Steven Allender, Peter Scarborough, Viv Peto and Mike Rayner

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1 2008 edition Steven Allender, Peter Scarborough, Viv Peto and Mike Rayner British Heart Foundation Health Promotion Research Group Department of Public Health, University of Oxford Jose Leal, Ramon Luengo-Fernandez and Alastair Gray Health Economics Research Centre, Department of Public Health, University of Oxford

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3 Contents Page Foreword 7 Summary 8 Introduction 9 Chapter 1 Mortality Table 1.1 Total numbers of deaths by cause and sex, latest available year, Europe 16 Figure 1.1a Deaths by cause, men, latest available year, Europe 18 Figure 1.1b Deaths by cause, women, latest available year, Europe 18 Figure 1.1c Deaths by cause, men, latest available year, EU 19 Figure 1.1d Deaths by cause, women, latest available year, EU 19 Table 1.2 Deaths under 75 by cause and sex, latest available year, Europe 20 Figure 1.2a Deaths under 75 by cause, men, latest available year, Europe 22 Figure 1.2b Deaths under 75 by cause, women, latest available year, Europe 22 Figure 1.2c Deaths under 75 by cause, men, latest available year, EU 23 Figure 1.2d Deaths under 75 by cause, women, latest available year, EU 23 Table 1.3 Deaths under 65 by cause and sex, latest available year, Europe 24 Figure 1.3a Deaths under 65 by cause, men, latest available year, Europe 26 Figure 1.3b Deaths under 65 by cause, women, latest available year, Europe 26 Figure 1.3c Deaths under 65 by cause, men, latest available year, EU 27 Figure 1.3d Deaths under 65 by cause, women, latest available year, EU 27 Table 1.4 Age-standardized death rates from CHD, adults aged 0 to 64, by sex, 1972 to 2005, Europe 28 Figure 1.4a Age-standardized death rates from CHD, men aged 0 to 64, latest available year 30 Figure 1.4b Age-standardized death rates from CHD, women aged 0 to 64, latest available year 30 Figure 1.4c Death rates from CHD, men aged under 65, 1972 to 2005, selected countries 31 Figure 1.4d Death rates from CHD, women aged under 65, 1972 to 2005, selected countries 31 Table 1.5 Age-standardized death rates from stroke, adults aged 0 to 64, by sex, 1972 to Figure 1.5a Age-standardized death rates from stroke, men aged 0 to 64, latest available year 34 Figure 1.5b Age-standardized death rates from stroke, women aged 0 to 64, latest available year 34 Figure 1.5c Death rates from stroke, men aged under 65, 1972 to 2005, selected countries 35 Figure 1.5d Death rates from stroke, women aged under 65, 1972 to 2005, selected countries 35

4 Chapter 2 Morbidity Table Coronary event rates, coronary case fatality, annual change in coronary event rates and annual change in coronary case fatality by sex, adults aged 35 to 64, latest available year, MONICA Project populations 38 Table 2.2 Disability-adjusted life years (DALYs) by cause, 2002, WHO Mortality Sub-Region, EU and Europe 39 Figure 2.2a Disability-adjusted life years lost by cause, 2002, Europe 40 Figure 2.2b Disability-adjusted life years lost by cause, 2002, EU 40 Table 2.3 Age-standardized DALYs rate for CHD, stroke and other CVD by country, 2002, Europe 41 Figure 2.3a Age-standardized DALYs rate for CHD, 2002, Europe 42 Figure 2.3b Age-standardized DALYs rate for stroke, 2002, Europe 42 Chapter 3 Treatment Table 3.1 Rates of hospital discharges from CVD, 1970 to 2005, Europe 45 Table 3.2 Rates of hospital discharges from CHD, 1970 to 2005, Europe 46 Figure 3.2 Rates of hospital discharge from CHD, latest available year, Europe 47 Table 3.3 Rates of hospital discharges from stroke, 1970 to 2005, Europe 48 Table 3.4 Rates of various procedures for treating CVD, around 2000, Europe 49 Figure 3.4a Crude rate of coronary artery bypass surgery, adults aged 35 to 74, around 2000, Europe 50 Figure 3.4b Crude rate of percutaneous coronary interventions, adults aged 35 to 74, around 2000, Europe 50 Table 3.5 Rates of percutaneous coronary interventions, 1990 to 2003, selected countries 51 Figure 3.5 Rates of percutaneous coronary interventions, 1990 to 2003, selected countries 52 Table 3.6 Reported medication, hospital patients with established CHD, around 1999/2000, EUROASPIRE II Survey populations 53 Chapter 4 Smoking 54 Table 4.1 Total numbers of deaths and numbers of deaths due to smoking by cause, adults aged 35 and over, by sex, Table 4.2 Total all-cause mortality rate and smoking attributable all-cause mortality rate by age and sex, Europe, 1950 to Figure 4.2a All-cause mortality due to smoking, men aged 35 to 69, Europe, Figure 4.2b All-cause mortality due to smoking, women aged 35 to 69, Europe, Figure 4.2c Change in mortality rate due to smoking between 1990 and 2000, men aged 35 to 69, Europe 61 Figure 4.2d Change in mortality rate due to smoking between 1990 and 2000, women aged 35 to 69, Europe 61 Table 4.3 Prevalence of smoking by sex, adults aged 15 and over, Europe, 1980 to Figure 4.3a Prevalence of smoking, men aged 15 and over, Europe, latest available year 63 Figure 4.3b Prevalence of smoking, women aged 15 and over, Europe, latest available year 63 Table 4.4 Prevalence of smoking by sex, 15 year olds, 1989/90 to 2001/02, Europe 64

