Fall In Coronary Heart Disease Mortality Research Articles

Explaining the decline in coronary heart disease mortality rates in the Slovak Republic between 1993-2008.

ObjectiveBetween the years 1993 and 2008, mortality rates from coronary heart disease (CHD) in the Slovak Republic have decreased by almost one quarter. However, this was a smaller decline than in neighbouring countries. The aim of this modelling study was therefore to quantify the contributions of risk factor changes and the use of evidence-based medical therapies to the CHD mortality decline between 1993 and 2008.MethodsWe identified, obtained and scrutinised the data required for the model. These data detailed trends in the major population cardiovascular risk factors (smoking, blood pressure, total cholesterol, diabetes prevalence, body mass index (BMI) and physical activity levels), and also the uptake of all standard CHD treatments. The main data sources were official statistics (National Health Information Centre and Statistical Office of the Slovak Republic) and national representative studies (AUDIT, SLOVAKS, SLOVASeZ, CINDI, EHES, EHIS). The previously validated IMPACT policy model was then used to combine and integrate these data with effect sizes from published meta-analyses quantifying the effectiveness of specific evidence-based treatments, and population-wide changes in cardiovascular risk factors. Results were expressed as deaths prevented or postponed (DPPs) attributable to risk factor changes or treatments. Uncertainties were explored using sensitivity analyses.ResultsBetween 1993 and 2008 age-adjusted CHD mortality rates in the Slovak Republic (SR) decreased by 23% in men and 26% in women aged 25–74 years. This represented some 1820 fewer CHD deaths in 2008 than expected if mortality rates had not fallen. The IMPACT model explained 91% of this mortality decline. Approximately 50% of the decline was attributable to changes in acute phase and secondary prevention treatments, particularly acute and chronic treatments for heart failure (≈12%), acute coronary syndrome treatments (≈9%) and secondary prevention following AMI and revascularisation (≈8%). Changes in CHD risk factors explained approximately 41% of the total mortality decrease, mainly reflecting reductions in total serum cholesterol. However, other risk factors demonstrated adverse trends and thus generated approximately 740 additional deaths.ConclusionOur analysis suggests that approximately half the CHD mortality fall recently observed in the SR may be attributable to the increased use of evidence-based treatments. However, the adverse trends observed in all the major cardiovascular risk factors (apart from total cholesterol) are deeply worrying. They highlight the need for more energetic population-wide prevention policies such as tobacco control, reducing salt and industrial trans fats content in processed food, clearer food labelling and regulated marketing of processed foods and sugary drinks.

OP54 Explaining the decline in coronary heart disease mortality in the Slovak Republic between 1993–2008

<h3>Background</h3> Although cardiovascular diseases remain the most important cause of death in the Slovak Republic, mortality rates from coronary heart disease (CHD) have substantially decreased in the last two decades. The aim of this modelling study was therefore to try and quantify the main contributions to this mortality decline. <h3>Methods</h3> Data covering adults aged 25–74 years in the Slovak Republic (population 3.5 million) between the years 1993–2008 were identified, obtained and scrutinised. These data detailed trends in major population cardiovascular risk factors (smoking, blood pressure, total cholesterol, diabetes prevalence, body mass index (BMI) and physical activity levels), and also the uptake of all standard CHD treatments. The main data sources were official statistics, national representative studies, published trials and meta-analyses, and the Slovak CINDI studies. The previously validated IMPACT policy model was then used to combine and integrate these data with effect sizes from published meta-analyses quantifying the effectiveness of specific evidence based treatments, and population-wide changes in cardiovascular risk factors. Results were expressed as deaths prevented or postponed (DPPs). Uncertainties were explored using probabilistic sensitivity analyses. <h3>Results</h3> Between 1993 and 2008 age-adjusted CHD mortality rates in the Slovak Republic decreased by 23% in men and 26% in women aged 25–74 years, representing 1950 fewer CHD deaths in 2008. Improvements in the uptake of evidence based treatments explained approximately 48% of the mortality fall (mainly reflecting contributions from treatments for acute coronary syndrome, acute and chronic heart failure and primary prevention, ie. statins and anti-hypertensives). Changes in CHD risk factors explained approximately 43% of the total mortality decrease (resulting mainly from positive changes in total serum cholesterol). However, most other risk factors demonstrated adverse trends and thus generated approximately 575 additional deaths. Results remained relatively stable under a range of sensitivity analyses. <h3>Conclusion</h3> This preliminary analysis suggests that approximately half the coronary heart disease mortality fall recently observed in the Slovak Republic may be attributable to evidence based treatments, with much of the remainder coming from large falls in total serum cholesterol. The adverse trends observed in all the other major cardiovascular risk factors (smoking, blood pressure, BMI, diabetes and physical inactivity) in the Slovak Republic are deeply worrying, and emphasise the need for more energetic population-wide prevention policies.

