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Contributions of risk factors and medical care to cardiovascular mortality trends

Key Points

  • Death rates from ischaemic heart disease (IHD), stroke, and other cardiovascular diseases (CVDs) are decreasing in high-income and many Latin American countries, and this trend shows no signs of slowing

  • Declines in some behavioural risk factors, including smoking, and physiological risk factors, such as blood pressure and serum cholesterol, are likely to have helped to reduce CVDs

  • By contrast, the nearly universal increase in adiposity seems not to have modified the long-term declining trend in CVD mortality, although it might have had some slowing effect

  • Improved medical care, including effective treatment of physiological risk factors, diagnosis, treatment of acute CVDs, and post-hospital care, has also contributed to declining CVD events and mortality

  • Measured risk factor and treatment variables, while important, explain neither why the decline began when it did nor many of the similarities and differences between countries or between men and women

  • Substantial fluctuations in CVDs, and in alcohol intake, in former communist countries of Europe have followed times of massive political and social changes since the early 1990s

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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Figure 1: Trends in age-standardized CVD death rates in adults aged ≥30 years, by geographical region and sex, from 2000 to 2012.
Figure 2: Relative change in CVD death rates by decade, sex, and age group in 20 western high-income countries.
Figure 3: Trends in CVD death rates in high-income countries for adults aged 30–69 years, by sex.
Figure 4: Trends in CVD death rates in high-income countries for adults aged ≥70 years, by sex.
Figure 5: Trends in death rates from cancers, cardiovascular diseases, and external causes in adults aged 25–64 years in Russia.
Figure 6: Trends in the male-to-female ratio of cardiovascular death rates for adults aged 30–69 years in countries with reliable mortality data.
Figure 7: Percentage of excess relative risk of cancers, COPD, and cardiovascular diseases remaining over time after exposure to a risk factor has stopped or been reduced.
Figure 8: Trends in recorded per-capita alcohol consumption among adults aged ≥15 years.
Figure 9: Cross-country associations between changes in risk factors and CVD death rates, between 1980 and 2008.

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Acknowledgements

We thank Colin Mathers and Gretchen Stevens (WHO, Switzerland), and Vasilis Kontis (Imperial College London, UK) for data and figures on mortality trends; Juergen Rehm (University of Toronto, Canada) for data on trends in alcohol consumption in Russia; Yasaman Vali (Imperial College London, UK) for assistance with references; and Mohammed Ali (Emory University, GA, USA), Perviz Asaria (Imperial College London, UK), Robert Beaglehole (University of Auckland, New Zealand), Peter Burney (Imperial College London, UK), Zhengming Chen (University of Oxford, UK), Goodarz Danaei (Harvard School of Public Health, MA, USA), Darwin Labarathe (Northwestern University, IL, USA), Juergen Rehm (University of Toronto, Canada), and Jonathan Samet (University of Southern California, CA, USA) for discussions on materials covered in the Review. M.E. is supported by a strategic grant from the UK Medical Research Council (MRC), and by the MRC and Public Health England (PHE) through support to the MRC–PHE Centre for Environment and Health. Z.O. is supported by a grant from the Common Fund of the US National Institutes of Health. P.E. has received funding from the National Institute for Health Research (NIHR) Biomedical Research Centre at Imperial College Healthcare NHS Trust and Imperial College London, the NIHR Health Protection Research Unit on the Impact of Environmental Hazards, and from the MRC and PHE in support of the MRC-PHE Centre for Environment and Health.

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Ezzati, M., Obermeyer, Z., Tzoulaki, I. et al. Contributions of risk factors and medical care to cardiovascular mortality trends. Nat Rev Cardiol 12, 508–530 (2015). https://doi.org/10.1038/nrcardio.2015.82

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