5 Figure 4.4a Prevalence of smoking, boys aged 15, 2001/02, Europe 65 Figure 4.4b Prevalence of smoking, girls aged 15, 2001/02, Europe 65 Table 4.5 Estimated number of deaths attributable to passive smoking, adults aged 20 and over, Europe, Chapter 5 Diet 67 Table 5.1 Table 5.2 Fruit and vegetable consumption by country, adults by sex, latest available year, Europe 69 Quantity of fruit and vegetables consumed, Europe, 1969/71 to 2001/03 70 Figure 5.2a Quantity of fruit and vegetables consumed, Europe, 2001/03 71 Figure 5.2b Quantity of fruit and vegetables consumed, selected countries, 1969/71 to 2001/03 71 Table 5.3 Table 5.4 Percentage of total energy from fat by country and sex, adults, latest available year, Europe 72 Quantity of fat consumed and percentage of energy from fat, Europe, 1969/71 to 2002/04 73 Figure 5.4a Quantity of fat consumed, Europe, 2001/03 74 Figure 5.4b Percentage of energy from fat, selected countries, 1969/71 to 2001/03 74 Table 5.5 Percentage of total energy from saturated fat, Europe, Chapter 6 Physical activity 76 Table 6.1 Self-reported physical activity levels, 2005, EU-15 countries 77 Figure 6.1 Percentage of adults who do no moderate-intensity activity in a typical week, 2005, EU-15 countries 78 Chapter 7 Alcohol 79 Table 7.1 Alcohol consumption, adults aged 15 years and above, 1970 to 2005, Europe 80 Figure 7.1 Alcohol consumption, adults aged 15 years and above, Chapter 8 Blood pressure 82 Table 8.1 Figure 8.1 Table 8.2 Systolic blood pressure levels, adults aged 35 to 64, by sex, latest available data, MONICA Project populations 83 Percentage with systolic blood pressure levels > 160mmHg by sex, adults aged 35 to 64, latest available year, MONICA Project populations 84 Mean systolic blood pressure by sex, adults aged 15 and over, Europe, 2002, and projections for 2005 and Chapter 9 Blood cholesterol 86 Table 9.1 Figure 9.1 Table 9.2 Mean total blood cholesterol and percentage with levels of 6.5mmol/l and above, adults aged 35 to 64, by sex, latest available data, MONICA Project populations 87 Percentage with blood cholesterol levels of 6.5mmol/l and over by sex, adults aged 35 to 64, latest available year, MONICA Project populations 88 Mean total cholesterol by sex, adults aged 15 and over, Europe, 2002, and projections for 2005 and

6 Chapter 10 Overweight and obesity 90 Table 10.1 Table 10.2 Prevalence of overweight and obesity, adults aged 35 to 64, by sex, latest available data, MONICA Project populations 92 Prevalence of obesity by sex, adults aged 15 and over, latest available year, Europe 93 Figure 10.2a Prevalence of obesity, men aged 15 and over, latest available year, Europe 94 Figure 10.2b Prevalence of obesity, women aged 15 and over, latest available year, Europe 94 Table 10.3 Mean Body Mass Index by sex, adults aged 15 and over, 2002 and projections for 2005 and 2010, Europe 95 Figure 10.3a Mean Body Mass Index, men aged 15 and over, 2002, Europe 96 Figure 10.3b Mean Body Mass Index, women aged 15 and over, 2002, Europe 96 Figure 10.3c Mean Body Mass Index, men aged 15 and over, projections for 2010, Europe 97 Figure 10.3d Mean Body Mass Index, women aged 15 and over, projections for 2010, Europe 97 Table 10.4 Prevalence of overweight and obesity in children, latest available year, Europe 98 Chapter 11 Diabetes 99 Table 11.1 Prevalence of diabetes, 1980 to 2005, adults, Europe 100 Table 11.2 Estimated prevalence of diabetes, 2003, 2007 and 2025, Europe 101 Figure 11.2 Estimated prevalence of diabetes, 2003, Europe 102 Chapter 12 Economic costs 03 Table 12.1 Health care costs of CVD, by country, 2006, EU 105 Figure 12.1 Costs of CVD to the health care system, 2006, EU 106 Table 12.2 Health care costs of CHD by country, 2006, EU 107 Table 12.3 Health care costs of stroke by country, 2006, EU 108 Table 12.4 Non health care costs of CVD, CHD and stroke, by country, 2006, EU 109 Table 12.5 Total cost of CVD, CHD and stroke, 2006, EU 110 Appendix: Member states of the WHO region 111 6

7 Foreword This is the third edition of. The first edition was published in 2000 when the Union (EU) consisted of 15 Member States. After enlargement in 2004 and then again in 2007, there are now 27 Member States. Much has changed in the last seven years, but disease (CVD) remains the main cause of death in the EU. The was the first publication to bring together all the available sources of information about the burden of CVD in Europe, including data on death and illness, treatment, the prevalence of behavioural risk factors for CVD (smoking, diet, physical inactivity and alcohol consumption), and the prevalence of medical conditions associated with CVD (raised cholesterol, raised blood pressure, overweight and obesity, and diabetes). It has become an indispensable resource for anybody working on reducing the burden of CVD in Europe or in public health generally. The publication also includes an update of the analysis of economic costs of CVD in Europe, first published in the 2005 edition. The figures are staggering: CVD cost the EU just under 192 billion in 2006, almost 110 billion of which were for health care costs and 82 billion were from lost productivity and the cost of informal care. The direct health care costs alone cost each resident of the EU 223 per annum. Coronary heart diseases (CHD) by itself remains the single most common cause of deaths in the EU but the 2008 shows a reduction in the crude number of CHD deaths when compared with the 2005 edition. This reflects a general trend in Western, Northern and Southern countries, where CHD mortality rates are falling steadily. The situation in some Central and Eastern countries is very different, with CHD rates rising dramatically. This gradient is more marked for stroke mortality, where the crude number of deaths increased since Over 200,000 men and nearly 300,000 women die of stroke in the EU every year. The third edition of the is published by the Heart Network. We hope that this important document will be used by policy makers, researchers, health professionals and all those working to improve the health and quality of life for people living in Europe. Susanne Løgstrup Director Heart Network 7