Abstract P448: Exploring Socioeconomic Inequalities In Coronary Heart Disease Prevention

Background: Between 2000 and 2007, coronary heart disease (CHD) mortality rates in England plummeted by one third. An important part of this substantial CHD mortality decline was achieved through reductions in major cardiovascular risk factors (primary prevention). However, the relative contributions from medications and from population-wide changes remains unclear, particularly the effects on health inequalities. Methods: Using a previously validated policy model, the fall in CHD mortality in England was analysed. The contributions from risk factor declines in asymptomatic individuals through medications and through population-wide changes were quantified. Data were stratified using the Index of Multiple Deprivation (IMD). Model outputs were quantified as deaths prevented or postponed (DPPs). Results: Between 2000 and 2007, approximately 21,900 fewer CHD deaths were attributable to risk factor declines in systolic blood pressure and cholesterol in the English population. Some 7,100 of these 21,900 fewer deaths (DPPs) were attributed to medications (32%) and approximately 14,800 DPPs were attributed to secular changes in asymptomatic individuals (68%). Substantial declines in systolic blood pressure were responsible for approximately 14,300 fewer deaths. This comprised approximately 12,500 DPPs attributable to population-wide changes and some 1,800 DPPs attributable to hypertension medications. The hypertension medications resulted in approximately 350 fewer deaths in the most affluent quintile compared with 270 DPP in the most deprived. In contrast, the population-wide (secular) falls in blood pressure resulted in approximately 2400 fewer deaths in the most deprived quintile compared with only 1900 DPPs in the most affluent. Cholesterol falls resulted in approximately 7,700 fewer deaths. This comprised some 5,300 fewer deaths attributable to statin medications and approximately 2,400 fewer deaths attributable to population-wide changes (mostly diet). Statin medications prevented more deaths in the most affluent quintile (1050 DPPs) compared with the most deprived (770 DPPs). Population-wide changes in cholesterol prevented substantially more deaths in the most deprived quintile (820 DPPs) compared with the most affluent (260 DPPs). Conclusions: Population-based declines in blood pressure and cholesterol resulted in much greater reductions in CHD deaths than did primary prevention medications. Mortality falls were greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Future CHD prevention policies should prioritise healthier diets ahead of medications.

Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008

BackgroundCoronary heart disease (CHD) mortality rates have been decreasing in Turkey since the early 1990s. Our study aimed to determine how much of the CHD mortality decrease in Turkey between 1995 and 2008 could be attributed to temporal trends in major risk factors and how much to advances in medical and surgical treatments.MethodsThe validated IMPACT CHD mortality model was used to combine and analyse data on uptake and effectiveness of CHD treatments and risk factor trends in Turkey in adults aged 35–84 years between 1995 and 2008.Data sources were identified, searched and appraised on population, mortality and major CHD risk factors for adults those aged 35–84 years. Official statistics, electronic databases, national registers, surveys and published trials were screened from 1995 onwards.ResultsBetween 1995 and 2008, coronary heart disease mortality rates in Turkey decreased by 34% in men and 28% in women 35 years and over. This resulted in 35,720 fewer deaths in 2008.Approximately 47% of this mortality decrease was attributed to treatments in individuals (including approximately 16% to secondary prevention, 3% angina treatments, 9% to heart failure treatments, 5% to initial treatments of acute myocardial infarction, and 5% to hypertension treatments) and approximately 42% was attributable to population risk factor reductions (notably blood pressure 29%; smoking 27%; and cholesterol 1%). Adverse trends were seen for obesity and diabetes (potentially increasing mortality by approximately 11% and 14% respectively). The model explained almost 90% of the mortality fall.ConclusionReduction in major cardiovascular risk factors explained approximately 42% and improvements in medical and surgical treatments explained some 47% of the CHD mortality fall. These findings emphasize the complimentary value of primary prevention and evidence-based medical treatments in controlling coronary heart disease.

OP54 Exploring Socioeconomic Inequalities in Coronary Heart Disease Prevention

BackgroundBetween 2000 and 2007, coronary heart disease (CHD) mortality rates in England plummeted by one third. An important part of this substantial CHD mortality decline was achieved through reductions in...

Unequal Trends in Coronary Heart Disease Mortality by Socioeconomic Circumstances, England 1982–2006: An Analytical Study

BackgroundCoronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles.MethodsWe calculated CHD mortality rates for 10-year age groups (from 35 to ≥85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas.ResultsBetween 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45–54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile.ConclusionsAge-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.

