age-standardized to the WHO standard population. Source: World Health Organization (WHO) Global Health Estimates. Note: WHO estimates mortality trends using on available data from vital statistics, from sample registration of deaths, and from representative verbal autopsy surveys. These data are used together with demographic and epidemiological models, to reconstruct trends. Trends are not shown for sub-Saharan Africa and for East, South, and Southeast Asia and the Pacific (with the exception of Japan, Singapore, and South Korea which are included in the high-income group) because mortality data from these regions are very limited, especially for estimating time trends. As described in the text, studies from selected countries and communities in these regions show a modest decline in total CVD mortality and in mortality from stroke and hypertensive disease.
Figure 2
Figure 2
Relative (per cent) decline in death rates from cardiovascular diseases by decade, sex, and age group in 20 western high-income countries. Within each age group, death rates were age-standardised using the WHO standard population. The countries are English-speaking high-income countries (Australia, Canada, Ireland, New Zealand, UK, and USA) and countries in Western Europe (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, and Switzerland). Germany was excluded because its boundaries changed during the period of display. We also have not shown data for smaller countries like Cyprus, Iceland, Luxemburg, and Malta.
Figure 3
Figure 3
Trends in death rates from cardiovascular diseases for adults (A) aged 30–69 years and (B) 70 years and older. Within each age group, death rates are age-standardized to the WHO standard population. Trends are smoothed using a 5-year moving average. See Figure S1 for results for 30 years and older combined. Countries in this figure were selected based on recent work by Mathers et al. on trends in life expectancy and cause-specific mortality in ageing populations. Of the countries analysed by Mathers et al., we have shown trends for Japan, English-speaking high-income countries, and countries in Western Europe (excluding the above-mentioned smaller countries and Germany), in Central and Eastern Europe, and in Latin America.
Figure 3
Figure 3
Trends in death rates from cardiovascular diseases for adults (A) aged 30–69 years and (B) 70 years and older. Within each age group, death rates are age-standardized to the WHO standard population. Trends are smoothed using a 5-year moving average. See Figure S1 for results for 30 years and older combined. Countries in this figure were selected based on recent work by Mathers et al. on trends in life expectancy and cause-specific mortality in ageing populations. Of the countries analysed by Mathers et al., we have shown trends for Japan, English-speaking high-income countries, and countries in Western Europe (excluding the above-mentioned smaller countries and Germany), in Central and Eastern Europe, and in Latin America.
Figure 4
Figure 4
Trends in death rates from cardiovascular diseases, compared with external causes and cancers, in adults aged 25–64 years of age in Russia.
Figure 5
Figure 5
Trends in male-to-female ratio of cardiovascular disease death rates for people aged 30–69 years in selected countries with reliable mortality data. Within this age group, death rates are age-standardized to the WHO standard population. Trends are smoothed using a 5-year moving average.
Figure 6
Figure 6
Proportion (percentage) of excess relative risk (relative risk minus one) of cardiovascular diseases remaining over time since smoking cessation, compared to cancers and chronic obstructive pulmonary disease (COPD). The shaded area shows the uncertainty of the fitted curve. Source: Kontis et al. In summary, data on changes in disease-specific mortality RRs after cessation were from a re-analysis of American Cancer Society Cancer Prevention Study II (CPS-II) data. A convex constrained b-spline (fitted using the library “cobs” in statistical software R) was fitted to the raw RR data (which can be seen in Figure 2 of Oza and colleagues) to obtain a smooth continuous relationship of RR over time since smoking cessation. The proportion (percentage) of excess relative risk over time since cessation as RRt−1RR0−1, where RRt is the RR t years after quitting smoking and RR0 is the RR of smokers.
Figure 7
Figure 7
Trends in recorded per-capita alcohol consumption by adults aged 15 years and older in selected countries. Data were smoothed using a 3-year moving average. Data on recorded consumption are from the WHO Global Information System on Alcohol and Health (http://apps.who.int/gho/data/node.main.GISAH). Note: In addition to recorded consumption, there is unrecorded consumption in some countries. For example, adult per capita unrecorded consumption is estimated to be less than 0.5 litres per year in Japan and France, and 1 to 2 litres per year in China, Sweden, the United Kingdom, and the United States. The unexpected drop followed by rise in Chinese trends may be due to change in the source of data on alcohol consumption from industry reports to government reports around 2000.
Figure 8
Figure 8
The cross-country associations between change in risk factors and change in cardiovascular death rates between 1980 and 2008 in 26 industrialised countries. Each point shows one country. All variables were age-standardized. The lines show the fitted linear associations. Source: Di Cesare et al. Note: Lung cancer (LC) death rate was used to measure cumulative population exposure to smoking using because data on lung cancer mortality trends are more widely available and more reliable than on smoking prevalence and intensity., ARG: Argentina; AUS: Australia; AUT: Austria; BEL: Belgium; CAN: Canada; CHE: Switzerland; CHL: Chile; DEU: Germany; DNK: Denmark; ESP: Spain; FIN: Finland; FRA: France; GBR: United Kingdom; GRC: Greece; IRL: Ireland; ISR: Israel; ITA: Italy; JPN: Japan; LUX: Luxembourg; MEX: Mexico; NLD: Netherlands; NOR: Norway; NZL: New Zealand; PRT: Portugal; SWE: Sweden; USA: United States of America
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