8 Summary n Each year disease (CVD) causes over 4.3 million deaths in Europe and over 2.0 million deaths in the Union (EU). n CVD causes nearly half of all deaths in Europe (48%) and in the EU (42%). n CVD is the main cause of death in women in all countries of Europe and is the main cause of death in men in all countries except France, the Netherlands and Spain. n CVD is the main cause of the disease burden (illness and death) in Europe (23% of all the disease burden) and the second main cause of the disease burden in those EU countries with very low child and adult mortality (17%). n Death rates from CHD are generally higher in Central and Eastern Europe than in Northern, Southern and Western Europe. n Death rates from stroke are higher in Central and Eastern Europe than in Northern, Southern and Western Europe. n CVD mortality, incidence and case fatality are falling in most Northern, Southern and Western Countries but either not falling as fast or rising in Central and Eastern countries. n Each year smoking kills over 1.2 million people in Europe (450,000 from CVD) and about 650,000 people in the EU (185,000 from CVD). The numbers dying in Europe from CVD due to smoking rose by 13% between 1990 and n Smoking has been declining in many countries but the rate of decline is now slowing. Women are now smoking nearly as much as men in many countries and girls often smoke more than boys. n Dietary patterns across Europe - once very different - are now converging. n Diets are generally improving in Northern and Western countries but deteriorating in Southern, Central and Eastern countries. n Levels of physical inactivity are high in many countries. n Levels of obesity are increasing across Europe in both adults and children. n Over 48 million adults in Europe and 23 million adults in the EU have diabetes and the prevalence is increasing. n Overall CVD is estimated to cost the EU economy 192 billion a year. n Of the total cost of CVD in the EU, around 57% is due to health care costs, 21% due to productivity losses and 22% due to informal care of people with CVD. 8

9 Introduction The aim of the publication This is the third edition of published by the Heart Network. is designed for policy makers, health professionals, medical researchers and anyone else with an interest in disease (CVD). It provides the most recent statistics related to the incidence, prevalence, causes and effects of the disease. The aim of is to show: (i) the extent to which CVD is a major health problem in Europe; (ii) where, in Europe, this problem is greatest; (iii) the variability in efforts to treat and prevent CVD across Europe as shown by differences in levels of treatment and in levels of risk factors for the disease; (iv) the economic costs of CVD in the Union; (v) trends in CVD mortality, morbidity, treatment and risk factors over time. is divided into 12 sections. The first two sections on mortality and morbidity deal with the burden of CVD in Europe. Next there is a section on treatment. Then there are four sections on the main aspects of lifestyle which affect the risk of the disease: smoking, diet, physical activity and alcohol consumption. These are followed by four sections on the main pathophysiological risk factors for the disease: raised blood pressure, raised blood cholesterol, overweight/obesity and diabetes. The final section provides information about the economic costs of CVD in the Union (EU) 1. Each section contains a set of tables and graphs and a brief description of the data presented. In we aim only to describe and not to explain. So, although there may be relationships between the various geographical and temporal patterns observed, we have made no attempt to draw any conclusions about the strength of these relationships or about causality. Sources and scope of the data In compiling the first 11 sections of we have only consulted international sources: that is the World Health Organization (WHO), the WHO MONICA (monitoring trends and determinants in disease) Project, Eurostat (provided by the Commission), the Food and Agriculture Organization of the United Nations, the EU, the Society of Cardiology etc. In the final section on economic costs, we have also consulted national sources. It should be noted that the data presented are extremely variable in quality and are only a selection of those available. The original sources need to be consulted for further information. 9

10 We also investigated several sources of data from which we have not extracted statistics: either because the data provided were similar, but less comprehensive or less recent than those we have included, or were not directly relevant to the focus of the publication. There are many different definitions of Europe. We have chosen to use the member states of the World Health Organization s Region as our definition of Europe. (An appendix provides a list and a map of the Region and the EU.) The number of countries covered in the tables and graphs varies considerably. We have, where possible, given an overall figure for Europe and also for the EU. Previous publications There have been several previous attempts to characterise the burden of CVD in Europe and to examine geographical and temporal patterns in the disease and its prevention and treatment. Notable in this regard is the 1997 report of a Task Force of the Society of Cardiology on Cardiovascular Mortality and Morbidity Statistics in Europe 2 and a report published by the Society of Cardiology entitled Cardiovascular diseases in Europe from which we draw data on rates of procedures in Europe 3., complements these publications. It is less detailed but more up-to-date than the Society of Cardiology Task Force report and, in contrast to both previous publications, includes data on the prevalence of risk factors for CVD and the economic costs of CVD. This publication is also designed to complement the work of the Commission on monitoring health in the EU. Since the mid-1990s health status reports have been prepared for the Commission on a regular basis. The recent The health status of the Union: narrowing the health gap, was published in This report- like - shows that CVD is the main health problem in the EU. 1. Because of a paucity of published economic data in many countries, the economic costs section of this publication relates only to the EU. 2. Task Force of the Society of Cardiology on Cardiovascular Mortality and Morbidity Statistics in Europe (1997) The burden of diseases mortality in Europe. Heart Journal 18; Society of Cardiology (2004) Cardiovascular Diseases in Europe. Nice: ESC. 4. Commission (2003) The health status of the Union: narrowing the health gap. Luxembourg: Office for Official Publications of the Union. 10