Explaining the decline in coronary heart disease mortality in the Czech Republic between 1985 and 2007

Coronary heart disease (CHD) mortality has declined substantially in the Czech Republic over the last two decades. The purpose of this study was to determine what proportion of this CHD mortality decline could be associated with temporal trends in major CHD risk factors and what proportion with advances in medical and surgical treatments. The validated IMPACT mortality model was used to combine and analyse data on uptake and effectiveness of CHD management and risk factor trends in the Czech Republic in adults aged 25-74 years between 1985 and 2007. The main sources were official statistics, national quality of care registries, published trials and meta-analyses, and the Czech MONICA and Czech post-MONICA studies. Between 1985 and 2007, age-adjusted CHD mortality rates in the Czech Republic decreased by 66.2% in men and 65.4% in women in the age group 25-74 years, representing 12,080 fewer CHD deaths in 2007. Changes in CHD risk factors explained approximately 52% of the total mortality decrease, and improvements in medical treatments approximately 43%. Increases in body mass index and in diabetes prevalence had a negative impact, increasing CHD mortality by approximately 1% and 5%, respectively. More than half of the very substantial fall in CHD mortality in the Czech Republic between 1985 and 2007 was attributable to reduction in major cardiovascular risk factors. Improvement in treatments accounted for approximately 43% of the total mortality decrease. These findings emphasize the value of primary prevention and evidence-based medical treatment.

Analysing Recent Socioeconomic Trends in Coronary Heart Disease Mortality in England, 2000–2007: A Population Modelling Study

Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups. A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%-107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%-47%) to the overall decline in CHD mortality: ranging from about 44% (31%-61%) in the most deprived to 29% (16%-42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%-40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (-9%; -17% to -3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%-70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions. The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.

Analyzing the Coronary Heart Disease Mortality Decline in a Mediterranean Population: Spain 1988-2005

Introduction and objectives To examine the extent to which the decrease in mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations.

Análisis de la disminución de la mortalidad por enfermedad coronaria en una población mediterránea: España 1988-2005

Introduction and objectives To examine the extent to which the decrease in coronary heart disease mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations. Full English text available from: www.revespcardiol.org

Explaining recent coronary heart disease mortality trends in England by socioeconomic circumstances, 2000–2007

BackgroundThe continuing fall in coronary heart disease (CHD) mortality is widely celebrated. However, the impact of public policies and treatments on socio-economic gradients in health is poorly quantified. Understanding the...

P03 *Explaining the decline in coronary heart disease mortality in Northern Ireland between 1987 and 2007

PurposeIn 1987, Northern Ireland had one of the highest rates of coronary heart disease (CHD) mortality in the world. However, CHD mortality has declined substantially over the last 2 decades....

P02 Risk factor and treatment contributions to the coronary heart disease mortality decline in a low risk Mediterranean population: Spain 1988–2005

BackgroundThe “Mediterranean Paradox” means that low risk countries such as Spain experience substantially less cardiovascular mortality than North Europe or the USA. Can cardiovascular mortality fall further?ObjectiveWe examined the extent...

Coronary Mortality Declines in the U.S. Between 1980 and 2000: Quantifying the Contributions from Primary and Secondary Prevention

Coronary heart disease (CHD) mortality rates in the U.S. have halved since 1980. However, CHD remains a leading cause of death. The relative importance of secondary and primary prevention in explaining falls in coronary heart disease mortality is debated. The aim of this study was to quantify the primary and secondary preventive contributions to the U.S. CHD mortality fall between 1980 and 2000. The IMPACT model was used to estimate contributions to the U.S. CHD mortality fall from risk factor declines in asymptomatic individuals (primary prevention) and in CHD patients (secondary prevention). Analyses were carried out in 2008. Approximately 316,100 fewer deaths were attributable to risk factor declines: 64,930 in CHD patients (21%) and 251,170 in asymptomatic individuals (79%). Smoking declines accounted for approximately 8390 fewer deaths in CHD patients and for 46,315 fewer deaths in asymptomatic people. Cholesterol falls gave approximately 22,210 fewer deaths in CHD patients and 107,300 fewer deaths in asymptomatic people. Statins accounted for approximately 16,580 fewer deaths, that is, one sixth of this mortality fall. Systolic blood pressure declines accounted for approximately 34,330 fewer deaths among CHD patients and 97,555 fewer deaths in asymptomatic individuals. Antihypertensive medications accounted for approximately 23,845 fewer deaths. Half of the U.S. mortality fall in coronary heart disease between 1980 and 2000 was attributable to risk factor declines, with primary prevention producing substantially larger mortality reductions than secondary.

Explaining the decrease in coronary heart disease mortality in Italy between 1980 and 2000.