11 1. Mortality Total mortality Diseases of the heart and circulatory system ( disease or CVD) are the main cause of death in Europe: accounting for over 4.30 million deaths each year 1. Nearly half (48%) of all deaths are from CVD (54% of deaths in women and 43% of deaths in men). The main forms of CVD are coronary heart disease (CHD) and stroke. Just under half of all deaths from CVD are from CHD and nearly a third are from stroke (Table 1.1, Figures 1.1a and 1.1b). CVD is also the main cause of death in the Union (EU) accounting for over 2.0 million deaths each year. Nearly half (42%) 2 of all deaths in the EU (45% deaths in women and 38% deaths in men) are from CVD - slightly less than for Europe as a whole. Over a third of deaths from CVD are from CHD and just over a quarter are from stroke (Table 1.1, Figures 1.1c and 1.1d). CHD by itself is the single most common cause of death in Europe: accounting for 1.92 million deaths in Europe each year. Over one in five women (22%) and over one in five men (21%) die from the disease (Table 1.1). CHD by itself is also the single most common cause of death in the EU: accounting for over 741,000 deaths in the EU each year. Around one in six men (16%) and over one in seven women (15%) die from the disease (Table 1.1). Stroke by itself is the second single most common cause of death in Europe: accounting for 1.24 million deaths in Europe each year. Over one in six women (17%) and one in ten men (11%) die from the disease (Table 1.1) Stroke by itself is also the second single most common cause of death in the EU: accounting for just over 508,000 deaths in the EU each year. Around one in ten men (9%) and one in eight women (12%) die from the disease (Table 1.1). CVD is the main cause of death for women in all 48 countries of Europe for which we have mortality data and it is the main cause of death for men in all these countries except France, the Netherlands and Spain 3. CVD causes more than 50% of deaths in women in 25 countries. These countries are mostly in Central and Eastern Europe but they also include some Southern and Western countries such as Greece. CVD causes more than 50% of deaths in men in eight countries: Armenia, Azerbaijan, Bulgaria, Georgia, FYR Macedonia, Serbia and Montenegro, Romania, and Ukraine (Table 1.1). CVD is the main cause of death for women in all 27 countries of the EU and it is the main cause of death for men in all these countries except France, the Netherlands and Spain 3. For men living in EU countries CVD causes between 62% (Bulgaria) and 26% of deaths (France) 3 and for women between 71% (Bulgaria) and 31% of deaths (France) 3 (Table 1.1). 11

12 Deaths before the age of 75 CVD is the main cause of deaths before the age of 75 in Europe: accounting for over 1.81 million deaths each year. 43% of deaths before the age of 75 in women and 38% of deaths before the age of 75 in men are from CVD. One in four of all men (25%) and one in six of all women (16%) die from CVD before the age of 75 (Tables 1.1 and 1.2, Figures 1.2a and 1.2b). CVD is the second main cause of death before the age of 75 in the EU: accounting for over 576,000 deaths. CVD causes 30% of deaths but cancer causes 36% of deaths. 31% of deaths before the age of 75 in men and 29% of deaths before the age of 75 in women are from CVD. One in six of all men (16%) and one in 12 of all women (8%) die from CVD before the age of 75 (Tables 1.1 and 1.2, Figures 1.2c and 1.2d). CHD by itself is the single most common cause of death before the age of 75 in Europe: accounting for over 900,000 deaths. 20% of deaths before the age of 75 in men and 19% of deaths before the age of 75 in women are from CHD (Table 1.2, Figures 1.2a and 1.2b). CHD by itself is the single most common cause of death before the age of 75 in the EU: accounting for over 250,000 deaths. In the EU CHD causes 15% of deaths before the age of 75 in men more than the most common form of cancer in men - lung cancer - which causes 11% of deaths. CHD causes 10% of deaths before the age of 75 in women - more that the most common form of cancer in women - breast cancer - which causes 8% of deaths (Table 1.2, Figures 1.2c and 1.2d). Stroke accounts for almost 500,000 deaths among those aged 75 and under in Europe. Of all deaths in Europe among those aged under 75 almost one in ten men (9%) and one in seven women (14%) die from stroke. Stroke accounts for just over 130,000 deaths among those aged 75 and under in the EU. Of the deaths in the EU among those aged under 75 6% of men and 8% of women die from stroke. CVD is the main cause of death before the age of 75 for men in 28 of the 48 countries of Europe for which we have mortality data and for women in 23 countries. The countries where CVD is the main cause of death before the age of 75 are generally Central and Eastern countries but, for men in particular, they also include Northern, Southern and Western countries. CVD causes between 61% (Georgia) and 18% (France) 3 of deaths before the age of 75 in men, and between 64% (Georgia) and 16% (France) 3 of deaths before the age of 75 in women (Table 1.2). CVD is the main cause of death before the age of 75 for men in 12 countries out of 27 in the EU (Bulgaria, Cyprus, Czech Republic, Estonia, Finland, Hungary, Latvia, Lithuania, Malta, Poland, Romania and Slovakia). For women it is the main cause in seven countries: Bulgaria, Estonia, Hungary, Latvia, Lithuania, Romania and Slovakia (Table 1.2). Deaths before the age of 65 CVD is the main cause of death before the age of 65 in Europe: accounting for over 803,000 deaths each year. 31% of deaths before the age of 65 in men and 29% of deaths before the age of 65 in women are from CVD. One in eight of all men (12%) and one in 20 of all women (5%) die from CVD before the age of 65 (Tables 1.1 and 1.3, Figures 1.3a and 1.3b). CVD is the second main cause of death before the age of 65 in the EU: accounting for just under 232,000 deaths. CVD causes 24% of deaths but cancer causes 35% of deaths. 26% of deaths 12

13 before the age of 65 in men and 19% of deaths before the age of 65 in women are from CVD. 7% of all men and 3% of all women die from CVD before the age of 65 (Tables 1.1 and 1.3, Figures 1.3c and 1.3d). CHD by itself is the single most common cause of death before the age of 65 in Europe: accounting for just under 401,000 deaths. 17% of deaths before the age of 65 in men and 12% of deaths before the age of 65 in women are from CHD (Table 1.3, Figures 1.3a and 1.3b). CHD by itself is the single most common cause of death before the age of 65 in the EU: accounting for just over 104,000 deaths. In the EU, CHD causes 13% of deaths before the age of 65 in men - more than the most common form of cancer in men - lung cancer - which causes 10% of deaths. CHD causes 6% of deaths before the age of 65 in women - less than the most common form of cancer in women - breast cancer - which causes 11% of deaths (Table 1.3, Figures 1.3c and 1.3d). Stroke accounts for more than 190,000 deaths among those aged 65 and under in Europe. Of all deaths in Europe among those aged under 65 6% of men and one in eleven women (9%) die from stroke. Stroke accounts for just under 48,000 deaths among those aged 65 and under in the EU. Of all deaths in the EU among those aged under 65 5% of men and 6% of women die from stroke. CVD is the main cause of death before the age of 65 for men in 26 of the 48 countries of Europe for which we have mortality data and for women in 17 countries. In women, the countries where CVD is the main cause of death before the age of 65 are all Central and Eastern countries. CVD causes between 50% (Georgia) and 15% (France) 3 of deaths before the age of 65 in men, and between 46% (Georgia) and 11% (France) 3 of deaths before the age of 65 in women (Table 1.3). CVD is the main cause of death before the age of 65 for men in 11 countries in the EU (Bulgaria, Cyprus, Estonia, Finland, Hungary, Latvia, Lithuania, Malta, Poland, Romania and Slovakia). For women it is the main cause of death before the age of 65 in three countries in the EU: Bulgaria, Latvia and Romania (Table 1.3). Death rates Death rates from CHD are generally higher in Central and Eastern Europe than in Northern, Southern and Western Europe. For example the death rate for men aged under 65 living in Ukraine is fourteen times higher than in France 3 and for women it is twenty-five times higher. Western countries generally have higher rates than Southern countries. For example the death rate for men aged under 65 living in Ireland is 1.6 times higher than in Italy and for women it is 1.8 times higher (Table 1.4, Figures 1.4a and 1.4b). 13 Death rates from stroke are higher in Central and Eastern Europe than in Northern, Southern and Western Europe. For example the death rate in men aged under 65 living in the Russian Federation is twenty times higher than in Switzerland and for women of the same age it is fifteen times higher (Table 1.5, Figures 1.5a and 1.5b). Over the past 30 years death rates from CHD have been falling rapidly in most Northern and Western countries but rising rapidly in some Central and Eastern countries.

14 For example death rates for men aged under 65 living in Finland and the United Kingdom fell by 37% and 42% respectively between 1994 and 2004, but rose by 57% for men of the same age living in Albania and by 19% for men living in the Ukraine. For women aged under 65 living in Finland and the United Kingdom death rates fell by 35% and 49% respectively, but rose by 46% for women living in Albania and by 19% for women living in Ukraine (Table 1.4, Figures 1.4c and 1.4d). Death rates from stroke are falling rapidly in most countries with some exceptions. For example death rates for men aged under 65 living in Germany and UK fell by 43% and 28% respectively between 1994 and For women aged 65 and under living in Germany and UK death rates fell by 37% and 28% respectively but rose by 15% for women living in Albania (Table 1.5, Figure 1.5c and 1.5d). A recent publication by the Institute des Sciences de la Sante, describes changes in CHD mortality in under 75s in the EU over a decade, between 1990/91 and 2000/02. Age-standardized death rates fell in all countries, but not equally across the EU. Death rates almost halved in four countries - the Czech Republic, the UK, Ireland and Finland. Elsewhere rates fell by about one fifth to one-third, the only exceptions being Latvia (men) and Poland (women) where there were improvements of just over 10% 4. The WHO MONICA Project measured trends in CHD mortality between the early 1980s and 1990s, in 37 populations worldwide, including 29 populations in Europe. Results showed that around two-thirds of the decline in CHD mortality during this period was due to a decline in CHD incidence rates and the remaining one-third was due to improvements in survival because of better treatments. This highlights the importance of improvements in risk factors such as smoking 5. This conclusion was also found in a recent study looking at the decline in CHD mortality over a 20-year period in the UK. The authors found that between 1981 and 2000 in England and Wales, 58% of the decline was attributable to reductions in major risk factors, principally smoking, whereas treatment of individuals, including secondary prevention, explained the remaining 42% of the mortality decline 6. Years of life lost due to an early death CVD is not only the main cause of death in Europe and the EU but is also the main cause of years lost due to an early death. The WHO Global Burden of Disease Study found that in 1990 on average 31% of years of life lost were due to CVD in Established Market Economies (mostly Northern, Southern and Western countries in Europe and all the member states of the EU - 15). This was more than any other cause. On average 16% of years of life lost were due to CHD in Established Market Economies, so by itself CHD was the most important cause of years of life lost in these countries 7. In Central and Eastern countries 35% of years of life lost were due to CVD - again more than from any other cause - and 18% were lost due to CHD 7. 14

15 15 1. When we state, in this section, that CVD is the main cause of death we are comparing Diseases of the circulatory system (Chapter IX 10th Revision) of the International Classification of Diseases, with other chapters (e.g. Chapter II Neoplasms ). When we state that CHD is the most common cause of death we are comparing CHD ( Chapter IX, I20-I25, 10th Revision) with all diseases within all chapters (e.g. with lung cancer, Chapter II, C33-C34, 10th Revision). 2. This figure and similar figures in the text are calculated from the tables rather than the graphs. Figures in the text may not seem to correspond exactly to figures in graphs because of rounding. 3. Data from the WHO MONICA project suggest that official mortality statistics in France under-report deaths from CVD compared to other countries. MONICA data from the French populations included in the MONICA Project (Lille, Strasbourg and Toulouse) show an underestimate of CHD deaths of over 75%. (See WHO Monica Project (2003) MONICA Monograph and Multimedia Sourcebook: World s largest study of heart disease stroke, risk factors and population trends Edited by Hugh Tunstall- Pedoe for the WHO MONICA Project. WHO: Geneva). Table 1.1 also highlights that doctors in France have a much higher rate of reporting deaths from all other causes. Together these suggest that the true numbers and proportions of deaths from CVD and CHD in France are likely to be higher than those reported in Table and Figures Newey C, Nolte E, Mckee M and Mossialos E (2004) Avoidable mortality in the Enlarged Union. ISS Statistics 2. Brussels:ISS. 5. Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P, for the WHO MONICA Project (1999) Contribution of trends in survival and coronary event rates to changes in coronary heart disease mortality: 10 year results from 37 WHO MONICA Project populations. Monitoring trends and determinants in disease. The Lancet; 353: Unal B, Critchley J and Capewell S (2004) Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and Circulation; 109: Murray JL and Lopez AD (1996) The global burden of disease. WHO: Geneva.