We examined the extent to which the decrease in coronary heart disease (CHD) mortality rates in Italy could be explained by changes in cardiovascular risk factors versus the use of medical and surgical treatments. We used a validated model to combine data on changes in risk factors and uptake and effectiveness of cardiac treatments among adult men and women in Italy between 1980 and 2000. Data sources included results of published trials, meta-analyses, official statistics, longitudinal studies, and national surveys. The difference between observed and expected CHD deaths in 2000 was partitioned among treatments and risk factors. From 1980 to 2000, the age-adjusted CHD mortality rate in Italy fell among persons aged 25 to 84 years, resulting in 42 930 fewer CHD deaths in 2000. Approximately 40% of this decrease was attributed to treatments and 55% to changes in risk factors. Over half of the CHD mortality fall in Italy between 1980 and 2000 was attributable to reductions in major risk factors, mainly cholesterol and blood pressure, and less than half to evidence-based medical therapies. These results are becoming increasingly important, both for understanding past trends and for planning future prevention and treatment strategies.

Lipids, lipid modifying agents and cardiovascular risk: a review of the evidence

It is well-established that serum total-cholesterol, LDL-cholesterol, low HDL-cholesterol and calculated indices such as total cholesterol:HDL-cholesterol ratio or less commonly used indices such as non-HDL cholesterol are strongly predictive of cardiovascular events. Serum triglycerides, by contrast, are only modestly associated with coronary heart disease (CHD) in multivariate analysis and incorporation of triglycerides into prediction algorithms is therefore unlikely to improve their prediction capability. Meta-analysis of studies including > 90,000 subjects has provided robust evidence that statins reduce important clinical end-points. These included a 12% fall in all-cause mortality, 19% fall in CHD mortality and 23% fall in CHD mortality or myocardial infarction. Furthermore there are high quality data showing additional benefit of intensive statin therapy over standard statin therapy for secondary prevention of cardiovascular disease. However, meta-analysis of 10 fibrate trials has shown inconsistent evidence of vascular benefit and non-cardiovascular mortality has been slightly but consistently elevated in most fibrate trials and in meta-analysis. The general use of fibrates for cardiovascular risk reduction can therefore not be supported at present. Other second line agents such as bile acid sequestrants, nicotinic acid and omega-3 fatty acid supplements have been evaluated in a few randomized controlled studies in which cardiovascular benefit has been found but clearly further data are required to properly establish their use in clinical practice. Ongoing studies such as ACCORD, IMPROVE-IT, ASCEND, ORIGIN and HPS2-THRIVE should assist in answering outstanding questions over the next 5 years.

Decline of Coronary Heart Disease Mortality in the Netherlands from 1978 to 1985: Contribution of Medical Care and Changes Over Time in Presence of Major Cardiovascular Risk Factors

To study the relative contributions of medical care and changes in cardiovascular risk factors to the decline in coronary heart disease (CHD) mortality in The Netherlands from 1978 to 1985. The number of potential CHD deaths prevented in this period was estimated by subtracting the number of observed CHD deaths from the number of deaths that would have occurred without any change in age-specific CHD mortality. In addition, the number of myocardial infarctions over this period was determined. Using estimates of risk associated with smoking, based on national and international data, of effects of changes in total cholesterol level, of benefits of antihypertensive drug treatment and effects of different intervention strategies in subjects with a previous myocardial infarction, we calculated the relative contribution of the separate factors to the decline in CHD mortality. The estimated contribution of treatment in coronary care units, postinfarction treatment and coronary bypass grafting to the fall in CHD mortality was 46%. Approximately 44% of the decline in CHD mortality could be attributed to primary prevention efforts (cessation of smoking, change in cholesterol level and treatment of hypertension). On the basis of available estimates of the potential effects of primary and secondary prevention it seems likely that a sizeable proportion of the age-specific reduction in mortality in The Netherlands during the period 1978-85 could have resulted from these measures. However, our findings should be considered to be estimates illustrating the relative benefits of different strategies rather than absolute figures.

Diet and coronary heart disease in England and Wales during and after the second world war.

During the second world war there were large changes in consumption of fats, fibre, and sugar in Britain. These changes matched recent recommendations made by the Committee on Medical Aspects of Food Policy (COMA) with the object of reducing the incidence of coronary heart disease (CHD). It is widely believed that CHD mortality fell during the war. This paper re-examines CHD mortality among middle-aged people in England and Wales from 1931 to 1967. After allowance for changes in the rules for coding cause of death, and for the sharp increase in all-causes mortality in 1940, there is little to suggest that time trends in CHD were much influenced by the war. Because of confounding variables, this does not argue against the COMA report. However, it gives no support to the view that compliance with the recommendations on fat, fibre, and sugar will lead, by itself, to an appreciable fall in CHD mortality in middle-aged people.