16 Table 1.1 Total number of deaths by cause and sex, latest available year, Europe Year All causes Coronary Stroke Other CVD Stomach Colo-rectal Lung Breast Other Respiratory Injuries and All other heart disease cancer cancer cancer cancer cancer disease poisoning causes MEN Albania ,949 1,593 1,521 1, ,083 Armenia ,093 4,292 1, , ,319 Austria ,757 6,908 2,103 4, ,230 2, ,850 2,219 2,769 6,505 Azerbaijan ,405 9,112 2,282 1, ,779 1,754 1,422 4,902 Belarus ,649 24,324 8,206 3,475 1,725 1,097 3, ,349 4,587 13,198 8,376 Belgium ,888 6,723 3,652 6, ,532 6, ,847 6,225 4,054 8,509 Bulgaria ,761 9,856 10,657 17, ,429 3, ,665 2,790 2,986 6,936 Croatia ,066 4,819 3,373 3, , ,566 1,817 1,950 3,526 Cyprus , Czech Republic ,072 11,330 5,808 7, ,463 4, ,890 3,237 4,333 6,362 Denmark ,877 4,832 2,129 3, ,024 2, ,428 2,542 1,815 5,746 Estonia ,834 2, , ,276 1,212 Finland ,965 5,916 1,792 1, , ,273 1,445 2,997 4,658 France ,553 23,300 14,844 33,413 3,177 8,856 23, ,454 18,365 23,399 73,075 Georgia ,569 7,518 4,323 1, , ,139 2,509 Germany ,554 72,003 24,786 55,485 6,211 13,696 30, ,569 29,333 20,358 74,521 Greece ,030 7,878 7,226 8, ,132 5, ,669 4,337 3,101 7,992 Hungary ,781 17,559 6,837 8, ,462 5, ,828 3,724 5,442 10,845 Iceland Ireland ,111 2, , , ,364 1, ,274 Israel ,836 3,100 1,013 1, ,571 1,386 1,446 5,982 Italy ,296 39,345 26,545 39,836 6,266 9,164 27, ,998 20,617 16,026 46,886 Kazakhstan ,913 19,788 8,664 8,027 1, , ,009 6,310 16,135 13,809 Kyrgyzstan ,249 4,178 2, ,366 2,905 4,387 Latvia ,632 4,403 2,217 1, , ,440 2,135 Lithuania ,384 6,950 2,010 1, , ,252 1,223 4,314 2,679 Luxembourg , Macedonia, TFYR ,000 1,300 1,722 2, ,583 Malta , Moldova ,518 7,129 2, ,485 1,721 2,723 3,854 Netherlands ,362 7,631 4,032 9, ,267 6, ,441 7,305 3,070 13,973 Norway ,025 3,557 1,541 2, , ,325 1,711 1,553 3,879 Poland ,786 27,016 16,702 35,537 3,562 4,959 18, ,375 11,066 19,211 36,203 Portugal ,753 4,586 7,112 4,785 1,463 1,856 2, ,136 6,139 3,297 16,413 Romania ,461 28,012 25,249 23,955 2,516 2,557 8, ,693 8,311 9,818 17,035 Russian Federation ,249, , , ,378 23,812 15,866 47, ,386 72, , ,276 San Marino Serbia and Montenegro ,656 7,763 8,616 15, ,276 3, ,795 3,191 3,401 11,905 Slovakia ,151 7,064 1,946 4, ,052 1, ,526 1,786 2,456 3,535 Slovenia ,413 1, , , ,580 Spain ,769 22,188 14,611 20,943 3,549 7,472 18, ,578 27,183 11,798 44,204 Sweden ,194 9,673 3,696 5, ,257 1, ,721 2,845 3,175 8,235 Switzerland ,991 4,603 1,626 3, , ,260 2,068 2,147 6,438 Tajikistan ,252 2, , ,910 1,065 4,316 Turkmenistan ,517 3, , ,543 1,842 3,917 Ukraine , ,352 42,226 23,168 7,090 5,925 14, ,614 22,777 60,298 47,106 United Kingdom ,309 56,337 21,899 21,706 3,527 8,653 20, ,414 36,737 12,648 48,198 Uzbekistan ,794 19,210 7,402 6, ,154 8,489 7,941 15,927 Union 2,409, , , ,356 38,749 75, ,056 1, , , , ,095 Total Europe 4,577, , , ,640 78, , ,136 1, , , , ,355 16

17 17 Table 1.1 continued Year All causes Coronary Stroke Other CVD Stomach Colo-rectal Lung Breast Other Respiratory Injuries and All other heart disease cancer cancer cancer cancer cancer disease poisoning causes WOMEN Albania ,799 1,065 1,661 1, ,855 Armenia ,461 4,193 2, ,484 Austria ,538 8,052 3,508 7, ,119 1,077 1,563 4,712 2,182 1,442 7,633 Azerbaijan ,121 8,609 2,914 1, ,404 1, ,191 Belarus ,650 26,335 11,768 2,628 1,241 1, ,272 3,863 1,928 3,441 12,575 Belgium ,912 5,256 5,801 9, ,627 1,145 2,416 6,118 4,447 2,238 12,499 Bulgaria ,613 7,897 11,715 17, , ,293 3,772 1, ,329 Croatia ,724 5,129 4,781 4, ,620 1, ,537 Cyprus , Czech Republic ,866 12,037 8,780 9, ,783 1,400 1,916 6,826 2,803 2,043 5,972 Denmark ,755 4,434 2,941 3, ,068 1,508 1,333 3,629 2,797 1,263 7,145 Estonia ,482 2,644 1,446 1, ,262 Finland ,786 5,812 2,669 1, ,924 1,022 1,298 5,974 France ,633 17,842 20,076 43,407 1,867 7,958 6,127 11,466 33,608 17,269 15,366 86,647 Georgia ,770 8,158 5,381 1, ,972 Germany ,672 76,638 42,332 96,120 5,090 13,843 11,871 17,454 51,076 28,411 12,687 86,150 Greece ,476 4,706 9,952 11, ,790 5,644 3, ,971 Hungary ,951 19,334 8,720 10, ,095 2,294 2,085 6,269 2,778 2,548 8,842 Iceland Ireland ,368 2,119 1,136 1, ,868 2, ,405 Israel ,455 2,699 1,260 1, ,234 1, ,284 Italy ,094 36,035 39,350 56,087 4,686 8,072 6,685 11,309 36,073 15,324 10,667 56,806 Kazakhstan ,787 19,355 11,577 8,036 1, ,317 4,807 3,475 4,558 10,110 Kyrgyzstan ,986 4,492 3, , ,304 Latvia ,177 4,565 3,833 1, , ,621 Lithuania ,415 8,099 3,400 1, , ,235 1,964 Luxembourg , Macedonia, TFYR , ,936 2, ,380 Malta , Moldova ,335 8,932 3, , ,293 Netherlands ,040 5,712 6,294 10, ,333 3,092 3,301 8,813 7,010 2,273 20,075 Norway ,232 3,212 2,287 3, ,513 1,783 1,002 4,978 Poland ,499 22,757 22,310 43,905 1,955 4,500 5,123 5,112 22,655 7,481 6,152 29,549 Portugal ,086 4,051 9,168 7, , ,479 4,744 5,160 1,260 16,123 Romania ,640 26,633 30,635 28,513 1,215 2,100 1,771 3,169 10,236 5,040 3,223 11,105 Russian Federation ,082, , , ,681 17,483 19,520 8,625 21,873 64,539 28,439 75, ,673 San Marino Serbia and Montenegro ,422 5,613 10,644 18, ,600 4,555 2,124 1,243 10,067 Slovakia ,324 8,201 2,375 5, ,757 1, ,769 Slovenia ,412 1, , , ,657 Spain ,586 17,125 20,139 31,901 2,132 5,462 2,540 5,727 20,036 19,906 5,104 55,514 Sweden ,891 8,298 5,379 6, ,289 1,507 1,572 5,799 2,902 1,941 11,067 Switzerland ,189 4,595 2,457 5, ,379 3,746 1,780 1,394 8,473 Tajikistan ,485 2, , , ,558 Turkmenistan ,179 3, , , ,596 Ukraine , ,579 65,305 29,715 4,497 5,692 2,625 7,954 20,088 9,048 16,013 40,010 United Kingdom ,551 44,876 35,829 28,085 2,152 7,464 14,194 12,434 37,706 44,662 7,963 70,186 Uzbekistan ,804 21,451 9,788 6, ,939 7,217 2,739 12,302 Union 2,406, , , ,606 26,168 67,465 65,135 89, , ,277 83, ,922 Total Europe 4,341, , , ,852 54,148 99,932 82, , , , , ,722 Notes: No national mortality data available for Andorra, Bosnia and Herzegovina, Monaco and Turkey. Source: World Health Organization (2007) Eurostat (2007)

18 Figure 1.1a Deaths by cause, men, latest available year, Europe Other cancer 11% Respiratory disease 7% Injuries and poisoning 12% Lung cancer 6% All other causes 17% Colo-rectal cancer 2% Stomach cancer 2% Other CVD 11% Stroke 11% Coronary heart disease 21% Figure 1.1b Deaths by cause, women, latest available year, Europe Respiratory disease 6% Injuries and poisoning 5% Other cancer 9% Breast cancer 3% Lung cancer 2% Colo-rectal cancer 2% Stomach cancer 1% All other causes 18% Other CVD 15% Stroke 17% Coronary heart disease 22% 18

19 Figure 1.1c Deaths by cause, men, latest available year, EU Other cancer 15% Respiratory disease 8% Injuries and poisoning 7% Lung cancer 8% All other causes 19% Colo-rectal cancer 3% Stomach cancer 2% Other CVD 13% Stroke 9% Coronary heart disease 16% Figure 1.1d Deaths by cause, women, latest available year, EU Respiratory disease 7% Injuries and poisoning 3% Other cancer 12% Breast cancer 4% Lung cancer 3% All other causes 22% Colo-rectal cancer 3% Stomach cancer 1% Other CVD 18% Stroke 12% Coronary heart disease 15% 19

20 Table 1.2 Deaths under 75 by cause and sex, latest available year, Europe Year All causes Coronary Stroke Other CVD Stomach Colo-rectal Lung Breast Other Respiratory Injuries and All other heart disease cancer cancer cancer cancer cancer disease poisoning causes MEN Albania ,084 1, ,148 Armenia ,701 2,873 1, , ,812 Austria ,529 2, , , , ,098 3,636 Azerbaijan ,036 6,821 1,692 1, ,617 1,545 1,396 4,327 Belarus ,025 17,160 6,107 2,973 1, , ,531 3,428 12,876 5,746 Belgium ,275 3,668 1,322 2, , ,463 2,346 3,344 4,134 Bulgaria ,515 5,608 5,072 8, , ,340 1,635 2,621 4,645 Croatia ,999 2,692 1,667 1, , , ,630 2,365 Cyprus , Czech Republic ,230 5,499 2,137 3, ,514 3, ,006 1,576 3,672 4,418 Denmark ,063 1, , , , ,294 2,951 Estonia ,072 1, , Finland ,919 2, , ,496 2,482 France ,665 9,379 4,565 10,217 1,697 4,295 16, ,506 4,937 16,352 33,276 Georgia ,913 4,846 2, ,091 2,053 Germany ,986 32,049 8,885 21,561 3,605 7,832 20, ,483 10,784 15,676 43,986 Greece ,500 4,411 2,070 2, , ,284 1,245 2,668 3,069 Hungary ,144 8,987 3,289 4, ,608 4, ,634 2,054 4,510 8,308 Iceland Ireland ,710 1, , ,104 Israel ,127 1, , ,172 2,834 Italy ,064 15,889 6,659 12,395 3,336 4,839 17, ,357 5,149 11,288 21,709 Kazakhstan ,914 14,885 6,649 6,604 1, , ,310 5,261 15,922 12,783 Kyrgyzstan ,933 2,803 2, ,842 2,859 4,062 Latvia ,987 2,812 1,269 1, , ,343 1,486 Lithuania ,578 3,821 1,073 1, , , ,114 2,262 Luxembourg Macedonia, TFYR , , ,072 Malta Moldova ,015 3,889 1, ,308 1,280 2,632 3,430 Netherlands ,466 3,598 1,317 3, ,235 3, ,223 1,855 2,211 6,072 Norway ,872 1, , ,148 1,538 Poland ,698 16,486 9,014 17,221 2,432 3,214 14, ,605 5,371 17,548 26,728 Portugal ,255 2,113 2,179 1, ,005 2, ,013 1,662 2,631 8,266 Romania ,734 15,495 12,885 10,342 1,858 1,784 7, ,629 5,331 9,076 14,130 Russian Federation ,046, , ,244 83,069 20,023 12,119 41, ,501 61, , ,379 San Marino Serbia and Montenegro ,147 5,749 5,347 7, , ,691 2,035 3,040 8,738 Slovakia ,670 3, , , , ,269 2,769 Slovenia , ,067 Spain ,825 9,740 4,267 6,513 1,951 3,666 11, ,532 6,981 9,282 18,096 Sweden ,187 3, , , , ,202 2,938 Switzerland ,464 1, , , , ,545 2,799 Tajikistan ,315 1, , ,616 1,057 3,850 Turkmenistan ,582 2, , ,436 1,815 3,749 Ukraine ,532 91,099 28,148 16,265 6,079 4,561 12, ,927 17,471 58,619 40,383 United Kingdom ,240 24,299 5,894 7,913 1,736 4,412 11, ,853 10,161 9,906 21,867 Uzbekistan ,744 12,793 4,998 5, ,854 7,749 7,837 15,059 Union 1,229, ,084 77, ,518 22,683 41, , ,027 67, , ,213 Total Europe 2,962, , , ,311 55,989 63, , , , , ,148 20

21 21 Table 1.2 continued Year All causes Coronary Stroke Other CVD Stomach Colo-rectal Lung Breast Other Respiratory Injuries and All other heart disease cancer cancer cancer cancer cancer disease poisoning causes WOMEN Albania , Armenia ,407 1,491 1, ,509 Austria , , ,987 Azerbaijan ,755 4,193 1,670 1, ,224 1, ,046 Belarus ,657 10,327 5,706 1, ,010 2, ,999 3,297 Belgium ,163 1,357 1,072 1, ,571 2, ,343 2,982 Bulgaria ,940 2,453 3,592 5, , ,487 Croatia ,582 1,274 1, , ,348 Cyprus Czech Republic ,377 2,444 1,463 2, ,155 3, ,034 2,627 Denmark , , ,944 Estonia , Finland , , ,398 France ,970 2,336 2,784 4, ,749 3,841 6,658 14,588 2,098 5,909 17,494 Georgia ,972 3,000 2, ,178 Germany ,398 10,980 5,822 11,671 1,983 4,750 7,347 10,308 23,431 5,277 5,445 23,384 Greece ,369 1,259 1,485 1, ,033 2, ,006 Hungary ,820 4,695 2,152 2, ,053 1,719 1,362 3,787 1,075 1,329 4,718 Iceland Ireland , Israel , , ,215 Italy ,218 5,470 4,739 7,278 1,754 3,310 3,630 6,758 16,201 2,236 3,293 14,549 Kazakhstan ,977 8,075 5,663 4, ,113 3,754 2,369 4,249 7,355 Kyrgyzstan ,453 1,709 1, , ,542 Latvia ,189 1,324 1, Lithuania ,745 1, , ,021 1,228 Luxembourg Macedonia,TFYR , Malta Moldova ,194 3,260 1, ,564 Netherlands ,012 1,278 1,037 1, ,171 1,976 4,286 1, ,089 Norway , , Poland ,229 6,263 6,387 8,697 1,070 2,307 3,728 3,570 13,565 2,146 3,732 11,764 Portugal , ,420 1, , ,332 Romania ,958 8,566 10,631 6, ,234 1,309 2,365 7,372 2,268 2,666 7,933 Russian Federation , , ,911 48,645 11,692 12,575 5,926 17,314 47,549 17,141 67,247 69,919 San Marino Serbia and Montenegro ,774 3,028 5,262 6, ,302 3,457 1, ,704 Slovakia ,279 1, , , ,534 Slovenia , Spain ,883 2,808 2,593 3, ,066 1,548 3,425 9,206 2,300 2,452 9,910 Sweden ,468 1, , ,832 Switzerland , , ,726 Tajikistan ,930 1, , , ,008 Turkmenistan ,701 1, , , ,313 Ukraine ,916 61,129 25,467 8,910 3,256 3,937 1,894 6,562 15,814 4,334 13,967 18,646 United Kingdom ,289 8,796 4,914 5, ,905 7,280 6,901 17,515 7,646 3,534 15,949 Uzbekistan ,495 9,112 4,318 4, ,555 6,054 2,605 10,740 Union 675,221 69,118 55,445 69,345 11,088 27,229 39,692 54, ,461 33,453 39, ,450 Total Europe 1,618, , , ,642 30,227 48,058 51,899 86, ,987 73, , ,721 Notes: No national mortality data available for Andorra, Bosnia and Herzegovina, Monaco and Turkey. Source: World Health Organization (2007) Eurostat (2007)

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